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    Rapid Urine Screen Test Results



    I certify that I provided my urine specimen to the collector and consent to have it analyzed, including laboratory confirmation analysis
    if requested by my employer. I provided my specimen and have not adulterated it in any manner. If prepared for laboratory
    confirmation, I certify that it was sealed in my presence with tamper evident labels

    X

    I certify that the specimen given to me by the donor identified above was collected, labeled, sealed and released as noted. If
    necessary for laboratory confirmation, I personally split the specimen in the presence of the donor and sealed the specimen for
    shipment

    X