MANILA HEALTH DEPARTMENT – PUBLIC HEALTH LABORATORY

1559 Alvarez Street Barangay 334 Santa Cruz Manila

Tel No. 5310-1329
DRUG TESTING CONSENT FORM
(Form DT – 001)

CODE No. ____________________

 OFFICIAL RECEIPT or REFERENCE NUMBER _____________________  TYPE OF ID __________________
 DATE _____________________  TIME _______________________  ID No.______________________
NAME ___________________________________________________  SEX  Male Female
Last Name First Name Middle Name
 ADDRESS________________________________________________  CONTACT No.________________
 BIRTHDATE [mm]_____ [dd] _____ [year] _________  AGE ________  CIVIL STATUS________________
 COMPANY ______________________________________________________________________________
 Purpose of Drug Test:
 EMPLOYMENT     Private  Government
 LICENSE   Driver’s  Firearm’s
 STUDENT   Secondary School  Tertiary School
 Candidate for Public Office whether Appointee or Elected
 Person apprehended or arrested for violating the provisions of this act
 Persons charge before the Prosecutor’s Office with a criminal offense having an
imposable penalty of imprisonment of not less than six (6) years and (1) day
 Others (please specify) ________________________________________

Instructions: Answer the questions below by checking the appropriate spaces below your answer.
Afterwards, read the statements below signing the two for your signature.
 Have you taken any medication or drugs in the past 30 days?  Yes  No
 Have you ingested any alcoholic beverage in the past 24 hours?  Yes  No
 If you are taking medication of drugs, list these items below:
_____________________________________________________________________________________
 I hereby consent and agree to give sample of my:
 URINE  Blood  Saliva  Hair Sweat  Tissue
The result of any tests performed shall be provided to the requesting office or agency. My signature below
acknowledges that I have read and understood the foregoing statement and i have answered all the
questions truthfully.
 DATE_______________  SIGNATURE_____________________________________
I hereby consent and agree that my _______________ specimen, if found positive be sent to duly
accredited/licensed Confirmatory Laboratory for confirmatory test.
I hereby acknowledge that the _______________ sample is my own and that the samples were sealed in
my presence. These samples are to be tested for dangerous drugs.
 DATE ______________  SIGNATURE_____________________________________
__________________________________________________________________________________________
CERTIFICATION
I hereby certify to the best of my knowledge that I have not been found positive of any Regulated
Drugs by any Drug Testing Laboratory for the past six (6) months.

And that should I be found making false statements to this regard, I shall be held liable and shall be
charged of perjury. And that all appurtenances in case I shall be found negative by this Drug Testing
Laboratory shall be revoked as a consequence of such false statements.
 NAME ___________________________________________________________
 SIGNATURE_________________________________________________________
 COMPLETE ADDRESS __________________________________________________
 DATE _____________________________________________________________

DTL Name : Manila Health Department – Public Health Laboratory

 MANILA HEALTH DEPARTMENT – PUBLIC HEALTH LABORATORY
1559 Alvarez Street Barangay 334 Santa Cruz Manila
Tel. No. 5310-1329
CUSTODY AND CONTROL FORM
(Form DT – 002.B – COPY FOR THE COLLECTION SITE)

