CD1022- Private Workplace - Oral Fluid / Urine / Breath POC

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CCN

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DB Record ID

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Welcome Donor and explain the procedure.

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GDPR Consent* This field is required.Prior to testing please ensure donor has a copy of the Privacy and Data Retention Policy and provide consent on CD1083 Nivha Privacy Notice for GDPR (Sample Collection). By signing below, I confirm that I have reviewed the GDPR / privacy information provided and I am happy to proceed with the Drug and Alcohol screening and/or sample collection procedure.

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Client* This field is required.

Ryobi (Recruitment / Direct)

Private Client

Workplace Client

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Select Company* This field is required.

Kenect (Ryobi Recruitment)

GenTech (Ryobi Recruitment)

TechTrade (Ryobi Recruitment)

Ryobi - Direct / Permanent

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Ryobi Company (To NIV Code)

Kenect (Ryobi Recruitment)

GenTech (Ryobi Recruitment)

TechTrade (Ryobi Recruitment)

Ryobi - Direct / Permanent

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Requesting Company* This field is required.

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Company Location* This field is required.

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Lab Selection Company Codes

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Company NIV Code -* This field is required.

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Company NIV Code* This field is required.

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Company NIV Code (Final)

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Confirm Company selection
Company: {comp_name}
NIV Code: {comp_code_final}
If this is not correct, go back and choose the correct company before proceeding.

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Collector's Organisation* This field is required.

NIVHA

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Type(s) of Testing* This field is required.

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Donor Name* This field is required.

First Name

Last Name

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Donor Date of Birth* This field is required.

Date

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Donor Gender* This field is required.

Male

Female

Other

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Is Donor verified?* This field is required.

YESNO

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Donor ID Number

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Donor Front Face / Copy of ID* This field is required.Take a photo of the Donor's Face if no ID is presented. OR take a photo of the Donor's identification

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Requestor's Email* This field is required.

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* This field is required.Has the donor eaten, drank, chewed or smoked within 15 minutes?

YESNO

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Donor Declaration and Consent (Screening)* This field is required.

1. I give my consent for a sample(s) of breath, oral fluid and/or urine to be screened for the presence of alcohol and/or drugs. I have no foreign substances in my mouth and have not had anything to eat or drink for at least 15 minutes. Smoking is not allowed during this period and for the duration of the test.

2. I understand that if my screening tests give a Non-Negative result(s) it may be necessary to collect additional samples under 'Full Chain of Custody' conditions which will be sent to an Accredited Laboratory for further analysis.

3. At this stage 'you' the donor will not be regarded as having provided a 'Positive' sample although precautionary steps (including temporary suspension) may need to be taken in case these sample(s) confirm as 'Positive'

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I have read the donor declaration and CONSENT / REFUSE to provide a Specimen(s)* This field is required.

ConsentRefuse

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Donor Consent Signature* This field is required.

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Collector Name* This field is required.

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Collector NIV Code* This field is required.

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Collector Signature* This field is required.

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Collection Date & Time* This field is required.

Date

Hour

Minutes

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Time of Breath Test* This field is required.This is important for potential alcohol count-backs. Please enter time accurately to the minute.

Hour

Minutes

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Breath Tester Serial No.* This field is required.

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Perform Breath Test 1&2* This field is required.

Number

Result (mg/L)

Sample #1

Sample #2

Sample #1

Sample #2

Number

Result (mg/L)

Number

Result (mg/L)

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Company cut-off level* This field is required.

0.35 mg/L

0.09 mg/L

0.22mg/L

Other

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Alcohol Result* This field is required.If alcohol was detected but the reading was below 0.10 mg/L, select PASS (count-back not applicable).

