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pdfFEDERAL DRUG TESTING CUSTODY AND CONTROL FORM
0000001
SPECIMEN ID NO.
STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE
A. Employer Name, Address, I.D. No.
OMB No. 0930-0158
ACCESSION NO.
B. MRO Name, Address, Phone No. and Fax No.
C. Donor SSN or Employee I.D. No.
D. Specify Testing Authority: c HHS
Specify DOT Agency: c FMCSA
c NRC
c FAA
c FRA
c FTA
c PHMSA
c USCG
E. Reason for Test: c Pre-employment c Random c Reasonable Suspicion/Cause c Post Accident c Return to Duty c Follow-up c Other (specify)
F. Drug Tests to be Performed:
c THC, COC, PCP, OPI, AMP
c THC & COC Only
c Other (specify)
G. Collection Site Address:
Collector Phone No.
STEP 3: Collector affixes bottle seal(s) to bottle(s). Collector dates seal(s). Donor initials seal(s). Donor completes STEP 5 on Copy 2 (MRO Copy)
STEP 4: CHAIN OF CUSTODY - INITIATED BY COLLECTOR AND COMPLETED BY TEST FACILITY
I certify that the specimen given to me by the donor identified in the certification section on Copy 2 of this form was
SPECIMEN BOTTLE(S) RELEASED TO:
collected, labeled, sealed and released to the Delivery Service noted in accordance with applicable Federal requirements.
X
Signature of Collector
/
(PRINT) Collector’s Name (First, MI, Last)
/
Date (Mo/Day/Yr)
AM
PM
X
Name of Delivery Service
Time of Collection
RECEIVED AT LAB OR IITF:
Primary Specimen
Bottle Seal Intact
c YES
Signature of Accessioner
/
(PRINT) Accessioner’s Name (First, MI, Last)
/
Date (Mo/Day/Yr)
SPECIMEN BOTTLE(S) RELEASED TO:
c NO
If NO, Enter remark
in Step 5A.
STEP 5A: PRIMARY SPECIMEN REPORT - COMPLETED BY TEST FACILITY
c 6-Acetylmorphine c OXYC
c HYC
c POSITIVE for: c Marijuana Metabolite ( 9-THCA) c Methamphetamine c MDMA
c HYM
c OXYM
c Morphine
c Cocaine Metabolite (BZE)
c Amphetamine
c MDA
c DILUTE
c PCP
c Codeine
c INVALID RESULT
c REJECTED FOR TESTING
c ADULTERATED
REMARKS:
Test Facility (if different from above) :
I certify that the specimen identified on this form was examined upon receipt, handled using chain of custody procedures, analyzed, and reported in accordance with applicable Federal requirements.
X
(PRINT) Certifying Technician/Scientist’s Name (First, MI, Last)
Signature of Certifying Technician/Scientist
/
PRESS HARD - YOU ARE MAKING MULTIPLE COPIES
Collector Fax No.
STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate) Collector reads specimen temperature within 4 minutes.
Temperature between 90º and 100º F? c Yes c No, Enter Remark
Collection: c Split c Single c None Provided, Enter Remark
c Observed, Enter Remark
REMARKS
/
Date (Mo/Day/Yr)
STEP 5b: COMPLETED BY SPLIT TESTING LABORATORY
Version C 14May2010
RECONFIRMED
FAILED TO RECONFIRM - REASON
I certify that the split specimen identified on this form was examined upon receipt, handled using chain of custody procedures, analyzed,
and reported in accordance with applicable Federal requirements.
Laboratory Name
X
Laboratory Address
(PRINT) Certifying Scientist’s Name (First, MI, Last)
0000001
A
SPECIMEN BOTTLE
SEAL
SPECIMEN ID NO.
0000001
SPECIMEN ID NO.
0000001
B
SPECIMEN BOTTLE
SEAL
(SPLIT)
COPY 1 - TEST FACILITY COPY
/
/
Date (Mo/Day/Yr)
Date (Mo/Day/Yr)
Date (Mo/Day/Yr)
80308
0000001
Signature of Certifying Scientist
FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM
0000001
SPECIMEN ID NO.
STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE
A. Employer Name, Address, I.D. No.
OMB No. 0930-0158
ACCESSION NO.
