Split Specimen Cancellation Notification (49 CFR Part 40.187 & Appendix D)

Published on Department of Transportation (http://www.dot.gov)

Split Specimen Cancellation Notification (49 CFR Part 40.187 & Appendix D) [1]

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

Medical Review Officer Information

Name

Address

City

State

Zip

Tel#

Fax#

Collection Site Information

Name

Address

City

State

Zip

Tel#

Fax#

Date of Collection

Month

Day

Year

Specimen I.D. #

Laboratory "A" accession #

Primary Specimen Laboratory

Name

Address

City

State

Zip

Tel#

Fax#

Date primary laboratory reported or certified result

Month

Day

Year

Split Specimen Laboratory

check here if not applicable

Name

Address

City

State

Zip

Tel#

Fax#

Date split laboratory reported or certified split specimen result

check here if not applicable

Month

Day

Year

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

Action taken by MRO

(e.g. notified employer of failure to reconfirm and requirement for recollection)

Additional information explaining reason for cancellation (comments)

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

If you would like an email copy of this completed form, enter your email address

Source URL: http://www.dot.gov/content/split-specimen-cancellation-notification-49-cfr-part-40187-appendix-d

Links:
[1] http://www.dot.gov/content/split-specimen-cancellation-notification-49-cfr-part-40187-appendix-d