Pass

Fail

Pass (Advisory)

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Record Breathalyser Model, Serial Number, Calibration Information

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Drager DC3000 Oral Fluid (POC) - Procedure (Skip for AllTest)

Donor & Collector put on the disposable gloves provided in the pack.
Open the Drugcheck 3000 test kit.
Remove the sample collector from the device and ask the donor to provide an Oral Fluid Specimen (adequacy confirmed by loss of pink colour on the collector (15-20s))
Place a barcode number on the DrugCheck3000 device just below the Security tab.
Press the collector firmly into the device funnel until the flange and funnel meet, shake device for 15-20 secs until pink colour at rim disappears.
Tap the base of the device on the bench and leave upright until breath test has been completed.

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AllTest / WeAreHealth / DrugSure Oral Fluid (POC) - Procedure

Record Serial No/ Lot no/Expiry Date for the ALL TEST device in the next section of the form
Donor & Collector put on the disposable gloves if they have not already done so
Open the ALL TEST drug test kit. Remove the cap from the device and ask the donor to provide a specimen
Donor to rub wick on gums & both cheeks before placing below tongue for approximately 90 seconds

Start timer and review as follows:

If device includes the alcohol indicator – read device after 2 minutes. If indicator turns blue/green, alcohol is present. Record result on Alcohol Screen section of collection form
Drugs – read device after 3-10 mins

If all lines are clearly visible at 3 minutes or sooner than the test can be interpreted as negative and discarded. If any lines are not visible at 3 minutes put back in mouth then the test should be re-read at 10 minutes

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For Urine (POC) - Procedure

Ask Donor to select a testing kit and hand it to you (of they've not already done so).
Donor & Collector put on the disposable gloves.
Ask Donor to open urine POC device, remove lid & provide a urine specimen in the prepared toilet cubicle.
Replace lid on urine collection device.
If using a key device (eg ALL Test) remove key from lid and insert in side of device.
Start timer (5-8 mins or see manufacturer's instructions.

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Drug Screening Device Type* This field is required.

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How do you want to input the Kit info?* This field is required.

Scan the QR CodeEnter it manually

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Select Collection kit and scan QR code on the foil pack* This field is required.

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Kit Ref Number* This field is required.

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Lot Number* This field is required.

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Expiry* This field is required.

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Drug Screen / Confirmation Checks* This field is required.

OBSERVED (Oral Fluid)

Temp OK (Urine)

Temp NOT OK (Urine)

Unable to Provide Sample

Unusual Appearance of Specimen

Other

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Drug Result* This field is required.

Negative

Non-Negative

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Drug Screen ResultTake a clear photograph of the Drug Screening Result

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Explain that the sample has screened Non-Negative and is now required to go back to the Laboratory. Inform the donor at this stage they are deemed as Non-Negative (Not Positive)* This field is required.

ProceedDo Not Proceed

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Reason for not going back to lab and / or accepting breath test* This field is required.

Donor Refusal to Provide

Company Policy

Unable to provide

Other

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Lab Name* This field is required.

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If Non-Negative, select Drug(s):* This field is required.

OF Quantisal - 6 Drugs Panel

Oral Fluid Q - Amphetamine Confirmation

Oral Fluid Q - Benzodiazepine Confirmation

Oral Fluid Q - Cannabis Confirmation

Oral Fluid Q - Cocaine Confirmation

Oral Fluid Q - Ketamine Confirmation

Oral Fluid Q - Methadone Confirmation

Oral Fluid Q - Opiate Confirmation

Urgent Testing Request OF

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Test Code(s)

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Declared MedicationType Donor's Medication in each row and date or day when last taken. Try to keep the format consistent like so: Paracetamol - Today Nurofen - 1/1/24

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Open the Collection Kit and select how you want to enter the Barcode?* This field is required.

ScanInput

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Scan the Barcode* This field is required.

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Input the Barcode* This field is required.

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Barcode (For Reports)

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Eurofins Fast Track Collection Procedure

- Please now complete a paper-based Further Analysis Form.

- You will be asked to scan a copy of the Laboratory Barcode Number and take a photo of the Further Analysis Form.

- Note: You are not required to email a copy of the Further Analysis Form after this collection as it will recorded in this form.

- Remember: (only for this process) Include a copy of the paper Further Analysis Form with the sample.

