RANDOM DRUG TEST

CERTIFICATION

I hereby certify to the best of my knowledge that I have not been found positive of any regulated drugs by any Drug
Test Laboratory for the past six (6) months. If I should be found making false statement to this regard, I shall be
held liable and shall be charged of perjury.

________________________________ ____________________________________________________________________ ___ __________________

Signature of Client (PRINT) Client’s Name (First,MI,Last) DATE

CONSENT FORM

Service/ Unit:________________________

Name:___________________________________________________________Date:____________Time:________
Last name First name Middle name
Address:______________________________________________________________________________________
Birth date:_________________________ Age:______ Gender: __________ Civil Status:________________
Place of Birth: _________________________________

Instructions: Answer the questions below by checking the appropriate boxes below. Afterwards, read the statements below
and sign the following signature.

Have you taken medication or drugs in the past 30 days?  Yes  No

Have you ingested any alcoholic beverage in the past 24 hours?  Yes  No
If you are taking medication of drugs, list these items below: .

I hereby consent and agree to give a sample of my urine. The result of any tests performed will only be provided to
the Committee of the Drug-free workplace. My signature below acknowledges that I have read and understood the
foregoing statement and I have answered all the questions truthfully.

Date: ___/___/___ Signature: ____________________________

(mm/dd/year)

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 RANDOM DRUG TEST
CUSTODY AND CONTROL FORM
Completed by the EMPLOYEE (Please Write Legibly).

Service/ Unit: ____________________

Name: ___________________________________________________________________________ Age: _______ Gender_ _

(Last name) (First name ) (Middle name)

Date of Birth: _______________________________ Place of Birth: ________________________

CHAIN OF CUSTODY - Completed by the EMPLOYEE

I certify that I provided my urine specimen to the collector, that I have not adulterated it in any manner, I sealed each
specimen bottle used with a tamper-evident seal; and that the information provided below this form and the sealed bottles are
correct.

Signature of EMPLOYEE (PRINT) EMPLOYEE’s Name (First,MI,Last) DATE ID Number

CHAIN OF CUSTODY
I certify that the specimen given to me by the donor identified in the certification section of this form was collected, sealed and
released to the laboratory service.

Name & Signature of ASC Month/day/year Time of Collection

Physical Examination
Read Specimen temperature within four (4) mins. Specimen Collection Specimen Volume (ml) Other Observation
Is the temperature between 32 & 38 degrees Observed (Enter Remarks)
Celsius? Unobserved Physical Appearance: Color
Yes No
Screening Test
As the duty chemist my determination / verification is:
THC  NEGATIVE  POSITIVE  TEST CANCELLED REMARKS
MET  NEGATIVE  POSITIVE  REFUSAL TO TEST BECAUSE REMARKS
COC  NEGATIVE  POSITIVE  SUBSTITUTED REMARKS
MDMA  NEGATIVE  POSITIVE  DILUTED REMARKS
OTHERS  NEGATIVE  POSITIVE  ADULTERATED REMARKS
(specify) Others (specify) REMARKS

Confirmatory Test
As the duty chemist my determination / verification for the specimen (if tested) is:
 CONFIRMED FOR:  THC  MET Others (specify)  CHALLENGE  FAILED TO CONFIRM
 COC  MDMA REASON:

I certify that the result in physical examination, screening test and confirmatory test in the analysis section of this form are
correct.

EXAMINED: NOTED:

Name & Signature of ANALYST Name & Signature of HEAD OF LABORATORY (DATE)
Completed by NATIONAL REFERENCE LABORATORY (NRL) (only filled out if Result is Challenged)
In accordance with applicable Department Of Health requirements, my determination/verification for the specimen (if tested) is:

 CONFIRMED FOR:  THC  MET Others (specify)  CHALLENGE  FAILED TO CONFIRM

 COC  MDMA REASON:

Name & Signature of ANALYST Name & Signature of HEAD OF LABORATORY (DATE)

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