U.S. Department of Transportation/ Office of the Secretary of Transportation/ Office of Drug & Alcohol Policy & Compliance

Office of Drug & Alcohol Policy & Compliance

SPLIT SPECIMEN CANCELLATION NOTIFICATION
(49 CFR Part 40.187 & Appendix D)

Note: Information is required only for those tests where donor requested test of split

1.	Medical Review Officer Information
	Name:		Tel#:	( ) - ( EXT . )
	Address:		Fax#:	( ) - ( EXT . )
	City:	State:	Zip:

2.	Collection Site Information
	Name:		Tel#:	( ) - ( EXT . )
	Address:		Fax#:	( ) - ( EXT . )
	City:	State:	Zip:

Date of Collection

/ /

Specimen I.D. #

Laboratory "A" accession #

6.	:Primary Specimen Laboratory
	Name
	Address:	Tel#:
	City:	Fax#:
	State:	Zip:

Date primary laboratory reported or certified result

/ /

9.	Date split laboratory reported or certified split specimen result
	( check here if not applicable )	/ /

10.	Primary specimen results in the primary specimen
	(e.g. name of drug, adulterant, etc.)

11.

Reason for split specimen failure-to-reconfirm result

split specimen failed to reconfirm for

adulteration or substitution criteria not met

split specimen reported as invalid

split specimen not available for testing

	split specimen not collected
	split specimen leaked in transit to lab B
	split specimen lost in transit to lab B
	insufficient volume (no leakage)

split failed to reconfirm: split specimen adulterated

other (explain in comments)

12.	Action taken by MRO
	(e.g. notified employer of failure to reconfirm and requirement for recollection)

13.	Additional information explaining reason for cancellation (comments)

14.

Name of individual submitting the report (if not the MRO)

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