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APPENDIX A TO PART 40-FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM

STEP 2: TO BE COMPLETED BY COLLECTOR - Specimen temperature must be read within 4 minutes of collection.
Specimen temperature within range: □ Yes, 90° - 100°F/32° - 38°C
No, Record specimen temperature here

STEP 3- YO BE COMPLETED BY COLLECTOR AND DONOR - Collector affores bottle seal(s) to bottle(s). Coffector deles seal(s). Donor Intists seat(s)
STEP 4 TO BE COMPLETED BY DONOR - Go to copy 4 (pink page), STEP 4

STEP 5: TO BE COMPLETED BY COLLECTOR
COLLECTION SITE LOCATION:

三

SPECIMEN RECEIVED BY

Signature

PURPOSE OF CHANGE
PROVIDE SPECIMEN

FOR TESTING

Name

Name

Signature

Name

Signatuon
Name

Signature

Name

Signature

Name

Signature
Home

STEP 7: TO BE COMPLETED BY THE LABORATORY Specimen Bottle Seals) Intact:

YESNO, Explain in Remarks Below.
THE RESULTS FOR THE ABOVE IDENTIFIED SPECIMEN ARE IN ACCORDANCE WITH THE APPLICABLE INITIAL TEST AND CONFIRMATORY TEST CUTOFF
LEVELS ESTABLISHED BY THE HKS MANDATORY GUIDELINES FOR FEDERAL WORKPLACE DRUG TESTING PROGRAMS
ONEGATIVE OPOSITIVE, for the following

Icarly that the specimen vierailed by the inberatory accession number on this form in the same specimen that bears the specimen temblication number set forth above, that the specimen has been examined upon receipt, handled and analyzed in accordance with applicable federal requirements, and that the results set forth are let that apscimen

Collectors RN)

=

Paperwork Reduction Act Notice (as required by 5 CFR 1320.21)

Public reporting burden for this collection of Information, including the time for reviewing instructions gathering and maintaining the data needed, and completing and reviewing the collection of Information is estimated for each respondent to average: 5 minutes/donor; 4 minutes/collector; 3 minutes/laboratory; and 3 minutes/ledical Review Officer. Federal employees may send comments regarding these burden estimates, or any other aspect of this collection of Information, Including suggestions for reducing the burden, to Public Health Service Reports Clearance Officer, Attn: PRA, Hubert H. Humphrey Buliding, Rm 721-8, 200 Independence Ave. S.W., Washington, D.C. 20201. Individuals from the private sector may send comments/suggestions to: Department of Transportation, Drug Enforcement and Program Compliance, Fm 9404, 400 Seventh St. S.W., Washington, D.C. 20590. In addition, copies of all commania/suggestions may be sent to: Office of Management and Budget, Paperwork Reduction Project, Rm 3001, 725 Seventeenth 81. N.W., Washington, D.C. 20603.

Back of Copy 1, 2, 3, 4, and 6.

STEP 2: TO BE COMPLETED BY COLLECTOR - Specimen temperature must be read within 4 minutes of collection.
Specimen temperature within range: Yes, 90°-100°F/32° - 38°C
No, Record specimen temperature here

STEP 3: TO BE COMPLETED BY COLLECTOR AND DONOR - Collector affixes bottle seal(s) to bottle(s). Collector dates seal(s). Donor initials seal(s).
STEP 4: TO BE COMPLETED BY DONOR - Go to copy 4 (pink page); STEP 4

REMARKS:
I certify that the specimen identified on this form is the specimen presented to me by the donor providing the certification on Copy 4 of this form, that it bears the same specimen
identification number as that set forth above, and that it has been collected, labelled and sealed as in accordance with applicable Federal requirements.
AM

STEP 6: TO BE INITIATED BY THE COLLECTOR AND COMPLETED AS NECESSARY THEREAFTER

(PRINT) Collector's Name (First, Mi, Last)

Signature of Collector

SPECIMEN RECEIVED BY

Signature

Name

Signature

Name

PURPOSE OF CHANGE
PROVIDE SPECIMEN
FOR TESTING

STEP 7: TO BE COMPLETED BY THE LABORATORY - Specimen Bottle Seal(s) Intact: YES NO, Explain in Remarks Below.

