Drug & Alcohol Test Report Record

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

Address: Post Office Box 55, 65 Bootooloo Road, Bowen, Queensland, Australia, 4805 Telephone: 07 47 852 850 Email: admin@corrsafe.com.au Web: www.corrsafe.com.au
Date & Time Of Collection:*

DayMonthYear
Date
Hour Minutes
Timing Of Test:*
Test Site Location:*
Address Map Locator:
Donor Name:*

First NameLast Name
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:*
Company Representative E-Mail:
example@example.com
Donor Reports To:

First NameLast Name
Donor Position Title*
Rail Safety Worker Type:*
Company Organisation:*
Sample Types:*

BreathSaliva
I the Donor declare that I have taken the following prescribed and or non prescribed medications and or drugs in the last 7 days:
Has the Donor consumed any food, drinks, cigarettes, within the last 10 minutes?*

NoYes
Test Reason:*
DONOR CERTIFICATION CONSENT DECLARATION*

I consent to the collection and testing of my specimen for the drug types detailed above, 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
Alcohol Device Type:*
Alcohol Test Result: %*
e.g. 0.000
Drug Test Device Type:*
Drug Test Device Batch No:*
Drug Test Device Expiry Date:*

DayMonthYear
Date
AMP-50 Result*
COC-50 Result*
BZO-50 Result*
MET-50 Result*
OPI-50 Result*
THC-15 Result*
OXY-40 Result*
K2-25 Result*
Saliva Alcohol Result-0.02*
Collector Name & Certification No:
Collector Signature:*

Clear
Notes / Comments:
Timer:
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.