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

GBF, INC. - HIGH POINT, NC 27265

128608 F-Forms

308139

Expires 10/31/2019

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.
Date (Mo/Day/Yr)

I

I

I

Sample Set Identification Number (Pre-printed)

Name of Employing Railroad

308100

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

I

City

Home Address

Employee Identification Number or Social Security Number
State

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

Remarks:

Zip Code

I

I

(

)

I

Date (Mo/Day/Yr)

I

Telephone Number

I

Time of Collection

AM
PM

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 me.
Signature of Collector

STEP 3. COMPLETED BY COLLECTOR OF URINE SPECIMEN

Name of Collector Print (last, first, mi)

I

Temperature of specimen was read
within 4 minutes

□ YES □ NO

Remarks:

I

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

Date (Mo/Day/Yr)

I

I

□ YES □ NO

I

I

Time of Collection

If not, actual
temperature was

AM

PM
0

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 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
has 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

I

I

STEP 5. COMPLETED BY THE PERSON TAKING POSSESSION OF SPECIMENS FOR SHIPMENT

I certify that I took possession of the sealed specimens with the sample set identification number as printed above from the blood and urine collectors,
maintained custody of the specimens, packaged and sealed them into the kit box, placed the kit into the transport box, and prepared the three-kit transport
box for shipment.
Received Blood --

Received Urine --

Name (print)

I

Signature

Date

I

Released specimens to:

•
•

Overnight courier service (name)
Railroad representative (name)

.QR
for delivery to overnight courier service (name if known)

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.

FRA F 6180.74 (Rev. 3-12)

COPY 1 - FRA/LAB COPY

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

_Yes

_No

0MB No. 2130-0526
Please see back page for
PRA Public Protection Statement

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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
0MB control number. The valid 0MB 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, 1200 New Jersey Ave., N.W., Washington D.C. 20590.

Expires 10/31/2019