Updated Manual

1. C H A I N O F C U S T O D Y F O R M - D r u g s o f A b u s e T e s t R e q u e s t
© Work Options PTY LTD 2009 D:A.Cameron StuartAA_WORKOPTIONS_DropboxForms and Documents for
WorkOptionsForms and Documents for WorkOptionsF066- Chain of Custody Form- 24 Aug 16.doc
Donor Identification:
Surname: __________________________ Given name: ______________________ D.O.B: / /
Address: ____________________________________________________________ Male / Female
ID Checked: _____________ Security number: _______________ Satchel Tag number: __________________
Test Request:
 Urine Drug screen AS/NZS 4308 GC/MS  Oral Fluid Drug Screen AS 4760 LC/MS
Results To: Invoices To:
Work Options
Attn: Margaret Stefanovska
PO Box 851, North Sydney, NSW 2059
Phone: (02) 9957 1300
Fax: (02) 9957 1311
Requesting Authority:
Margaret Stefanovska
Work Options – WO
H18840-R
Address – same as results
Donor Certification/ Consent/ Declaration (To be completed by test subject)
I certify that the specimens accompanying this form are my own and were provided by me to the authorized
collector. Further, I certify that for any onsite testing performed, was carried out in my presence. I certify that the
specimen containers were sealed with tamper evident seals in my presence and that the information on this form
and on the labels is correct. I consent to the analysis of the specimen for drugs and the release of these results to
the company listed above or their authorised representative
Signature of donor/ guardian: ____________________________________ Date: __________________________
Medications: Please list any prescription or non prescription medications or other agents taken in the last month
Collector Certification (To be completed by authorised collector)
Collector: ____________________________ Collection date: / / Collection time: _________ am/ pm
Collection site: __________________ Specimen Temperature: _________ Adulterant check: normal / abnormal
Comments/ observations on validity of sample: ______________________________________________________
Results of drug screen: (  those drug classes that were unconfirmed from initial testing and require confirmatory analysis)
□ THC □ OPI □ COC □ METH □ AMP □ BENZ
I certify that I witnessed the donor signature and that the specimen identified on this form was provided by me to the donor
whose consent and certification appears above, bears the same identification as set forth above and that the oral fluid specimen
has been collected, divided, labelled and sealed in accordance with the instructions provided.
Collector Signature: ___________________________________________ Date: / /
To be completed by all persons handing specimen
Name Date and time received Seals Intact Labels Match Signature