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)
Urine Monitor Name: _________________________________
CPH Participant 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/ordered by you:
________
________
4. Please indicate medication(s) taken by participant (if applicable): _____________________________
______________________________________________________________________
5. Did participant miss any screens? (If yes, please explain in comment section below.)
( ) Yes ( ) No
6. Did this participant respond within EIGHT hours of call for urine specimen collection?
( ) Yes ( ) No
7. Did you directly observe urine specimen collection?
( ) Yes ( ) No
8. Would you like CPH to call you about this individual?
( ) Yes ( ) No
Please comment on participant’s compliance regarding urine monitoring. Indicate any concerns that you may have
and/or any recommendations.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please complete urine calendar on back by circling the dates screens were collected.
*My signature verifies that I have directly observed all urine specimen collections for the above mentioned
participant:
_____________________________
_____________
_______________________________________
Monitor Signature
Date
E-Mail Address
Revised: 1/15/2015
Please list the testing date and requisition number (which is located in box #3 on the chain of
custody form) for each sample collected.
Date
Date
Requisition Number
Requisition Number
2016
January '16
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
Su
M
Tu
W
Th
3
10
17
24
4
11
18
25
5
12
19
26
6
13
20
27
7
14
21
28
February '16
F
1
8
15
22
29
Sa
2
9
16
23
30
Su
7
14
21
28
M
1
8
15
22
29
Tu
2
9
16
23
F
1
8
15
22
29
Sa
2
9
16
23
30
Su
1
8
15
22
29
M
2
9
16
23
30
Tu
3
10
17
24
31
April '16
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
Th
4
11
18
25
F
5
12
19
26
Sa
6
13
20
27
Su
M
6
13
20
27
7
14
21
28
Tu
1
8
15
22
29
F
6
13
20
27
Sa
7
14
21
28
Su
M
Tu
5
12
19
26
6
13
20
27
7
14
21
28
May '16
July '16
Su
W
3
10
17
24
March '16
W
4
11
18
25
Th
5
12
19
26
Sa
2
9
16
23
30
Su
7
14
21
28
October '16
M
1
8
15
22
29
Tu
2
9
16
23
30
W
3
10
17
24
31
Th
4
11
18
25
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
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
F
4
11
18
25
Sa
5
12
19
26
W
1
8
15
22
29
Th
2
9
16
23
30
F
3
10
17
24
Sa
4
11
18
25
September '16
F
5
12
19
26
Sa
6
13
20
27
Su
M
Tu
W
4
11
18
25
5
12
19
26
6
13
20
27
7
14
21
28
November '16
Su
Th
3
10
17
24
31
June '16
August '16
F
1
8
15
22
29
W
2
9
16
23
30
F
4
11
18
25
Th
1
8
15
22
29
F
2
9
16
23
30
Sa
3
10
17
24
December '16
Sa
5
12
19
26
[42]
Su
M
Tu
W
4
11
18
25
5
12
19
26
6
13
20
27
7
14
21
28
Th
1
8
15
22
29
F
2
9
16
23
30
Sa
3
10
17
24
31