B. MRO Name, Address, Phone No. and Fax No.
C. Donor SSN or Employee I.D. No.
D. Specify Testing Authority: c HHS
c NRC
Specify DOT Agency: c FMCSA
c FAA
c FRA
c FTA
c PHMSA
c USCG
E. Reason for Test: c Pre-employment c Random c Reasonable Suspicion/Cause c Post Accident c Return to Duty c Follow-up c Other (specify)
F. Drug Tests to be Performed:
c THC, COC, PCP, OPI, AMP
c THC & COC Only
c Other (specify)
G. Collection Site Address:
Collector Phone No.
Collector Fax No.
STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate) Collector reads specimen temperature within 4 minutes.
Temperature between 90º and 100º F? c Yes c No, Enter Remark
Collection: c Split c Single c None Provided, Enter Remark
c Observed, Enter Remark
REMARKS
STEP 3: Collector affixes bottle seal(s) to bottle(s). Collector dates seal(s). Donor initials seal(s). Donor completes STEP 5 on Copy 2 (MRO Copy)
STEP 4: CHAIN OF CUSTODY - INITIATED BY COLLECTOR AND COMPLETED BY TEST FACILITY
I certify that the specimen given to me by the donor identified in the certification section on Copy 2 of this form was
SPECIMEN BOTTLE(S) RELEASED TO:
collected, labeled, sealed and released to the Delivery Service noted in accordance with applicable Federal requirements.
X
Signature of Collector
/
(PRINT) Collector’s Name (First, MI, Last)
/
Date (Mo/Day/Yr)
AM
PM
Name of Delivery Service
Time of Collection
STEP 5: COMPLETED BY DONOR
I certify that I provided my urine specimen to the collector; that I have not adulterated it in any manner; each specimen bottle used was sealed with a tamper-evident seal in
my presence; and that the information provided on this form and on the label affixed to each specimen bottle is correct.
X
Signature of Donor
Daytime Phone No. ( )
Evening Phone No. ( )
/
/
/
/
Date (Mo/Day/Yr)
(PRINT) Donor’s Name (First, MI, Last)
Date of Birth
(Mo/Day/Yr)
After the Medical Review Officer receives the test results for the specimen identified by this form, he/she may contact you to ask about prescriptions and
over-the-counter medications you may have taken. Therefore, you may want to make a list of those medications for your own records. THIS LIST IS NOT
NECESSARY. If you choose to make a list, do so either on a separate piece of paper or on the back of your copy (Copy 5). – DO NOT PROVIDE THIS
INFORMATION ON THE BACK OF ANY OTHER COPY OF THE FORM. TAKE COPY 5 WITH YOU.
STEP 6: COMPLETED BY MEDICAL REVIEW OFFICER - PRIMARY SPECIMEN
In accordance with applicable Federal requirements, my verification is:
c NEGATIVE
c POSITIVE for:
c DILUTE
c REFUSAL TO TEST because – check reason(s) below:
c ADULTERATED (adulterant/reason):
c SUBSTITUTED
c OTHER:
c TEST CANCELLED
REMARKS:
X
Signature of Medical Review Officer
(PRINT) Medical Review Officer’s Name (First, MI, Last)
/
/
/
/
Date (Mo/Day/Yr)
STEP 7: COMPLETED BY MEDICAL REVIEW OFFICER - SPLIT SPECIMEN
In accordance with applicable Federal requirements, my verification for the split specimen (if tested) is:
c RECONFIRMED for:
c TEST CANCELLED
c FAILED TO RECONFIRM for:
REMARKS:
X
Signature of Medical Review Officer
(PRINT) Medical Review Officer’s Name (First, MI, Last)
COPY 2 - MEDICAL REVIEW OFFICER COPY
Date (Mo/Day/Yr)
FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM
0000001
SPECIMEN ID NO.
STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE
A. Employer Name, Address, I.D. No.
OMB No. 0930-0158
ACCESSION NO.
