Contact Information
The medical Review Officer may need to contact you for more information to properly interpret your drug test results.
PLEASE PRINT CLEARLY
Company Name:__________________________________ Social Security #:_________________________________________
Name:___________________________________________________________________________________________________
Last
First
MI
Address:_________________________________________________________________________________________________
Street
City
State
Zip Code
Home #:_________________________________________
Cell #:________________________________________
Birth Date:________________________________________
Gender (please circle one)
Male
Female
** YOU ARE NOT ALLOWED TO LEAVE THE WAITING ROOM DURING THE DRUG SCREEN PROCESS **
Please read carefully
Urine Drug Screening Procedure
You have been asked by your employer or prospective employer to provide a urine specimen for drug testing. You
will need to provide photo-identification at the front desk as well as to the health care professional collecting your
specimen. Acceptable forms of identification are valid: driver’s license, military ID, passport, state, federal or
government issued ID or school photo-ID.
Your urine specimen will be collected according to procedures described by the National Institute on Drug Abuse
(NIDA). You will be asked to remove your outer garments (coat, hat, etc) and leave them along with any personal
belongings outside the bathroom. Valuables will be locked in a cabinet. You will wash and dry your hands in the
collector’s presence both before and after producing the urine specimen. After washing your hands, the collector will
turn off the water supply to the restroom. A bluing agent will be added to the toilet water. You will be told not to
flush the toilet or use the sink after you void. You will be given a container in which to urinate. You must produce at
least 45-60 ccs of urine in the collection container. If you feel that you cannot produce this amount of urine, tell the
collector. Within four minutes after you produce the urine specimen, the collector will measure the urine temperature
and inspect the specimen for color, appearance, and signs of contamination. If you do not produce enough urine you
will be provided with up to 40 ounces of water to drink. During this time, you must remain in the waiting room. If
the specimen is of sufficient quantity you and the collector will complete the process by following a chain of custody
procedure.
The urine will be tested for the following drugs:
For 5 panel: Amphetamines, Cocaine, Marijuana, Opiates, and Phencyclidine.
For 10 panel: Amphetamines, Cocaine, Marijuana, Opiates, Phencyclidine, Barbituates, Benzodiazepines,
Methadone, Methaqualone, and Propoxyphene.
Other:_________________________________________________________________________________________
All test results are reviewed by a Medical Review Officer. If the laboratory indicates that the specimen tests positive
for one of the drugs listed above, the Medical Review Officer will call you to discuss the test results. When the test
results are determined the results will be reported to your company or prospective company.
Signature____________________________________________________
Witness______________________________________________________
Date_________________________