0930-0158 _2023_Fe 0930-0158 _2023_FedCCF_PROOF

FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM

0000001

SPECIMEN ID NO.
STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE
A. Employer Name, Address, I.D. No.

ACCESSION NO.
OMB No. 0930-0158

B. MRO Name, Address, Phone No. and Fax No.

C. Donor SSN, Employee I.D., or CDL State and No.
D. Specify Testing Authority: 

HHS

 NRC

Specify DOT Agency:  FMCSA

 FAA

 FRA

 FTA

 PHMSA

 USCG

E. Reason for Test:  Pre-employment  Random  Reasonable Suspicion/Cause  Post Accident  Return to Duty  Follow-up  Other (specify)
F. Drug Tests to be Performed:

 THC, COC, PCP, OPI, AMP

 THC & COC Only

 Other (specify)

G. Collection Site Address:

Collector Contact Info: Phone
Fax
Other

STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate).

 URINE

 ORAL FLUID

ORAL FLUID: Split Type:  Serial  Concurrent  Subdivided

Each Device Within Expiration Date?  Yes  No

 Volume Indicator(s) Observed

REMARKS:
STEP 3: Collector affixes seal(s) to bottle(s)/tube(s). Collector dates seal(s). Donor initials seal(s). Donor completes STEP 5 on Copy 2 (MRO Copy)
STEP 4: CHAIN OF CUSTODY - INITIATED BY COLLECTOR AND COMPLETED BY TEST FACILITY
SPECIMEN BOTTLE(S)/TUBE(S) RELEASED TO:
I certify that the specimen given to me by the donor identified in the certification section on Copy 2 of this form
was collected, labeled, sealed and released to the Delivery Service noted in accordance with applicable federal requirements.

X

Signature of Collector

(PRINT) Collector’s Name (First, MI, Last)

AM
PM

/

Date (Mo/Day/Yr)

RECEIVED AT LAB OR IITF:

X

Name of Delivery Service

Time of Collection

Primary Specimen
Seal Intact
 YES

Signature of Accessioner

/

(PRINT) Accessioner’s Name (First, MI, Last)

Primary/Single Specimen Device Expiration Date:

/

/

Date (Mo/Day/Yr)

SPECIMEN BOTTLE(S)/TUBE(S)
RELEASED TO:

 NO

If NO, Enter remark
in Step 5A.

Split Specimen Device Expiration Date:

/

(Mo/Day/Yr)

STEP 5A: PRIMARY SPECIMEN REPORT - COMPLETED BY TEST FACILITY
 REJECTED FOR TESTING
 ADULTERATED
 NEGATIVE
 DILUTE
 POSITIVE for:

 SUBSTITUTED

/

/

(Mo/Day/Yr)

PRESS HARD - YOU ARE MAKING MULTIPLE COPIES

COLLECTION:  Split  Single  None Provided, Enter Remark.
URINE: Collector reads urine temperature within 4 minutes. Temperature between 90º and 100º F?  Yes  No, Enter Remark  Observed, Enter Remark

 INVALID RESULT

Analyte(s) in ng/mL

Version C 6May2020

REMARKS:
Test Facility (if different from above) :
I certify that the specimen identified on this form was examined upon receipt, handled using chain of custody procedures, analyzed, and reported in accordance with applicable f ederal requirements.

X

Signature of Certifying Technician/Scientist

(PRINT) Certifying Technician/Scientist’s Name (First, MI, Last)

/ 

Date (Mo/Day/Yr)

STEP 5b: COMPLETED BY SPLIT TESTING LABORATORY

Laboratory Name

0000001

X

/
Signature of Certifying Scientist

/

/

/

/

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

Date (Mo/Day/Yr)

SPECIMEN A

0000001

Date (Mo/Day/Yr)

SPECIMEN B

COPY 1 - TEST FACILITY COPY

/

Date (Mo/Day/Yr)

80308

Laboratory Address

 RECONFIRMED  FAILED TO RECONFIRM - REASON
I certify that the split specimen identified on this form was examined upon receipt, handled using chain of custody procedures,
analyzed, and reported in accordance with applicable federal requirements.

FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM

0000001

ACCESSION NO.
OMB No. 0930-0158

SPECIMEN ID NO.
STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE
A. Employer Name, Address, I.D. No.

