Note: Information is required only for those tests where donor requested test of splitMedical Review Officer Information Name Address City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Tel# Fax# Collection Site Information Name Address City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Tel# Fax# Date of Collection Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year201420152016201720182019 Specimen I.D. # Laboratory "A" accession # Primary Specimen Laboratory Name - None -ACL Laboratories - West Allis - WIACM Laboratories Inc. - Rochester - NYAdvance Toxicology Network - Memphis - TNAegis Analytical Laboratories, Inc. - Nashville - TNBapist Medical Center-Toxicology Laboratory - Little Rock - ARClinical Reference Lab - Lenexa - KSDiagnostic Services Inc. - Fort Meyers - FLDoctors Laboratory, Inc. - Valdosta - GADrugScan, Inc. - Warminster - PADynacare Kasper Medical Laboratories - Edmonton, Alberta - CanadaElSohly Laboratories, Inc. - Oxford - MSExpress Analytical Labs - Marion - IAGamma-Dynacare Medical laboratories - London, ONT - CanadaGeneral Medical Loboratories - Madison - WIKroll Laboratory Specialists, Inc. - Gretna - LAKroll Scientific Testing Laboratories - Richmond - VALaboratory Corporation of America Holdings - Houston - TXLaboratory Corporation of America Holdings - Raritan - NJLaboratory Corporation of America Holdings - Research Triangle Park - NCLaboratory Corporation of America Holdings - San Diego - CALaboratory Corporation of America Holdings - Seattle - WALaboratory Corporation of America Holdings - Southhaven - MSMarshfield Laboratories, Forensic Toxicology Laboratory - Marshfield - WIMAXXAM Analytics Inc. - Mississauga, ON, - CanadaMedTox Laboratories, Inc. - St. Paul - MNMedroLab-Legacy Labortory Services - Portland - ORMinneapolis Veterans Affairs Medical Center, Forensic Toxicology Laboratory - Minneapolis - MNNational Toxicology Laboratories, Inc. - Bakersfield - CAOne Source Toxicology Laboratory, Inc. - Pasadena - TXOregon Medical Laboratories - Springfield - ORPacific Toxicology Laboratories - Chatsworth - CAPathology Associates Medical Laboratories - Spokane - WAPhysicians Reference laboratory - Overland Park - KSQuest Diagnostics Incorporated - Atlanta - GAQuest Diagnostics Incorporated - Irving - TXQuest Diagnostics Incorporated - Las Vegas - NVQuest Diagnostics Incorporated - Lenexa - KSQuest Diagnostics Incorporated - Norristown - PAQuest Diagnostics Incorporated - Schaumburg - ILQuest Diagnostics Incorporated - Van Nuys - CAQuest Diagnostics Incorporated - West Valley - UTS.E.D. Medical Laboratories - Albuquerque - NMSouth Bend Medical Foundation, Inc. - South Bend - INSouthwest Laboratories - Phoenix - AZSparrow Health System, Toxicology Testing Center - Lansing - MISt. Anthony Hospital Toxicology Laboratory - Oklahoma City - OKToxicology & Drug Monitoring - Columbia - MOToxicology Testing Service, Inc. - Miami - FLUS Army Forensic Toxicology Drug Testing Laboratory - Fort George G. Meade - MD Address City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Tel# Fax# Date primary laboratory reported or certified result Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year201420152016201720182019 Split Specimen Laboratory check here if not applicable check here if not applicable Name - None -ACL Laboratories - West Allis - WIACM Laboratories Inc. - Rochester - NYAdvance Toxicology Network - Memphis - TNAegis Analytical Laboratories, Inc. - Nashville - TNBapist Medical Center-Toxicology Laboratory - Little Rock - ARClinical Reference Lab - Lenexa - KSDiagnostic Services Inc. - Fort Meyers - FLDoctors Laboratory, Inc. - Valdosta - GADrugScan, Inc. - Warminster - PADynacare Kasper Medical Laboratories - Edmonton, Alberta - CanadaElSohly Laboratories, Inc. - Oxford - MSExpress Analytical Labs - Marion - IAGamma-Dynacare Medical laboratories - London, ONT - CanadaGeneral Medical Loboratories - Madison - WIKroll Laboratory Specialists, Inc. - Gretna - LAKroll Scientific Testing Laboratories - Richmond - VALaboratory Corporation of America Holdings - Houston - TXLaboratory Corporation of America Holdings - Raritan - NJLaboratory Corporation of America Holdings - Research Triangle Park - NCLaboratory Corporation of America Holdings - San Diego - CALaboratory Corporation of America Holdings - Seattle - WALaboratory Corporation of America Holdings - Southhaven - MSMarshfield Laboratories, Forensic Toxicology Laboratory - Marshfield - WIMAXXAM Analytics Inc. - Mississauga, ON, - CanadaMedTox Laboratories, Inc. - St. Paul - MNMedroLab-Legacy Labortory Services - Portland - ORMinneapolis Veterans Affairs Medical Center, Forensic Toxicology Laboratory - Minneapolis - MNNational Toxicology Laboratories, Inc. - Bakersfield - CAOne Source Toxicology Laboratory, Inc. - Pasadena - TXOregon Medical Laboratories - Springfield - ORPacific Toxicology Laboratories - Chatsworth - CAPathology Associates Medical Laboratories - Spokane - WAPhysicians Reference laboratory - Overland Park - KSQuest Diagnostics Incorporated - Atlanta - GAQuest Diagnostics Incorporated - Irving - TXQuest Diagnostics Incorporated - Las Vegas - NVQuest Diagnostics Incorporated - Lenexa - KSQuest Diagnostics Incorporated - Norristown - PAQuest Diagnostics Incorporated - Schaumburg - ILQuest Diagnostics Incorporated - Van Nuys - CAQuest Diagnostics Incorporated - West Valley - UTS.E.D. Medical Laboratories - Albuquerque - NMSouth Bend Medical Foundation, Inc. - South Bend - INSouthwest Laboratories - Phoenix - AZSparrow Health System, Toxicology Testing Center - Lansing - MISt. Anthony Hospital Toxicology Laboratory - Oklahoma City - OKToxicology & Drug Monitoring - Columbia - MOToxicology Testing Service, Inc. - Miami - FLUS Army Forensic Toxicology Drug Testing Laboratory - Fort George G. Meade - MD Address City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Tel# Fax# Date split laboratory reported or certified split specimen result check here if not applicable check here if not applicable Date split laboratory reported or certified split specimen result Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year201420152016201720182019 Primary specimen results in the primary specimen (e.g. name of drug, adulterant, etc.) Reason for split specimen failure-to-reconfirm result Reason for split specimen failure-to-reconfirm result split specimen failed to reconfirm for adulteration or substitution criteria not met split specimen reported as invalid split specimen not available for testing split failed to reconfirm: split specimen adulterated other (explain in comments) Enter drug/metabolite Specimen not available for testing reasons split specimen not collected split specimen leaked in transit to lab B split specimen lost in transit to lab B insufficient volume (no leakage) Action taken by MRO (e.g. notified employer of failure to reconfirm and requirement for recollection) Additional information explaining reason for cancellation (comments) Name of individual submitting the report (if not the MRO) If you would like an email copy of this completed form, enter your email address Leave this field blank Printer-friendly version
