Drug Testing Collection Form

Impact Evaluation of Mandatory-Random Student Drug Testing

Appendix D School-LevelTesting Collection Final

Drug Testing Collection Form

OMB: 1850-0818

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Appendix B School-Level Testing Form

SCHOOL IDENTIFICATION
(ATTACH LABEL HERE)

School Name:

School Address:

DRUG TESTING COLLECTION FORM

OMB No.: 1850-0808


Expiration Date: MM/DD/YY

Name of person completing this form:


Phone of person completing this form:


(__ __ __) __ __ __ - __ __ __ __


Email of person completing this form:

Date of original test: _ __ / ___ / ______

Month Day Year

Was any confirmatory testing needed? Yes No

Date confirmatory testing occurred: _ __ / ___ / ______

Month Day Year


INSTRUCTIONS: Please complete one form on each original test day that drug-testing is conducted for this school. Answer each of the following questions for this testing date. Please record a number on each line. If none, please write “0”


1. On this testing date, how many students:

Check that the numbers of students in lines b + c + d + e add up to the number of students recorded in line a.



a. Were scheduled
to be tested?

b. Were actually
tested?

c. Refused to be
tested?

d. Were absent or
not available?

e. Not tested for other reasons
(e.g., could not produce specimen)?

2. On this testing date, how many of the students actually tested were:

Check that the numbers of males + females tested add up to the number of tested students recorded in question 1b above.





Male

Female



3. On this testing date, how many of the students actually tested were from each of the following grades:

Check that the numbers of students in each grade add up to the number of tested students recorded in question 1b above.



Grade 9

Grade 10

Grade 11

Grade 12

4. On this testing date, how many of the students actually tested were eligible for testing due to participation in the following activities?

Check that the numbers of students in the three activity types add up to the number of tested students recorded in question 1b above.




Sports

Extracurricular activity
other than sports

Both



5. Where was drug-testing conducted on this date? (Please check one)


At this School

Off-Site Location


Please list:

(Skip to Q8, next page)

6. Who conducted the drug tests at this school on this testing date? (Please check all that apply)


Trained Faculty Member


Drug-testing Program Contractor

School Nurse

Other (Please list):

7. Was there a break in the chain of custody procedure (including specimen documentation) during drug-testing at this school on this date?


Yes Please specify:

No

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is xxxx‑xxxx. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collected. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, DC 20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: U.S. Department of Education, Institute for Education Sciences, 555 New Jersey Avenue, Washington, DC 20208‑5651. This survey is authorized by law (INSERT LEGISLATION, IF APPLICABLE).

8. Please indicate which drugs were tested on this testing date, and the method of testing used to test each drug.

DRUG

TESTED

METHOD OF TESTING

TEST RESULTS

PLEASE CHECK THE METHOD(S) USED TO TEST EACH DRUG

Yes

No

Urine

Oral Fluid

Breath

Alcohol

Hair

Sweat Patch

Other

(List):

#
Tested Positive

# Confirmatory Tests

# Positive Confirmatory Tests

Marijuana


____

____

____

Phencyclidine (PCP)


____

____

____

Opiates (Heroin, morphine, codeine)


____

____

____

Amphetamines/Methamphetamine


____

____

____

Cocaine


____

____

____

Synthetic Opiates (Oxycodone Methadone)


____

____

____

Steroids


____

____

____

Alcohol


____

____

____

Ecstasy/MDMA


____

____

____

GHB


____

____

____

LSD


____

____

____

Nicotine


____

____

____

Other (Please list)


____

____

____


____

____

____


____

____

____


Please answer the following questions about procedures for positive tests acquired on this testing date. (Please check one for each)


9. Were all positive tests verified through a Medical Review Officer? Yes No


10. Were positive samples retained for future re-testing? Yes No

Prepared by Mathematica Policy Research, Inc. Page 2

The Impact Evaluation of Mandatory-Random Student Drug Testing

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File TitleMEMORANDUM
AuthorAugust Pitt
Last Modified Bypaul.strasberg
File Modified2007-02-05
File Created2007-02-05

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