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The Drug Screen form, officially known as the Federal Drug Testing Custody and Control Form, serves as a critical tool in the drug testing process, ensuring compliance with federal regulations. This form is meticulously designed to track the collection and testing of urine specimens for the presence of controlled substances. Key components include the identification of the employer and the medical review officer (MRO), as well as the donor's social security number or employee ID. The form specifies the testing authority, which may include agencies like the Department of Transportation (DOT) or the Department of Health and Human Services (HHS), and outlines the reason for the test, such as pre-employment or post-accident scenarios. Additionally, the form details the types of drug tests to be performed, covering substances like THC, cocaine, and amphetamines. The meticulous steps outlined in the form ensure that the specimen is collected, labeled, and sealed properly, maintaining a chain of custody from the collection site to the testing facility. Each section of the form requires careful attention to detail, including temperature checks and collector remarks, to uphold the integrity of the testing process. The final results, whether negative or positive, are documented by the certifying scientist, affirming that the specimen has been handled according to federal standards. This comprehensive approach not only safeguards the rights of the donor but also reinforces the accountability of the testing process.

Drug Screen Example

FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM

800-877-7484

SPECIMEN ID NO.

 

STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE

LAB ACCESSION NO.

Quest, Quest Diagnostics, the associated logo and all associated Quest Diagnostics marks are the trademarks of Quest Diagnostics Incorporated. © Quest Diagnostics Incorporated. All rights reserved. QD20315-FED. Revised 10/10. SC2K - 111192.

A. Employer Name, Address, I.D. No.

 

 

B. MRO Name, Address, Phone and Fax No.

 

 

 

 

 

 

 

 

 

C. Donor SSN or Employee I.D. No. _______________________________________________________________

 

 

 

 

D. SpecifyTesting Authority: ￿ HHS

￿ NRC

￿ DOT – Specify DOT Agency: ￿ FMCSA

￿ FAA

￿ FRA ￿ FTA ￿ PHMSA ￿ USCG

E. Reason forTest: ￿ Pre-employment

￿ Random

￿ Reasonable Suspicion Cause ￿ Post Accident

￿ Return to Duty

￿ Follow-up ￿ Other (specify) ____________________________

F. DrugTests to be Performed:

￿ THC, COC, PCP, OPI, AMP

￿THC & COC Only

￿ Other (specify) ________________________________________________

G. Collection Site Name:

 

 

 

 

 

Collection Site Code:

 

 

 

 

Address:

 

 

 

 

 

 

Collector Phone No.:

 

 

City, State and Zip:

 

 

 

 

 

Collector Fax No.:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate) Collector reads specimen temperature within 4 minutes.

Temperature between 90° and 100° F? ￿ Yes ￿ No, Enter Remark

Collection: ￿ Split ￿ Single ￿ None Provided, Enter Remark

￿ Observed, (Enter Remark)

REMARKS

STEP 3: Collector affixes bottle seal(s) to bottle(s). Collector dates seal(s). Donor initials seal(s). Donor completes STEP 5 on Copy 2 (MRO Copy)

STEP 4: CHAIN OF CUSTODY - INITIATED BY COLLECTOR AND COMPLETED BY TEST FACILITY

 

I certify that the specimen given to me by the donor identified in the certification section on Copy 2 of this form was

 

SPECIMEN BOTTLE(S) RELEASED TO:

 

collected, labeled, sealed, and released to the Delivery Service noted in accordance with applicable Federal requirements.

￿ Quest Diagnostics Courier

 

 

X

 

 

 

 

 

￿ FedEx

 

 

Signature of Collector

 

 

 

 

 

￿ Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AM

 

 

 

 

 

 

 

 

 

PM

 

 

 

 

 

(Print) Collector's Name (First, MI, Last)

Date (Mo./Day/Yr.)

 

Time of Collection

 

 

Name of Delivery Service

RECEIVED AT LAB OR IITF:

 

 

 

 

 

Primary Specimen

SPECIMEN BOTTLE(S) RELEASED TO:

 

X

 

 

 

 

 

Bottle Seal Intact

 

 

 

 

 

 

 

￿ Yes ￿ No

 

 

 

Signature of Accessioner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If No, Enter remarks

 

 

 

 

 

 

 

 

 

in Step 5A.

 

 

 

(Print) Accessioner’s Name (First, MI, Last)

 

 

 

Date (Mo./Day/Yr.)

