FMS Drug/Alcohol Screening Consent Form

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

DONOR INFORMATION

• Surname:

• Given Name:

• Date of Birth

  Date

• Male or Female?

  Male

  Female
• Address:
  Address

• Take photo of ID or Donor

  Media

REQUESTING AUTHORITY

• Company:

• Position:

• Telephone:

• Email:

DONOR CERTIFICATION/CONSENT/DECLARATION

• 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 agree that if I provide an insufficient sample, that this will be treated the same as a Non Negative result (Fail)

• Other comments

• in the last 2 weeks, have you had, or are you taking any medications either prescribed or herbal that may effect your sample.

  No

  Yes

• 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, and that the urine/oral fluid specimen has been collected, divided, labelled and sealed in accordance with the relevant Standard.

• COLLECTOR Name & Signature

  Sign

• Date and time of Collection:

  Date

• Collection Site:

TEST RESULTS

• Initial Testing Device/Method:

• Batch Number:

• Expiry Date:

  Date

INITIAL TEST RESULT 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

• 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

• Do you believe this was an unadulterated sample

  YES

  NO

2ND TEST RESULT (alcohol only)

• Alcohol

  Unconfirmed / Non Negative

  Negative

• Collector/ Technician’s Name & Signature

  Sign