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Drug Screen Consent

Donor Information:

Donor Name:

Social Security Number:

Identification Type: Expiration Date:

Email:

Comments:

Certification Information: (Must be signed by both Donor and Collector)

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.

Donor's Signature

Date

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.

Collector's Signature

Date

Initial Screen Results: (All "Positive") results must be confirmed by GC/MS confirmation

Substance	Device Code	Positive
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:

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Timestamp

Audit

March 7, 2026 9:07 pm CDT

Drug Screen Consent Uploaded by Cheyenne Noland - [email protected] IP 46.110.217.61