Drug and Alcohol Checks

This checklist is designed to be used when staff or drivers need to be screened for any alcohol or other drugs in their system.

Drug and Alcohol Checks



Drug/ Drug Class

1. Which Drug/Drug Class is tested?


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ALCOHOL TEST RESULT

1. Alcohol


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2. Collector/ Technician’s Name


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3. Collector/ Technician’s Name Signature


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Custody Information

1. Received By


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3. Date and Time received


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4. Seal Intact


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5. Labels Match


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DONOR INFORMATION

1. Last name:


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2. First Name:


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3. Date of Birth


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4. Male or Female?


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5. Address:


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6. Take photo of ID/ license




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REQUESTING AUTHORITY

1. Nominated Representative:


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2. Company:


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3. Position:


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4. Telephone:


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6. ID number:


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DONOR CERTIFICATION/CONSENT/DECLARATION

1. I consent to the testing of my breath/urine/oral fluids sample for alcohol/drugs. I certify that the breath/urine/oral fluid specimen accompanying this form is my own and was provided by me to the authorized collector. Further, I certify that for any on-site testing performed, such testing was carried out in my presence. I certify that for any of my specimens that are to be sent for laboratory testing, the containers were sealed with tamper evident seals in my presence and that the information on the labels Is correct. Also, I certify that the Information provided on this form is correct and I consent to the release of all test results together with all relevant details on this form to the nominated representative(s) of the requesting authority indicated above.


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2. Any other comments


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3. Donor Signature


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COLLECTOR CERTIFICATION

1. I certify that I witnessed the donor signature and that the specimen identified on this form was provided to me by the donor whose consent and certification appears above, bears the same identification as set forth above, and that the urine/oral fluid specimen has been collected, divided, labelled and sealed in accordance with the relevant Standard.


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2. Collector Signature


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3. Date of Collection:


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4. Collection Site:


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6. Creatinine Level


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TEST RESULTS

1. Initial Testing Device/Method:


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2. Batch Number:


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3. Expiry Date:


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4. Breathalyser Serial No:


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Checklist by GoAudits.com – Please note that this checklist is intended as an example. We do not guarantee compliance with the laws applicable to your territory or industry. You should seek professional advice to determine how this checklist should be adapted to your workplace or jurisdiction.

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