Track 2, Module 3 Homework1. SUBMITTING UNIT 2. ADDITIONAL SERVICE INFORMATION (Second Echelon)

B. BATCH NUMBER6. DATE SPECIMEN COLLECTED

CODE CODE (YYYY) (MM) (DD)

W 3 V S A A D. DRUGS TESTED

10. TEST E. DISCINFORMATION CODE

B

B

B

A

A

A

A

A

B

B

(1) SIGNATURE (2) DATE SIGNED

2 0 0 5 0 4 2 6

SPECIMEN CUSTODY DOCUMENT - DRUG TESTING A. LABORATORY CONDUCTING DRUG TESTING

C. REPORT OF RESULT (DTG/Serial No.)3. BASE/AREA 5. DOCUMENT/4. UNIT IDENTIFIACTION

ASAP BUILDING 1234 CAMP SWAMPY, MO 55673

COMPANY B 901st FINANCE BN CAMP SWAMP, MO 55673

7. SPECIMEN NUMBER

BATCH NUMBER

F C 4 5 0 0 0 1

H. CERTIFICATION. I certify that I am a laboratory certifying official, that the laboratory results indicated on this form were correctly determined by proper laboratory procedures, and that they are correctly annotated.

(3) CERTIFYING OFFICIAL (Printed Name and Title)

246-78-3242

311-90-7842

256-43-5672

435-97-2232 IR

345-88-4392 IR

312-67-2342

718-76-2212

F. ACCESSION NUMBER G. RESULTBASIS11. PRESCREENTHC COC 8. COMPLETE SSN 9. TEST

445-88-9762

983-10-2312

IR

IR

IR

IR

IR

IR

IR

IR

(7)

(8)

(1)

(2)

(3)

(4)

895-43-5632

DD Form 2624, FEB 93 Replaces OPNAV 5350/2 (FEB 82), DA Form 5180 (AUG 86), and AF Form 1890 (APR 86), which are obsolete.

(9)

(10)

(11)

(12)

(5)

(6)

This is the front of the DD Form 2624 for batch 1. It is batch 1 because the first person to provide a sample was Dwayne Jenkins.

Note the Test basis is IR, because the commander randomly selected all personnel whose SSN ended in 2.

2-3-5

Track 2, Module 3 Homework

Practical Exercise1. SUBMITTING UNIT 2. ADDITIONAL SERVICE INFORMATION (Second Echelon)

B. BATCH NUMBER6. DATE SPECIMEN COLLECTED

CODE CODE (YYYY) (MM) (DD)

W 3 V S A A D. DRUGS TESTED

10. TEST E. DISCINFORMATION CODE

A

A

(1) SIGNATURE (2) DATE SIGNED

H. CERTIFICATION. I certify that I am a laboratory certifying official, that the laboratory results indicated on this form were correctly determined by proper laboratory procedures, and that they are correctly annotated.

(3) CERTIFYING OFFICIAL (Printed Name and Title)

DD Form 2624, FEB 93 Replaces OPNAV 5350/2 (FEB 82), DA Form 5180 (AUG 86), and AF Form 1890 (APR 86), which are obsolete.

(12)

(11)

(10)

(9)

(8)

(7)

(6)

(5)

(4)

(3)

(2) 453-22-9658 RO

2 0 0 5 0 4 2 68. COMPLETE SSN

BATCH NUMBER

(1) 254-56-3694 RO

G. RESULTBASIS THC COC 9. TEST 11. PRESCREEN

SPECIMEN CUSTODY DOCUMENT - DRUG TESTING A. LABORATORY CONDUCTING DRUG TESTING

ASAP BUILDING 1234 CAMP SWAMPY, MO 55673

COMPANY B 901st FINANCE BN CAMP SWAMP, MO 55673

C. REPORT OF RESULT (DTG/Serial No.)3. BASE/AREA 5. DOCUMENT/

F. ACCESSION NUMBER

4. UNIT IDENTIFIACTION

7. SPECIMEN NUMBER

F C 4 5 0 0 0 2

This is the front of the DD Form 2624 for batch 2. It is batch 2 because when SPC green approached your desk for his rehabilitation test you needed to start a new batch. Remember, do not mix Test Basis codes on the same DD Form 2624.

The reason it is a rehabilitation test is that these soldiers were not randomly selected, but were directed to provide a specimen by the commander as part of their ASAP rehabilitation program.

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Track 2, Module 3 Homework

Practical Exercise

LAN THRUDATE PURPOSE O F CHANGE/

(YYMMDD) RELEASED BY RECEIVED BY REMARKSa. b. c. d. 1 SUBMITTING UNIT

SIGNATURE

Michael C. BiggerstaffSIGNATURE

Building 125NAME

Michael C. BiggerstaffNAME

Room 6B, locker #2SIGNATURE

Building 125SIGNATURE

Michael C. BiggerstaffNAME

Room 6B, locker #2NAME

Michael C. BiggerstaffSIGNATURE SIGNATURE

NAME NAME

SIGNATURE SIGNATURE

NAME NAME

SIGNATURE SIGNATURE

NAME NAME

SIGNATURE SIGNATURE

NAME NAME

SIGNATURE SIGNATURE

NAME NAME

SIGNATURE SIGNATURE

NAME NAME

SIGNATURE SIGNATURE

NAME NAME

SIGNATURE SIGNATURE

NAME NAME

DD Form 2624, FEB 93 (Back)

