Bowen Rail Company Form

Corrsafe - Bowen Rail Company - Saliva Drug & Alcohol Test Report Record
CORRSAFE DRUG & ALCOHOL TESTING SERVICES

Address: Post Office Box 55 | 65 Bootooloo Road Bowen QLD 4805
Telephone: 07 4785 2850
Email: admin@corrsafe.com.au Web: www.corrsafe.com.au
Date & Time Of Collection:*

DayMonthYear
Date
Hour Minutes
Address Map Locator:
Timing Of Test:*
Has the Donor consumed any food, drinks, cigarettes, within the last 10 minutes?*

No
Test Site Location:*
Donor Name:*

First NameLast Name
I the Donor declare that I have taken the following prescribed and or non prescribed medications and or drugs in the last 7 days:*
DONOR CERTIFICATION CONSENT DECLARATION*

By signing below, I consent to the collection and testing of my specimen for the drug types detailed on this form, using onsite equipment and or other test devices and or an accredited laboratory if required for confirmatory testing. I understand the tests are being performed as part of the company and or site fitness for work policy and or drug and alcohol policy applicable. I authorise the release of the results to the nominated collector and or company representative. I certify the information supplied on this record is true and correct.
Donor Signature:*

Clear
Donor Gender:*
Male / Female
Donor Photo ID Type:*
Donor Photo ID No:*
Donor Date Of Birth:*

DayMonthYear
Donor Email Address:*
example@example.com
Donor Contact Number:*
Donor Company Name:*
Donor Reports To:*

First NameLast Name
Company Representative E-Mail:*
ben.homewood@bowenrail.com.au
Company Representative E-Mail:*
brandan.mackie@bowenrail.com.au
Donor Position Title*
Rail Safety Worker Type:*
Company Organisation:*
Sample Types:*

Breath & Saliva
Test Reason:*
Alcohol Device Type:*
Drug Test Device Type:*
Drug Test Device Batch No:*
Drug Test Device Expiry Date:*

DayMonthYear
Date
Alcohol Test Result: %*
e.g. 0.000
THC - 15ng/ml Result*
MET - 50ng/ml Result*
COC Result - 50ng/ml*
OXY - 40ng/ml Result*
OPI - 50ng/ml Result*
BZO - 10ng/ml Result*
AMP-50ng/ml Result*
Collector Name & Certification No:*
If Presumptive Positive is selected, confirm submission:*

Confirm
Collector Signature:*

Clear
Notes / Comments:
For alcohol, a second breathalyser test is given at least 20 minutes after the first positive result to confirm initial BAC levels.
All drug and alcohol collecting, testing and analysis is fully compliant with the relevant Australian Standards

AS4308 - AS3547 - AS4760.
Should be Empty:

Corrsafe - Bowen Rail Company - Saliva Drug & Alcohol Test Report Record

For alcohol, a second breathalyser test is given at least 20 minutes after the first positive result to confirm initial BAC levels.