DOT Rule 49 CFR Part 40 Appendix D

Appendix D to Part 40 - Report Format: Split Specimen Failure to Reconfirm

Mail, fax, or submit electronically to:

U.S. Department of Transportation
Office of Drug and Alcohol Policy and Compliance
W62-300
1200 New Jersey Avenue, S.E.
Washington, DC 20590
Fax: (202) 366-3897

Submit Electronically: https://www.transportation.gov/split-specimen-cancellation-notification-49-cfr-40187-appendix-d

The following items are required on each report:

1. MRO name, address, phone number, and fax number.
2. Collection site name, address, and phone number.
3. Date of collection.
4. Specimen I.D. number.
5. Laboratory accession number.
6. Primary specimen laboratory name, address, and phone number.
7. Date result reported or certified by primary laboratory.
8. Split specimen laboratory name, address, and phone number.
9. Date split specimen result reported or certified by split specimen laboratory.
10. Primary specimen results (e.g., name of drug, adulterant) in the primary specimen.
11. Reason for split specimen failure-to-reconfirm result (e.g., drug or adulterant not present, specimen invalid, split not collected, insufficient volume).
12. Actions taken by the MRO (e.g., notified employer of failure to reconfirm and requirement for recollection).
13. Additional information explaining the reason for cancellation.
14. Name of individual submitting the report (if not the MRO).

[65 FR 79526, Dec. 19, 2000, as amended 73 FR 35975, June 25, 2008; 82 FR 52247, November 13, 2017]