Medical Review Officer (MRO) Result Verification Note

MRO Result Verification Note

MRO: [MRO name, credentials, license state/number, organization, contact phone]

Case Identifiers: [MRO case ID]; [Laboratory accession/specimen ID]; [CCF/ECCF ID]

Donor/Employee: [Full name]; [DOB / Employee ID]; [Identifiers matching CCF/ECCF]

Testing Context: [Test reason: pre-employment / random / post-accident / reasonable suspicion / return-to-duty / follow-up / other]; [Specimen type: urine / oral fluid]; [Collection date/time]

Program Authority: [DOT (mode: FMCSA / FAA / FRA / FTA / PHMSA / USCG) / HHS Federal Agency / Non-regulated employer program]

Designated Recipient (DER/DPC): [Name, role, organization, contact method]

Result Received

[Date/time result received from laboratory; result category: negative / positive / adulterated / substituted / invalid / negative-dilute; implicated drug(s)/analyte(s) if applicable; statement that verification will proceed per applicable program requirements]

Documents Reviewed

• Custody and Control Form: [Format: paper / electronic]; [Legibility/completeness status]; [Collector and donor signatures: present / missing]; [Discrepancies or errors identified, if any]
• Laboratory Report: [Received date/time]; [Certifying scientist signature: present / not applicable]; [Result summary as reported]
• Supplemental Materials: [Corrective action documents, prescription images, pharmacy printouts, prescriber correspondence, or other attachments reviewed] (Only include items actually received.)
• Form/Process Issues: [Deficiencies identified: incomplete fields, mismatched identifiers, signature omissions, temperature or seal issues] (If corrective documentation was requested, note from whom, date/time, and outcome.)
• Cancellation Basis: [Specific flaw requiring cancellation per governing program rule] (Only include if cancellation is required.)

Contact Attempts and Timeline

(For routine verified negatives requiring no donor contact: state "No donor contact required under applicable program; verification performed based on laboratory documentation alone.")

(For non-negative results or cases requiring donor contact, document chronologically:)

• [Date/time; method: phone / voicemail / text / email; party contacted: donor / DER; outcome: spoke / left message / no answer / delivery failure]
• (Add additional entries as needed. Include when DER involvement was requested and outcomes.)

Verification Interview

(Include this section only if an interview was conducted or attempted.)

Interview Date/Time: [Date/time; duration; time zone]

Modality: [Phone / Video / In-person]

Identity Verification: [Method used: DOB, last 4 SSN, employee ID, other]

Interpreter: [None / Language and interpreter identification]

Required Disclosures Provided: [Yes / No]

Donor Explanation Summary: [Narrative summary of donor's explanation for the result, including reported medications, OTC products, supplements, herbal products, environmental exposures, and any collection issues]

• Medication: [Name]; [Dose/route/frequency]; [Last dose timing relative to collection]; [Indication]; [Prescriber]; [Documentation provided: Rx label / pharmacy printout / prescriber letter / none] (Repeat for each relevant medication.)
• Validity/Exposure Claims: [Medical conditions, exposures, or collection factors relevant to invalid/adulterated/substituted findings] (Only include if applicable.)

Prescription Verification: [Pharmacy or prescriber contacted: name, role, callback number, date/time]; [Information confirmed: medication, strength, dates filled, prescriber]; [Prescription active during relevant timeframe: Yes / No]; [Plausibility of medication accounting for analyte: plausible / not plausible / indeterminate] (Only include if verification was performed.)

Interview Not Completed: [Reason: declined / unreachable / medically unable]; [Summary of attempts]; [Donor advised of reopening period: Yes / No; timeframe per program] (Only include if interview was not completed.)

MRO Determination

Final Verified Disposition: [Verified Negative / Verified Positive (specify drug/analyte) / Refusal to Test (specify basis) / Cancelled (specify reason)]

Rationale: [Explanation linking determination to evidence: CCF findings, laboratory report, interview content, prescription verification results, laboratory consultations; explicitly state why medical explanation was accepted or rejected, or why cancellation was required]

Recollection Required: [Yes / No]; [Conditions: direct observation, timing, specimen type] (Only include if test was cancelled.)

Notifications

• Report to DER/DPC/Employer: [Date/time]; [Method: secure portal / encrypted email / fax / phone]; [Recipient name/title]; [Confirmation of receipt: yes / no]
• Employee Notification: [Date/time]; [Method]; [Result category and next steps/rights communicated]
• Split Specimen Rights/Request: [Employee informed: date/time]; [Request window per program]; [Request received: yes / no; date/time]; [Actions taken to direct split to certified laboratory] (Only include if applicable.)
• Pending Verification: [Result not yet reported]; [Materials being obtained]; [Follow-up plan and timeline] (Only include if verification is incomplete.)

Additional Actions

(Include this section only when applicable.)

• Laboratory Consultation: [Question posed]; [Lab contact name and role]; [Date/time]; [Lab explanation or recommendation]
• Safety-Sensitive Communication: [Trigger for concern]; [Recipient: medical department / safety officer / other]; [Brief summary of safety concern] (Keep separate from standard result reporting per DOT 40.327.)

Attestation

MRO Signature: _______________________________________________

Date/Time Authenticated: [Date/time; time zone]

I attest that this MRO determination is independent and based solely on the materials reviewed and applicable program requirements. Any subsequent changes will be documented as dated addenda without altering original content.

Confidentiality: This verification record is confidential and released only to authorized parties per the governing program and applicable law. MRO records are maintained separately from general medical and personnel files.