Drug and Alcohol Testing

Drug and Alcohol Chain of Custody

Chain of Custody

Name of Donor
Name of Donor
Donor's email address if they want a summary of this report

Donor Details

I was notified that a Drug & Alcohol Test would be performed by TAPS
As the Donor I consent to proceeding with testing for alcohol and drugs. By my signature I certify that the specimens will be my own and I consent to the release of my test results.
If other, include the name of manager verifying the donor's ID, or the type of ID documentation presented
Enter the name of the responsible manager who is verifying the ID
ID Number or License Number

Recent Activity

In the last 48 hours have you consumed alcohol?
Provide details e.g. type, quantity and timing of consumption
In the last 14 days have you taken any prescription medication (doctor prescribed not over-the-counter)
What is the name OR purpose of the medication
In the last 14 days have you taken any illicit drugs (illegal substances)
When was the illicit substance consumed?
In the last 10 minutes have you consumed any: alcohol-based products (e.g. mouth wash), chewing gum, food or water?
Have you had a conviction or been charged with any offense associated with drugs or alcohol?

Drug (Initial) Test Details

If the test is conducted outside of TAPS, details are required to be entered manually.
Collection Time (24hr)
Enter name of the site manager informed of a positive or unconfirmed non-negative drug test result

Alcohol (Inital) Test Details

g/210L exhaled breath
Time of Reading (24hr)
Negative Unconfirmed Non Negative Confirmed Positive
Time of Confirmation Reading (24hr)

Collector's Declaration

Sample(s) collected/tested in accordance with:
Do not verbally ask this question - Are there any other issues, concerns or comments about this test that have not been captured above? Record these here.