13. DAMAGE TO SHIPPING CONTAINER/DISCREPANCIES

(10)

(9)

12. CHAIN OF CUSTODY (line (1))

(8)

(7)

(5)

(4)

(2)

050427

(3)

Removed from Temporary Storage

Placed into Temporary Storage

(6)

12. CHAIN O F CUSTODY INSTRUCTIO NS

BLO CK USA USN/MC USAF

Message address of unit submitting urine samples (1)

050426

12. CHAIN OF CUSTODY (LINE (1)). a. DATE - Date of collection/shipment. b. RELEASED BY - Signature and printed or typewritten name of the urinalysis coordinator having custody of the samples. c. RECEIVED BY - Use only if physicial change of custody is occurring prior to shipment. Otherwise leave blank. d. PURPOSE OF CHANGE/REMARK - Specify the mode of accountable transportation/system utilized to ship specimens to the lab.NOTE; If/when custody of specimens changes other than for shipment (unless hand carried to lab), each change of custody requires line number signatures in the (b) RELEASED BY and (c) RECEIVED BY blocks to document change in a custody with comment in block (d). If a continuation sheet is necessary, it must contain information/signatures of blocks (a) - (d).

This is the back of the DD Form 2624 for both batches. The specimens were collected on 5 Dec and placed into temporary storage, they were then removed from storage on 6 Dec to be transported to the IBTC.

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Track 2, Module 3 Homework

Practical ExerciseINITALS: 4. UNIT IDENTIFICATION 5. DATE SPECIMEN COLLECTED:

(YYYY) (MM) (DD) 3. PHONE: W 3 V S A A 2 0 0 5 0 4 2 6

11. SOLDIER'S SIGNATURE 13. OBSERVER'S SIGNATURE

SOLDIER'S PRINTED NAME OBSERVER'S PRINTED NAME

Dwayne E. Jenkins John T. ObserverDwayne E. Jenkins John T. Observer

Pamela A. Smith Jane CuppPamela A Smith Jane Cupp

John T. Thomas John T. ObserverJohn T. Thomas John T. Observer

Janet Jones Jane CuppJanet Jones Jane Cupp

Robert M. Ansell John T. ObserverRobert M. Ansell John T. Observer

Thomas M. Hightower John T. ObserverThomas M. Hightower John T. Observer

Rebecca T. Bowers Jane CuppRebecca T. Bowers Jane Cupp

Elizabeth A. Schoen Jane CuppElizabeth A. Schoen Jane Cupp

Randolph Cunningham John T. ObserverRandolph Cunningham John T. Observer

Chuck B. Brown John T. ObserverChuck B. Brown John T. Observer

CD ADAPCP Form 1

MB

1

1

1

IR

IR

IR

SFC10 895-43-56321 IR

PFC

1 9 718-76-2212 IR 1LT

1 IR8 312-67-2342

PFC 1st Attempt -Short Sample- Voided, 2nd attempt - ok

1 IR

1 7 983-10-2312 IR

6 445-88-9762

4 256-43-5672

SPC

SPC

SPC1 5 345-88-4392 IR

SGT

3 435-97-2232 SGT

311-90-78422

SSG

9.TEST BASIS

6. DOCUMENT/ BATCH NUMBER

7. SPECIMEN NUMBER

1 1 246-78-3242 IR

8. COMPLETE SOCIAL SECURITY NUMBER 10. RANK 12. ACTION TAKEN / REMARKS

UNIT URINALYSIS LEDGER1. SUBMITTING UNIT 2. UADC:

Company B 901st Finance BN Camp Swampy MO, 55673

Michael C. Biggerstaff CODE:

703-681-5560

This is the Unit Ledger for batch 1. Your unit ledgers should match your DD Form 2624 in order. Notice the comment on Rebecca Bowers, she had a short sample originally that was

destroyed, but successfully provided a specimen the second time she tried.2-3-5

Track 2, Module 3 Homework

Practical ExerciseINITALS: 4. UNIT IDENTIFICATION 5. DATE SPECIMEN COLLECTED:

(YYYY) (MM) (DD) 3. PHONE: W 3 V S A A 2 0 0 5 0 4 2 6

11. SOLDIER'S SIGNATURE 13. OBSERVER'S SIGNATURE

SOLDIER'S PRINTED NAME OBSERVER'S PRINTED NAME

Michael C. Green John T. ObserverMichael C. Green John T. Observer

Jeffrey G. Walls John T. ObserverJeffrey G. Walls John T. Observer

UNIT URINALYSIS LEDGER1. SUBMITTING UNIT 2. UADC:

Company B 901st Finance BN Camp Swampy MO, 55673

Michael C. Biggerstaff MB CODE:

703-681-55606. DOCUMENT/

BATCH NUMBER7. SPECIMEN

NUMBER8. COMPLETE SOCIAL

SECURITY NUMBER9.TEST BASIS

PFC

2 1 254-56-3694 RO

10. RANK 12. ACTION TAKEN / REMARKS

SPC

2 2 453-22-9658 RO

CD ADAPCP Form 1

This is the Unit Ledger for batch 2.

2-3-5