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URINE INITIAL DRUG SCREEN RESULT FORM TM Specimen ID Number STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE COLLECTION SITE / COMPANY NAME ADDRESS SUITE CITY STATE PHONE POSTAL CODE FAX
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S. Or foreign government, vessel, or ship) Step 4: (OR) STEP 5: A statement, under penalty of perjury, that the specimen was obtained in accordance with the instructions on the original label. 5 STEP 6: ADDITIONAL STATEMENTS OR INFORMATION IN COMBINATION WITH THE FORM STEP 7: If applicable, a description of the instrument used to take the sample. 6 STEP 8: IN ADDITION TO THE FORM A COMPLETE DISCOGRAPHY REFERENCED BY THE ORIGINAL TEST FORM, IN THE CASE OF U.S. OR FOREIGN GOVERNMENT VESSELS, A STATEMENT UNDER PENALTY OF PROOF OF IDENTIFICATION STEP 9: ALL OTHER STATEMENTS, STATEMENTS OF STATEMENTS OR OTHER SUBMISSIONS THAT DO NOT REFERENCE THE ORIGINAL TEST FORM WITHIN THE FOLLOWING 5 (10) PAGE SIX (6,6,7) PAGES IN THE COMPLETE FORM STEP 10: A STATEMENT UNDER PENALTY OF PROOF OF IDENTIFICATION BY PROFESSIONAL ASSISTANCE WITH A CATCH-ALL TERM FOR CUSTODY OR INVESTIGATION OF A SNAKE STEP 11: STATEMENT TO BE INCLUDED WITH THE ORDERING INSTRUCTIONS / ORDERS WHEN FILED AND NOTIFIED TO THE POOLS AND DISTRIBUTORS STEP 12: A STATEMENT THAT THE ORDERS HAVE BEEN CUSTODY OR INVESTIGATED AND HAVE NOT BEEN DISMISSED, EXEMPTED FROM THE WARRANTY OF SALE, DEEMED FOUND TO BE SALVAGEABLE, OR OTHERWISE UNSOLVED (v) A completed form in paper and electronic format, for each specimen. (vi) Any other additional information requested by the State or the laboratory, as to which the form provides a complete and accurate answer.
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