Employee Drug Screen Results

EMPLOYEE DRUG SCREEN RESULTS

Personal Information

Date of Birth:    Phone:

Position Information

Reporting Manager:    Start Date:

Collection Details & Chain of Custody

Collection Date/Time:    Collection Location:

Specimen ID:    Type: Urine Breath Blood

Observed Collection:    Refusal to Test:

Seal/Bag ID:    Date/Time Sealed:

Test Panel and Results

Check tests performed. For each test indicate initial result, confirmation result (if applicable), and concentration or numerical value where reported.

Amphetamines — Result:    Concentration:

Cocaine — Result:    Concentration:

Marijuana (THC) — Result:    Concentration:

Opiates (e.g., morphine, codeine) — Result:    Concentration:

PCP — Result:    Concentration:

Benzodiazepines — Result:    Concentration:

Methadone — Result:    Concentration:

Barbiturates — Result:    Concentration:

Confirmatory Testing & Laboratory Certification

Lab Certifying Official:    Certification/Accreditation #:

Medical Review Officer (MRO) Determination

Employee Acknowledgment, Disclosures, and Authorizations

At-Will Employment: The employee acknowledges that employment is at-will and that nothing in this test, the results, or any related communications alters the at-will relationship unless an authorized representative executes a separate written agreement.

Equal Opportunity: The employer maintains an equal opportunity policy and drug testing is applied in a nondiscriminatory manner in accordance with company policy and applicable law.

Authorization to Release Results: I authorize the release of these test results and related medical information to the employer, the designated medical review officer, and as required for safety-sensitive positions. I understand that confirmatory results and the MRO determination will be retained in a confidential medical file.

Authorization to Contact: I authorize the employer and its representatives to contact previous employers and testing facilities to verify prior test results and relevant employment history when required for safety-sensitive positions or regulatory compliance.

Applicant Certification: By signing below I certify that all information contained in this form is true and complete to the best of my knowledge. I understand that falsification, omission, or misrepresentation may result in disciplinary action up to and including termination.

Consent: I consent to release of results and to the employer's handling of the information as described above.

Employee Statement / Comments

Employment History (Most Recent Two Employers)

Title:    Dates Employed:

Title:    Dates Employed:

Education

Graduation Date:

Professional References (3)

Phone:    Email:

Phone:    Email:

Phone:    Email:

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