B. MRO Name, Address, Phone No. and Fax No.
C. Donor SSN or Employee I.D. No.
D. Specify Testing Authority: c HHS
c NRC
Specify DOT Agency: c FMCSA
c FAA
c FRA
c FTA
c PHMSA
c USCG
E. Reason for Test: c Pre-employment c Random c Reasonable Suspicion/Cause c Post Accident c Return to Duty c Follow-up c Other (specify)
F. Drug Tests to be Performed:
c THC, COC, PCP, OPI, AMP
c THC & COC Only
c Other (specify)
G. Collection Site Address:
Collector Phone No.
Collector Fax No.
STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate) Collector reads specimen temperature within 4 minutes.
Temperature between 90º and 100º F? c Yes c No, Enter Remark
Collection: c Split c Single c None Provided, Enter Remark
c Observed, Enter Remark
REMARKS
STEP 3: Collector affixes bottle seal(s) to bottle(s). Collector dates seal(s). Donor initials seal(s). Donor completes STEP 5 on Copy 2 (MRO Copy)
STEP 4: CHAIN OF CUSTODY - INITIATED BY COLLECTOR AND COMPLETED BY TEST FACILITY
I certify that the specimen given to me by the donor identified in the certification section on Copy 2 of this form was
SPECIMEN BOTTLE(S) RELEASED TO:
collected, labeled, sealed and released to the Delivery Service noted in accordance with applicable Federal requirements.
X
Signature of Collector
(PRINT) Collector’s Name (First, MI, Last)
/
/
Date (Mo/Day/Yr)
AM
PM
Name of Delivery Service
Time of Collection
STEP 5: COMPLETED BY DONOR
I certify that I provided my urine specimen to the collector; that I have not adulterated it in any manner; each specimen bottle used was sealed with a tamper-evident seal in
my presence; and that the information provided on this form and on the label affixed to each specimen bottle is correct.
X
Signature of Donor
Daytime Phone No. ( )
Evening Phone No. ( )
/
/
/
/
Date (Mo/Day/Yr)
(PRINT) Donor’s Name (First, MI, Last)
Date of Birth
(Mo/Day/Yr)
After the Medical Review Officer receives the test results for the specimen identified by this form, he/she may contact you to ask about prescriptions and
over-the-counter medications you may have taken. Therefore, you may want to make a list of those medications for your own records. THIS LIST IS NOT
NECESSARY. If you choose to make a list, do so either on a separate piece of paper or on the back of your copy (Copy 5). – DO NOT PROVIDE THIS
INFORMATION ON THE BACK OF ANY OTHER COPY OF THE FORM. TAKE COPY 5 WITH YOU.
STEP 6: COMPLETED BY MEDICAL REVIEW OFFICER - PRIMARY SPECIMEN
In accordance with applicable Federal requirements, my verification is:
c NEGATIVE
c POSITIVE for:
c DILUTE
c REFUSAL TO TEST because – check reason(s) below:
c ADULTERATED (adulterant/reason):
c SUBSTITUTED
c OTHER:
c TEST CANCELLED
REMARKS:
X
Signature of Medical Review Officer
(PRINT) Medical Review Officer’s Name (First, MI, Last)
/
/
/
/
Date (Mo/Day/Yr)
STEP 7: COMPLETED BY MEDICAL REVIEW OFFICER - SPLIT SPECIMEN
In accordance with applicable Federal requirements, my verification for the split specimen (if tested) is:
c RECONFIRMED for:
c TEST CANCELLED
c FAILED TO RECONFIRM for:
REMARKS:
X
Signature of Medical Review Officer
(PRINT) Medical Review Officer’s Name (First, MI, Last)
COPY 3 - COLLECTOR COPY
Date (Mo/Day/Yr)
FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM
0000001
SPECIMEN ID NO.
STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE
A. Employer Name, Address, I.D. No.
OMB No. 0930-0158
ACCESSION NO.
B. MRO Name, Address, Phone No. and Fax No.
C. Donor SSN or Employee I.D. No.
D. Specify Testing Authority: c HHS
c NRC
Specify DOT Agency: c FMCSA
c FAA
c FRA
c FTA
c PHMSA
c USCG
E. Reason for Test: c Pre-employment c Random c Reasonable Suspicion/Cause c Post Accident c Return to Duty c Follow-up c Other (specify)
F. Drug Tests to be Performed:
c THC, COC, PCP, OPI, AMP
c THC & COC Only
c Other (specify)
G. Collection Site Address:
Collector Phone No.
