Drug & Alcohol Test Consent

Consent form for drug & alcohol testing per DOT 49 CFR Part 40 and state law. Captures consent, chain of custody initiation, and refusal documentation.

Test Notice

• I have read and understand the testing notice
  You must acknowledge the notice before proceeding.
• Reason for test
• If other, describe the reason
• Test type

Participant Information

• Full name
• Employee ID or badge number
  Use an internal identifier if available. Do not enter SSN.
• Date of birth
  Collect only if required by your testing program or chain-of-custody process.
• Phone number

Consent and Authorization

• Do you consent to the requested drug and/or alcohol test?
• Consent acknowledgment
  By consenting, I authorize specimen collection, testing, laboratory analysis, and release of results to authorized parties as permitted by law.
• Reason for refusal
  Provide a brief reason if the individual refuses the test.
• Refusal acknowledgment
  I understand that refusal may have employment, regulatory, or safety consequences under applicable policy and law.

Chain of Custody Initiation

• Collection site
• Collection date
• Collection time
• Collector name
• Specimen type

Acknowledgment and Signature

• I certify that the information provided is true and complete to the best of my knowledge
• Signature
• Date signed