DONOR CERTIFICATION: SPECIMEN IDENTIFICATION DAYTIME PHONE NUMBER DATE OF BIRTH I certify that I provided my urine specimen to the collector; that the specimen bottle was sealed with a tamper-proof seal in my presence; and that the information provided on this form and on the label affixed to the specimen bottle is correct. Should the results of the laboratory tests for the specimen identified by this form be confirmed positive, the Medical Review Officer will contact you to ask about prescriptions and over-the-counter medications you may have taken. Therefore, you may want to make a list of those medications as a "memory jogger." THIS LIST IS NOT NECESSARY. If you choose to make a list, do so either on a separate piece of paper or on the back of your copy (Copy 4-Donor) of this form-DO NOT LIST ON THE BACK OF ANY OTHER COPY OF THE FORM. TAKE YOUR COPY WITH YOU. TO BE COMPLETED BY PERSON COLLECTING SPECIMEN AFTER DONOR HAS COMPLETED SECTION VII-(See Copy 3 of Form) COLLECTOR'S NAME-PRINT (first, middle, last) VIII. COLLECTION SITE LOCATION DATE OF COLLECTION REMARKS CONCERNING COLLECTION: Split sample collected in accordance Yes No I certify that the specimen identified on this form is the specimen presented to me by the donor providing the certification on Copy 3 of this form, that it bears the same identification number as that set forth above, and that it has been collected, labelled and sealed as in accordance with applicable Federal requirements. SIGNATURE OF COLLECTOR: COPY 3-TO MEDICAL REVIEW OFFICER DONOR CERTIFICATION: SPECIMEN IDENTIFICATION DAYTIME PHONE NUMBER DATE OF BIRTH I certify that I provided my urine specimen to the collector, that the specimen bottle was sealed with a tamper-proof seal in my presence; and that the information provided on this form and on the label affixed to the specimen bottle is correct. Should the results of the laboratory tests for the specimen identified by this form be confirmed positive, the Medical Review Officer will contact you to ask about prescriptions and over-the-counter medications you may have taken. Therefore, you may want to make a list of those medications as a "memory jogger." THIS LIST IS NOT NECESSARY. If you choose to make a list, do so either on a separate piece of paper or on the back of your copy (Copy 4-Donor) of this form-DO NOT LIST ON THE BACK OF ANY OTHER COPY OF THE FORM. TAKE YOUR COPY WITH YOU. TO BE COMPLETED BY PERSON COLLECTING SPECIMEN AFTER DONOR HAS COMPLETED SECTION VII-See Copy 3 of Form) COLLECTION SITE LOCATION DATE OF COLLECTION REMARKS CONCERNING COLLECTION: Split sample collected in accordance No I certify that the specimen identified on this form is the specimen presented to me by the donor providing the certification on Copy 3 of this form, that it bears the same identification number as that set forth above, and that it has been collected, labelled and sealed as in accordance with applicable Federal requirements. SIGNATURE OF COLLECTOR: COPY 4-DONOR BACK-SIDE OF COPY 4-DONOR LIST PRESCRIPTION DRUGS. IT IS NOT REQUIRED, AND IS FOR YOUR USE ONLY. DONOR CERTIFICATION: I certify that I provided my urine specimen to the collector; that the specimen bottle was sealed with a tamper-proof seal in my presence; and that the information provided on this form and on the label affixed to the specimen bottle is correct. TO BE COMPLETED BY PERSON COLLECTING SPECIMEN AFTER DONOR HAS COMPLETED SECTION VII-See Copy 3 of Form) COLLECTION SITE LOCATION DATE OF COLLECTION REMARKS CONCERNING COLLECTION: Split sample collected in accordance Yes No I certify that the specimen identified on this form is the specimen presented to me by the donor providing the certification on Copy 3 of this form, that it bears the same identification number as that set forth above, and that it has been collected, labelled and sealed as in accordance with applicable Federal requirements. SIGNATURE OF COLLECTOR: COPY 5-COLLECTOR DONOR CERTIFICATION: I certify that I provided my urine specimen to the collector, that the specimen bottle was sealed with a tamper-proof seal in my presence; and that the information provided on this form and on the label affixed to the specimen bottle is correct. TO BE COMPLETED BY PERSON COLLECTING SPECIMEN AFTER DONOR HAS COMPLETED SECTION VII-See Copy 3 of Form) COLLECTOR'S NAME-PRINT (first, middle, last) VIII. COLLECTION SITE LOCATION DATE OF COLLECTION REMARKS CONCERNING COLLECTION: Split sample collected in accordance Yes No I certify that the specimen identified on this form is the specimen presented to me by the donor providing the certification on Copy 3 of this form, that it bears the same identification number as that set forth above, and that it has been collected, labelled and sealed as in accordance with applicable Federal requirements. SIGNATURE OF COLLECTOR: COPY 6-EMPLOYER TO BE COMPLETED BY PERSON COLLECTING SPECIMEN AFTER DONOR HAS COMPLETED SECTION VII-(See Copy 3 of Form) COLLECTOR'S NAME-PRINT (first, middle, last) VIII. DATE OF COLLECTION COLLECTION SITE LOCATION REMARKS CONCERNING COLLECTION Split sample collected in accordance Yes No I certify that the specimen identified on this form is the specimen presented to me by the donor providing the certification on Copy 3 of this form, that it bears the same identification number as that set forth above, and that it has been collected, labelled and sealed as in accordance with applicable Federal requirements. THE RESULTS FOR THE ABOVE IDENTIFIED SPECIMEN ARE IN ACCORDANCE WITH THE APPLICABLE SCREENING AND CONFIRMATION CUTOFF LEVELS ESTABLISHED BY THE HHS MANDATORY GUIDELINES FOR FEDERAL WORKPLACE DRUG TESTING PROGRAMS (found only on copies one and two) X. I have reviewed the laboratory results for the specimen identified by this form in accordance with applicable Federal requirements My final determination/ verification is POSITIVE (Check one) NEGATIVE |