B. MRO Name, Address, Phone No. and Fax No.

C. Donor SSN, Employee I.D., or CDL State and No.
D. Specify Testing Authority: 

HHS

 NRC

Specify DOT Agency:  FMCSA

 FAA

 FRA

 FTA

 PHMSA

 USCG

E. Reason for Test:  Pre-employment  Random  Reasonable Suspicion/Cause  Post Accident  Return to Duty  Follow-up  Other (specify)
F. Drug Tests to be Performed:

 THC, COC, PCP, OPI, AMP

 THC & COC Only

 Other (specify)

G. Collection Site Address:

Collector Contact Info: Phone
Fax
Other

STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate).

 URINE

 ORAL FLUID

COLLECTION:  Split  Single  None Provided, Enter Remark.
URINE: Collector reads urine temperature within 4 minutes. Temperature between 90º and 100º F?  Yes  No, Enter Remark  Observed, Enter Remark
Each Device Within Expiration Date?  Yes  No

ORAL FLUID: Split Type:  Serial  Concurrent  Subdivided

 Volume Indicator(s) Observed

REMARKS:
STEP 3: Collector affixes seal(s) to bottle(s)/tube(s). Collector dates seal(s). Donor initials seal(s). Donor completes STEP 5 on Copy 2 (MRO Copy)
STEP 4: CHAIN OF CUSTODY - INITIATED BY COLLECTOR AND COMPLETED BY TEST FACILITY
SPECIMEN BOTTLE(S)/TUBE(S) RELEASED TO:
I certify that the specimen given to me by the donor identified in the certification section on Copy 2 of this form
was collected, labeled, sealed and released to the Delivery Service noted in accordance with applicable federal requirements.

X

Signature of Collector

(PRINT) Collector’s Name (First, MI, Last)

/

AM
PM

/

Date (Mo/Day/Yr)

Name of Delivery Service

Time of Collection

STEP 5: COMPLETED BY DONOR
I certify that I provided my specimen to the collector; that I have not adulterated it in any manner; each specimen bottle/tube used was sealed with a tamper-evident seal
in my presence; and that the information provided on this form and on the label affixed to each specimen bottle/tube is correct.

X

Signature of Donor

(
) 

Email address:

    (

)

/ 

/ 

/ 

/ 

Date (Mo/Day/Yr)

(PRINT) Donor’s Name (First, MI, Last)

Date of Birth

(Mo/Day/Yr)

After the Medical Review Officer receives the test results for the specimen identified by this form, he/she may 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 for your own records. 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 5). – DO NOT PROVIDE THIS
INFORMATION ON THE BACK OF ANY OTHER COPY OF THE FORM. TAKE COPY 5 WITH YOU.
STEP 6: COMPLETED BY MEDICAL REVIEW OFFICER - PRIMARY SPECIMEN

 URINE

 ORAL FLUID

 TEST CANCELLED

 ADULTERATED (adulterant/reason):
 SUBSTITUTED

REMARKS:  

X

Signature of Medical Review Officer

(PRINT) Medical Review Officer’s Name (First, MI, Last)

/

/

/

/

Date (Mo/Day/Yr)

STEP 7: COMPLETED BY MEDICAL REVIEW OFFICER - SPLIT SPECIMEN
In accordance with applicable federal requirements, my verification for the split specimen (if tested) is:
 TEST CANCELLED

 RECONFIRMED for:
 FAILED TO RECONFIRM for:
REMARKS:

X

Signature of Medical Review Officer

(PRINT) Medical Review Officer’s Name (First, MI, Last)

COPY 2 - MEDICAL REVIEW OFFICER COPY

Date (Mo/Day/Yr)

FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM

0000001

ACCESSION NO.
OMB No. 0930-0158

SPECIMEN ID NO.
NO.
STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE
A. Employer Name, Address, I.D. No.

B. MRO Name, Address, Phone No. and Fax No.

C. Donor SSN, Employee I.D., or CDL State and No.
D. Specify Testing Authority: 

HHS

 NRC

Specify DOT Agency:  FMCSA

 FAA

 FRA

 FTA

 PHMSA

 USCG

E. Reason for Test:  Pre-employment  Random  Reasonable Suspicion/Cause  Post Accident  Return to Duty  Follow-up  Other (specify)
F. Drug Tests to be Performed:

 THC, COC, PCP, OPI, AMP

 THC & COC Only

 Other (specify)

G. Collection Site Address:

Collector Contact Info: Phone
Fax
Other

STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate).