Collector Fax No.
STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate) Collector reads specimen temperature within 4 minutes.
Temperature between 90º and 100º F? c Yes c No, Enter Remark
Collection: c Split c Single c None Provided, Enter Remark
c Observed, Enter Remark
REMARKS
STEP 3: Collector affixes bottle seal(s) to bottle(s). Collector dates seal(s). Donor initials seal(s). Donor completes STEP 5 on Copy 2 (MRO Copy)
STEP 4: CHAIN OF CUSTODY - INITIATED BY COLLECTOR AND COMPLETED BY TEST FACILITY
I certify that the specimen given to me by the donor identified in the certification section on Copy 2 of this form was
SPECIMEN BOTTLE(S) RELEASED TO:
collected, labeled, sealed and released to the Delivery Service noted in accordance with applicable Federal requirements.
X
Signature of Collector
(PRINT) Collector’s Name (First, MI, Last)
/
/
Date (Mo/Day/Yr)
AM
PM
Name of Delivery Service
Time of Collection
STEP 5: COMPLETED BY DONOR
I certify that I provided my urine specimen to the collector; that I have not adulterated it in any manner; each specimen bottle used was sealed with a tamper-evident seal in
my presence; and that the information provided on this form and on the label affixed to each specimen bottle is correct.
X
Signature of Donor
Daytime Phone No. ( )
Evening Phone No. ( )
/
/
/
/
Date (Mo/Day/Yr)
(PRINT) Donor’s Name (First, MI, Last)
Date of Birth
(Mo/Day/Yr)
After the Medical Review Officer receives the test results for the specimen identified by this form, he/she may contact you to ask about prescriptions and
over-the-counter medications you may have taken. Therefore, you may want to make a list of those medications for your own records. THIS LIST IS NOT
NECESSARY. If you choose to make a list, do so either on a separate piece of paper or on the back of your copy (Copy 5). – DO NOT PROVIDE THIS
INFORMATION ON THE BACK OF ANY OTHER COPY OF THE FORM. TAKE COPY 5 WITH YOU.
STEP 6: COMPLETED BY MEDICAL REVIEW OFFICER - PRIMARY SPECIMEN
In accordance with applicable Federal requirements, my verification is:
c NEGATIVE
c POSITIVE for:
c DILUTE
c REFUSAL TO TEST because – check reason(s) below:
c ADULTERATED (adulterant/reason):
c SUBSTITUTED
c OTHER:
c TEST CANCELLED
REMARKS:
X
Signature of Medical Review Officer
(PRINT) Medical Review Officer’s Name (First, MI, Last)
/
/
/
/
Date (Mo/Day/Yr)
STEP 7: COMPLETED BY MEDICAL REVIEW OFFICER - SPLIT SPECIMEN
In accordance with applicable Federal requirements, my verification for the split specimen (if tested) is:
c RECONFIRMED for:
c TEST CANCELLED
c FAILED TO RECONFIRM for:
REMARKS:
X
Signature of Medical Review Officer
(PRINT) Medical Review Officer’s Name (First, MI, Last)
COPY 4 - EMPLOYER COPY
Date (Mo/Day/Yr)
Paper CCF: Back of Copy 1-4
Electronic CCF: Separate Page
Public Burden Statement:
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number. The OMB control number for this project is 0930-0158. Public reporting burden for this collection of information is estimated to average: 5 minutes/donor;
4 minutes/collector; 3 minutes/test facility; and 3 minutes/Medical Review Officer. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 5600 Fishers Lane, Room 15E57B, Rockville,
Maryland, 20852.
FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM
0000001
SPECIMEN ID NO.
STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE
A. Employer Name, Address, I.D. No.
OMB No. 0930-0158
ACCESSION NO.
B. MRO Name, Address, Phone No. and Fax No.
C. Donor SSN or Employee I.D. No.
D. Specify Testing Authority: c HHS
c NRC
Specify DOT Agency: c FMCSA
c FAA
c FRA
c FTA
c PHMSA
c USCG
E. Reason for Test: c Pre-employment c Random c Reasonable Suspicion/Cause c Post Accident c Return to Duty c Follow-up c Other (specify)
F. Drug Tests to be Performed:
c THC, COC, PCP, OPI, AMP
c THC & COC Only
c Other (specify)
G. Collection Site Address:
Collector Phone No.