 

STEP 5A: PRIMARY SPECIMEN REPORT - COMPLETED BY TEST FACILITY

NEGATIVE

POSITIVE for:

Marijuana Metabolite ( 9-THCA)

6- Acetylmorphine

Methamphetamine

MDMA

DILUTE

 

 

Cocaine Metabolite (BZE)

Morphine

Amphetamine

MDA

 

 

 

PCP

Codeine

 

MDEA

REJECTED FOR TESTING

ADULTERATED

SUBSTITUTED

INVALID RESULT

 

 

REMARKS:

Test Facility (if different from above):

I certify that the specimen identified on this form was examined upon receipt, handled using chain of custody procedures, analyzed, and reported in accordance with applicable Federal requirements.

X

Signature of Certifying Scientist

(Print) Certifying Scientist's Name (First, MI, Last)

Date (Mo./Day/Yr.)

STEP 5b: COMPLETED BY SPLIT TESTING LABORATORY

￿RECONFIRMED ￿ FAILED TO RECONFIRM - REASON ____________________________________________

___________________________________________

I certify that the split specimen identified on this form was examined upon receipt, handled using chain of custody

procedures, analyzed and reported in accordance with applicable Federal requirements.

 

 

 

 

 

 

 

 

 

 

 

 

Laboratory Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

___________________________________________

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Certifying Scientist

 

 

 

(Print) Certifying Scientist's Name (First, MI, Last)

Date (Mo./Day/Yr.)

 

 

 

 

 

 

 

Laboratory Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OMB No. 0930-0158

PRESS HARD - YOU ARE MAKING MULTIPLE COPIES

Click for Drug Screen File

File Breakdown

Fact Name Details
Form Title Federal Drug Testing Custody and Control Form
Contact Number 800-877-7484
Specimen ID Unique identifier assigned to each specimen for tracking purposes.
Testing Authority Tests can be conducted under HHS, NRC, or DOT regulations.
Reason for Test Includes pre-employment, random, reasonable suspicion, post-accident, return to duty, follow-up, and other specified reasons.
Drug Tests Common tests include THC, COC, PCP, OPI, AMP, and combinations thereof.
Chain of Custody Must be initiated by the collector and completed by the test facility to ensure specimen integrity.
Results Reporting Test results can be negative, positive, dilute, adulterated, substituted, or invalid.
Legal Compliance All procedures must comply with applicable federal requirements.

Guide to Using Drug Screen

Completing the Drug Screen form is a critical step in the testing process. It requires attention to detail to ensure that all necessary information is accurately recorded. After filling out the form, it will be submitted for processing, where the specimen will be tested according to federal guidelines.

  1. Begin by entering the Employer Name, Address, and I.D. No. in Section A.
  2. In Section B, provide the MRO Name, Address, Phone, and Fax No.
  3. For Section C, write down the Donor SSN or Employee I.D. No.
  4. In Section D, specify the Testing Authority by selecting from the options: HHS, NRC, or DOT. If DOT is selected, specify the agency.
  5. For Section E, indicate the Reason for Test by checking the appropriate box or specifying another reason.
  6. In Section F, list the Drug Tests to be Performed by checking the relevant options or specifying others.
  7. Complete Section G with the Collection Site Name, Code, Address, Collector Phone No., City, State, and Zip. Also, include the Collector Fax No.
  8. In Step 2, the Collector will read the specimen temperature within 4 minutes. Indicate whether the temperature is between 90° and 100° F by selecting Yes or No, and enter any necessary remarks.
  9. Also in Step 2, specify whether the collection was Split, Single, or None Provided, and add any remarks as needed.
  10. In Step 3, the Collector will affix bottle seals to the bottles, date them, and the Donor will initial the seals. The Donor must complete Step 5 on Copy 2.
  11. Step 4 involves the Chain of Custody. The Collector certifies that the specimen was collected, labeled, sealed, and released according to federal requirements. Fill in the details for the Delivery Service and have the Collector sign and date the form.
  12. In Step 5A, the Test Facility will report the results. Indicate whether the result is negative or positive for various substances, and add any remarks as necessary.
  13. Step 5B is for the Split Testing Laboratory to confirm or reject the split specimen. Include the reason for any failure to reconfirm.
  14. Finally, ensure that all signatures are obtained from the Certifying Scientist and that the date is recorded for each relevant section.

Get Answers on Drug Screen

What is the purpose of the Drug Screen form?

The Drug Screen form is used to document the collection and testing of urine specimens for drug use. It ensures compliance with federal regulations and provides a clear record of the testing process. This form is essential for employers who conduct drug testing for various reasons, including pre-employment screening, random testing, and post-accident evaluations.

Who completes the Drug Screen form?

The Drug Screen form is typically completed by the collector or an employer representative. This individual is responsible for ensuring that all necessary information is accurately filled out, including the donor's identification and the reason for the test. Proper completion of the form is crucial for maintaining the integrity of the testing process.

