The Clinical Reference lab form is a multi-part form that is to be used whenever a John Deere employee Drug Screen collection is ordered. The sample is collected, sealed, and packaged for transport to the Clinical Reference Lab (CRL) via Federal Express.
II. Clinical Significance: N.A.
Fresh urine collected using the appropriate protocol.
1. CRL collection kit (CRL: 1(800) 773-7214 request Toxicology Customer Service)
A. One urine cup with temperature strip attached.
B. Two specimen bottles.
C. One absorbent pad
D. Tamperproof security bag
E. CRL Tox cardboard box
2. Non-Federal Chain of Custody & Control form or Federal Chain of Custody & Control form
3. Federal Express air bill and bag.
V. Reagents: N.A.
VI. Standardization: N.A.
1. Request photo identification from the individual selected for testing.
Note: Photo identification is REQUIRED. We cannot collect the specimen without it.
2. Inquire as to whether the donor has presented for a routine pre-employment collection or a DOT collection.
A. If the collection is for routine pre-employment, use the “Non-Federal Chain of Custody & Control” form.
Note: Most John Deere employees will be presenting for pre-employment collections.
B. If the collection is for Dept of Transportation (DOT), inform the client that we do not collect those at UCL Finley site and they should contact John Deere for the appropriate collection agency.
C. The collector must record the reason for the test in step 1 of the appropriate form.
3. The collector should fill in the employee name and assigned ID number, in step 1 of the chain of custody & control form. John Deere will provide the ID number on the order request. If the ID number is not present, use the first and last name initials and the last 4 digits of the social security number. (Example: RM2431)
Non-Federal Chain of Custody & Control form: copy 1 step 1.
4. Instruct the donor to read, sign, and date the chain of custody & control form.
Non-Federal Chain of Custody & Control form: copy 1 step 4.
The phone numbers can be listed, but they are not required.
5. The collector obtains the urine sample using the following procedure.
Note: To deter the possibility of dilution of specimens during the collection it is suggested that toilet-bluing agents be placed in toilet tank. There should be no other source of water in the immediate area (i.e. shower or sinks). If there are other sources of water in the area, they must have an external shut off valve.
A. Briefly explain the urine collection procedure to the donor.
B. Ask the donor to remove unnecessary outer garments such as coat or jacket.
C. All personal belongings such as purse or briefcase remain with the outer garments.
Note: Donor may keep their wallet.
D. The donor is instructed to wash their hands.
E. The water source is turned off after hand washing is completed.
F. The donor is given the urine specimen collection container with the temperature strip attached and instructed to go into the restroom where they can provide the sample in private.
6. The collector receives the sample from the donor. The specimen must be kept in view of the collector and the donor at all times until it is completely labeled and packaged for transport.
7. Turn the water source on and instruct the donor to wash their hands if they wish to do so. Remain in the presence of the individual.
8. After receiving the specimen ensure there is at least 45 ml of sample.
Note: 20 ml is the minimum requirement.
9. Measure and record the temperature of the sample in step 2 of the appropriate chain of custody& control form. Time from urination to temperature measurement should not exceed 4 minutes.
Non-Federal Chain of Custody & Control form: copy 1 step 2.
Note: If less than 20 ml is collected the donor is instructed to collect more sample. As the additional sample is collected, the temperature of the additional sample needs to be measured. The samples may then be combined in one container.
Note: If the temperature of the urine is outside the 90.0 - 100.0 degrees F range, there is reason to believe that the sample is adulterated. Notify the site supervisor and/or the company contact for guidance. The patient may volunteer to have their oral temperature taken to provide evidence.
10. Inspect specimen color, and look for signs of contaminants.
Note: When using the Non-Federal Chain of Custody & Control form, mark the box in step 2 indicating that the specimen was “observed”.
11. Show the donor that the specimen vial(s) is tamper-evident due to the plastic filament link between the cap and the base of the vial. Explain that because the filament is intact, the vial has never been opened or tampered with prior to pour-off.
12. Turn the vial upside down so the cap is pointing toward the ground or toward the trash receptacle.
Note: As the cap is opened, the filament will fly in direction the vial cap is pointing.
13. Pour approximately 30 ml of urine into one specimen bottle and 15 ml of the urine into the other specimen bottle supplied in the kit. (If the minimum of 20 ml is collected, it can all be placed in one specimen bottle.)
14. Close the vial by placing 2 fingers to the rear of the lid, swing fingers forward until the “snap” is heard, indicating complete seal.
15. Inspect the lid around the entire vial to ensure that it is level and completely sealed. Secure the lock latch over the male nut.
16. Indicate on the chain of custody & control form if a split specimen was collected by checking Yes or No.
Non-Federal Chain of Custody & Control form: step 2.
17. Instruct the donor to initial the security seals that are located on the bottom of the Non-Federal form. The collector must date the security seals.
18. Label both specimen containers with the seals from the change of custody form by placing the seals over each specimen cup.
19. Place the samples into the plastic bag with the absorbent pad.
20. The collector must complete all highlighted areas on the chain of custody & control form.
Non-Federal Chain of Custody & Control form: copy 2 step 5.
21. Distribute the copies as labeled on the bottom of the forms:
A. Donor copy is given to the John Deere employee.
B. The UCL collection site retains collector copy.
22. Place the remaining copies in the front pouch of the specimen bag and seal with the glue strip provided.
23. Place the sealed bag with the urine samples inside a CRL Tox cardboard box and then place inside the Federal Express bag.
24. Complete the Federal Express air bill.
25. FedEx picks up daily Monday through Friday.
VIII. Limitations: N.A.
IX. Results Derivation: N.A.
X. Expected Results(s) and/or Critical Values: N.A.
XI. Quality Control: N.A.
Clinical Reference Laboratory Non-DOT Instructions
i. March 2000 S. Hosch
ii. June 2001 A. McCrea (Revised: VII. for new forms.)
iii. December 2002 R.A. Maiers (Revised: deleted references to DOT (Federal) chain of custody form)
February 2010 L. Dolphin (Revised: IV.1.E.,3.; VII.4.,8.,20-25.)
March 2011 C. Leslein (Revised: IV.1.; VII.3.)