FRA F 6180.74 FRA Post-Accident Testing/Blood Urine Custody and Contro

OMB No. 2130-0526
FEDERAL RAILROAD ADMINISTRATION
POST-ACCIDENT TESTING BLOOD/URINE CUSTODY AND CONTROL FORM (49 CFR 219)
NOTE: This form must be completed in accordance with instructions provided by the Railroad representative. Separate instructions are available
for the employee and the collectors. If more than one collector provides services, each must direct special attention to properly documenting the
chain of custody for the blood and urine specimens, as applicable.
Employee Identification Number or Social Security Number

Sample Set Identification Number (Pre-printed)

STEP 1. COMPLETED BY EMPLOYEE (DONOR) PROVIDING SPECIMENS
Name Print (last, first, mi)

Name of Employing Railroad

Home Address

Name of Home terminal

STEP 2. COMPLETED BY COLLECTOR OF BLOOD SPECIMEN
Name of Collector Print (last, first, mi)

Date

Collection

Time

Remarks:

/
I certify the blood specimen was presented to me by the person named in Step 1. The specimen (in two blood tubes) bears the sample set identification number
as printed above and was collected, labeled, and sealed according to the Federal Railroad Administration’s instructions provided to me.
I HAVE COMPLETED THE REQUIRED ENTRY IN STEP 5 BELOW,
AS EXPLAINED IN THE INSTRUCTIONS GIVEN TO ME.

____________________________________________________________
Signature of Collector

STEP 3. COMPLETED BY COLLECTOR OF URINE SPECIMEN
Name of Collector Print (last, first, mi)

Date

Collection

Time

Remarks:

/
Temperature of Specimen was read
within 4 minutes

Yes

No

Temperature was within range of
32 – 38 C / 90 – 100 F

Yes

No

If not, actual
temperature was

I certify the urine specimen was presented to me by the person named in Step 1. The specimen (in two bottles) bears the sample set identification number as
printed above and was collected, labeled, and sealed according to the Federal Railroad Administration’s instructions provided to me.
I HAVE COMPLETED THE REQUIRED ENTRY IN STEP 5 BELOW,
AS EXPLAINED IN THE INSTRUCTIONS GIVEN TO ME.

____________________________________________________________
Signature of Collector

STEP 4. COMPLETED BY EMPLOYEE
I certify the information I have given in Step 1 is correct and that I provided the specimens described in Steps 2 and 3; that each specimen is in a container which
have the above sample set identification numbers recorded on the tamper-evident seals; that I have not adulterated the urine specimen in any manner, that each
container has a tamper-evident seal that was applied by the collector in my presence, and I have placed my initials on each label. (SIGN AFTER ALL
SPECIMENS ARE SEALED.)
____________________________________________________________
EXAMPLE OF MY INITIALS
Signature of Employee

STEP 5. COMPLETED IN SEQUENCE BY COLLECTORS AND OTHERS TAKING POSSESSION ON SPECIMENS
DATE
MO. DAY YR.

SPECIMEN RELEASED BY

TYPE OF FLUID(S)
BLOOD URINE

DONORNO SIGNATURE

SPECIMEN RECEIVED BY
Signature

/

/
Signature

Signature

/

/

Name

Name

Signature

Signature

/

/

Name

Name

Signature

Signature

Name

Name

/

/

(Including Laboratory)
PURPOSE OF CHANGE

PROVIDE SPECIMEN
FOR TESTING

Name

STEP 6. COMPLETED BY MEDICAL FACILITY/PHYSICIAN
Describe any medication, solution, transfusion, anesthetic, or other treatment the employee
received after the accident that might affect toxicological analyses.

Was a breath alcohol test conducted
on the donor above, pursuant to this
accident, using FRA Authority?

_____

Yes

_____

No

Public reporting burden for this information collection is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. According to the Paperwork Reduction Act of 1995, a federal
agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with, a collection of
information unless it displays a currently valid OMB control number. The valid OMB control number for this information collection is 2130-0526. All responses to this
collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden
to: Information Collection Officer, Federal Railroad Administration, 1120 Vermont Ave., N.W., Washington, D.C. 20590.

FORM FRA F 6180.74 (Rev. 10/94)