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Take a photo of the paper Further Analysis Form (NOTUSED)

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Take and Upload another (High-Resolution) photo of the Further Analysis Form

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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Select Quantisal / Intercept Kit

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Collection Process - Oral Fluid

1. Donor selects & collector opens a Confirmation kit (Purple Pack used for standard turnaround testing and sent to Matrix, Green Pack used for express testing and sent to Eurofins), Collector & Donor To put on Gloves

2. Record both device pack (Oral-Eze, Quantisal or Intercept) batch numbers and expiry dates in the next section.

3. Open device packs & remove contents

4. Give collection devices to the donor and ask them to place the pads below tongue & rub inside cheeks

5. When indicator window on devices turns blue (indicating adequate sample) after 15 minutes, place devices in the tubes containing the buffer, ensuring the lid is firmly closed (illustrated on back of Oral Eze, Quantisal or Intercept pack)

6. Confirm that the Oral Fluid Sample collection has been observed

7. Ask donor to initial and date two of the long tamper evident bar-coded strips. Carefully stick one marked ‘A’ over the lid and down the sides of tube ‘A’. Repeat the above process for the ‘B’ sample

8. Place Printed Barcode Numbers around the base of the two sealed collection tubes and on the tamperproof bag

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Consent of Donor

I consent to my sample being submitted to a laboratory for testing.

I understand that the results of the test will only be made available to the organisation requesting the test or their authorised representatives. (includes Medical Review Officer if required)

I have witnessed my sample(s) being sealed in my presence with tamper-evident tape.

I have initialled and dated the tamper-evident tape.

I have checked that the same identifying barcode number is on each portion of this form and each portion of my sample.

I have declared any medication taken during the last 14 days.

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Specimen Type* This field is required.

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Laboratory Request* This field is required.

Drug Screening

Confirmation

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Laboratory Test Request* This field is required.If you selected Drug Screening, please type in the panel required (Urine Only). If you selected Confirmation, please type in the Drug(s) requiring Confirmation.

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Donor Signature -* This field is required.I hereby consent to the submission of my sample to a laboratory for testing and understand that the results will be disclosed solely to the organisation requesting the test or their authorised representatives, including a Medical Review Officer if necessary. I confirm that I have witnessed my sample(s) being sealed with tamper-evident tape in my presence, on which I have affixed my initials and date. I have verified that the same identifying barcode number is present on every part of this form and my sample(s). Furthermore, I have declared any medication I have taken in the last 14 days.

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Collector Signature -* This field is required.I certify that the sample identified on this form is the sample provided to me by the donor who has consented to this test. The sample was collected, labelled, sealed and packaged. in the donor's presence as required by the instructions provided.

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Donor Signature - I do not consent to test* This field is required.

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Donor Statement* This field is required.I confirm that I agree with the screening procedure performed and am satisfied with the process.

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Consent Date/Time* This field is required.

Date

Hour

Minutes

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Scan the Postage Tracking Number

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Input the Postal Tracking Number (if scanner is not working)

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Postal Tracking Number (hidden)

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Comments/Screen/Confirmation

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Urine Specimen Transportation Instructions

1. Place both specimens in the tamperproof bag and seal the bag.

2. Place sealed bag in the laboratory postage-paid envelope provided

3. Seal envelope and make preparation to post sample.

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Oral Fluid Specimen Transportation Instructions

1. Place both specimens in the transport protector provided.

2. Close the device and place this in the tamperproof bag and seal the bag.

3. Place sealed bag in the laboratory postage paid envelope provided

4. Seal envelope and make preparation to post sample.

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Was there a company representative / witness present?

YESNO

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Witness / Representative Name

First Name

Last Name

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Witness Signature

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Collector Declaration* This field is required.I certify that the test and results specified on this form relate to the individual concerned. I am satisfied that the donor's identify has been verified and I have carried out the procedure in accordance with instructions and have not left the Donor unattended during the course of the procedure.

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NIVHA Signature EmailTo receive a copy of Jotform Sign PDF

example@example.com