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Reason for Test
• • •
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Person Performing Test
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Alcohol Breathalyzer Test was done
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Breathalyzer Results:
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Instrument Used
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Urine Drug Test Done
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COC
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THC
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OPI
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AMP
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OXY
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MET
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Sent to Lab (confirmatory test)
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ALL Positive Results: Notify RMI MRO (Occupational Health Director)
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RMI Medical Review Officer notified:
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Work/Duty Status
• • •
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Safety/Management Notified
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Name: Safety/Management notified
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Reason for not notify Safety/Management
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Additional Comments:
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