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Fill in Your Drug Screen Template

The Drug Screen form is a document used to ensure proper handling and testing of urine samples for drug use. It outlines the steps involved in the collection, chain of custody, and reporting of test results. This form is essential for employers and testing facilities to maintain compliance with federal regulations.

Table of Contents

The Drug Screen form is a crucial document in the drug testing process, ensuring compliance with federal regulations and maintaining the integrity of the testing procedure. This form includes several key sections that capture essential information, such as the employer's details, the Medical Review Officer's (MRO) contact information, and the donor's identification number. It specifies the testing authority, which may include agencies like HHS, NRC, or DOT, and outlines the reasons for testing, such as pre-employment, random checks, or post-accident evaluations. Additionally, the form lists the specific drug tests to be performed, including substances like THC, cocaine, and amphetamines. The collection site details, including the collector's contact information, are also documented. The form guides the collector through steps to ensure proper specimen handling, including temperature checks and chain of custody procedures. Each step is designed to maintain transparency and accountability throughout the testing process, from collection to laboratory analysis. The final sections of the form provide space for certifying scientists to confirm the integrity of the specimen and report results, whether negative or positive, thereby safeguarding the rights of all parties involved.

Sample - Drug Screen Form

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
		Signature of Collector
				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
	X				Yes No
		Signature of Accessioner			Yes No
		Signature of Accessioner
					If No, Enter remarks
					in Step 5A.
		(Print) Accessioner’s Name (First, MI, Last)		Date (Mo./Day/Yr.)	in Step 5A.

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.

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

___________________________________________

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

↓ Drug Screen PDF

File Specs

Fact Name	Description
Form Title	The form is officially titled the "Federal Drug Testing Custody and Control Form." It is used for documenting the process of drug testing in compliance with federal regulations.
Governing Authority	The drug testing process is governed by the Department of Health and Human Services (HHS) and other federal agencies such as the Department of Transportation (DOT).
Employer Information	Employers must provide their name, address, and identification number on the form. This information is crucial for tracking and accountability.
Donor Identification	The form requires the donor's Social Security Number or Employee ID Number to ensure accurate identification of the individual being tested.
Testing Authority Options	Testing authorities can include various federal agencies such as FMCSA, FAA, FRA, FTA, PHMSA, and USCG. Employers must specify which authority applies.
Reason for Testing	Multiple reasons for testing can be indicated, including pre-employment, random testing, reasonable suspicion, post-accident, and follow-up. This flexibility allows for a tailored approach to drug testing.
Collection Site Information	Details about the collection site, including name, address, and contact information, must be documented to ensure transparency in the testing process.
Chain of Custody	Maintaining a chain of custody is critical. The collector must certify that the specimen was collected, labeled, sealed, and released according to federal requirements.
Test Results Reporting	Results are reported as negative, positive, or rejected. The form includes sections for certifying scientists to sign, ensuring accountability in the reporting process.

Drug Screen - Usage Guidelines

Filling out the Drug Screen form is a straightforward process. Make sure to gather all necessary information before you start. Follow the steps below to ensure that the form is completed correctly.

Begin with the section labeled "STEP 1." Enter the Employer Name, Address, and I.D. No..
Provide the MRO Name, Address, Phone, and Fax No..
Fill in the Donor SSN or Employee I.D. No..
Specify the Testing Authority by checking the appropriate box (HHS, NRC, DOT) and indicate the DOT Agency if applicable.
Choose the Reason for Test from the provided options and write in any other reason if necessary.
Select the Drug Tests to be Performed and specify any other tests if needed.
Complete the Collection Site Name, Collection Site Code, Address, Collector Phone No., City, State, and Zip.
Move to "STEP 2." The collector should read the specimen temperature within 4 minutes. Indicate if the temperature is between 90° and 100° F.
Document whether the collection is Split, Single, or None Provided.
If observed, make any necessary remarks.
In "STEP 3," the collector affixes bottle seals to the bottles and dates them. The donor initials the seals and completes STEP 5 on Copy 2 (MRO Copy).
Proceed to "STEP 4." The collector certifies that the specimen was collected and released in accordance with Federal requirements. Fill in the name of the Delivery Service.
Ensure that the Signature of Accessioner is obtained and document the date and time of collection.
In "STEP 5A," the test facility completes the primary specimen report. Indicate if the result is negative or positive and specify the substances tested.
Document any remarks as needed.
In "STEP 5B," if applicable, the split testing laboratory certifies the results and provides a reason if the reconfirmation failed.
Finally, ensure that all signatures are obtained where required.

