QUEENSLAND CORRECTIVE SERVICES
ADMINISTRATIVE FORM –DRUG TEST (CUSTODIAL)
Availability: Public
Implement Date: 23 June 2010
Corrective Services Act 2006 sections 41-43
PRISONER TO BE TESTED:
ID No:
Surname:
Given Name/s:
DOB:
Test location:
Requirement to give test sample. You, the above named, have provided a test sample of
urine as part of the Urinalysis Testing process.
Surname:
Given name/s:
Position:
as authorised delegate of the chief executive.
Date:
Date of sample:
/
/ 20
Time of sample:
:
Pre-test medication declared (indicating time of last use and quantity used):
am/pm
Admissions of alcohol/illicit drug use (indicating time of last use and quantity used):
Expiry date of test:
Time taken to read test:
Temp of test:
Time Taken to Provide Sample/Failure to Provide:
TEST RESULTS
AMP
BZD
(Mark only ‘+’ for a
positive test result, NT
for not tested and ‘C’
in all other boxes)
COC
Amphetamine
Benzodiazepine
Cocaine
MET
OPI
THC
Methamphetamine
Opiates
Cannabis
BUP
Breath 1
Breath 2
Buprenorphine
Additional comments: ____________________________________________________________
______________________________________________________________________________
Action taken: __________________________________________________________________
______________________________________________________________________________
This test has been carried out in accordance with approved procedures and to the
satisfaction of the officer/s involved.
Collecting Officers’ names:
_____________________
_______________________
Collecting Officers’ signatures:
_____________________
_______________________
AFFIX LABEL HERE
(Prisoner Name and ID)
Drug Test (Custodial)
106740322
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