Sample Collector Checklists for DATIA Accreditation
Part 1. Urine Collection Checklist
Collection Site: Address: Date of Service: Employer Name: Employee Name: Soc. Sec. No:
Collection Site: Please note that the specimen should be sent to the laboratory designated on the attached Chain of Custody (COC). This voucher is for a DoT, 5 Drug, urine screen only. On this COC form, you should check the box for THC, Cocaine, PCP, Opiates, and Amphetamines. Please make sure the test type is indicated. Verify that the temperature of the specimen was checked within four minutes of collection and that the specimen was sealed with proper materials as provided on the COC. Payment will not be made if improper collection procedures result in a "no test" from the laboratory. This checklist is to be completed by the collector performing the procedure and verified by the donor.
1. Did the donor furnish positive identification? Yes ______ No ______
2. Did the donor print initials and/or ID number on the specimen bottle? Yes _____ No _____
3. Was the label placed on the specimen bottle? Yes _____ No _____
4. Did the identification on the label match the identification on the COC form? Yes _____ No _____
5. Did the donor wash their hands prior to the specimen collection? Yes _____ No _____
6. Were faucets taped or water cutoff valves closed? Yes _____ No _____
7. Was bluing placed in the toilet? Yes _____ No _____
8. Were all potential adulterants ( soaps, cleansing agents ) removed from the restroom? Yes _____ No _____
9. Did the collector transfer the specimen from the collection container while being observed by the donor? Yes _____ No_____
10. Was the sample checked for discoloration, unusual odors, or other possible signs of adulteration? Yes _____ No _____
I I - Was the specimen bottle sealed with security tape in the presence of the donor? Yes _____ No ______
12. Was the specimen bag or box sealed with security tape, if provided? Yes_____ No_____
I verity that the above procedures have been performed as indicated.
Collector's Signature Date
Donor's Signature Date
Part 2. Sample Alcohol Voucher Form
Employer Name: _______________________
Collection Site Name: _______________________
Voucher No.: __________
Collection Site: Please complete this form for the alcohol test and return the Employer copy of the test form, the results, and this check sheet. This checklist is to be completed by the Breath Technician performing the breath test procedure and verified by the donor.
Section 1: please answer the three questions below for each test.
1. Did the Employee provide positive identification? Yes _____ No _____
2. Did the Employee sign in Step 2 and Step 4? Yes _____ No _____
3. Did the BAT sign in Step 3? Yes _____ No _____
If the screening test is negative, as soon as possible, please fax the test form with the result and this checklist to the fax number given above. You have completed our protocol for negative tests. If the test is positive continue on to Section 2.
Section 2: Prior to beginning the Confirmation Test please fax the following: the test result of the Screening Test, this checklist form completed through Section 2, the BAT training certificate, and the calibration log showing your last calibration. Since you have to wait 15 minutes to perform a confirmation test that is the best time to fax the requested information. Be sure to run an airblank prior to the confirmation test.
Section 3: Please complete after the Confirmation Test.
1. Did you perform an external accuracy check of the EBT after a positive Confirmation Test? Yes _____ No _____
2. Did you observe the minimum 15 waiting period prior to a Confirmation Test? Yes _____ No _____
3. Did you perform an airblank of the EBT before the Confirmation Test which resulted in a reading of 0.00? Yes _____ No _____
4. Did the Employee sign in Step 2 and Step 4? Yes _____ No _____
5. Did the BAT sign in Step 3? Yes _____ No _____
6. Did the BAT note in the Remarks Section if the Employee failed or refused to sign the test form? Yes _____ No _____
7. Did you verify that the test number and the test reading are the same on the EBT and the printed result? Yes _____ No _____
8. Did you fax the completed test form with the Confirmation Test results to NTSA? Yes _____ No _____
I verify that none of the above fatal flaws have occurred in accordance with DoT alcohol regulations.
BAT's Signature Date
Donor's Signature Date