Affidavit_of_Correction_Form.pdf
PDF 104 KB Posted
- Attached to
- City Wide Occupational Health Services
- Solicitation number
- 240140
- Issued by
- Pima County, Tucson City, Arizona
About this file
This document is an Affidavit of Correction form for drug testing procedures, governed by 49 CFR Part 40, which provides a standardized method for addressing errors on the Federal Drug Testing Custody and Control Form. The form is designed to ensure that drug tests are not cancelled due to procedural mistakes and allows collectors to document and correct specific errors across five key steps of the drug testing process.
The form comprehensively outlines potential errors in various stages of drug testing, including issues with employer information, collection site details, specimen handling, signatures, and donor information. Collectors must specify the exact nature of the error, describe the corrective action taken, and outline measures to prevent similar errors in the future. The document requires the collector to sign and date the form, certifying that appropriate steps have been taken to address and prevent recurring mistakes in the drug testing documentation process.
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Text version
According to 49 CFR Part 40, as amended, the collector of the drug test referenced below must take all practicable action to correct errors on the Federal Drug Testing Custody and Control Form so that the test is not cancelled.
AFFIDAVIT OF CORRECTION
Transit System Name: __________________________________________ Date of Test:__________________________
Test Category: _______________________________________ Specimen ID#:__________________________________
Donor Name: ________________________________________ Collector Name:________________________________
Date Collector Was Notified of Error: ___________________________________________________________________
This affidavit addresses the following errors that were not performed in accordance with 49 CFR Part 40, as amended:
Step 1 Requirements (§40.63) ___ A. Missing/Incorrect Employer Name, Address
(check all that apply)
___ B. Missing/Incorrect MRO Name, Address, Phone and Fax No.
___ C. Missing Donor SSN or Employee I.D. No.
___ D. Missing/Incorrect Testing Authority ___ E. Missing/Incorrect Reason for Test ___ F. Missing/Incorrect Drug Tests to be Performed ___ G. Missing/Incorrect Collection Site Name, Address, Phone and Fax No.
Step 2 Requirements (§40.65-70) ___ Collector failed to indicate if the specimen was within the acceptable temperature range
(check all that apply)
___ Collector failed to mark ‘Split’ ___ Collector arbitrarily marked ‘Observed’ ___ Collector failed to mark ‘Observed’ ___ Missing explanation within ‘Remarks’ section. (i.e. any unusual circumstances that occur during collection) Step 3 Requirements (§40.71) ___ Bottle seals were filled out while still affixed to the CCF
(check all that apply)
Step 4 Requirements (§40.73) ___ Missing collector’s signature
(check all that apply)
___ Missing collector’s printed name (First, MI, Last) ___ Missing/Incorrect Date of Collection ___ Missing/Incorrect Time of Collection ___ Missing Courier Name Step 5 Requirements (§40.73) ___ Missing donor’s signature
(check all that apply)
___ Missing donor’s printed name (First, MI, Last) ___ Missing/Incorrect Date of Collection ___ Missing donor’s Daytime and/or Evening Phone No.
___ Missing/Incorrect donor’s Date of Birth Collector Remarks:
1. Description of error:_______________________________________________________________________________
2. Description of corrective action:______________________________________________________________________
3. Measures taken to ensure the same error(s) do not reoccur:_________________________________________________
By signing below, in accordance with 49 CFR Part 40.209, I certify that the aforementioned errors occurred on the referenced drug test and that appropriate measures have been taken to ensure the same errors will not reoccur.
Collector Signature / Title Date
File details come from the government source that posted it. Updated .