On-Site Drug/Alcohol Authorization Form

• Conducted on

  Date

• Prepared by

• Location
  Address

• On-Site Post Accident/Incident Drug/Alcohol Testing: This document must be completed by the collector prior to testing. (Wait at least 15 minutes after eating. No mouthwash or other items in mouth prior to the screening.)

• Date:

  Date

• Employee Name:

• Test Administrator/Collector:

Donor must read and understand the following before signing:

• I authorize the collection of the specimen for the purpose of a drug and/or alcohol screen. I authorize the collector to release any results of the test to Human Resources and other members of management as may be appropriate.

I have read and understand the information above:

• Employee Name:

  Sign

• Test Administrator/Collector Signature:

  Sign

• Saliva Drug Test Lot Number:

• Expiration Date:

  Date

• 2nd Test Required:

  Yes

  No

• Saliva Drug Test Lot Number (2nd Test):

• Expiration Date (2nd Test):

  Date

If first test is "Invalid" a second test may be conducted.

• Send for additional testing:

  Yes

  No

• Date/Time of additional testing:

  Date

• Returned to Work (Date & Time):

  Date

• Return completed form to Safety & Human Resources