FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM @) Quest Bagnostics™ DAMOUR tsp 10176862 7352718 seecamen 0 no. : STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE LAB ACCESSION NO. ‘A. Employer Name, Address, LD, No, 8. MRO Name, Address, Phone No. and Fax Nox le anen " E ARRETERA JUG ORVENIR 886 EB C.bonerSenempoed.ccorsmanane, CH APNG D. Spocify Testing Authority: LIHHS CINAC SpecifyDOT Agency: [ZFMCSA (CJFAA [lFRA Leta (ClpHmsa (Jusca Reason for Tost: [2Pre-employment [_]Random [] Reasonable Suspicion Cause []Post Accident ]Rotumto Dury [TFolow-up (]Other(specity) F. Drug Tests to be Performed: (Citmc, coc, pcp, oF, amp = CJTHC & COC Only other (specify). a x RUE PRN Collection Site Code: Collector Contact Info: G. Collection Site Name: vt? Phone Cc ost f ~ Address: Ab J 476A Ae fé Fax__£f€ @ SAT PRE Cty, Suto and Zip. Cu Den ee Other DL STEP 2: COMPLETED BY COLLECTOR (make romerka when appropriate| (URINE ~~T "ORAL FLUID (Collection: _GXSplit_ [Single []None Provided, Enter Remark URINE: Collector reads urine temperature within 4 minutes. Tom perature between SO” and 100° F? [i Yes C]No, Enter Remark L] Observed, Enter Romar JORAL FLUID: Split ype: (Serial [j Concurrent ( Subdivided [Esch Device Within Expiration Date? ]Yes [1 No [L]Volume Indicators) Observed REMARKS: ‘STEP 3: Collector affies sealla) to bottlo(a)/ tubele). Collector dates soallel. Donor initials sealla), Donoy complates STEP 5 on Copy 2 WHO Copy] ‘CHAIN OF CUSTODY - INITIATED BY COLLECTOR AND COMPLETED BY TEST FACILITY. TEP Text respon goers Poy fe coe Laied Posmeser oars oop oA EEE : Ste yest | SRE POT TURE RELEASED x = |C Fedex whit TOMALS 8 12923 04°16 BA [Other Fr ces a Tom ang “otro Tae Daven Sania STEP 5: COMPLETED BY DONOR Teri tat | rovided my spscimen to the collector hat Thave not sdiFaated in any manner each apacan Bote be ws6d wes sealed wit a Tamar ode ear In my presence; and thatthe information provided on this form and on the label afixad to each specimen bate ls correct x sae Wolters rade eyed. 12. | O9/ 20:7 raaaal Tr a ne sah Lm oovim mene) SEZ IT O2 cong rem nb 65 E2552 om ainen 22/24 [1922 Aor the Medical Review Officer receives the test results fr 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 maka 9 let of those medications for your own records. THIS LIST IS NGT NECESSARY you ghoosy to make als. do t eer on 9 separate ple of banat or on te bac ol your copy (Copy 6-00 NOT PROVIDE THIS INFORMATION ON THE BAGK OF ANY OTHER COPY OF THE FORM, TAKE COPY § WITH YOU. STEP 6: COMPLETED BY MEDICAL REVIEW OFFICER - PRIMARY SPECIMEN. URINE: [ORAL FLUID Th accordance with applicable federal requirements, ny verfcation is: Onecative — Clposmve tor: —_ Oowute Cnersat To Test bcsso check eau low Crest cancetten TyADULTERATED amare Csvesrmureo Cotter x ‘STEP; COMPLETED BY MEDICAL REVIEW OFFICER SPL SPEGmmEN hit in acordncy th appa fda egceons my verison for spit apart) NT TIRECONFIAMED for: _ = 1 1D festicanceneo LiFAIeD To RECONFIRM fo = —— Ht aa new HI aT ae OnE x