DOT Drug Testing Form CCF OMB 0930 0158 pdf

Updated 2-5-2014. Federal DOT Drug Testing Custody Control Form (CCF) OMB-0930-0158 for transportation industry DOT physical examinations and “Safety-Sensitive” employees. PDF-Printable-Free. Includes Instructions to Specimen Collectors and Maximum Allowable Drug Analyte Concentrations. Get Adobe Reader Here

Instructions for Completing the Federal Drug Testing Custody and Control Form (CCF).

When making entries use black or blue ink pen and press firmly Collector ensures that the name and address of the HHS-certified Instrumented Initial Test Facility (IITF) or HHS-certified laboratory are on the top of the CCF and that the Specimen I.D. number on the top of the CCF matches the Specimen I.D. number on the labels/seals.

STEP 1:

Collector ensures that the required information is in STEP 1. Collector enters a remark in STEP 2 if Donor refuses to provide his/her SSN or Employee I.D. number.

Collector gives collection container to Donor and instructs Donor to provide a specimen. Collector notes any unusual behavior or appearance of Donor in the remarks line in STEP 2. If Donor conduct at any time during the collection process clearly indicates an attempt to tamper with the specimen, Collector notes the conduct in the remarks line in STEP 2 and takes action as required.

STEP 2:

Collector checks specimen temperature within 4 minutes after receiving the specimen from Donor, and marks the appropriate temperature box in STEP 2. If temperature is outside the acceptable range, Collector enters a remark in STEP 2 and takes action as required.

Collector inspects the specimen and notes any unusual findings in the remarks line in STEP 2 and takes action as required. Any specimen with unusual physical characteristics (e.g. unusual color, presence of foreign objects or material, unusual odor) cannot be sent to an Instrumented Initial Test Facility (IITF) and must be sent to a Department of Health and Human Services (HHS) certified laboratory for testing as required.

Collector determines the volume of specimen in the collection container. If the volume is acceptable, Collector proceeds with the collection. If the volume is less than required by the Federal Agency, Collector takes action as required, and enters remarks in Step 2. If no specimen is collected by the end of the collection process, Collector checks the None Provided box, enters a remark in STEP 2, discards Copy 1 and distributes remaining copies as required.

Collector checks the Split or Single specimen collection box. If the collection is observed, Collector checks the Observed box and enters a remark in STEP 2.

STEP 3:

Donor watches Collector pour the specimen from the collection container into the specimen bottle(s), place the cap(s) on the specimen bottle(s), and affix the label(s)/seal(s) on the specimen bottle(s).

Collector dates the specimen bottle label(s)/seal(s) after placement on the specimen bottle(s).

Donor initials the specimen bottle label(s)/seal(s) after placement on the specimen bottle(s).

Collector turns to Copy 2 (Medical Review Officer Copy) and instructs Donor to read and complete the certification statement in STEP 5 (signature, printed name, date, phone numbers, and date of birth). If Donor refuses to sign the certification statement, Collector enters a remark in STEP 2 on Copy 1.

STEP 4:

Collector completes STEP 4 on Copy 1 (signature, printed name, date, time of collection, and name of delivery service), placesthe sealed specimen bottle(s) and Copy 1 of the CCF in a leak-proof plastic bag, seals the bag, prepares the specimen packagefor shipment, and distributes the remaining CCF copies as required.

Analyte Maximum Concentrations:

Initial test analyte Initial test cutoff concentration Confirmatory test analyte Confirmatory test cutoff concentration
Marijuana metabolites 50 ng/mL THCA1 15 ng/mL
Cocaine metabolites 150 ng/mL Benzoylecgonine 100 ng/mL
Opiate metabolites Codeine/Morphine2 2000 ng/mL Codeine Morphine 2000 ng/mL
6-Acetylmorphine 10 ng/mL 6-Acetylmorphine 10 ng/mL
Phencyclidine 25 ng/mL Phencyclidine 25 ng/mL
Amphetamines3 AMP/MAMP4 500 ng/mL Amphetamine Methamphetamine5 250 ng/mL
MDMA6 500 ng/mL MDMA MDA7 MDEA8 250 ng/mL

1 Delta-9-tetrahydrocannabinol-9-carboxylic acid (THCA).

2 Morphine is the target analyte for codeine/morphine testing.

3 Either a single initial test kit or multiple initial test kits may be used provided the single test kit detects each target analyte independently at the specified cutoff.

4 Methamphetamine is the target analyte for amphetamine/methamphetamine testing.

5 To be reported as positive for methamphetamine, a specimen must also contain amphetamine at a concentration equal to or greater than 100 ng/mL.

6 Methylenedioxymethamphetamine (MDMA).

7 Methylenedioxyamphetamine (MDA).

8 Methylenedioxyethylamphetamine (MDEA).



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