Your Questions, Answered

What is the purpose of the Drug Screen form?

The Drug Screen form is used to document the process of collecting and testing a urine sample for drugs. It ensures compliance with federal regulations and provides a clear record of the chain of custody for the specimen. This form is essential for employers, especially those in safety-sensitive industries, to maintain a drug-free workplace and to comply with testing requirements set by various authorities.

Who completes the Drug Screen form?

The form is primarily completed by the collector or an employer representative. This individual is responsible for gathering the specimen, ensuring proper labeling, and maintaining the chain of custody. Additionally, the Medical Review Officer (MRO) may also have a role in completing parts of the form, particularly regarding the interpretation of test results.

What information is required on the Drug Screen form?

Key information includes the employer's name and address, the MRO's contact details, the donor's Social Security Number or employee ID, the testing authority, the reason for the test, and the specific drugs to be tested. The form also requires details about the collection site and the collector's information, ensuring that all necessary parties are clearly identified.

What steps are involved in the collection process?

The collection process involves several steps. First, the collector verifies the donor's identity and reads the specimen temperature within four minutes to ensure it falls within the acceptable range. Next, the specimen is collected, labeled, and sealed. The donor then initials the seals to confirm their agreement with the process. Finally, the collector documents the chain of custody, ensuring the specimen is securely handled until it reaches the testing facility.

What happens if a specimen is rejected for testing?

If a specimen is rejected, the form will indicate the reason, such as being adulterated, substituted, or invalid. The testing facility must document these reasons clearly. This information is crucial as it informs the employer and the donor about the status of the test and any necessary follow-up actions that may be required.

How is confidentiality maintained during the testing process?

Confidentiality is a priority throughout the drug testing process. The Drug Screen form is designed to limit access to sensitive information. Only authorized personnel, such as the collector, MRO, and designated testing facility staff, have access to the results. Additionally, results are typically reported in a manner that protects the identity of the donor, ensuring compliance with privacy regulations.

What should I do if I have questions about the Drug Screen results?

If you have questions regarding the Drug Screen results, it is important to contact the MRO listed on the form. The MRO is responsible for interpreting the results and discussing any potential implications with the donor. They can provide clarity on the findings and guide individuals on the next steps, especially if a positive result is reported.

Common mistakes

Incomplete Information: Failing to provide all required details, such as the employer name or donor SSN, can lead to delays or invalid results.
Incorrect Testing Authority: Selecting the wrong testing authority (HHS, NRC, DOT) may result in the test being conducted under inappropriate regulations.
Wrong Reason for Test: Not accurately stating the reason for the test can lead to misunderstandings and possible legal issues.
Missing Drug Tests: Omitting specific drugs to be tested, such as THC or COC, can result in incomplete testing and unreliable outcomes.
Temperature Reading Errors: Not reading the specimen temperature within the specified time frame can invalidate the test.
Improper Chain of Custody: Failing to follow the chain of custody procedures correctly can compromise the integrity of the test results.
Ignoring Remarks Section: Not using the remarks section to note any unusual circumstances during collection can lead to confusion later.
Collector Information Mistakes: Providing incorrect or incomplete information about the collector can complicate verification and accountability.
Signature Issues: Not signing the form or having incomplete signatures can render the form invalid.
Failing to Review the Form: Not double-checking the entire form for accuracy before submission can lead to simple mistakes that may have significant consequences.

Documents used along the form

When conducting drug screenings, several forms and documents are typically used alongside the Drug Screen form. These documents help ensure that the process is thorough, compliant, and well-documented. Below is a list of common forms that may accompany the Drug Screen form.

Chain of Custody Form: This document tracks the handling of the specimen from collection to testing. It ensures that the sample remains secure and that the results are valid.
Consent Form: A signed agreement from the donor allowing for the drug test. This form confirms that the individual understands the testing process and its implications.
Medical Review Officer (MRO) Report: After the testing is completed, the MRO reviews the results and provides a report. This document explains any positive results and may include medical explanations.
Donor Information Sheet: This sheet provides details about the testing process, including what to expect and how to prepare. It helps educate the donor on the procedure.
Laboratory Test Results: The official results from the testing facility. This document outlines whether the specimen tested positive or negative for specific substances.
Employee Handbook Addendum: An addendum to the employee handbook that outlines the company's drug testing policy. It informs employees of the rules and consequences related to drug testing.
Incident Report Form: If the drug test is conducted due to an incident (like an accident), this form documents the details of the incident and the rationale for testing.

