FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM

SPECIMEN ID NO. 0000001 ACCESSION NO.

STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE

A. Employer Name, Address, I.D. No.

C. Donor SSN, Employee I.D., or CDL State and No.

D. Specify Testing Authority:  HHS  NRC Specify DOT Agency:  FMCSA  FAA  FRA  FTA  PHMSA  USCG

F. Drug Tests to be Performed:  THC, COC, PCP, OPI, AMP  THC & COC Only  Other (specify) 

B. MRO Name, Address, Phone No. and Fax No.

OMB No. 0930-0158

STEP 3: Collector affixes seal(s) to bottle(s)/tube(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

 

 

 

 

 

 

 

 

 Volume Indicator(s) Observed

Version C 6May2020

E. Reason for Test:  Pre-employment  Random  Reasonable Suspicion/Cause  Post Accident  Return to Duty Follow-up Other (specify)

G. Collection Site Address: Collector Contact Info: Phone 

Fax

Other

STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate).  URINE  ORAL FLUID

COLLECTION:  Split  Single  None Provided, Enter Remark.

URINE: Collector reads urine temperature within 4 minutes. Temperature between 90o and 100o F?  Yes  No, Enter Remark  Observed, Enter Remark

ORAL FLUID: Split Type:  Serial  Concurrent  Subdivided Each Device Within Expiration Date?  Yes  No

REMARKS:

I certify that the specimen given to me by the donor identified in the certification section on Copy 2 of this form 

was co ected, abe ed, sea ed and re eased to the De ivery Service noted in accordance with app icab e federa requirements. 

X 

Signature of Collector

AM

PM / /

(PRINT) Collector’s Name (First, MI, Last) Date (Mo/Day/Yr) Time of Collection

SPECIMEN BOTTLE(S)/TUBE(S) RELEASED TO:

Name of Delivery Service

RECEIVED AT LAB OR IITF:

X 

Signature of Accessioner

/ /

(PRINT) Accessioner’s Name (First, MI, Last) Date (Mo/Day/Yr)

Primary Specimen

Seal Intact

 YES  NO

If NO, Enter remark

in Step 5A.

SPECIMEN BOTTLE(S)/TUBE(S)

RELEASED TO:

Primary/Single Specimen Device Expiration Date: / / Split Specimen Device Expiration Date: / / 

(Mo/Day/Yr) (Mo/Day/Yr)

STEP 5A: PRIMARY SPECIMEN REPORT - COMPLETED BY TEST FACILITY

 NEGATIVE  REJECTED FOR TESTING  ADULTERATED  SUBSTITUTED  INVALID RESULT

  DILUTE

 POSITIVE for:

Analyte(s) in ng/mL

REMARKS:

Test Facility (if different from above) : 

I certify that the specimen identified on this form was examined upon receipt, hand ed using chain of custody procedures, ana yzed, and reported in accordance with app icab efedera requirements. 

X / / 

Signature of Certifying Technician/Scientist (PRINT) Certifying Technician/Scientist’s Name (First, MI, Last) Date (Mo/Day/Yr)

STEP 5b: COMPLETED BY SPLIT TESTING LABORATORY

 RECONFIRMED  FAILED TO RECONFIRM - REASON

Laboratory Name

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 applica le federal requirements. 

X / / 

Laboratory Address Signature of Certifying Scientist (PRINT) Certifying Scientist’s Name (First, MI, Last) Date (Mo/Day/Yr)

PRESS HARD - YOU ARE MAKING MULTIPLE COPIES

80308

SPECIMEN A

0000001

Date (Mo/Day/Yr)

SPECIMEN B

0000001

Date (Mo/Day/Yr)

/ /

/ /

COPY 1 - TEST FACILITY COPY
FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM

SPECIMEN ID NO. 0000001

OMB No. 0930-0158

 

 / /



 

 

 

 

 

 

 

 

 

 

ACCESSION NO.

STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE

A. Employer Name, Address, I.D. No. B. MRO Name, Address, Phone No. and Fax No.

C. Donor SSN, Employee I.D., or CDL State and No.

D. Specify Testing Authority:  HHS  NRC Specify DOT Agency:  FMCSA  FAA  FRA  FTA  PHMSA  USCG

E. Reason for Test:  Pre-employment  Random  Reasonable Suspicion/Cause  Post Accident  Return to Duty Follow-up Other (specify)

F. Drug Tests to be Performed:  THC, COC, PCP, OPI, AMP  THC & COC Only  Other (specify) 

G. Collection Site Address: Collector Contact Info: Phone 

Fax

Other

STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate).  URINE  ORAL FLUID

COLLECTION:  Split  Single  None Provided, Enter Remark.

URINE: Collector reads urine temperature within 4 minutes. Temperature between 90o and 100o F?  Yes  No, Enter Remark  Observed, Enter Remark

ORAL FLUID: Split Type:  Serial  Concurrent  Subdivided Each Device Within Expiration Date?  Yes  No  Volume Indicator(s) Observed

REMARKS:

STEP 3: Collector affixes seal(s) to bottle(s)/tube(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 co ected, abe ed, sea ed and re eased to the De ivery Service noted in accordance with app icab e federa requirements. 

X 

Signature of Collector

AM

PM / / 

(PRINT) Collector’s Name (First, MI, Last) Date (Mo/Day/Yr) Time of Collection

SPECIMEN BOTTLE(S)/TUBE(S) RELEASED TO:

Name of Delivery Service

STEP 5: COMPLETED BY DONOR

I certify that I provided my specimen to the collector; that I have not adulterated it in any manner; each specimen bottle/tube 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/tube is correct.

X / /

Signature of Donor (PRINT) Donor’s Name (First, MI, Last) Date (Mo/Day/Yr)

Email address: Daytime Phone No. ( ) Evening Phone No. ( ) Date of Birth 

(Mo/Day/Yr)

After the Medical Review Offc r receives the test results for the specimen id ntif d 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  URINE  ORAL FLUID

In accordance with applicable federal requirements, my verification is:

 NEGATIVE  POSITIVE for: 

 DILUTE

 REFUSAL TO TEST because – check reason(s) below: TEST CANCELLED

 ADULTERATED (adulterant/reason):

 SUBSTITUTED

 OTHER: 

REMARKS: 

/ / 

Signature of Medical Review Offc r (PRINT) Medical Review Offc r’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:

 RECONFIRMED for:  TEST CANCELLED

 FAILED TO RECONFIRM for:

REMARKS: 

X 

Signature of Medical Review Offc r (PRINT) Medical Review Offc r’s Name (First, MI, Last)

/ / 

Date (Mo/Day/Yr)

COPY 2 - MEDICAL REVIEW OFFICER COPY

X 
 

 

 

 

 

 

 

 

 

FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM

SPECIMEN ID NO. 0000001 ACCESSION NO.

STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE

A. Employer Name, Address, I.D. No. B. MRO Name, Address, Phone No. and Fax No.

OMB No. 0930-0158

C. Donor SSN, Employee I.D., or CDL State and No.

D. Specify Testing Authority:  HHS  NRC Specify DOT Agency:  FMCSA  FAA  FRA  FTA  PHMSA  USCG

E. Reason for Test:  Pre-employment  Random  Reasonable Suspicion/Cause  Post Accident  Return to Duty Follow-up Other (specify)

F. Drug Tests to be Performed:  THC, COC, PCP, OPI, AMP  THC & COC Only  Other (specify) 

G. Collection Site Address: Collector Contact Info: Phone

Fax

Other

STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate).  URINE  ORAL FLUID

COLLECTION:  Split  Single  None Provided, Enter Remark.