Collector Fax No.
STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate) Collector reads specimen temperature within 4 minutes.
Temperature between 90º and 100º F? c Yes c No, Enter Remark
Collection: c Split c Single c None Provided, Enter Remark
c Observed, Enter Remark
REMARKS
STEP 3: Collector affixes bottle seal(s) to bottle(s). Collector dates seal(s). Donor initials seal(s). Donor completes STEP 5 on Copy 2 (MRO Copy)
STEP 4: CHAIN OF CUSTODY - INITIATED BY COLLECTOR AND COMPLETED BY TEST FACILITY
I certify that the specimen given to me by the donor identified in the certification section on Copy 2 of this form was
SPECIMEN BOTTLE(S) RELEASED TO:
collected, labeled, sealed and released to the Delivery Service noted in accordance with applicable Federal requirements.
X
Signature of Collector
(PRINT) Collector’s Name (First, MI, Last)
/
/
Date (Mo/Day/Yr)
AM
PM
Name of Delivery Service
Time of Collection
STEP 5: COMPLETED BY DONOR
I certify that I provided my urine specimen to the collector; that I have not adulterated it in any manner; each specimen bottle used was sealed with a tamper-evident seal in
my presence; and that the information provided on this form and on the label affixed to each specimen bottle is correct.
X
Signature of Donor
Daytime Phone No. ( )
Evening Phone No. ( )
/
/
/
/
Date (Mo/Day/Yr)
(PRINT) Donor’s Name (First, MI, Last)
Date of Birth
(Mo/Day/Yr)
After the Medical Review Officer receives the test results for the specimen identified by this form, he/she may contact you to ask about prescriptions and
over-the-counter medications you may have taken. Therefore, you may want to make a list of those medications for your own records. THIS LIST IS NOT
NECESSARY. If you choose to make a list, do so either on a separate piece of paper or on the back of your copy (Copy 5). – DO NOT PROVIDE THIS
INFORMATION ON THE BACK OF ANY OTHER COPY OF THE FORM. TAKE COPY 5 WITH YOU.
STEP 6: COMPLETED BY MEDICAL REVIEW OFFICER - PRIMARY SPECIMEN
In accordance with applicable Federal requirements, my verification is:
c NEGATIVE
c POSITIVE for:
c DILUTE
c REFUSAL TO TEST because – check reason(s) below:
c ADULTERATED (adulterant/reason):
c SUBSTITUTED
c OTHER:
c TEST CANCELLED
REMARKS:
X
Signature of Medical Review Officer
(PRINT) Medical Review Officer’s Name (First, MI, Last)
/
/
/
/
Date (Mo/Day/Yr)
STEP 7: COMPLETED BY MEDICAL REVIEW OFFICER - SPLIT SPECIMEN
In accordance with applicable Federal requirements, my verification for the split specimen (if tested) is:
c RECONFIRMED for:
c TEST CANCELLED
c FAILED TO RECONFIRM for:
REMARKS:
X
Signature of Medical Review Officer
(PRINT) Medical Review Officer’s Name (First, MI, Last)
COPY 5 - DONOR COPY
Date (Mo/Day/Yr)
Paper CCF: Back of Copy 5
Electronic CCF: Separate Page
Instructions for Completing the Federal Drug Testing Custody and Control Form for Urine Specimen Collection
When making entries on a paper CCF, use black or blue ink pen and press firmly
Collector ensures that the name and address of the HHS-certified Instrumented Initial Test Facility (IITF) or HHS-certified laboratory are on
the top of the Federal CCF and the Specimen Identification (I.D.) number on the top of the Federal CCF matches the Specimen I.D. number
on the labels/seals.
STEP 1:
• Collector ensures that the required information is in STEP 1. Collector enters a remark in STEP 2 if Donor refuses to provide his/her SSN
or Employee I.D. number.
• Collector gives collection container to Donor and instructs Donor to provide a specimen. Collector notes any unusual behavior or
appearance of Donor in the remarks line in STEP 2. If the Donor’s conduct at any time during the collection process clearly indicates an
attempt to tamper with the specimen, Collector notes the conduct in the remarks line in STEP 2 and takes action as required.