What information is required on the form?

Several key pieces of information are required on the Drug Screen form, including:

  • Employer name and address
  • Medical Review Officer (MRO) contact details
  • Donor's Social Security Number or Employee ID
  • Testing authority (e.g., HHS, DOT)
  • Reason for the test (e.g., pre-employment, random)
  • Drugs to be tested
  • Collection site details

Each of these elements plays a vital role in ensuring that the testing is conducted according to regulations and that results can be accurately interpreted.

What happens if the specimen temperature is not within the acceptable range?

If the specimen temperature is not within the acceptable range of 90° to 100° F, the collector must make a remark on the form. This could indicate potential tampering or issues with the specimen collection process. Further investigation may be necessary to determine the validity of the specimen.

What is the chain of custody, and why is it important?

The chain of custody refers to the process of maintaining and documenting the handling of the specimen from the time it is collected until the results are reported. This process is crucial for ensuring the integrity of the testing results. Any break in the chain of custody can lead to questions about the validity of the results, potentially impacting employment decisions or legal proceedings.

What should I do if the test results are positive?

If the test results are positive, the next steps typically involve a confirmation process. The Medical Review Officer (MRO) will review the results and may contact the donor to discuss any potential explanations for the positive result. It is important for the donor to be aware of their rights and the procedures that will follow a positive result, including the opportunity for a split specimen test if requested.

How can I obtain a copy of the Drug Screen form?

A copy of the Drug Screen form can usually be obtained from the employer or the collection site where the test was administered. It is important for individuals to keep a personal record of their testing documentation for future reference, especially if there are questions or disputes regarding the results.

Common mistakes

Filling out the Drug Screen form correctly is crucial for ensuring that the testing process runs smoothly. However, many individuals make mistakes that can lead to complications. One common error is failing to provide accurate personal identification information. This includes the donor's Social Security Number or Employee ID. If this information is incorrect or missing, it can delay the processing of the test results.

Another frequent mistake is not specifying the correct testing authority. The form requires the donor or collector to indicate whether the test is under the Department of Transportation (DOT), the Department of Health and Human Services (HHS), or the Nuclear Regulatory Commission (NRC). Omitting this detail can lead to confusion about which regulations apply to the test.

Many people also overlook the importance of selecting the appropriate reason for the test. Options include pre-employment, random, or post-accident testing. If the reason is not clearly marked, it can create ambiguity about the context of the test, potentially impacting the interpretation of results.

In addition, individuals often forget to include remarks when necessary. For example, if the specimen temperature is outside the acceptable range, a remark should be made. Ignoring this step can result in questions about the validity of the test, as proper documentation is essential for maintaining the integrity of the testing process.

Finally, a significant mistake occurs when collectors fail to properly complete the chain of custody section. This section is vital for tracking the specimen from collection to analysis. If any part of this process is not documented correctly, it could lead to disputes regarding the test results. Ensuring that every step is accurately recorded is essential for upholding the integrity of the drug testing procedure.

Documents used along the form

When conducting drug screenings, several forms and documents often accompany the Drug Screen form to ensure compliance, accuracy, and proper documentation throughout the process. Each document serves a specific purpose in the overall drug testing procedure.

  • Chain of Custody Form: This document tracks the handling of the specimen from the time it is collected until the results are reported. It ensures that the sample has not been tampered with and maintains the integrity of the testing process.
  • Consent Form: Before testing, donors typically sign a consent form, which confirms their understanding of the testing process and grants permission for the collection and analysis of their specimen.
  • Medical Review Officer (MRO) Report: This report is prepared by a qualified MRO who reviews the test results and evaluates any potential medical explanations for positive findings. The MRO plays a crucial role in interpreting results and communicating them to the employer.
  • Test Results Report: This document provides the final results of the drug test, indicating whether the specimen tested negative or positive for specific substances. It is essential for employers to make informed decisions based on these results.
  • Recollection Form: In cases where a specimen may be compromised or invalid, a recollection form is used to document the need for a new sample. This ensures that the testing process can be repeated without loss of accountability.
  • Follow-Up Testing Form: If an employee tests positive, follow-up testing may be required. This form outlines the procedures and timelines for subsequent tests, ensuring ongoing compliance with drug testing policies.

Each of these documents plays a vital role in the drug testing process, ensuring that it is conducted fairly, legally, and with respect for the individuals involved. Proper documentation not only protects the rights of the donor but also helps employers maintain a safe and compliant workplace.

Similar forms

The Drug Screen form is an essential document in the process of drug testing. It bears similarities to several other documents used in various contexts. Below are five documents that share characteristics with the Drug Screen form, along with explanations of how they are alike.

