DRUG / ALCOHOL TEST REPORT

Rank Photograph
Tabular No
Name
Address
Civil status
Weight (kg)
Height (cm)
Hair colour
Eye colour
Distinguishing marks
I certify that I am the person being tested for the presence of drugs and/or alcohol in my
blood/urine whose name appears on this medical record, and that I have truthfully answered the
questions asked regarding my well being.
Date of test: Signature of Applicant:

CERTIFICATION
I certify that the laboratory examination I certify that the laboratory examination
of the blood/urine samples of the applicant of the blood/urine samples of the applicant
named above for prohibited drugs has been named above for significant level of alcohol
carried out using the test principle of has been carried out using
agglutination immunoassay. Test results chromatography method. Test results are
are as shown below. as shown below.
Negative Positive Negative Positive
Amphetamines incl. Alcohol
Ecstasy
Barbiturates &
Benzodiazepines
Cannabis
Cocaine
Methadone
Opiates incl. Heroin
Phencyclidine
Propoxyphene
Ketamine

Other comments: Other comments:

Signed Signed Signed Signed

(Medical Technician) (Pathologist) (Medical Technician) (Pathologist)
Date: Date:

Note for Medical Examiner: Each line should be completed. Please tick in the appropriate box to show whether
each test was positive/or negative.

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