Workplace Drug Screening Laboratory Request Form
Employer / Company Information
Company Name
Contact Person
Phone Number
Email
Address
Employee Information
Employee Name
Employee ID / SSN
Date of Birth
Department / Job Title
Test Details
Date of Request
Type of Test
Pre-Employment
Random
Post-Accident
Other
Substances to Screen
Amphetamines
Cannabis
Cocaine
Opiates
PCP
Other
Additional Requests / Notes
Specimen Collection
Collection Site
Date of Collection
Specimen Type
Urine
Saliva
Hair
Other
Authorization & Certification
Authorized By
Date
Employer/Representative Signature
Date