COMMITTEE FOR PHYSICIAN HEALTH-MEDICAL SOCIETY OF THE STATE OF NEW YORK
99 WASHINGTON AVENUE, SUITE 410 ALBANY, NEW YORK 12210
(518) 436-4723 – (800) 338-1833 – Fax: (518) 436-7943
Downloadable forms at www.cphny.org (select “Forms”)
QUARTERLY URINE MONITOR REPORT
(Please Print Clearly)
Date: _________________
Urine Monitor Name: ____________________
CPH Participant Name or Number: ______________________
CPH Assistant Director: _______________________________
REPORTING PERIOD: (Please CHECK)
____1st Quarter (January – March) – Due March 31
____3rd Quarter (July – September) – Due September 30
____2nd Quarter (April – June) – Due June 30
____4th Quarter (October – December) – Due December 31
1. Please list any additional testing (fentanyl, breathalyzer, etc…)
________________________________________________________________________
________________________________________________________________________
Weekday
Weekend
2. Number of random urine screens required by CPH:
________
________
3. Number of random urine screens collected:
________
________
4. How many screens were ordered by you?
________
________
5.
Please indicate medication(s) taken by participant (if applicable): _____________________________
______________________________________________________________________
6. Did participant miss any screens? ( ) Yes
( ) No If yes, explain
_________________________________
7. Did this participant respond within EIGHT hours of call for urine specimen collection? ( ) Yes ( ) No
8. Did you directly observe urine specimen collection? ( ) Yes ( ) No
9. Would you like CPH to call you about this individual? ( ) Yes ( ) No (If yes, please indicate issues addressed)
_____________________________________________________________________
_____________________________________________________________________
Please complete urine calendar on back.
Please comment on participant’s compliance regarding urine monitoring. Indicate any concerns that you may have
and/or any recommendations. (Please use the back of this report if needed.)
________________________________________________________________________
________________________________________________________________________
*My signature verifies that I have directly observed all urine specimen collections for the above mentioned
participant:
_____________________________
_____________
_______________________________________
Monitor Signature
Date
E-Mail Address
Comments:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
2014
January '14
Su
M
Tu
5
12
19
26
6
13
20
27
7
14
21
28
W
1
8
15
22
29
Th
2
9
16
23
30
February '14
F
3
10
17
24
31
Sa
4
11
18
25
M
Tu
W
Th
F
2
9
16
23
3
10
17
24
4
11
18
25
5
12
19
26
6
13
20
27
7
14
21
28
April '14
Su
M
6
13
20
27
7
14
21
28
Tu
1
8
15
22
29
W
2
9
16
23
30
Th
3
10
17
24
M
Tu
1
8
15
22
29
6
13
20
27
7
14
21
28
Su
M
Tu
5
12
19
26
6
13
20
27
7
14
21
28
W
2
9
16
23
30
Th
3
10
17
24
31
F
4
11
18
25
Sa
5
12
19
26
Su
M
Tu
W
4
11
18
25
5
12
19
26
6
13
20
27
7
14
21
28
Th
2
9
16
23
30
Su
M
Tu
W
Th
F
2
9
16
23
30
3
10
17
24
31
4
11
18
25
5
12
19
26
6
13
20
27
7
14
21
28
Sa
1
8
15
22
29
Th
1
8
15
22
29
F
6
13
20
27
Sa
7
14
21
28
June '14
F
2
9
16
23
30
Sa
3
10
17
24
31
Su
1
8
15
22
29
August '14
M
2
9
16
23
30
Tu
3
10
17
24
W
4
11
18
25
Th
5
12
19
26
September '14
F
4
11
18
25
Sa
5
12
19
26
Su
M
Tu
W
Th
3
10
17
24
31
4
11
18
25
5
12
19
26
6
13
20
27
7
14
21
28
F
3
10
17
24
31
Sa
4
11
18
25
Su
M
Tu
W
Th
F
2
9
16
23
30
3
10
17
24
4
11
18
25
5
12
19
26
6
13
20
27
7
14
21
28
October '14
W
1
8
15
22
29
Sa
1
8
15
22
May '14
July '14
Su
March '14
Su
F
1
8
15
22
29
Sa
2
9
16
23
30
Su
Sa
1
8
15
22
29
Su
7
14
21
28
November '14
M
1
8
15
22
29
Tu
2
9
16
23
30
W
3
10
17
24
Th
4
11
18
25
F
5
12
19
26
Sa
6
13
20
27
December '14
7
14
21
28
[42]
M
1
8
15
22
29
Tu
2
9
16
23
30
W
3
10
17
24
31
Th
4
11
18
25
F
5
12
19
26
Sa
6
13
20
27