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Attachment E <br />MARCH@ <br />BCRC is exercising extreme care to ensure that strict quality control nicasures are <br />followed in the collection, handling, and analysis ofyour specimen. You play an <br />important role in this process and should be certain that you have provided an <br />unadulterated specimen to the laboratory. Remember, you are certifying that the <br />specimen which you provide is yours and is unadulterated. Any adulteration or <br />switching of specimen is a breach of BCRC's rules and, if you are employed, may <br />subjject you to discipline tip to and including termination by your, Employer. <br />Foryour own protection and peace of mind, we ask t1tat you: <br />• Provide a picture, identification to the collection site/technician at time <br />of arrival; <br />• Be escorted to a collection room and asked to provide an unadulterated <br />specimen in the collection bottle provided, 'Die bottle should be faded <br />to 45 ml; <br />• Return the spccirnen bottle to the medical technician and witness, <br />initial and date the integrity seals placed on your specimen; <br />Verify the proper spelling ofyour name as recorded on the: log sheet-, <br />• Verify that your social security number has been properly recorded; <br />• Verify that the social security number placed on your specimen bottle <br />is the same as that recorded on the log sheet and the Custody and <br />Control Form. <br />I HAVE READTHEABOVE AND HAVE HAD AN OPPORTUNITY <br />TO ASK QUESTIONS REGARDING THIS PROCEDURE, <br />BICK Applicant/Cardholder Signature Date <br />Fly-*] <br />wul_e� <br />