 URINE

 ORAL FLUID

COLLECTION:  Split  Single  None Provided, Enter Remark.
URINE: Collector reads urine temperature within 4 minutes. Temperature between 90º and 100º F?  Yes  No, Enter Remark  Observed, Enter Remark
Each Device Within Expiration Date?  Yes  No

ORAL FLUID: Split Type:  Serial  Concurrent  Subdivided

 Volume Indicator(s) Observed

REMARKS:
STEP 3: Collector affixes seal(s) to bottle(s)/tube(s). Collector dates seal(s). Donor initials seal(s). Donor completes STEP 5 on Copy 2 (MRO Copy)
STEP 4: CHAIN OF CUSTODY - INITIATED BY COLLECTOR AND COMPLETED BY TEST FACILITY
SPECIMEN BOTTLE(S)/TUBE(S) RELEASED TO:
I certify that the specimen given to me by the donor identified in the certification section on Copy 2 of this form
was collected, labeled, sealed and released to the Delivery Service noted in accordance with applicable federal requirements.

X

Signature of Collector

/

(PRINT) Collector’s Name (First, MI, Last)

AM
PM

/

Date (Mo/Day/Yr)

Name of Delivery Service

Time of Collection

STEP 5: COMPLETED BY DONOR
I certify that I provided my specimen to the collector; that I have not adulterated it in any manner; each specimen bottle/tube used was sealed with a tamper-evident seal
in my presence; and that the information provided on this form and on the label affixed to each specimen bottle/tube is correct.

X

Signature of Donor

Daytime Phone No. (

Email address:

)

Evening Phone No. (

)

/

/

/

/

Date (Mo/Day/Yr)

(PRINT) Donor’s Name (First, MI, Last)

Date of Birth

(Mo/Day/Yr)

After the Medical Review Officer receives the test results for the specimen identified by this form, he/she may 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 for your own records. 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 5). – DO NOT PROVIDE THIS
INFORMATION ON THE BACK OF ANY OTHER COPY OF THE FORM. TAKE COPY 5 WITH YOU.
STEP 6: COMPLETED BY MEDICAL REVIEW OFFICER - PRIMARY SPECIMEN
In accordance with applicable federal requirements, my verification is:
 NEGATIVE
 POSITIVE for:
 DILUTE
 REFUSAL TO TEST because – check reason(s) below:
 ADULTERATED (adulterant/reason):
 SUBSTITUTED
 OTHER:

 URINE

 ORAL FLUID

 TEST CANCELLED

REMARKS:

X

Signature of Medical Review Officer

(PRINT) Medical Review Officer’s Name (First, MI, Last)

/

/

/

/

Date (Mo/Day/Yr)

STEP 7: COMPLETED BY MEDICAL REVIEW OFFICER - SPLIT SPECIMEN
In accordance with applicable federal requirements, my verification for the split specimen (if tested) is:
 TEST CANCELLED

 RECONFIRMED for:
 FAILED TO RECONFIRM for:
REMARKS:

X

Signature of Medical Review Officer

(PRINT) Medical Review Officer’s Name (First, MI, Last)

COPY 3 - COLLECTOR COPY

Date (Mo/Day/Yr)

FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM

0000001

ACCESSION NO.
OMB No. 0930-0158

SPECIMEN ID NO.
STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE
A. Employer Name, Address, I.D. No.

B. MRO Name, Address, Phone No. and Fax No.

C. Donor SSN, Employee I.D., or CDL State and No.
D. Specify Testing Authority: 

HHS

 NRC

Specify DOT Agency:  FMCSA

 FAA

 FRA

 FTA

 PHMSA

 USCG

E. Reason for Test:  Pre-employment  Random  Reasonable Suspicion/Cause  Post Accident  Return to Duty  Follow-up  Other (specify)
F. Drug Tests to be Performed:

 THC, COC, PCP, OPI, AMP

 THC & COC Only

 Other (specify)

G. Collection Site Address:

Collector Contact Info: Phone
Fax
Other

STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate).

 URINE

 ORAL FLUID

COLLECTION:  Split  Single  None Provided, Enter Remark.
URINE: Collector reads urine temperature within 4 minutes. Temperature between 90º and 100º F?  Yes  No, Enter Remark  Observed, Enter Remark
Each Device Within Expiration Date?  Yes  No

ORAL FLUID: Split Type:  Serial  Concurrent  Subdivided

 Volume Indicator(s) Observed

REMARKS:
STEP 3: Collector affixes seal(s) to bottle(s)/tube(s). Collector dates seal(s). Donor initials seal(s). Donor completes STEP 5 on Copy 2 (MRO Copy)
STEP 4: CHAIN OF CUSTODY - INITIATED BY COLLECTOR AND COMPLETED BY TEST FACILITY
SPECIMEN BOTTLE(S)/TUBE(S) RELEASED TO:
I certify that the specimen given to me by the donor identified in the certification section on Copy 2 of this form
was collected, labeled, sealed and released to the Delivery Service noted in accordance with applicable federal requirements.

