🧪 Drug Screen Form
Record member drug test results
View Test History
Applications
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Member Information
Member ID *
Member Name *
Test Information
Test Date *
Test Time *
Test Type *
Select test type...
Urine Test
Saliva Test
Blood Test
Staff Member Conducting Test *
Member was observed:
YES
NO
Temp checked:
YES
NO
Test Results
THC
NEG
POS
COC
NEG
POS
MOP/OPI 300
NEG
POS
AMP
NEG
POS
mAMP
NEG
POS
BZO
NEG
POS
FENT
NEG
POS
BAR
NEG
POS
MDMA
NEG
POS
MTD
NEG
POS
OXY
NEG
POS
PCP
NEG
POS
TCA
NEG
POS
Breathalyzer
ALCOH
NEG
POS
Blood Alcohol Content (BAC)
Other Substances
Additional Substances Not Listed
Additional Information
Notes / Comments
Action Taken
Select action...
None - All Negative
Verbal Warning
Written Warning
Referred to Counseling
Placed on Probation
Discharged from Program
Other (see notes)
Signatures
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Staff Member Signature *
Clear
Member Signature *
Clear
Submit Drug Screen