THE RESULTS FOR THE ABOVE IDENTIFIED SPECIMEN ARE IN ACCORDANCE WITH THE APPLICABLE INITIAL TEST AND CONFIRMATORY TEST CUTOFF
LEVELS ESTABLISHED BY THE HHS MANDATORY GUIDELINES FOR FEDERAL WORKPLACE DRUG TESTING PROGRAMS
NEGATIVE POSITIVE, for the following:

TEST NOT
PERFORMED

CANNABINOIDS as Carboxy-THC
OPIATES:
codeine

morphine

COCAINE METABOLITES as Benzoylecgonine
☐ AMPHETAMINES:

PHENCYCLIDINE

amphetamine

OTHER

methamphetamine

REMARKS

TEST LAB (if different from above).

NAME

ADDRESS

PHONE NO.

I certify that the specimen identified by the laboratory accession number on this form is the same specimen that bears the specimen identification number set forth above, that the specimen has been examined upon receipt, handled and analyzed in accordance with applicable Federal requirements, and that the results set forth are for that specimen.

(PRINT) Cerifying Scientist's Name (First, Mi, Last)

Signature of Certifying Scientist

Date (Mo./Day/Yr.)

STEP 8: TO BE COMPLETED BY THE MEDICAL REVIEW OFFICER
I have reviewed the laboratory results for the specimon identified by this form in accordance with applicable Federal requirements. My determination/verification is:
Negative
Positive
Test Not Performed
Test Cancelled

STEP 2: TO BE COMPLETED BY COLLECTOR - Specimen temperature must be read within 4 minutes of collection.
Specimen temperature within range: Yes, 90° - 100°F/32° - 38°C
No, Record specimen temperature here

STEP 3: TO BE COMPLETED BY COLLECTOR AND DONOR - Collector affixes bottle seal(s) to bottle(s). Collector dates seal(s). Donor initials seal(s).
STEP 4: TO BE COMPLETED BY DONOR - Go to copy 4 (pink page); STEP 4

STEP 5: TO BE COMPLETED BY COLLECTOR

COLLECTION SITE LOCATION:

Collection Facility

Address

REMARKS:
I certify that the specimen identified on this form is the specimen presented to me by the donor providing the certification on Copy 4 of this form, that it bears the same specimen
identification number as that set forth above, and that it has been collected, labelled and sealed as in accordance with applicable Federal requirements.
AM

STEP 6: TO BE INITIATED BY THE COLLECTOR AND COMPLETED AS NECESSARY THEREAFTER

DATE

MO. DAY YR.

(PRINT) Collector's Name (First, Mu, Last)

SPECIMEN RELEASED BY

DONOR-NO SIGNATURE

Signature
Name

Signature

Name

Signature
Name

STEP 7: TO BE COMPLETED BY THE LABORATORY - Specimen Bottle Seal(s) Intact: YES NO, Explain in Remarks Below.

THE RESULTS FOR THE ABOVE IDENTIFIED SPECIMEN ARE IN ACCORDANCE WITH THE APPLICABLE PROCEDURES ESTABLISHED BY THE HHS MANDATORY
GUIDELINES FOR FEDERAL WORKPLACE DRUG TESTING PROGRAMS

I certify that the specimen identified by the laboratory accession number on this form is the same specimen that bears the specimen identification number set forth above, that the specimen has been examined upon receipt, handled and analyzed in accordance with applicable Federal requirements, and that the results set forth are for that specimen.

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

Signature of Certifying Scientist

Date (Mo./Day/Yr.)

STEP 8: TO BE COMPLETED BY THE MEDICAL REVIEW OFFICER
I have reviewed the aboratory results for the specimen identified by this form in accordance with applicable Federal requirements. My determination/verification is:
Reconfirmed Failed to reconfirm-
Test not performed