URINE: Collector reads urine temperature within 4 minutes. Temperature between 90o and 100o F?  Yes  No, Enter Remark  Observed, Enter Remark

ORAL FLUID: Split Type:  Serial  Concurrent  Subdivided Each Device Within Expiration Date?  Yes  No  Volume Indicator(s) Observed

REMARKS:

STEP 3: Collector affixes seal(s) to bottle(s)/tube(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 co ected, abe ed, sea ed and re eased to the De ivery Service noted in accordance with app icab e federa requirements. 

X 

Signature of Collector

AM

PM / / 

(PRINT) Collector’s Name (First, MI, Last) Date (Mo/Day/Yr) Time of Collection

SPECIMEN BOTTLE(S)/TUBE(S) RELEASED TO:

Name of Delivery Service

STEP 5: COMPLETED BY DONOR

I certify that I provided my specimen to the collector; that I have not adulterated it in any manner; each specimen bottle/tube 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/tube is correct.

X / / 

Signature of Donor (PRINT) Donor’s Name (First, MI, Last) Date (Mo/Day/Yr)

Email address: Daytime Phone No. ( ) Evening Phone No. ( ) Date of Birth / / 

(Mo/Day/Yr)

After the Medical Review Offc r receives the test results for the specimen id ntif d 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  URINE  ORAL FLUID

In accordance with applicable federal requirements, my verification is:

 NEGATIVE  POSITIVE for: 

 DILUTE

 REFUSAL TO TEST because – check reason(s) below:  TEST CANCELLED

 ADULTERATED (adulterant/reason):

 SUBSTITUTED

 OTHER: 

REMARKS: 

X / / 

Signature of Medical Review Offc r (PRINT) Medical Review Offc r’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:

 RECONFIRMED for:

 FAILED TO RECONFIRM for:

REMARKS: 

 TEST CANCELLED

X 

Signature of Medical Review Offc r (PRINT) Medical Review Offc r’s Name (First, MI, Last)

/ / 

Date (Mo/Day/Yr)

COPY 3 - COLLECTOR COPY
 

 

 

 

 

 

 

 

 

FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM

SPECIMEN ID NO. 0000001 ACCESSION NO.

STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE

A. Employer Name, Address, I.D. No. B. MRO Name, Address, Phone No. and Fax No.

OMB No. 0930-0158

C. Donor SSN, Employee I.D., or CDL State and No.

D. Specify Testing Authority:  HHS  NRC Specify DOT Agency:  FMCSA  FAA  FRA  FTA  PHMSA  USCG

E. Reason for Test:  Pre-employment  Random  Reasonable Suspicion/Cause  Post Accident  Return to Duty Follow-up Other (specify)

F. Drug Tests to be Performed:  THC, COC, PCP, OPI, AMP  THC & COC Only  Other (specify) 

G. Collection Site Address: Collector Contact Info: Phone

Fax

Other

STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate).  URINE  ORAL FLUID

COLLECTION:  Split  Single  None Provided, Enter Remark.

URINE: Collector reads urine temperature within 4 minutes. Temperature between 90o and 100o F?  Yes  No, Enter Remark  Observed, Enter Remark

ORAL FLUID: Split Type:  Serial  Concurrent  Subdivided Each Device Within Expiration Date?  Yes  No  Volume Indicator(s) Observed

REMARKS:

STEP 3: Collector affixes seal(s) to bottle(s)/tube(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 co ected, abe ed, sea ed and re eased to the De ivery Service noted in accordance with app icab e federa requirements. 

X 

Signature of Collector

AM

PM / / 

(PRINT) Collector’s Name (First, MI, Last) Date (Mo/Day/Yr) Time of Collection

SPECIMEN BOTTLE(S)/TUBE(S) RELEASED TO:

Name of Delivery Service

STEP 5: COMPLETED BY DONOR

I certify that I provided my specimen to the collector; that I have not adulterated it in any manner; each specimen bottle/tube 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/tube is correct.

