FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM

SPECIMEN ID NO.

STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE ACCESSION NO.

STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate) Collector reads specimen temperature within 4 minutes.

A. Employer Name, Address, I.D. 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) 

Collector Phone No. 

Collector Fax No. 

G. Collection Site Address:

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

0000001

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

OMB No. 0930-0158

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 

collected, labeled, sealed and released to the Delivery Service noted in accordance with applicable Federal requirements.

SPECIMEN BOTTLE(S) RELEASED TO:

Name of Delivery Service

Signature of Collector

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

AM

/ / PM

X

COPY 1 - TEST FACILITY COPY

80308

PRESS HARD - YOU ARE MAKING MULTIPLE COPIES

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

c POSITIVE for: c Marijuana Metabolite (∆ 9-THCA) c Methamphetamine c MDMA

c Amphetamine c MDA 

c PCP

c ADULTERATED    c INVALID RES

/ /

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

RECEIVED AT LAB OR IITF: SPECIMEN BOTTLE(S) RELEASED TO:

Signature of Accessioner

(PRINT) Accessioner’s Name (First, MI, Last)

Primary Specimen

Bottle Seal Intact

c YES c NO

If NO, Enter remark

Date (Mo/Day/Yr) in Step 5A.

/ /

X

X

Version C 14May2010

A SPECIMEN BOTTLE

SPECIMEN ID NO. SEAL 0000001

0000001

Date (Mo/Day/Yr)

B

(SPLIT) SPECIMEN BOTTLE

SPECIMEN ID NO. SEAL 0000001

0000001

Date (Mo/Day/Yr)

STEP 5b: COMPLETED BY SPLIT TESTING LABORATORY

Laboratory Name

Laboratory Address Date (Mo/Day/Yr)

/ /

Signature of Certifying Scientist (PRINT) Certifying Scientist’s Name (First, MI, Last)

X

 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.

c 6-Acetylmorphine 

c Morphine 

c Codeine 

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.

c REJECTED FOR TESTING

c OXYC

c OXYM

c HYC

c c Cocaine Metabolite (BZE) c HYM DILUTE
FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM

SPECIMEN ID NO.

STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE ACCESSION NO.

STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate) Collector reads specimen temperature within 4 minutes.

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

C. Donor SSN or Employee I.D. No. 

D. Specify Testing Authority: c HHS c NRC

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) 

Collector Phone No. 

Collector Fax No. 

G. Collection Site Address:

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

0000001

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

OMB No. 0930-0158

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 

collected, labeled, sealed and released to the Delivery Service noted in accordance with applicable Federal requirements.

SPECIMEN BOTTLE(S) RELEASED TO:

Name of Delivery Service

Signature of Collector

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

AM

/ / PM

X

COPY 2 - MEDICAL REVIEW OFFICER COPY

STEP 5: COMPLETED BY DONOR

STEP 6: COMPLETED BY MEDICAL REVIEW OFFICER - PRIMARY SPECIMEN

STEP 7: COMPLETED BY MEDICAL REVIEW OFFICER - SPLIT SPECIMEN

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.

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.

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

/ /

Daytime Phone No. ( ) Evening Phone No. ( ) Date of Birth / /

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 TEST CANCELLED

c ADULTERATED (adulterant/reason):

c SUBSTITUTED

c OTHER:

REMARKS: 

/ /

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: 

/ /

Signature of Medical Review Officer

Signature of Medical Review Officer

(PRINT) Medical Review Officer’s Name (First, MI, Last)

(PRINT) Medical Review Officer’s Name (First, MI, Last)

Date (Mo/Day/Yr)

Date (Mo/Day/Yr)

(Mo/Day/Yr)

X

X

X

Specify DOT Agency: c FMCSA c FAA c FRA c FTA c PHMSA c USCG
FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM

SPECIMEN ID NO.

STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE ACCESSION NO.

STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate) Collector reads specimen temperature within 4 minutes.

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

C. Donor SSN or Employee I.D. No. 

D. Specify Testing Authority: c HHS c NRC

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) 

Collector Phone No. 

Collector Fax No. 

G. Collection Site Address:

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

0000001

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

OMB No. 0930-0158

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 

collected, labeled, sealed and released to the Delivery Service noted in accordance with applicable Federal requirements.

SPECIMEN BOTTLE(S) RELEASED TO:

Name of Delivery Service

Signature of Collector

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

AM

/ / PM

X

COPY 3 - COLLECTOR COPY

STEP 5: COMPLETED BY DONOR

STEP 6: COMPLETED BY MEDICAL REVIEW OFFICER - PRIMARY SPECIMEN

STEP 7: COMPLETED BY MEDICAL REVIEW OFFICER - SPLIT SPECIMEN

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.

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.

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

/ /

Daytime Phone No. ( ) Evening Phone No. ( ) Date of Birth / /

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 TEST CANCELLED

c ADULTERATED (adulterant/reason):

c SUBSTITUTED

c OTHER:

REMARKS:

/ /

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: 

/ /

Signature of Medical Review Officer

Signature of Medical Review Officer

(PRINT) Medical Review Officer’s Name (First, MI, Last)

(PRINT) Medical Review Officer’s Name (First, MI, Last)

Date (Mo/Day/Yr)

Date (Mo/Day/Yr)

(Mo/Day/Yr)

X

X

X

Specify DOT Agency: c FMCSA c FAA c FRA c FTA c PHMSA c USCG
FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM

SPECIMEN ID NO.

STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE ACCESSION NO.

STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate) Collector reads specimen temperature within 4 minutes.

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

C. Donor SSN or Employee I.D. No. 

D. Specify Testing Authority: c HHS c NRC

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) 

Collector Phone No. 

Collector Fax No. 

G. Collection Site Address:

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

0000001

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

OMB No. 0930-0158

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 

collected, labeled, sealed and released to the Delivery Service noted in accordance with applicable Federal requirements.

SPECIMEN BOTTLE(S) RELEASED TO:

Name of Delivery Service

Signature of Collector

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

AM

/ / PM

X

COPY 4 - EMPLOYER COPY

STEP 5: COMPLETED BY DONOR

STEP 6: COMPLETED BY MEDICAL REVIEW OFFICER - PRIMARY SPECIMEN

STEP 7: COMPLETED BY MEDICAL REVIEW OFFICER - SPLIT SPECIMEN

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.

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.

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

/ /

Daytime Phone No. ( ) Evening Phone No. ( ) Date of Birth / /

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 TEST CANCELLED

c ADULTERATED (adulterant/reason):

c SUBSTITUTED

c OTHER:

REMARKS: 

/ /

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: 

/ /

Signature of Medical Review Officer

Signature of Medical Review Officer

(PRINT) Medical Review Officer’s Name (First, MI, Last)

(PRINT) Medical Review Officer’s Name (First, MI, Last)

Date (Mo/Day/Yr)

Date (Mo/Day/Yr)

(Mo/Day/Yr)

X

X

X

Specify DOT Agency: c FMCSA c FAA c FRA c FTA c PHMSA c USCG
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.

Paper CCF: Back of Copy 1-4

Electronic CCF: Separate Page
FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM

SPECIMEN ID NO.

STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE ACCESSION NO.

STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate) Collector reads specimen temperature within 4 minutes.

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

C. Donor SSN or Employee I.D. No. 

D. Specify Testing Authority: c HHS c NRC

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) 

Collector Phone No. 

Collector Fax No. 

G. Collection Site Address:

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

0000001

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

OMB No. 0930-0158

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 

collected, labeled, sealed and released to the Delivery Service noted in accordance with applicable Federal requirements.

SPECIMEN BOTTLE(S) RELEASED TO:

Name of Delivery Service

Signature of Collector

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

AM

/ / PM

X

COPY 5 - DONOR COPY

STEP 5: COMPLETED BY DONOR

STEP 6: COMPLETED BY MEDICAL REVIEW OFFICER - PRIMARY SPECIMEN

STEP 7: COMPLETED BY MEDICAL REVIEW OFFICER - SPLIT SPECIMEN

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.

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.

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

/ /

Daytime Phone No. ( ) Evening Phone No. ( ) Date of Birth / /

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 TEST CANCELLED

c ADULTERATED (adulterant/reason):

c SUBSTITUTED

c OTHER:

REMARKS: 

/ /

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: 

/ /

Signature of Medical Review Officer

Signature of Medical Review Officer

(PRINT) Medical Review Officer’s Name (First, MI, Last)

(PRINT) Medical Review Officer’s Name (First, MI, Last)

Date (Mo/Day/Yr)

Date (Mo/Day/Yr)

(Mo/Day/Yr)

X

X

X

Specify DOT Agency: c FMCSA c FAA c FRA c FTA c PHMSA c USCG
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.