Attachment C - Federal CCF

FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM

II IIII/Ifill1'11111/1111
111/1/11
1234567

C

I

SPECIMEN
10NO
1 i234567
STEP1: C~PLETEOBY COLLECTOROR EMPLOYERREPRESENTATIVE
A. Employer Name, Address, I.D.No.
~-..,
8. MR~ Name, Address, Phone ~ndFax N~.

C. Donor SSN or Employee 1.0. No.
D. Reason forTest:

0 Pre-employment

0 Random

0 AeasoMble

0 Return to Duty
0 Follow.up
E. Drug Tests to be Perlormed:
OTHC, COC,PCp, OPI, AMP
F. Collection Site Address:

0

Other

OTHC&CO

(

f

0 Post Accident

peaty)
uspicion/Cause

Only

CollectorPhoneNO~
Collector Fax No.
STEP 2: COMPLETED BY COLLECTOR

REMARKS

~
STEP Sa: PRIMARY SPECIMEN TEST RESULTS -COMPLETED

l~

BY PRIMARY LABORATbRY
I
I
(
(

f
(

STEP 5b: SPLIT SPECIMEN TEST RESULTS -(IFTESTED)

COMPLETED

0 RECONFIRMED
laboratory

BY SECONDARY LABORATORY

0 FAILED TO RECONFIRM -REASON

I certify that the split specimen
identified on /his fomj was examined
and reported in accordance
with applicable Fedetal fMuirementsI

Name

X
laborat()!Y AMress

~t'

-,
$iQna.!:!!!eof Cer1ifyingSOentist

at

~
~

Attachment
i

(PR~

A

SPECIMEN 10 NO.

1234567

8
(SPLIT)

SPECIMEN

10 NO.

CAP

~'::V

handled

using dJain of custody

procedures,

ana/yz

,

...I

Cert~Scientist's

Name(First, MI,

SPECIMEN BOTTLE

SEAL

I~~~
~
\ ~V_E_R)

receipl,

/

~

1234567

PLACE
OVER

1234567

~

Date
~o ~; Yr.)
Donor's Initials

1234567
SPECIMEN BOTtLE

COPY1-LABORATOR~COPY

SEAL

~~yyq
o;;:;;~~~;;:-;-;-

.

FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM

Collector PhoneNo.
CotlectorFaxNo.

STEP2: COMPLETEDBY COLLECTOR
Read specimen temperature within 4 minutes. Is temperature
between 90" and 100" F? 0 Yes 0 No, Enter Remark

Collection:I

Specimen

0 Split

0 Single

0 None Provided (Enter Remark)

0 Observed (Enter Remark)

REMARKS
STEP 3: Collector affixes bottle seal(s) to bottle(s). Coflector dates seal(s). Donor initials seal(s). Donor completes
STEP 4: CHAIN OF CUSTODY -INmATED
BY COLLECTOR
AND COMPLETED
BY LABORATORY

-

AT LAB:
!X

..

-'

Signatu(e of AFile Typeapplication/pdfAuthorWVogl [ MD-CC-2-1031 ]File Modified0000-00-00File Created2006-04-20