Random Drug and Alcohol Test

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Type of Test

  Drug

  alcohol

• Type of testing equipment used

  Approved mouth (saliva) swab testing equipment

  Breath Analysis Equipment

• Select date

  Date

• Screening Test Number

  Yes

  No

  N/A

Employee Details

• Employee Name

  Yes

  No

  N/A

• Should the Employee refuse to take this test, the company will take this as a positive test, and disciplinary action will take place, which may include dismissal. Should the Employee decide to take the test after this has been explained and it is a negative test they will resume normal duties after the testing procedure.

• Screening conducted in neutral location

  Yes

  No

  N/A

• Has employee selected a witness? If yes who?

  Yes

  No

  N/A

• The actual screening mouth swab used on the employee is called a primary sample

• Each employee is asked a series of six questions prior to their individual screening.

• 1. Have you consumed any Alcohol in the previous 8 hours?

  Yes

  No

  N/A

• If yes more info required.

• What type of drug?

  Yes

  No

  N/A

• At what time

  Date

• What was the quantity consumed?

  Yes

  No

  N/A

• Are these prescribed drugs?

  Yes

  no

• 2. Have you taken any illicit (illegal) drugs in the previous 12 hours?

  Yes

  No

  N/A

• If yes more info required.

• What type of drug?

  Yes

  No

  N/A

• At what time

  Date

• What was the quantity consumed?

  Yes

  No

  N/A

• Are these prescribed drugs?

  Yes

  no

• 3. Are you currently under the effect of any illicit drugs?

  Yes

  No

  N/A

• If yes more info required.

• What type of drug?

  Yes

  No

  N/A

• At what time

  Date

• What was the quantity consumed?

  Yes

  No

  N/A

• Are these prescribed drugs?

  Yes

  no

• 4. Are you taking any pharmaceutical drugs?

  Yes

  No

  N/A

• If yes more info required.

• What type of drug?

  Yes

  No

  N/A

• At what time

  Date

• What was the quantity consumed?

  Yes

  No

  N/A

• Are these prescribed drugs?

  Yes

  no

• 5. Are you presently on any medication?

  Yes

  No

  N/A

• If yes more info required.

• What type of drug?

  Yes

  No

  N/A

• At what time

  Date

• What was the quantity consumed?

  Yes

  No

  N/A

• Are these prescribed drugs?

  Yes

  no

• 6. Have you taken anything orally in the previous 10 minutes?

  Yes

  No

  N/A

• If yes more info required.

• What type of drug?

  Yes

  No

  N/A

• At what time

  Date

• What was the quantity consumed?

  Yes

  No

  N/A

• Are these prescribed drugs?

  Yes

  no

Test Results

• Test Result

  Negative

  Positive

• If positive any comment from employee yes or n/a.

  Yes

  No

  N/A

• Comment

  Yes

  No

  N/A

• Employee

  Sign

• Company Representative

  Sign

• If positive what was the course of action

  Referred to a Pathology Laboratory for urine test

  dismissal

  counseling