6207 Jim Snow Way · Chattanooga, TN 37421
Office 423.541.3210 · Fax 423.541.3209

Random Drug Screening — Collection Log

Non-DOT · oral fluid · confidential

Confidential. This log shows other employees’ results — do not hand this screen to an employee. Each employee completes the separate Donor Consent form. DOT-covered employees (for example CDL drivers under FMCSA) must be tested under 49 CFR Part 40 in a separate DOT pool with a DOT custody form and certified lab; do not use this form for them.

How to use this form (collector)

Run the random draw and fill in the selection record below. Employees are identified only by the last 4 of their SSN. If two share the same last 4, add a letter (1234-A, 1234-B); the list matching last-4 numbers to employees stays in the confidential file.
Check the test kits: in date, sealed, stored at the maker’s temperature. Record brand, lot and expiration.
Each employee fills in and initials their own Donor Consent form before collection. Never let employees see this log; it shows other people’s results.
Make sure the donor has had nothing in their mouth for 10 minutes. Open the device in front of them and read it at the time the maker’s instructions say.
Record the result from the drop-down. A refusal to test or to initial the consent form is recorded as “Refused to test” and described on that employee’s consent form with a witness.
A non-negative field result is preliminary, not a positive. Take the employee to the clinic the same shift for a test by a certified collector; do not let them drive. The clinic’s lab result, reviewed by a Medical Review Officer (MRO), is the final result. No discipline based on the on-site screen alone; removal from safety-sensitive work while waiting follows company policy.
Do not write a full SSN, medications, or any medical information on these forms. Employees discuss prescriptions only with the MRO.
File the set in the confidential drug-testing file, separate from personnel files, with access limited to Safety and HR.

1 · Random selection record

How the employees were chosen. Every non-DOT employee goes into every draw, including people tested before. Use alternates in the order drawn, only when a selected employee can’t be tested.

Date and time of draw *

Draw ID *

Drawn by (print) *

Witness (print) *

Number selected *

Selection method

Computer-generated random draw; every employee had an equal chance

Day shift in pool *

Night shift in pool *

Total in pool (adds up)

#	Last 4 of SSN	Shift	Selected or alternate	Tested?	If not tested, why
1			Selected
2			Selected
3			Selected
4			Selected
5			Selected
6			Selected
7			Selected
8			Selected
Alt 1			Alternate
Alt 2			Alternate
Alt 3			Alternate
Alt 4			Alternate

Drawn by (signature)

Witness (signature)

2 · Test event

Date of test *

Project site *

Job number *

Reason for test *

Start time *

Collector (print) *

Random draw ID

Date selected

Pool size (day / night)

3 · Test device

Device brand / model *

Drugs on panel (10)

Lot number *

Expiration date *

Stored at maker’s temp? *

Device in date

Package sealed, opened in front of donor

Nothing in donor’s mouth 10 min before

Read at the time the maker’s instructions require

4 · Employees tested

Rows 1–8: employees selected. Alt 1–4: alternates, used in order only if a selected employee can’t be tested. Last 4 and shift copy across from the selection record.

#	Last 4	Shift	Time notified	Time collected	Time result read	Device / specimen ID	Field result	Clinic custody # (if sent)	Consent initialed?	Collector initials
1
2
3
4
5
6
7
8
Alt 1
Alt 2
Alt 3
Alt 4

Notes

Refusals, recollections, device problems, anyone not tested and why

Sign-off

Collector (print) *

Date *

Time finished *

Collector signature

Safety Supervisor (print) *

Date

Time

Safety Supervisor signature