X

Signature of Collector

(PRINT) Collector’s Name (First, MI, Last)

/

AM
PM

/

Date (Mo/Day/Yr)

Name of Delivery Service

Time of Collection

STEP 5: COMPLETED BY DONOR
I certify that I provided my specimen to the collector; that I have not adulterated it in any manner; each specimen bottle/tube used was sealed with a tamper-evident seal
in my presence; and that the information provided on this form and on the label affixed to each specimen bottle/tube is correct.

X

Signature of Donor

Daytime Phone No. (

Email address:

)

Evening Phone No. (

)

/

/

/

/

Date (Mo/Day/Yr)

(PRINT) Donor’s Name (First, MI, Last)

Date of Birth

(Mo/Day/Yr)

After the Medical Review Officer receives the test results for the specimen identified by this form, he/she may 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 for your own records. 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 5). – DO NOT PROVIDE THIS
INFORMATION ON THE BACK OF ANY OTHER COPY OF THE FORM. TAKE COPY 5 WITH YOU.
STEP 6: COMPLETED BY MEDICAL REVIEW OFFICER - PRIMARY SPECIMEN
In accordance with applicable federal requirements, my verification is:
 NEGATIVE
 POSITIVE for:
 DILUTE
 REFUSAL TO TEST because – check reason(s) below:
 ADULTERATED (adulterant/reason):
 SUBSTITUTED
 OTHER:

 URINE

 ORAL FLUID

 TEST CANCELLED

REMARKS:

X

Signature of Medical Review Officer

(PRINT) Medical Review Officer’s Name (First, MI, Last)

/

/

/

/

Date (Mo/Day/Yr)

STEP 7: COMPLETED BY MEDICAL REVIEW OFFICER - SPLIT SPECIMEN
In accordance with applicable federal requirements, my verification for the split specimen (if tested) is:
 TEST CANCELLED

 RECONFIRMED for:
 FAILED TO RECONFIRM for:
REMARKS:

X

Signature of Medical Review Officer

(PRINT) Medical Review Officer’s Name (First, MI, Last)

COPY 4 - EMPLOYER COPY

Date (Mo/Day/Yr)

Paper CCF: Back of Copy 1-4
Electronic CCF: Separate Page

Public Burden Statement

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid
OMB control number. The OMB control number for this project is 0930-0158. Public reporting burden for this collection of information is estimated
to average: 5 minutes/donor; 4 minutes/collector; 3 minutes/test facility; and 3 minutes/Medical Review Officer. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance
Officer, 5600 Fishers Lane, Room 15E57B, Rockville, Maryland, 20852.

FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM

0000001

ACCESSION NO.
OMB No. 0930-0158

SPECIMEN ID NO.
STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE
A. Employer Name, Address, I.D. No.

B. MRO Name, Address, Phone No. and Fax No.

C. Donor SSN, Employee I.D., or CDL State and No.
D. Specify Testing Authority: 

HHS

 NRC

Specify DOT Agency:  FMCSA

 FAA

 FRA

 FTA

 PHMSA

 USCG

E. Reason for Test:  Pre-employment  Random  Reasonable Suspicion/Cause  Post Accident  Return to Duty  Follow-up  Other (specify)
F. Drug Tests to be Performed:

 THC, COC, PCP, OPI, AMP

 THC & COC Only

 Other (specify)

G. Collection Site Address:

Collector Contact Info: Phone
Fax
Other

STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate).

 URINE

 ORAL FLUID

COLLECTION:  Split  Single  None Provided, Enter Remark.
URINE: Collector reads urine temperature within 4 minutes. Temperature between 90º and 100º F?  Yes  No, Enter Remark  Observed, Enter Remark
Each Device Within Expiration Date?  Yes  No

ORAL FLUID: Split Type:  Serial  Concurrent  Subdivided

 Volume Indicator(s) Observed

REMARKS:
STEP 3: Collector affixes seal(s) to bottle(s)/tube(s). Collector dates seal(s). Donor initials seal(s). Donor completes STEP 5 on Copy 2 (MRO Copy)
STEP 4: CHAIN OF CUSTODY - INITIATED BY COLLECTOR AND COMPLETED BY TEST FACILITY
SPECIMEN BOTTLE(S)/TUBE(S) RELEASED TO:
I certify that the specimen given to me by the donor identified in the certification section on Copy 2 of this form
was collected, labeled, sealed and released to the Delivery Service noted in accordance with applicable federal requirements.

