Drug and Alcohol Testing Consent Form

• Name

• Reason

  Random

  For Cause

• Conducted on

  Date

• Prepared by

DONOR INFORMATION

• Surname:

• First Name:

• Date of Birth

  Date

• Male or Female?

  Male

  Female

• Take photo of ID/ license

  Media

REQUESTING AUTHORITY

• Nominated Representative:

• Company:

• Position:

• Telephone:

• Email:

DONOR CERTIFICATION/CONSENT/DECLARATION

• Other comments

• DONOR Signature

  Sign

COLLECTOR CERTIFICATION

• 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.

• COLLECTOR Name & Signature

  Sign

• Date and time of Collection:

  Date

• Collection Site:

TEST RESULTS

• Initial Testing Device/Method:

  Select Drugwipe Breathalyser

  • Drugwipe
  • Breathalyser

• Drugwipe Batch Number:

• Drugwipe Expiry Date:

  Date

• Breathalyser Serial No:

• Breathalyser Calibration Date

INITIAL TEST Drug and Alcohol Drug/Drug Class

• Select which Drug/Drug Class is tested (select all that apply)

  Select ALCOHOL COC AMP MET THC OPI BZO

  • ALCOHOL
  • COC
  • AMP
  • MET
  • THC
  • OPI
  • BZO

• Alcohol

  Unconfirmed / Non Negative

  Negative

• COC

  Unconfirmed / Non Negative

  Negative

• AMP

  Unconfirmed / Non Negative

  Negative

• MET

  Unconfirmed / Non Negative

  Negative

• THC

  Unconfirmed / Non Negative

  Negative

• OPI

  Unconfirmed / Non Negative

  Negative

• BZO

  Unconfirmed / Non Negative

  Negative

2ND TEST RESULT (alcohol only)

• Alcohol

  Unconfirmed / Non Negative

  Negative

FINAL CONCLUSION

• Final Result

  Select Pass Fail Drugwipe Fail Breathalysers

  • Pass
  • Fail Drugwipe
  • Fail Breathalysers

• Collector/ Technician’s Name & Signature

  Sign