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Periodic Drug Testing Form Mobile App

The periodic drug testing form is utilized for employers or government agencies that perform workplace drug testing for reasonable suspicion of substance abuse, or those that engage in random drug testing for employees such as truck drivers, CDL operators, bus drivers, and more. A drug-free workplace, especially for certain key positions and jobs where public safety is involved, is of paramount importance. Urine drug tests are used to test for metabolites of common drugs including marijuana, cocaine, amphetamines, opiates, and phencyclidines. Drug tests can be issued as a part of a medical examination, or simply as a part of a drug-free workplace program.

Substance abuse causes employers significant sums each year by employees, in the best cases only missing work, and in the more severe cases, causing dangers to the well-being of the public. This form can be customized to take into account state by state regulations, such as medical marijuana which may, in the future, be precluded from such tests either by state regulation, federal regulation, or employers' own policies. A positive test can warrant dismissal, future testing, or disciplinary actions including further employee drug testing, while adulterated or tainted samples may call for a more closely monitored urine sample collection.

  • Lendlease
  • The Cooperative
  • PG&E
  • Toys R Us
  • Red Bull
  • Mirvac

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Take a peek inside the Periodic Drug Testing Form Mobile App

Included Features

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  • {{data.title}}

Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    I certify that I am the described applicant and that I have provided the specimen(s) described be...

  • Ico textbox

    Last Name

  • Ico textbox

    First Name

  • Ico textbox

    Middle Name/Initial

  • Ico textbox

    Reference Number

  • Ico textbox

    Social Security Number

  • Ico signature

    Signature of Applicant

  • Ico date

    Date

  • Ico textbox

    Name of Laboratory

  • Ico textbox

    Street Address

  • Ico textbox

    City

  • Ico dropdown

    State

  • Ico textbox

    Zip Code

  • Ico date

    Date Specimen Collected

  • Ico statictext

    Specimen Analyzed For (DOT 5 Panel): Marijuana metabolites, cocaine metabolites, opiate metabolit...

  • Ico dropdown

    Laboratory Results

  • Ico multiline

    The specimen is verified positive for:

  • Ico multiline

    The specimen was identified as being substituted or containing the adulterant:

  • Ico multiline

    The test was cancelled because:

  • Ico statictext

    I certify that I meet qualifications for a Medical Review Officer as outlined in Title 49 CFR 40.

  • Ico statictext

    Medical Review Office Contact Information

  • Ico textbox

    Last Name

  • Ico textbox

    First Name

  • Ico textbox

    Middle Name/Initial

  • Ico textbox

    Street Address

  • Ico textbox

    City

  • Ico dropdown

    State

  • Ico textbox

    Zip Code

  • ...and More!

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