Donor Name:
Social Security Number:
Identification Type:
Expiration Date:
Email:
Comments:
I hereby certify that the specimen, provided is my own and has not been substitute or adulterated. I further agree and grant permission for the testing of my specimen for drug metabolites and/or alcohol.
I hereby certify that I collected the specimen provided by the aforementioned donor and that, to the best of my knowledge, it was not substituted or adulterate. The specimen temperature and color where acceptable.
| Substance |
Device Code |
Negative |
Positive |
Not Tested |
| Cocaine |
COC |
|
|
|
| Marijuana |
THC |
|
|
|
| Opiates/ Morphine |
OPI/MOR |
|
|
|
| Amphetamines |
AMP |
|
|
|
| Methamphetamine |
m/AMP |
|
|
|
| Phencyclidine |
PCP |
|
|
|
| Benzodiazepines |
BZO |
|
|
|
| Barbiturates |
BAR |
|
|
|
| Oxycodone |
OXY |
|
|
|
| Buprenorphine |
BUP |
|
|
|
| Alcohol Screen |
ALC |
|
Level
|
SPECIMEN ID NUMBER:
COLLECTION DATE:
