Drug/Alcohol Test Collection Note (DOT/Non-DOT)

Date: [Date of encounter]
Start Time: [Start time]
End Time: [End time]
Collection Site: [Site name and full address]
Encounter Type: Specimen Collection

Parties and Roles

• Collector: [Name, qualification/credential, contact info] (Required; if not obtained, enter "Not obtained: [explanation]")
• BAT/STT: [Name, qualification/credential] (Include only if alcohol testing performed)
• Observer/Monitor: [Name, role, gender match status: matched / not matched] (Include only if observed or monitored collection occurred)
• DER Contact: [Name, phone, organization]

Test Authorization

• Program Type: [DOT / Non-DOT] (Required; do not infer. If not obtained, enter "Not obtained: [explanation]")
• DOT Agency: [FMCSA / FAA / FRA / FTA / PHMSA / USCG] (Include only if DOT)
• Reason for Test: [pre-employment / random / post-accident / reasonable suspicion / return-to-duty / follow-up / other]
• Specimens Ordered: [drug test / alcohol test / both]
• Specimen Matrix: [urine / oral fluid]
• Panel: [Panel name or number] (Non-DOT only; include only if specified)
• POCT Performed: [yes / no] (Non-DOT only)

Identity Verification

• Donor Identifiers: [Full name, DOB, secondary identifier per policy]
• ID Method: [government photo ID / employer photo ID / DER verification / other] (Required; if not obtained, enter "Not obtained: [explanation]")
• Alternate Verification Detail: [Verification method used if donor lacked acceptable ID; DER consulted with name and time] (Include only if applicable)
• Communication Accommodations: [Interpreter or alternative communication method] (Include only if applicable)

Drug Test Collection

(Include this section only if a drug test was performed)

• CCF/Chain-of-Custody ID: [CCF number] (Required; if not obtained, enter "Not obtained: [explanation]")
• Collection Mode: [unobserved / directly observed / monitored] — [Reason for observed/monitored collection; observer/monitor name and role] (Required; include reason and observer identity only if observed or monitored)
• Site Integrity: Standard site preparation completed: [yes / no]. Deviations: [None / description of deviations]

Urine Collection (Include only if specimen matrix is urine)

• Specimen Volume: [Volume in mL]
• Temperature Check: [Time checked] — Within range: [yes / no] — [Action taken if out of range] (Required; if not obtained, enter "Not obtained: [explanation]")
• Split Specimen: A/B prepared in donor presence, donor initialed seals: [yes / no] (If no, explain)
• Donor Certification: Signed: [yes / no] (If no, explain)

Oral Fluid Collection (Include only if specimen matrix is oral fluid)

• Device: [Device name] — Expiration verified: [yes / no]
• Visual Contact Maintained: [yes / no]
• Oral Cavity Check: Performed: [yes / no] — Items removed: [yes / no / not applicable]
• Sufficient Volume Indicator: Observed: [yes / no]
• Split Handling: A/B sealed, donor initialed: [yes / no] (If no, explain)

Insufficient Specimen Protocol (Include only if shy bladder or dry mouth protocol initiated)

• Protocol Start/End Time: [Start time] — [End time]
• Fluids Offered: [Type and volume per protocol; donor accepted / declined]
• Attempts: [Number of attempts with times]
• Outcome: [Outcome description]
• DER Notified: [Time and method]

Alcohol Test

(Include this section only if alcohol testing was performed)

• ATF ID: [ATF number] (Required; if not obtained, enter "Not obtained: [explanation]")
• Device: [Type, model, serial number or expiration]
• Screening Time: [Time]
• Screening Result (BrAC): [Result]
• Donor Released: [Time] (Include only if below threshold and donor released)

Confirmation Test (Include only if screening at or above threshold)

• Waiting Period: Start [Time] — End [Time] — Donor observed by [Name/role] — Waiting instructions followed: [yes / no]
• Air Blank: Performed: [yes / no]
• Confirmation Time: [Time]
• Confirmation Result (BrAC): [Result]
• Result Transmitted to DER: [Time and method]

Irregularities and Exceptions

(Always include this section)

[None noted.] (Use if no irregularities occurred)

(If irregularities occurred, document as time-stamped entries with objective facts only. Include donor behaviors affecting collection integrity, procedural deviations, device issues, specimen integrity concerns, and notifications made. Do not include legal conclusions such as "refusal.")

• [Time] — [Objective description of event] — [Action taken and/or notification made]

Chain of Custody and Shipment

• CCF/ATF Completed: Collector signed: [yes / no] — Date/Time: [Date and time]
• Copies Distributed: Donor copy provided: [yes / no] — Copies to MRO/DER: [method and date/time]
• Specimen Packaged and Sealed: [yes / no]
• Transferred to Courier: [Date/time, courier service, tracking number if available]
• CCF/ATF Storage Location: [Location where form is stored, e.g., scanned to media tab]

Collector Attestation

I attest that this collection was performed in accordance with applicable protocol, chain-of-custody was maintained, required forms were completed, and any deviations are documented above.

• Collector Signature: [Name/signature] — Date/Time: [Date and time]
• BAT/STT Signature: [Name/signature] — Date/Time: [Date and time] (Include only if alcohol testing performed)
• Observer/Monitor Signature: [Name/signature] — Date/Time: [Date and time] (Include only if observed/monitored collection occurred)