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Get CLIAwaived PN: 2380

OTO ID q DONOR SSN, DRIVER’S LICENSE or EMPLOYEE I.D. NO. DONOR NAME: Last: REASON FOR TEST: COLLECTOR NAME EMPLOYER REP. q First: Pre Employment q Random q Reasonable Suspicion / Cause q Post Accident q Return to Duty q (PRINT) Read specimen temperature with in (4) minutes: q q Yes, 90º - 100ºF (32º - 38ºC) Follow Up q Other q ____________________________________________ Collector Phone No. (__________) _____________________________________ Collector Fax No. (________.

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