Page 150 - Personnel Policy and Procedures Manual

Collection Procedures Check List

Employee Last Name: ______________ First Name__________ Employee number: _________
PLEASE READ!!!!
In an effort to provide the best protection possible for each employee and the collection agent, this checklist is being provided for
use with each collection. Your participation is required to ensure that each step of the collection process is completed to standard.
You will be required to initial each block by the procedure you were involved in. Your initials signify that the procedure was
completed properly. If there is any deviation of procedures you should make a note at the bottom of the sheet and sign your name.
Designated Employer Representative is Sandy Wright, Risk Management…direct any questions of concerns to the DER.
# Procedure Collector Donor
1 Prepare collection site; ensure coloring agent present in commode.
2 Verify identity of employee with picture ID.
3 Prepare Top section of Chain of Custody form: (donor ID, reason for test)
4 If required: ask donor to remove bulky or unnecessary items (exterior clothing, store in
secure area.
5 Employee washes hands and returns to the collector.
6 Collector gives (sealed collection bottle) or lets donor pick (non-sealed collection
bottle). NOTE: only one collection container allowed in the rest room.
7 Employee/donor provides urine sample in the collection container and immediately
provides the container to the collector. (Note: do not flush the commode until told to
do so)
8 Collector annotates the temperature on the Chain of Custody form and insures there is
at least 45 ml. If the temperature is outside the acceptable range follow the procedures
of SAMSHA.
9 Donor observes the splitting of the sample and sealing.
10 Collector splits the sample, writes the date on the labels/seals and seals the containers
(In the presence of the donor).
11 Donor initials security seal.
12 Donor flushes the commode and washes hands.
13 Donor reads the certification statement of the Chain of Custody form and signs the
form.
14 Collector completes the Chain of Custody form and provides copy to the
employee/donor.
Collector Comments:

Employee Comments:

CERTIFICATION
I certify that the above procedures were satisfactorily completed and that any questions concerning the procedure by
the employee were satisfied at the time of the collection. I also state that I was given the opportunity to write
comments concerning any aspect of the collection process.

__________________________________ _____________ ____________________________________
(Signature of Collector) (Date) (Signature of Employee)

NOTE: This form is an internal document for use by Augusta, Georgia Risk Management and is not required by DOT/FTA

FORM SA-6

All Rights Reserved – As approved by the Commission on 05-07-2019 150 | P a g e