X

Signature of Collector

(PRINT) Collector’s Name (First, MI, Last)

/

AM
PM

/

Date (Mo/Day/Yr)

Name of Delivery Service

Time of Collection

STEP 5: COMPLETED BY DONOR
I certify that I provided my specimen to the collector; that I have not adulterated it in any manner; each specimen bottle/tube used was sealed with a tamper-evident seal
in my presence; and that the information provided on this form and on the label affixed to each specimen bottle/tube is correct.

X

Signature of Donor

Daytime Phone No. (

Email address:

)

Evening Phone No. (

)

/

/

/

/

Date (Mo/Day/Yr)

(PRINT) Donor’s Name (First, MI, Last)

Date of Birth

(Mo/Day/Yr)

After the Medical Review Officer receives the test results for the specimen identified by this form, he/she may 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 for your own records. 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 5). – DO NOT PROVIDE THIS
INFORMATION ON THE BACK OF ANY OTHER COPY OF THE FORM. TAKE COPY 5 WITH YOU.
STEP 6: COMPLETED BY MEDICAL REVIEW OFFICER - PRIMARY SPECIMEN
In accordance with applicable federal requirements, my verification is:
 NEGATIVE
 POSITIVE for:
 DILUTE
 REFUSAL TO TEST because – check reason(s) below:
 ADULTERATED (adulterant/reason):
 SUBSTITUTED
 OTHER:

 URINE

 ORAL FLUID

 TEST CANCELLED

REMARKS:

X

Signature of Medical Review Officer

(PRINT) Medical Review Officer’s Name (First, MI, Last)

/

/

/

/

Date (Mo/Day/Yr)

STEP 7: COMPLETED BY MEDICAL REVIEW OFFICER - SPLIT SPECIMEN
In accordance with applicable federal requirements, my verification for the split specimen (if tested) is:
 TEST CANCELLED

 RECONFIRMED for:
 FAILED TO RECONFIRM for:
REMARKS:

X

Signature of Medical Review Officer

(PRINT) Medical Review Officer’s Name (First, MI, Last)

COPY 5 - DONOR COPY

Date (Mo/Day/Yr)

Paper CCF: Back of Copy 5
Electronic CCF: Separate Page

Privacy Act Statement: (For Federal Employees Only)

Submission of the information on the Federal Drug Testing Custody and Control Form is voluntary. However, incomplete submission of the
information, refusal to provide a specimen, or substitution or adulteration of a specimen may result in delay or denial of your application for
employment/appointment or may result in removal from the federal service or other disciplinary action.
The authority for obtaining the specimen and identifying information contained herein is Executive Order 12564 (“Drug-Free Federal Workplace”),
5 U.S.C. Sec. 3301 (2), 5 U.S.C. Sec. 7301, and Section 503 of Public Law 100-71, 5 U.S.C. Sec. 7301 note. Under provisions of Executive Order
12564 and 5 U.S.C. 7301, test results may only be disclosed to agency officials on a need-to-know basis. This may include the agency Medical
Review Officer (MRO), the administrator of the Employee Assistance Program, and a supervisor with authority to take adverse personnel action. This
information may also be disclosed to a court where necessary to defend against a challenge to an adverse personnel action.
Submission of your SSN is not required by law and is voluntary. Your refusal to furnish your number will not result in the denial of any right,
benefit, or privilege provided by law. Your SSN is solicited, pursuant to Executive Order 9397, for purposes of associating information in agency files
relating to you and for purposes of identifying the specimen provided for testing. If you refuse to indicate your SSN, a substitute number or other
identifier will be assigned, as required, to process the specimen.

Public Burden Statement

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid
OMB control number. The OMB control number for this project is 0930-0158. Public reporting burden for this collection of information is estimated
to average: 5 minutes/donor; 4 minutes/collector; 3 minutes/test facility; and 3 minutes/Medical Review Officer. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance
Officer, 5600 Fishers Lane, Room 15E57B, Rockville, Maryland, 20852.