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further understand that if I refuse, this refusal (State of Tennessee)

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Drug Screen Consent / Refusal and Results
Check the “Forms” Webpage for the current version and disregard previous versions. This form may not be altered without prior approval.
Page 1
Distribution: Child/Youth’s Case File, Juvenile Court (if requested)
CS-0831
Rev: 11/15
RDA 2876
Client Name: Date of Birth:
Location of Test: Date of Drug Screen:
DCS Worker assigned to case: DCS Worker conducting drug screen:
* Initials
*
I hereby consent to allow a specimen** to be collected for the purpose of a substance abuse screening.
*
I hereby refuse to allow a specimen** to be collected for the purpose of a substance abuse screening. I
further understand that if I refuse, this refusal can be considered a positive result.
*
I hereby waive my option of providing a specimen** and admit that I used the below substance(s) on the
following date(s):
**A specimen could include saliva, urine, hair follicle, etc.
Drug Screen Results
Name of Drug Test
Admit to use
*(Initials and date of last use)
Positive
Results
Negative
Results
No Test
Performed
Hard Copy
Attached
Alcohol *
Amphetamine *
Barbiturates *
Benzodiazepines *
Bupronephrine (Suboxone/Subutex) *
Cocaine *
MDMA (Ecstasy) *
Methadone *
Methamphetamine *
Opiate *
Oxycodone *
Phencyclidine (PCP) *
Propoxyphene *
THC/Cannabinoids *
Tricyclic Antidepressants *
Other: *
Signature of person being screened:
Signature acknowledges you were screened or admitted to use on the above date.
Signature of witness:
Signature acknowledges you reviewed screening results and
results
are accurate to the best of your knowledge.
Signature of person administering the screenings:
Signature acknowledges you performed this drug screen, reviewed the
results and results are accurate to the best of your knowledge.
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Drug Screen Consent / Refusal and Results
Check the “Forms” Webpage for the current version and disregard previous versions. This form may not be altered without prior approval.
Page 2
Distribution: Child/Youth’s Case File, Juvenile Court (if requested)
CS-0831
Rev: 11/15
RDA 2876
Instructions for use of form CS-0831
Use this form to obtain the consent or refusal of a client to a substance abuse urine screening. Please ensure that the client’s
initials * the appropriate selection where indicated on this page.
Actual testing results with hazardous materials should never be placed in the case file; this form will serve as documentation of
that process.
The client will sign the form as indicated to verify the screening process took place. See DCS Policy 13.12 Substance Abuse
Screening for Youth on Probation or After Care.
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further understand that if I refuse, this refusal (State of Tennessee)

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Completed 20 June 2022

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