CONTROLLED DANGEROUS SUBSTANCE TEST ORDER

THIS IS A CONFIDENTIAL DOCUMENT

Employee's Name:	Social Security #: XXX-XX-
Classification:	Position Identification #:
Agency/Institution:	Appropriation Code:

In accordance with Code of Maryland Regulation (COMAR) 17.04.09, Testing for Illegal Use of Drugs, I am directing you to submit to a urinalysis test based on:

Random	Other (Arrest for a Controlled Dangerous Substance Offense)

Reasonable Suspicion	Other (Participation in a Drug Abuse Rehabilitation Program)

Other (Incident Triggered)	Other Personnel Action:

The collection is scheduled as follows:

Location:

Collection Date:	Time of Collection:

At the time of the collection, you will be required to present positive identification in the form of a valid photo driver's license, a State-issued identification card or a State employee photo identification card.

Phamatech, Inc., 15175 Innovation Drive, San Diego, CA 92128, will conduct the test, and the specimen will be screened for the following drugs:

Amphetamines	Benzodiazepines	Marijuana/Cannabinoids	Phencyclidine (PCP)
Barbiturates	Cocaine	Opiates

The test will not reveal information pertaining to any prescription and/or non-prescription drugs that are not cited above. All test results are confidential as required by applicable laws and regulations.

If you refuse to comply with this order, you may be subject to disciplinary action up to and including termination from State Service for gross and willful misconduct.

IF YOUR TEST YIELDS A VERIFIED LABORATORY POSITIVE RESULT:

The State Medical Director's Office will contact you and give you an opportunity to present information to establish a legal medical explanation for the positive result. The Office will make three attempts to contact you within 48 hours of receipt of the positive result.

Verified laboratory positive test results may result in disciplinary action up to and including termination from State Service for gross and willful misconduct and/or mandatory participation in a drug abuse rehabilitation program.

You may request an independent test of a portion of the original specimen. The retest must be performed by a U.S. Department of Health and Human Services certified laboratory that has been licensed in accordance with the laws of Maryland. You will be provided a list of certified laboratories from which to make your selection. You are responsible for all costs associated with the retest.

You have the right to appeal any action taken against you as a result of a verified laboratory positive test through the appropriate disciplinary action or grievance appeal process.

Agency Technical Representative ____________________________________	Date:

Employee _______________________________________________________	Date:

Original - AGENCY ATR	● Copy - EMPLOYEE	● Copy - COLLECTION REPRESENTATIVE

FORM MS - DT4 (Revised November, 2014)

Form MS-DT4 - Controlled Dangerous Substance Test Order (fillable form)

Form MS-DT4 - Controlled Dangerous Substance Test Order (Revised 1/22/08)

Form MS-DT4 - Controlled Dangerous Substance Test Order (Revised 1/22/08)

Carole Wollenweber

2013-02-19

Wollenweber, Carole

state of md