These documents work together to create a comprehensive framework for drug screening. Each form plays a vital role in ensuring the process is transparent, fair, and compliant with regulations.

Similar forms

The Chain of Custody form is similar to the Drug Screen form in that it documents the handling of a specimen throughout the testing process. This form ensures that there is a clear record of who collected, transported, and analyzed the sample. It includes signatures from each person involved, which helps maintain the integrity of the specimen. Both forms emphasize the importance of tracking the sample to prevent tampering or contamination, thus ensuring reliable results.

The Consent Form is another document that bears similarities to the Drug Screen form. It is designed to obtain permission from the donor before conducting the drug test. Like the Drug Screen form, the Consent Form outlines the purpose of the testing and the substances that will be screened. This document ensures that the donor is informed and agrees to the testing process, which is crucial for ethical and legal compliance.

The Medical Review Officer (MRO) Report shares characteristics with the Drug Screen form as it provides a summary of the test results and any relevant medical history that could affect interpretation. After the initial testing, the MRO evaluates the results and communicates findings to the employer or requesting party. Both documents play a critical role in the overall drug testing process, ensuring that results are accurately assessed and reported.

Finally, the Employee Handbook often includes policies related to drug testing, making it similar to the Drug Screen form. This handbook outlines the procedures, expectations, and consequences associated with drug testing within the organization. Like the Drug Screen form, it serves to inform employees about the testing process and their rights, ensuring transparency and adherence to company policies.

Dos and Don'ts

Filling out a Drug Screen form can seem daunting, but following some simple guidelines can make the process smoother. Here are nine things you should and shouldn’t do when completing this important document:

Do: Double-check all personal information for accuracy.
Do: Clearly specify the reason for the test.
Do: Use a black or blue pen to ensure legibility.
Do: Follow instructions for temperature readings carefully.
Do: Sign and date the form where required.

Don’t: Leave any fields blank; complete every section.
Don’t: Use corrections fluid or tape to alter the form.
Don’t: Provide false information, as this can lead to serious consequences.
Don’t: Forget to keep a copy of the completed form for your records.

By adhering to these guidelines, you can ensure that your Drug Screen form is filled out correctly and efficiently. Remember, accuracy is key in this process!

Misconceptions

Understanding the Drug Screen form is crucial for both employers and employees involved in drug testing. However, several misconceptions can lead to confusion. Here are five common misunderstandings:

The Drug Screen form is only for new hires. Many people believe this form is exclusively for pre-employment testing. In reality, it is used for various situations, including random testing, post-accident evaluations, and follow-up tests.
All drug tests are the same. Some assume that every drug test checks for the same substances. Different tests can be performed based on the employer's needs, such as testing for specific drugs like THC or cocaine, or a broader panel.
The temperature check is unnecessary. There is a belief that monitoring the specimen's temperature is not important. However, it is a critical step to ensure the integrity of the sample and to prevent tampering.
Only the collector needs to fill out the form. Many think that the responsibility lies solely with the collector. In fact, both the donor and the collector must complete specific sections of the form to ensure accuracy and compliance.
A negative result means no issues. Some people mistakenly believe that a negative result indicates complete safety. It's essential to understand that a negative result does not guarantee the absence of impairment, as it only reflects the substances tested at that time.

Clarifying these misconceptions can help ensure a smoother drug testing process for everyone involved.

Key takeaways

Filling out and using the Drug Screen form correctly is essential for ensuring compliance and accuracy in drug testing procedures. Here are ten key takeaways:

Complete all required fields: Ensure that the employer name, MRO information, donor identification, and testing authority are accurately filled out.
Specify the reason for the test: Clearly indicate whether the test is for pre-employment, random selection, reasonable suspicion, or other valid reasons.
Choose the correct drug tests: Select the appropriate tests to be performed, such as THC, COC, or AMP, based on the testing requirements.
Record specimen temperature: The collector must check the specimen temperature within four minutes of collection. Document the results accurately.
Use proper chain of custody: Follow the chain of custody procedures to maintain the integrity of the specimen from collection to testing.
Seal the specimen bottle: Ensure that the collector affixes the bottle seal and that it is dated and initialed by the donor.
Document remarks: Make any necessary remarks during the collection process, especially if there are issues with the specimen.
Verify delivery service: Clearly indicate which delivery service will transport the specimen to the testing facility.
Understand test results: Be aware of the different possible outcomes, including negative, positive, or rejected results, and what they mean.
Retain copies: Keep copies of the completed form for your records, as they may be needed for future reference or audits.