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Does the employer utilize the standard five-part, carbonless, standard Federal Drug Testing
CCF?
Does the collector securely place an identification label on the bottles that displays the date,
the number, and any other identifying information provided or required by the employer? If
separate from the label, is the tamper-proof seal also applied?
Does the collector write the date on the seals?
Does the employee initial the identification label on the specimen bottles for the purpose of
certifying that it is the specimen collected from him/her?
Does the collector enter on the CCF all information identifying the specimen and sign the form
certifying that collection was accomplished in accordance with federal regulations?
Is the employee asked to read and sign a statement on the CCF certifying that the specimen
identified as having been collected from him/her is in fact the specimen he/she provided?
Does the collector check the CCF to assure that the dates and signatures are correct and
complete?
Does the collector complete the chain of custody portion of the CCF to indicate receipt of the
specimen from the employee and certify proper completion of the collection?
Are both bottles placed in a single shipping container, together with only Copy 1 of the CCF?
Are copies 1 through 5 of the CCF sent to the (1) laboratory, (2) MRO, (3) collector, (4) DER,
and (5) employee, respectively?
Were the collector and employee both present and was the specimen in view of both the
collector and employee during sealing, identification and labeling of the specimen bottles?
Was the collection site person the ONLY one to handle the specimen before it was poured
into the bottles and sealed with tamper-evident seals?
Does the collector have only one employee under his/her supervision at one time until the
collection process is completed (i.e., specimen has been collected, the urine bottle has been
sealed and initialed, the CCF has been completed and the employee has departed)?
Is the employee's employee identification or Social Security number completed and legible on
the CCF?
Is the employer's name, address, telephone, and fax numbers completed and legible on the
CCF?
Is the MRO's name and address, telephone and fax numbers completed and legible on the
CCF? A C/TPA may also be included.
Are the drugs for which testing is to be performed (unless the list is preprinted) completed and
legible on the CCF?
Is the reason for testing (pre-employment, random, etc. ) completed and legible on the CCF?
Is the time elapsed between when the employee finished voiding the specimen and when the
temperature reading was taken (must be less than 4 minutes), and whether the temperature
was within the required range (32°-38°C/90°-100°F) completed and legible on the CCF?
Is the chain of custody block for any transfer of the specimen at the collection site completed
and legible on the CCF?
Is the collector's name, date of collection, collection site location, remarks concerning unusual
collection circumstances, and whether a split sample was legibly completed on the CCF?
Is the collector's printed name, signature, time and date completed and legible on the CCF?
Is a dedicated facility securely maintained at all times?
Are only authorized personnel permitted in any area of the designated collection site where
urine specimens are collected or stored?
Is security of the collection materials and completed specimens within the collection site
maintained at all times?
Appendix K. Substance Abuse Management Oversight Questionnaires
K-17
August 2002