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Split Specimen Cancellation Notification (49 CFR 40.187 & Appendix D)

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Note: Information is required only for those tests where donor requested test of split.

Medical Review Officer Information
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Collection Site Information
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Primary Specimen Laboratory
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Split Specimen Laboratory
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Date split specimen laboratory reported or certified split specimen result
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Search (e.g. name of drug, adulterant, etc.)
Reason for split specimen failure-to-reconfirm result
Reasons
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Reasons
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(e.g. notified employer of failure to reconfirm and requirement for recollection)
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