Alcohol and Other Drug Screening Record
Complete this screening record using the fields from the provided PDF.
Screening Details
Date of Screening
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Time of Screening
*
Hour Minutes
AM
PM
AM/PM Option
Location / Site
*
Screening Type
*
Pre-employment
Random
For cause / reasonable suspicion
Post-incident
Return to work
Other
Screening Type - Other (specify)
Worker Name
*
Employee / Contractor
*
Employee
Subcontractor
Other
Company / Employer
Position / Role
Alcohol Screening
Alcohol Screening Completed
*
Please Select
Yes
No
Alcohol Device Used
*
Please Select
AlcoSense Nexus
Other
Alcohol Result
*
Please Select
Negative / 0.000 BAC
Non-negative / alcohol detected
Invalid test
Test refused
Not applicable
Recorded BAC Reading
Was the AlcoSense / Andalink app used to record the result?
Please Select
Yes
No
Not applicable
App Record Available
Please Select
Yes – result saved in app
Yes – result shared/exported
No
Not applicable
Drug Screening
Drug Screening Completed
*
Please Select
Yes
No
Drug Device Used
*
Please Select
DrugSense DS08 Plus Saliva Screen
Other
Test Kit Lot / Batch Number
Test Kit Expiry Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Sample Collection Time
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Drug Screening Result Summary
*
Please Select
Negative
Non-negative
Invalid test
Test refused
Not applicable
Amphetamine — AMP
*
Please Select
Negative
Non-negative
Invalid / unclear
Not applicable
Cocaine — COC
*
Please Select
Negative
Non-negative
Invalid / unclear
Not applicable
Methamphetamine — MET / METH
*
Please Select
Negative
Non-negative
Invalid / unclear
Not applicable
Opiates — OPI
*
Please Select
Negative
Non-negative
Invalid / unclear
Not applicable
Cannabis / THC — THC
*
Please Select
Negative
Non-negative
Invalid / unclear
Not applicable
Benzodiazepines — BZO
*
Please Select
Negative
Non-negative
Invalid / unclear
Not applicable
Oxycodone — OXY
*
Please Select
Negative
Non-negative
Invalid / unclear
Not applicable
Synthetic Cannabis — K2
*
Please Select
Negative
Non-negative
Invalid / unclear
Not applicable
Alcohol Indicator on Saliva Test — ALC
*
Please Select
Negative
Non-negative
Invalid / unclear
Not applicable
Actions and Confirmatory Testing
Was any result non-negative, invalid or refused?
*
Please Select
Yes
No
Confirmatory Testing Required
Please Select
Yes
No
To be confirmed
Not applicable
Confirmatory Testing Provider / Location
Collector and Declaration
Collector / Tester Name
*
Collector / Tester Signature
*
Worker Name (Declaration)
*
Worker Signature
*
Worker Declaration Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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