Drug and Alcohol Testing Consent & Chain of Custody Form
Male or Female?
I consent to the testing of my breath/urine/oral fluids sample for alcohol/drugs. I certify that the breath/urine/oral fluid specimen accompanying this form is my own and was provided by me to the authorized collector. Further, I certify that for any on-site testing performed, such testing was carried out in my presence. I certify that for any of my specimens that are to be sent for laboratory testing, the containers were sealed with tamper evident seals in my presence and that the information on the labels Is correct. Also I certify that the Information provided on this form is correct and I consent to the release of all test results together with all relevant details on this form to the nominated representative(s) of the requesting authority indicated above.
I certify that I witnessed the donor signature and that the specimen identified on this form was provided to me by the donor whose consent and certification appears above, bears the same identification as set forth above, and that the urine/oral fluid specimen has been collected, divided, labelled and sealed in accordance with the relevant Standard.
Initial Testing Device/Method:
Breathalyser Serial No:
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