Preliminary Drug Screen Result Form - O'Mahony Safety Solutions

Preliminary Drug Screen Result Form

                        
                            Drug screen
                            
							"*" indicates required fields
                        

                        Company Information
Company Name:*
Company Address*
Phone*
Company Address*
Phone
Phone
Donor Information
Donor name:*
Company ID:*
Test Information
Reason for Test:*
								
								Pre Employment
							

								
								Random
							

								
								Post Accident
							

								
								Reasonable Suspicion
							

								
								Periodic
							
Date of Collection:*
                            
                            MM slash DD slash YYYY
                        
                        
Time of Collection:*
                        
                             
                            Hours
                        
                        :
                        
                            
                            Minutes
                        
                        
                                
                                 
                                AM/PM                                
                           
                    
Specimen Type:*
								
								Oral Fluid
							

								
								Urine
							
Test Lot#:*
Remarks:
Certification and Consent
I certify that the specimen provided is my own and has not been substituted or adulterated. I further agree and grant permission for the testing of my specimen for the presence of drugs and/or alcohol. Also, I hereby give permission for the release of the results of these test to my employer/prospective employer and/or their authorized healthcare professionals. 



O'Mahony Safety will securely retain all relevant information from this test for a specified period, as outlined in our GDPR Privacy Policy. For more details, please refer to our privacy policy available at omahonysafety.ie.
Donor Signature
No signature
								
								Refusal to sign
							
Date:*
                            
                            MM slash DD slash YYYY
                        
                        
I certify that I collected the specimen provided by the aforementioned donor and that it was not substituted or adulterated to the best of my knowledge.
Collector Name*
Collector Signature*
Date:*
                            
                            MM slash DD slash YYYY
                        
                        
Preliminary Test Results
Results*
			
					
					Negative
			
			
					
					Positive
			
Positive for the drugs marked:*
								
								Cannabis (THC)
							

								
								Amphetamines
							

								
								Methamphetamines
							

								
								Opiates
							

								
								Cocaine
							

								
								Benzodiazepines
							

								
								Alcohol
							
Remarks: (eg.specimen integrity checks)
Confirmation
Specimen Sent to Lab for GC/MS Confirmation:
								
								Yes
							

								
								No
							
Laboratory Specimen ID#:
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Company base address
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