Template Information
Use this form as consent for conducting drug and alcohol testing
Category: general
Template Questions
- Surname:
- Given Name:
- Date of Birth Date
- DONOR INFORMATION
- Address: Address
- Take photo of ID/ license
- Nominated Representative:
- Company:
- Position:
- Telephone:
- Email:
- ID number:
- I consent to the testing of my breath/urine/oral fluids sample for alcohol/drugs. I certify that the
- Other comments
- DONOR Signature
- I certify that I witnessed the donor signature and that the specimen identified on this form was prov
- COLLECTOR Name & Signature
- Date and time of Collection: Date
- Collection Site:
- Colour
- COLLECTOR CERTIFICATION
- Initial Testing Device/Method:
- Batch Number:
- Expiry Date: Date
- Breathalyser Serial No:
- Select which Drug/Drug Class is tested (select all that apply)
- 2ND TEST RESULT (alcohol only)
- Collector/ Technician’s Name & Signature
- Click ADD to add new Custody Information.
- Received By
- Date/Time Received Date
- CHAIN-OF-CUSTODY