Urine Toxicology Service Request Form - Targeted
TO MINIMISE THE CHANCE OF LEAKING SAMPLES, PLEASE REFER TO FSS PACKAGING GUIDELINES DOCUMENT # 17306
NOTE: ALL FIELDS MARKED WITH AN ASTERISK ( * ) ARE MANDATORY FIELDS
QUEENSLAND HEALTH FORENSIC AND SCIENTIFIC SERVICES
39 Kessels Road
Coopers Plains Q 4108
Phone: (07) 3274 9000
*AUSLAB BARCODE LABEL
P.O. Box 594
Archerfield Q 4108
Stick Label Here
Fax: (07) 3274 9042
* Requested By
Centre/District Office
(Name and Location)
*Please tick one option
DPSOA
Drug Court
Parole
Probation/ICO
Custodial
* Date Sampled
FSS Lab No.
(Laboratory Staff Only)
/
 Cannabis
 Amphetamines
/
Test Requested: (Please identify ALL specific tests required)
(Laboratory Staff Only)
Immunoassay:
Seal Intact:
Confirmation/Quantitation Instructions:
Screen
(Amphets,Benzos,Opiates,Cannabis & creatinine)
OR
ONLY do the following immunoassay
requests (Creatinine is Mandatory)
Amphetamines
Benzodiazepines
Opiates
Cannabis
Methadone
6-Monoacetyl Morphine (6-MAM)
Cocaine
Creatinine
Confirm/quantitate all positive results
Await advice from Centre
Yes 
Initials:.....………...
(Laboratory Staff Only)
OR
ONLY Confirm (with levels) the following
Drug groups as use is suspected: (Please Tick)
Date Received
/
Amphetamines
 Cannabis
Benzodiazepines
 Amphetamines
Morphine/Codeine
 Benzodiazepines
Cannabis
 Cocaine
6-MAM
 6-MAM
Cocaine
Buprenorphine Quantitation
No 
/
(Laboratory
Staff Only)
 Cannabis
Sample Comments
 Amphetamines
 Benzodiazepines
 Cocaine
OTHER:
Laboratory Staff Only)
General Drug Screen (GCMS)
(eg Prescription Drugs)
Checked By:
……………………...
* Known medication or suspected drug use:
Page: 1 of 1
Filename: 17300 R12
Authorised By: N Bailey
Case File Page Number:
Attachments: ……………
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