First Choice Diagnostics

Date:

Time Taken:

Test Type: Random Fitness For Work Post Incident

Other:

DONOR INFORMATION AND CONSENT

Donor Name:

DOB:

Requesting Orginsation:

ID No:

Have you taken any prescription or non-prescription drugs in the past 7 days?: YES NO

Drug(s) Description:

DONOR CERTIFICATION: I certify that the specimen(s) accompanying this form are my own and were provided to me by the collector. Further, I certify that the specimen(s) were sealed with tamper-proof seals in my presence and the information provided on this form and the seals is correct. Also, I consent to the analysis of the specimen(s) for drugs and the release of these results to my employer, prospective employer or his/her authorised representative

Donor Signature Clear

Click to Sign

Seal No A:

Seal No B:

Date:

SCREENING DETAILS

Device/Lot:

Exp:

Alcohol Device Number:

Breath Analysis

Site Cutoff:

Time Test 1:

Test 1:

Time Test 2:

Test 2:

Time Test 3:

Test 3:

Time Test 4:

Test 4:

Drug Screen Results	Not Detected	Further Testing Required
AMP
COC
MET
OPI
THC

FIRST CHOICE DIAGNOSTIC CO. COLLECTER CERTIFICATION

Collectors Name:

Collector Signature Clear

Click to Sign

Further laboratory testing of sample needed:

Chain of Custody form completed:

Client offered sample for independant testing: YES NO Accept Decline NA

Collectors Comments:

Collectors Accreditation Number: