Graham Smith successfully completed a Department of Transportation urine specimen collection training course on August 6, 2015. The course covered proper urine specimen collection procedures and handling situations like temperature issues, insufficient quantities, and donor refusal. Graham performed mock collections and was observed by a qualified collector, Denise Harrison, who verified Graham completed the tasks correctly.

1. This is to certify that:
Graham Smith
has successfully completed the course:
Department of Transportation (DOT) Federally Regulated Urine Specimen Collection Training
Provider Name: MediaLab, Inc.
ASCLS P.A.C.E. Provider #578
Florida Board of Clinical Laboratory Personnel Provider #50­10293
Date Completed: 8/6/2015
Assignment#: 8642023
Content: Complete
Exam: 90%
Checklist Tasks: Complete (5 of 5 checklist tasks)
Continuing Education Credits
P.A.C.E. Contact Hours: 2.5
Florida Board of Clinical Laboratory Science CE ­ General: 2.5
P.A.C.E. Contact Hours
Course Number: 578­010­11
This program is approved for 2.5 P.A.C.E.® contact hours.
Paul Fekete, MD, Program Administrator
MediaLab Inc. (Provider #578)
242 S. Culver St, Suite 300, Lawrenceville, GA 30046
www.MediaLabInc.net | www.LabCE.com
P.A.C.E.®
American Society for Clinical Laboratory Science
1861 International Drive, Suite 200, McLean, VA 22102
MediaLab is approved as a provider of continuing education programs in the clinical laboratory sciences by the ASCLS P.A.C.E.® Program.
California Accrediting Agency (CAA) #0001
Florida Board of Clinical Laboratory Science CE ­ General
This course qualifies for 2.5 credit hour(s) towards the Florida Board of Clinical Laboratory Science requirement in General.

2. Checklist: Department of Transportation (DOT) Federally Regulated Urine Specimen Collection Training
Assigned to: Graham Smith Date: 8/6/2015
Checklist status: Complete
Applicable CLIA Competency Assessment Procedures: No CLIA competency assessment procedures are specified for this checklist.
The following checklist items must be performed in the presence of a qualified collector, who has demonstrated necessary
knowledge, skills, and abilities by meeting one or more of the following critera: (i) Regularly conducting DOT drug test collections for
a period of at least a year; (ii) Conducting collector training under this part for a year; or (iii) Successfully completing a "train the
trainer" course.
The qualified collector's name and contact information (including e­mail and phone number) must be listed in the comment field for
each task that he / she observed. By checking the Y (Meets standard) column and providing his / her name and contact
information, the collector attests in writing that he / she is a qualified collector as described above, and that the observed mock
collection was error­free.
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N Y n/a N = Does not meet standard; Y = Meets standard; n/a = Not applicable Comments
8/6/2015
Task 1: 1. Uneventful collection.
Perform an uneventful urine collection in the presence of a qualified collector.
Denise Harrison 907­790­4111
leadma@juneauurgentcare.com
8/6/2015
Task 2: 2. Uneventful collection
Perform a second uneventful urine collection in the presence of a qualified
collector.
Denise Harrison 907­790­4111
leadma@juneauurgentcare.com
8/6/2015
Task 3: 3. Collection of specimen in which temperature of the urine specimen
is outside the acceptable rang
Perform a urine collection in which the temperature of the urine specimen is
out of range, in the presence of a qualified collector.
Denise Harrison 907­790­4111
leadma@juneauurgentcare.com
8/6/2015
Task 4: 4. Collection of specimen in which quantity is not sufficient.
Perform a collection in which the quantity of urine is not sufficient, in the
presence of a qualified collector.
Denise Harrison 907­790­4111
leadma@juneauurgentcare.com
8/6/2015
Task 5: 5. Donor refusal.
Perform, in the presence of a qualified collector, a urine collection in which
the donor refuses to sign either the certification on the pink copy of the CCF,
or initial the security strips.
Denise Harrison 907­790­4111
leadma@juneauurgentcare.com
N Y n/a N = Does not meet standard; Y = Meets standard; n/a = Not applicable Comments
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