SPECIMEN ID NO.:_____________________ LAB ACCESSION NO.:_____________________

STEP 1 COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE
Client’s/Donor’s/Subject’s Code______________ADDRESS______________________________________AGE____SEX____
Employer’s Name and Address_______________________________________________________________________________
TYPE OF SPECIMEN: REASON FOR TEST:
 Urine  Pre-Employment  Random  Reasonable Suspicion/Cause
 Blood  Return-to-Duty  Mandatory  Post Accident
 Others (specify) _____________________  Follow-up  Other’s (specify)_____________________
Drug Test to be Performed:  THC, COC, PCP, OPI, AMP  THC & MET Only  Others (specify) ________________________
STEP 2 COMPLETED BY COLLECTOR
Read specimen temp. within 4 mins. Specimen Collection:  Observed  Unobserved Other Observation
Is temperature between 32oC & 38oC? Specimen Sampling:  Single  Split (Enter Remark)
 Yes  No Specimen Volume ___ml Physical Appearance: Color ____
REMARKS
STEP 3 Collector affixes bottle seal(s) to bottle(s). Collector dates seal(s). Donor initial seal(s). Donor completes STEP 5.
STEP 4 CHAIN OF CUSTODY – INITIATED BY COLLECTOR AND COMPLETED BY LABORATORY
I certify that the specimen given to me by the identified in the certification section on Step 5 of this form was collected, sealed
and released to the Delivery Service noted in accordance with applicable DOH requirements.
SPECIMEN BOTTLE(S) RELEASED TO:
X____________________________ _______________AM/PM 
Signature of Collector Time of Collection
______________________________________________
_____________________________ _____________________ 
Name of Delivery Service Transferring Specimen to Lab.
(PRINT) Collector’s Name (First,M.I.,Last) Date (mm/dd/year)
RECEIVED AT LAB: STATUS OF THE SPECIMEN: SPECIMEN BOTTLE(S) RELEASED
a) Seal Intact  Yes  No TO:
X____________________________ _____________AM/PM
Signature of Accessioner Time of Collection b) Transport Service _____ ______________________
Signature of Receiving Person
______________________________ _____________ c) Description __________
(PRINT) Accessioner’s Name(First,MI,Last) Date(mm/dd/year) _______________ ____________
Printed Name (First,MI,Last) Date(mm/dd/year)
STEP 5 COMPLETED BY THE DONOR
I certify that I provided my urine specimen to the collector, that I have not adulterated it in any manner, each specimen bottle
used was sealed with a tamper-evident seal in my presence and that the information on this form on the bottle is correct.

___________________________________ ____________________________________ __________________

SIGNATURE OF DONOR (PRINT) DONOR’S NAME (FIRST, MI, LAST) DATE (MM/DD/YEAR)

Contact No. _________________________ DATE OF BIRTH _______________________

(MM/DD/YEAR)
Additional information may be asked from you by the laboratory particularly on drug and medications.
STEP 6 COMPLETED BY HEAD OF SCREENING LABORATORY
In accordance with applicable Department of Health requirements, my determination/verification is:
 NEGATIVE  POSITIVE  TEST CANCELLED  REFUSAL TO TEST BECAUSE:
 DILUTED  SUBSTITUTED
REMARKS_________________________________________________  ADULTERATED  OTHERS(specify)_________

X___________________________________ ___________________________________________ _____________

(PRINT) Signature & Name of Analyst (First, MI, Last) (PRINT) Signature & Name of Head of Laboratory (First, MI, Last) DATE (mm/dd/year)
STEP 7 COMPLETED BY CONFIRMATORY LABORATORY
In accordance with applicable Department of Health requirements, my determination/verification for the specimen (if tested) is:
 CONFIRMED FOR:  CHALLENGE  FAILED TO CONFIRM - REASON________________________
THC  MET  OTHERS (SPECIFY)________________
X_____________________________________ _____________________________________________ __________________
(PRINT) Signature & Name of Analyst (First,MI,Last) (PRINT) Signature & Name of Head of Laboratory(First,MI,Last) Date (mm/dd/year)
STEP 8 COMPLETED BY THE NATIONAL REFERENCE LABORATORY (NRL)
In accordance with applicable Department of Health requirements, my determination/verification for the specimen (if tested) is:
 RECONFIRMED FOR:  FAILED TO RECONFIRM - REASON_____________________
 THC  MET  OTHERS (specify)_________________
X____________________________________ ______________________________________________ _________________
(PRINT) Signature & Name of Analyst (First,MI,Last) (PRINT) Signature & Name of Head of Laboratory (First,MI,Last) Date (mm/dd/year)
 MANILA HEALTH DEPARTMENT – PUBLIC HEALTH LABORATORY
1559 Alvarez Street Barangay 334 Santa Cruz Manila
Tel. No. 5310-1329
CUSTODY AND CONTROL FORM
(Form DT – 002.C – COPY FOR THE LABORATORY)

