Appendix B School-Level Testing Form
SCHOOL IDENTIFICATION(ATTACH LABEL HERE)School Name: School Address:
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DRUG TESTING COLLECTION FORM |
OMB No.: 1850-0818
Expiration Date: MM/DD/YY |
Name of person completing this form:
Phone of person completing this form:
(__ __ __) __ __ __ - __ __ __ __
Email of person completing this form:
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Date of original test: _ __ / ___ / ______ Month Day Year Was any confirmatory testing needed? Yes No Date confirmatory testing occurred: _ __ / ___ / ______ Month Day Year |
INSTRUCTIONS: Please complete one form on each original test day that drug-testing is conducted for this school. Answer each of the following questions for this testing date. Please record a number on each line. If none, please write “0” |
1. On this testing date, how many students: Check that the numbers of students in lines b + c + d + e add up to the number of students recorded in line a. |
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a. Were
scheduled
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b.
Were actually |
c.
Refused to be |
d.
Were absent or |
e.
Not tested for other reasons |
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2. On this testing date, how many of the students actually tested were: Check that the numbers of males + females tested add up to the number of tested students recorded in question 1b above. |
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Male |
Female |
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3. On this testing date, how many of the students actually tested were from each of the following grades: Check that the numbers of students in each grade add up to the number of tested students recorded in question 1b above. |
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Grade 9 |
Grade 10 |
Grade 11 |
Grade 12 |
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4. On this testing date, how many of the students actually tested were eligible for testing due to participation in the following activities? Check that the numbers of students in the three activity types add up to the number of tested students recorded in question 1b above. |
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Sports |
Extracurricular
activity |
Both
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5. Where was drug-testing conducted on this date? (Please check one) |
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At this School Off-Site Location |
Please list: |
(Skip to Q8, next page) |
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6. Who conducted the drug tests at this school on this testing date? (Please check all that apply) |
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Trained Faculty Member
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Drug-testing Program Contractor |
School Nurse |
Other (Please list):
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7. Was there a break in the chain of custody procedure (including specimen documentation) during drug-testing at this school on this date? |
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Yes Please specify: |
No |
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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is xxxx‑xxxx. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collected. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, DC 20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: U.S. Department of Education, Institute for Education Sciences, 555 New Jersey Avenue, Washington, DC 20208‑5651. This survey is authorized by law (INSERT LEGISLATION, IF APPLICABLE). |
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8. Please indicate which drugs were tested on this testing date, and the method of testing used to test each drug.
DRUG |
TESTED |
METHOD OF TESTING |
TEST RESULTS |
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PLEASE CHECK THE METHOD(S) USED TO TEST EACH DRUG |
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Yes |
No |
Urine |
Oral Fluid |
Breath Alcohol |
Hair |
Sweat Patch |
Other |
(List): |
# |
# Confirmatory Tests |
# Positive Confirmatory Tests |
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Marijuana |
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Phencyclidine (PCP) |
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Opiates (Heroin, morphine, codeine) |
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Amphetamines/Methamphetamine |
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Cocaine |
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Synthetic Opiates (Oxycodone Methadone) |
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Steroids |
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Alcohol |
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Ecstasy/MDMA |
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GHB |
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LSD |
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Nicotine |
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Other (Please list) |
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Please answer the following questions about procedures for positive tests acquired on this testing date. (Please check one for each) |
9. Were all positive tests verified through a Medical Review Officer? Yes No
10. Were positive samples retained for future re-testing? Yes No
Prepared
by Mathematica Policy Research, Inc. Page
The Impact Evaluation of Mandatory-Random Student Drug Testing
| File Type | application/msword |
| File Title | MEMORANDUM |
| Author | August Pitt |
| Last Modified By | Sheila.Carey |
| File Modified | 2007-04-26 |
| File Created | 2007-04-26 |