Drug and Alcohol Testing

Chain of Custody

Collection Date

Location

Name of Donor

First

Last

Email

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

Donor Details

Test Notification

I was notified that a Drug & Alcohol Test would be performed by TAPS

Donor's Consent

Clear

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.

Employment Type

Reason for Test

Other Reason for Test

Donor's Date of Birth

Donors Gender

ID Verified By ID Verified By

If other, include the name of manager verifying the donor's ID, or the type of ID documentation presented

Manager's Name

Enter the name of the responsible manager who is verifying the ID

ID Number

ID Number or License Number

Recent Activity

Alcohol Consumed

In the last 48 hours have you consumed alcohol?

Alcohol Details

Provide details e.g. type, quantity and timing of consumption

Prescription Medication

In the last 14 days have you taken any prescription medication (doctor prescribed not over-the-counter)

Prescribed Medication Name

What is the name OR purpose of the medication

Illicit Drugs

In the last 14 days have you taken any illicit drugs (illegal substances)

Illicit Substance

Other Illicit Substance

When

When was the illicit substance consumed?

In the last 10 minutes

In the last 10 minutes have you consumed any: alcohol-based products (e.g. mouth wash), chewing gum, food or water?

Details of items consumed in last 10 minutes

Past Convictions

Have you had a conviction or been charged with any offense associated with drugs or alcohol?

Conviction Details

Drug (Initial) Test Details

Collection Method Collection Method

Alternate Method Collection Details

If the test is conducted outside of TAPS, details are required to be entered manually.

Oral Fluid / Toxwipe Device Name Oral Fluid / Toxwipe Device Name

Lot Number:

Expiry Date

Collection Time (24hr)

Drug Inital Test Result

Which drugs require further testing

Site Manager Informed

Enter name of the site manager informed of a positive or unconfirmed non-negative drug test result

Alcohol (Inital) Test Details

Device Used Device Used

Device Serial Number

Initial Test Reading

g/210L exhaled breath

Time of Reading (24hr)

Alcohol Initial Test Result

Confirmation Test Reading

Negative Unconfirmed Non Negative Confirmed Positive

Time of Confirmation Reading (24hr)

Alcohol Confirmation Test Result

Collector's Declaration

VQF Assessed and Certified

Sample(s) collected/tested in accordance with:

AS 4760:2006 (Oral Fluid Drug Testing)

AS 3547:1997 (Breath Alcohol Testing)

AS/NZS 4308:2008 (Urine Drug Testing)

Declaration

I certify that I witnessed the donor's signature and that the specimen(s) identified on this form have been provided to me by the donor whose consent appears above, bears the correct identification.

Collector's Name and Certification Number Collector's Name and Certification Number

Collector's Signature

Clear

Collector's Final Observations

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.

Are samples to be sent to the laboratory for analysis?

Additional laboratory testing information