SPECIMEN ID NO.:______________________ LAB ACCESSION NO.: _____________________

STEP 1 COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE
Client’s/Donor’s/Subject’s Code______________ ADDRESS____________________________________AGE____SEX____
Employer’s Name and Address___________________________________________________________________________________
TYPE OF SPECIMEN: REASON FOR TEST:
 Urine  Pre-Employment  Random  Reasonable Suspicion/Cause
 Blood  Return-to-Duty  Mandatory  Post Accident
 Others (specify) _____________________  Follow-up  Other’s (specify) _____________________________
Drug Test to be Performed:  THC, COC, PCP, OPI, AMP  THC & MET Only  Others (specify) ________________________
STEP 2 COMPLETED BY COLLECTOR
Read specimen temp within 4 mins. Specimen Collection:  Observed  Unobserved Other Observation
Is temperature between 32oC & 38oC? Specimen Sampling:  Single  Split (Enter Remark)
 Yes  No Specimen Volume ___ml Physical Appearance: Color ____
REMARKS
STEP 3 Collector affixes bottle seal(s) to bottle(s). Collector dates seal(s). Donor initial seal(s). Donor completes STEP 5.
STEP 4 CHAIN OF CUSTODY – INITIATED BY COLLECTOR AND COMPLETED BY LABORATORY
I certify that the specimen given to me by the identified in the certification section on Step 5 of this form was collected, sealed
and released to the Delivery Service noted in accordance with applicable DOH requirements.
SPECIMEN BOTTLE(S) RELEASED TO:
X____________________________ _______________AM/PM 
Signature of Collector Time of Collection _______________________________________
Name of Delivery Service Transferring Specimen to Lab.
_____________________________ _____________________ 
(PRINT) Collector’s Name (First,M.I.,Last) Date (mm/dd/year)
RECEIVED AT LAB: STATUS OF THE SPECIMEN: SPECIMEN BOTTLE(S) RELEASED TO:
a) Seal Intact  Yes  No
X_____________________________ _________AM/PM ___________________________
Signature of Accessioner Time of Collection b) Transport Service ______ Signature of Receiving Person

______________________________ _____________ c) Description __________ ________________ ___________

(PRINT) Accessioner’s Name(First,MI,Last) Date(mm/dd/year) Printed Name (First,MI,Last) Date(mm/dd/year)
STEP 5 COMPLETED BY THE DONOR
I certify that I provided my urine specimen to the collector, that I have not adulterated it in any manner, each specimen bottle
used was sealed with a tamper-evident seal in my presence and that the information on this form on the bottle is correct.

___________________________________ __________________________
SIGNATURE OF DONOR DATE (MM/DD/YEAR)

 DATE OF BIRTH ________________________

(MM/DD/YEAR)
STEP 6 COMPLETED BY HEAD OF SCREENING LABORATORY
In accordance with applicable Department of Health requirements, my determination/verification is:
 NEGATIVE  POSITIVE  TEST CANCELLED  REFUSAL TO TEST BECAUSE:
 DILUTED  SUBSTITUTED
REMARKS____________________________________________  ADULTERATED  OTHERS (specify) _____________

X____________________________________ ____________________________________________ _____________

(PRINT) Signature & Name of Analyst (First, MI, Last) (PRINT) Signature & Name of Head of Laboratory (First, MI, Last) DATE (mm/dd/year)
STEP 7 COMPLETED BY CONFIRMATORY LABORATORY
In accordance with applicable Department of Health requirements, my determination/verification for the specimen (if tested) is:
 CONFIRMED FOR:  CHALLENGE  FAILED TO CONFIRM - REASON_______________________
THC  MET  OTHERS (SPECIFY)________________
X_____________________________________ _____________________________________________ __________________
(PRINT) Signature & Name of Analyst (First,MI,Last) (PRINT) Signature & Name of Head of Laboratory(First,MI,Last) Date (mm/dd/year)
STEP 8 COMPLETED BY THE NATIONAL REFERENCE LABORATORY (NRL)
In accordance with applicable Department of Health requirements, my determination/verification for the specimen (if tested) is:
 RECONFIRMED FOR:  FAILED TO RECONFIRM - REASON_____________________
 THC  MET  OTHERS (specify)_________________
X_____________________________________ ______________________________________________ _________________
(PRINT) Signature & Name of Analyst (First,MI,Last) (PRINT) Signature & Name of Head of Laboratory (First,MI,Last) Date (mm/dd/year)