STEP 2:
• Collector checks specimen temperature within 4 minutes after receiving the specimen from Donor, and marks the appropriate
temperature box in STEP 2. If temperature is outside the acceptable range, Collector enters a remark in STEP 2 and takes action as
required.
• Collector inspects the specimen and notes any unusual findings in the remarks line in STEP 2 and takes action as required. Any
specimen with unusual physical characteristics (e.g. unusual color, presence of foreign objects or material, unusual odor) cannot be sent
to an IITF and must be sent to an HHS-certified laboratory for testing as required
• Collector determines the volume of specimen in the collection container. If the volume is acceptable, Collector proceeds with the
collection. If the volume is less than required by the federal agency, Collector takes action as required, and enters remarks in STEP 2.
If no specimen is collected by the end of the collection process, Collector checks the None Provided box, enters a remark in STEP 2,
discards Copy 1 and distributes remaining copies as required.
• Collector checks the Split or Single specimen collection box. If the collection is observed, Collector checks the Observed box and enters
a remark in STEP 2.
STEP 3:
• Donor watches Collector pour the specimen from the collection container into the specimen bottle(s), place the cap(s) on the specimen
bottle(s), and affix the label(s)/seal(s) on the specimen bottle(s).
• Collector dates the specimen bottle label(s)/seal(s) after placement on the specimen bottle(s).
• Donor initials the specimen bottle label(s)/seal(s) after placement on the specimen bottle(s).
• Collector instructs the Donor to read and complete the certification statement in STEP 5 on Copy 2 (signature, printed name, date, phone
numbers, and date of birth). If Donor refuses to sign the certification statement, Collector enters a remark in STEP 2 on Copy 1.
STEP 4:
• Collector completes STEP 4 on Copy 1 (signature, printed name, date, time of collection, and name of delivery service) and places the
sealed specimen bottle(s) in a leak-proof plastic bag.
• Paper CCF: Collector places Copy 1 in the leak-proof plastic bag. Electronic CCF: Collector places printed copy of Copy 1 in the leak-proof
plastic bag and/or places package label (with Specimen I.D., test facility name and contact information, and collection site name and
contact information) on the outside of the bag.
• Collector seals the bag, prepares the specimen package for shipment, and distributes the remaining CCF copies as required.
Privacy Act Statement: (For Federal Employees Only)
Submission of the information on the Federal Drug Testing Custody and Control Form is voluntary. However, incomplete submission of the
information, refusal to provide a specimen, or substitution or adulteration of a specimen may result in delay or denial of your application for
employment/appointment or may result in removal from the federal service or other disciplinary action.
The authority for obtaining the specimen and identifying information contained herein is Executive Order 12564 (“Drug-Free Federal
Workplace”), 5 U.S.C. Sec. 3301 (2), 5 U.S.C. Sec. 7301, and Section 503 of Public Law 100-71, 5 U.S.C. Sec. 7301 note. Under provisions
of Executive Order 12564 and 5 U.S.C. 7301, test results may only be disclosed to agency officials on a need-to-know basis. This may include
the agency Medical Review Officer (MRO), the administrator of the Employee Assistance Program, and a supervisor with authority to take
adverse personnel action. This information may also be disclosed to a court where necessary to defend against a challenge to an adverse
personnel action.
Submission of your SSN is not required by law and is voluntary. Your refusal to furnish your number will not result in the denial of any
right, benefit, or privilege provided by law. Your SSN is solicited, pursuant to Executive Order 9397, for purposes of associating information in
agency files relating to you and for purposes of identifying the specimen provided for testing. If you refuse to indicate your SSN, a substitute
number or other identifier will be assigned, as required, to process the specimen.
Public Burden Statement
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-0158. Public reporting burden for
this collection of information is estimated to average: 5 minutes/donor; 4 minutes/collector; 3 minutes/test facility; and 3 minutes/Medical
Review Officer. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to SAMHSA Reports Clearance Officer, 5600 Fishers Lane, Room 15E57B, Rockville, Maryland, 20852.
| File Type | application/pdf |
| File Title | Federal Drug Test COC_vC.indd |
| File Modified | 2017-04-07 |
| File Created | 2010-05-17 |