X / / 

Signature of Donor (PRINT) Donor’s Name (First, MI, Last) Date (Mo/Day/Yr)

Email address: Daytime Phone No. ( ) Evening Phone No. ( ) Date of Birth / / 

(Mo/Day/Yr)

After the Medical Review Offc r receives the test results for the specimen id ntif d 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  URINE  ORAL FLUID

In accordance with applicable federal requirements, my verification is:

 NEGATIVE  POSITIVE for: 

 DILUTE

 REFUSAL TO TEST because – check reason(s) below:  TEST CANCELLED

 ADULTERATED (adulterant/reason):

 SUBSTITUTED

 OTHER: 

REMARKS: 

X / / 

Signature of Medical Review Offc r (PRINT) Medical Review Offc r’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:

 RECONFIRMED for:

 FAILED TO RECONFIRM for:

REMARKS:

 TEST CANCELLED

X 

Signature of Medical Review Offc r (PRINT) Medical Review Offc r’s Name (First, MI, Last)

/ / 

Date (Mo/Day/Yr)

COPY 4 - EMPLOYER COPY
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

 

 

 

 

 

 

 

 

 

 

SPECIMEN ID NO. 0000001 ACCESSION NO.

STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE

A. Employer Name, Address, I.D. No. B. MRO Name, Address, Phone No. and Fax No.

OMB No. 0930-0158

C. Donor SSN, Employee I.D., or CDL State and No.

D. Specify Testing Authority:  HHS  NRC Specify DOT Agency:  FMCSA  FAA  FRA  FTA  PHMSA  USCG

E. Reason for Test:  Pre-employment  Random  Reasonable Suspicion/Cause  Post Accident  Return to Duty Follow-up Other (specify)

F. Drug Tests to be Performed:  THC, COC, PCP, OPI, AMP  THC & COC Only  Other (specify) 

G. Collection Site Address: Collector Contact Info: Phone

Fax

Other

STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate).  URINE  ORAL FLUID

COLLECTION:  Split  Single  None Provided, Enter Remark.

URINE: Collector reads urine temperature within 4 minutes. Temperature between 90o and 100o F?  Yes  No, Enter Remark  Observed, Enter Remark

ORAL FLUID: Split Type:  Serial  Concurrent  Subdivided Each Device Within Expiration Date?  Yes  No  Volume Indicator(s) Observed

REMARKS:

STEP 3: Collector affixes seal(s) to bottle(s)/tube(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 co ected, abe ed, sea ed and re eased to the De ivery Service noted in accordance with app icab e federa requirements. 

X 

Signature of Collector

AM

PM / / 

(PRINT) Collector’s Name (First, MI, Last) Date (Mo/Day/Yr) Time of Collection

SPECIMEN BOTTLE(S)/TUBE(S) RELEASED TO:

Name of Delivery Service

STEP 5: COMPLETED BY DONOR

I certify that I provided my specimen to the collector; that I have not adulterated it in any manner; each specimen bottle/tube 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/tube is correct.

X / / 

Signature of Donor (PRINT) Donor’s Name (First, MI, Last) Date (Mo/Day/Yr)

Email address: Daytime Phone No. ( ) Evening Phone No. ( ) Date of Birth / / 

(Mo/Day/Yr)

After the Medical Review Offc r receives the test results for the specimen id ntif d 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  URINE  ORAL FLUID

In accordance with applicable federal requirements, my verification is:

 NEGATIVE  POSITIVE for: 

 DILUTE

 REFUSAL TO TEST because – check reason(s) below:  TEST CANCELLED

 ADULTERATED (adulterant/reason):

 SUBSTITUTED

 OTHER: 

REMARKS:

X / / 

Signature of Medical Review Offc r (PRINT) Medical Review Offc r’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:

 RECONFIRMED for:

 FAILED TO RECONFIRM for:

REMARKS:

 TEST CANCELLED

X 

Signature of Medical Review Offc r (PRINT) Medical Review Offc r’s Name (First, MI, Last)

/ / 

Date (Mo/Day/Yr)

COPY 5 - DONOR COPY
Paper CCF: Back of Copy 5 Electronic CCF: Separate Page

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

 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.