Please upgrade your browser to ensure an optimum experience
or click on Compatibility View.

1-800-463-4310

Donor Information Referral Form

ATTENTION: After two consecutive missed collections, the contractor must notify the caseworker or supervisor for approval to continue testing. Please respond quickly so that collections can resume.

Note: For a paternity DNA analysis, please use a DNA collection order form.

Donor Information

Name

Case File Number

Phone Number

Male Female

Birth Date

Caseworker Information

Name

Agency

Phone Number

Fax Number

Email

Supervisor Information

Name

Phone Number

Safety Concerns

Address of Collection

Street

Postal Code

City

Entry (i.e. side door)

Urine/Oral Fluid/Breath

Lab-Based Urine Alcohol Analysis

Lab-Based 5-Panel Urine Drug Analysis

Lab-Based 10-Panel Urine Drug Analysis

Lab-Based Oral Fluid Drug Analysis

Instant 6-Panel Urine Drug Screen (+ Lab Confirmation if screen test result is non-negative)

Instant 10-Panel Urine Drug Screen (+ Lab Confirmation if screen test result is non-negative)

Breathalyzer (EBT)

Other:

Frequency of Testing

1 time only

1 time per month

Other:

2 times per month

1 time per week

2 times per week

3 times per week

Duration

1 time only

1 week

1 month

Other:

Donor Availability

Comments

Please confirm that you have received supervisor authorization for this test.