  • Chain of Custody Form: This document ensures that the sample collected is tracked throughout the testing process. Like the Drug Screen form, it requires detailed information about the collector, the donor, and the handling of the specimen to maintain integrity and accountability.
  • Consent Form: A consent form is used to obtain permission from the individual being tested. Similar to the Drug Screen form, it includes personal information and outlines the purpose of the testing, ensuring that the individual is informed and agrees to the process.
  • Laboratory Report: This document provides the results of the drug test. It parallels the Drug Screen form in that it details the substances tested for, the outcomes, and any remarks regarding the testing process, thereby ensuring transparency and clarity.
  • Medical Review Officer (MRO) Report: An MRO report evaluates the results of the drug test and provides a professional interpretation. Like the Drug Screen form, it includes information about the donor and the substances tested, emphasizing the importance of accurate reporting in the drug testing process.
  • Accreditation Certificate: This document certifies that a testing facility meets specific standards. It is similar to the Drug Screen form because it provides essential information about the facility, ensuring that the testing is conducted in accordance with regulatory requirements.

Dos and Don'ts

When filling out the Drug Screen form, it's important to follow specific guidelines to ensure accuracy and compliance. Here’s a list of things you should and shouldn’t do:

  • Do provide accurate personal information, including your SSN or Employee ID.
  • Do specify the reason for the test clearly, whether it’s for pre-employment or another reason.
  • Do ensure the collection site information is complete and correct.
  • Do check the temperature of the specimen within the specified time frame.
  • Do initial the bottle seal after it has been affixed by the collector.
  • Don’t leave any section of the form blank. Fill in all required fields.
  • Don’t provide false information about your drug use or the specimen.
  • Don’t forget to sign the form where required, as your signature is essential.
  • Don’t alter or tamper with the specimen or the collection process.
  • Don’t ignore any remarks or instructions provided by the collector.

Following these guidelines will help ensure a smooth testing process and accurate results.

Misconceptions

Understanding the Drug Screen form is essential for both employers and employees involved in the testing process. However, several misconceptions often arise. Here are seven common misunderstandings:

  • The Drug Screen form is only for pre-employment testing. Many believe this form is solely for new hires. In reality, it is used for various testing reasons, including random testing, post-accident assessments, and follow-up tests.
  • Only illegal drugs are tested. Some assume that the form only screens for illicit substances. However, it also tests for prescription medications that can impair an individual's ability to perform their job safely.
  • The collector must be a medical professional. There is a misconception that only doctors or nurses can collect specimens. In fact, trained collectors can perform this task, ensuring proper protocol is followed.
  • A positive result means immediate termination. Many fear that any positive test will lead to job loss. It's important to understand that there are processes in place, including confirmation tests and the opportunity for the employee to explain the result.
  • The form is only relevant for safety-sensitive positions. While safety-sensitive roles often require drug testing, the form can be applicable across various industries and positions, depending on company policy and federal regulations.
  • Chain of custody is not important. Some individuals underestimate the significance of chain of custody. This procedure is crucial to ensure that the specimen is handled properly and the results are reliable.
  • All drug tests are the same. There is a belief that all drug tests yield identical results. However, different tests may screen for different substances and have varying detection windows, making it essential to understand the specifics of each test.

By clarifying these misconceptions, both employers and employees can navigate the drug testing process with greater confidence and understanding.

Key takeaways

When filling out and using the Drug Screen form, it is essential to follow specific guidelines to ensure accuracy and compliance. Here are some key takeaways:

  • Ensure Accurate Information: Fill in all required fields, including the employer's name, donor's identification, and the testing authority. Incomplete information can lead to delays or issues with the testing process.
  • Specify the Reason for Testing: Clearly indicate why the test is being conducted, whether it’s for pre-employment, random testing, or another reason. This helps in maintaining transparency and understanding of the testing purpose.
  • Temperature Check: The collector must read the specimen temperature within four minutes. A temperature reading between 90° and 100° F indicates the specimen is likely valid. Document any discrepancies.
  • Chain of Custody: Follow the chain of custody procedures diligently. This ensures the specimen is collected, labeled, sealed, and transferred correctly, maintaining its integrity throughout the testing process.
  • Proper Documentation: All signatures and dates must be clearly documented. This includes the collector's signature, the date of collection, and the name of the delivery service. Accurate records are vital for legal and compliance reasons.
  • Review Results Carefully: After testing, review the results thoroughly. If the specimen is rejected or produces an invalid result, ensure that remarks are made in the appropriate section to clarify the situation.

By adhering to these guidelines, you contribute to a smoother and more reliable drug testing process. Your attention to detail is crucial for the integrity of the results and the overall effectiveness of the program.