Title Page
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Document No.
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Workplace Drug and Alcohol Testing
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Client
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Conducted on
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Conducted By
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Location
Donor Information
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First Name, Last Name
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Date of Birth
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Sex
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Address
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ID Type
- Drivers Licence
- Passport
- Adult proof of age card
- Employee ID
- Other
- Known to tester
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Capture a photo of the evidence, showing ID number. If no ID and the person is known, capture their photograph.
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I have taken medications/drugs (prescription, over the counter or recreational) in the past 7 days?
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- Prescription
- Over the Counter
- Recreational/Illegal
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Please provide the following information.
Name of medication.
When was each medication last taken? Date and Time approx. -
Prescription Medication
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When was the medication last taken? Date and Time approx.
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Over the Counter
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Please provide the following information.
Name of medication.
When was each medication last taken? Date and Time approx. -
Recreational/Illegal When it was last taken? Date and Time approx.
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I consent to the testing of my breath, oral fluid and urine for drugs and alcohol. I certify that the specimen’s 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 on this form.
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Donor/Guardian Signature
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Requesting Authority/Company and Representative's Name
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Collection Site
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Substances been tested for
- Alcohol
- Amphetamine
- Benzodiazepines
- Cocaine
- Methamphetamine
- Opiates
- Cannabis
Alcohol Test Results
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Is Alcohol testing been conducted?
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Target Alcohol Concentration
- 0.00
- 0.01
- 0.02
- 0.03
- 0.04
- 0.05
- .0.06
- 0.07
- 0.07-0.10
- Greater then 0.10
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Test Unit used, showing unit serial number
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BAC Test Result
BAC Test
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BAC Result
- 0.00
- 0.01
- 0.02
- 0.03
- 0.04
- 0.05
- .0.06
- 0.07
- 0.07-0.10
- Greater then 0.10
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BAC Outcome Classification
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Select date
Drug Test Results
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Is drug testing been conducted?
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Drug Test Kit, showing kit details including expiry and batch number.
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Sample collection technique?
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Positive Control Response Acceptable?
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Negative Control Response Acceptable?
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Are adulteration tests acceptable?
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Screening Test Results
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Screen Test Results
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AMP (Amphetamine) - 50 ng/ml
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BZO (Benzodiazepines) - 50 ng/ml
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COC (Cocaine) - 20 ng/ml
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MET (Methamphetamine) - 50 ng/ml
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OPI (Opiates) - 40 ng/ml
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THC (found in cannabis); cutoff level - 12 ng/ml
Collectors Certification
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Confirmation Tests are required
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Confirmation tests required:
- Alcohol
- Amphetamine
- Benzodiazepines
- Cocaine
- Methamphetamine
- Opiates
- Cannabis
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How will confirmation testing be conducted?
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Individual is to be taken to
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Confirmation Sample Collected?
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Chain of Custody Completed
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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 specimen has been collected, divided, labelled and sealed in accordance with the instructions provided.
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Add signature
