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MED EXPRESS DOT DRUG TESTIMG PROCEDURE � <br /> Fatient . ' CHS STA�F , <br /> Patient presents for a d sl ' Introduce yourself to the patient <br /> � i <br /> No Donor � rRequest Donor � Ste 1-COC <br /> identification Identification __�+ p <br /> � ^— a. Donor Social Security No. <br /> ���� Picture Qf Donor Wi#h b. Reason For Test <br /> upervisor Signature c. Test To Be Performed <br /> ..--' <br /> Request Donor Remov2"� Secure The Lavatory, Shut Water Off, <br /> Coat And Hat emove Saap,Add bluing To Toilet <br /> BOWI <br /> Request Donor Wash � ' <br /> Hands Step 2-COC <br /> A. Collector Paurs 30 ml into <br /> Open Spe imen Kit Collection Bottle A and 15 ml <br /> Donor Given Specimen Collection Con#ainer B. <br /> Cup B.Check Specimen Temp.Within 4 5pecimen <br /> inutes. Temp. not ; <br /> C. Check Yes If Temp 90-100 � ithin range ; <br /> Request Specimen Of ___.__�___.___.__ i <br /> At Least 45 ml. I _ Record Actual ' <br /> � j Step 3-COC Temp. On CQC I i <br /> Step 3-COC 'Coilector Dates And Affixes I Direct Obervation If <br /> Donor Initials A.Body Temp.Varies <br /> Label A Over Collection Take bral emp <br /> Specimen Bottle Seals ontainer With 30 mi. and --- - y More Than 1 <br /> Dates Label B And Affixes Over Qbtain A econd �egree C/1.8 F <br /> Collection Container With �5 Specimen From � ` � Donor Refuses To <br /> Step 4-COC , - ml. Donor Provide Body Temp. I <br /> A. Go to Gopy 4-COC(pink) � {- <br /> B. Donor com letes Ste 4- GOGStep 5 ' (—. . --T-- -�_� <br /> , P P Initiate a 2nd CdC <br /> � 1. Daytime Phone, A. Complete Gollection <br /> 2. Evening Phone, acility Name �S ecimen and 2 To <br /> 3. DOB and printed B. Collector Telephone NO. � — � <br /> C.Address, Cit State,Zip Laboratory <br /> �4. Print and Sign signature Y� <br /> � D. Check Split 5pecimen <br /> ' Box-Yes <br /> E. Print Name, Sign Name, <br /> Collection Date And Time — <br /> ;tAm, Pm} <br /> L---= <br /> Step 6-COC�` <br /> Line 1- Date& Under 5pecimen <br /> Received By: Coilectvr Signs and <br /> �Prints Name. <br /> Line 2-Date, Specimen Released <br /> 8y:Gollector Signs and Prints IUame <br /> Line 2: Specimen Received <br /> By-Collector Signs and Prints <br /> Courrier:Purpose Of Change Write <br /> "Intact". <br /> Place Both Specimen In Bag(Side A) <br /> Affix Collection ID No. On Bag <br /> COC Copies 1,2&3, 5ide B Of Bag <br /> Seal Side B <br /> I COC Donor Copy To �istribute C(JC Copies 4&7 Envelope <br /> ' Patient Co 5 <br />