mo v wilson darren wilson drug testing results

8/10/2019 Mo v Wilson Darren Wilson Drug Testing Results

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'ECIMEN ID NO.

Collector Fax No.

Collector Phone No ...

o Reasonable Suspicion/Cause ~ s tACcidento Other (specify) ~ ~ _ _ ~ _

Specimen Collection (CHECKALL THATAPPLy)

:il:rJrine Split . 0 Saliva. . 0 Urine Sincile ' 0 Blood

DonorName(F,MI,l.)

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EMARKS:

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onsent to have my specimen collected. by the. name.d collector, analyi/ d, including drug analysis by Clinical Reference Labamtaly Inc. itsemployees,agents, and/or represflntatives mCRL'?;and the reSults of that analysis made aVailable to the above named CampanylEmployerandlor fheirdesignee./certily thatI provided my specimen to the collector; that/ ~ e not .ulfJrated It in .any manner; that each specimen container used was sealed with a tamper-evident seal in my p ~ ;and that the information providedOf this fOrm and anthe label s:xed to eadi . s p e c ~container is COJT6ct... . ~Date 01 Coi.eclion . ~ ~ ? ... .~, I '7 [ 2 0 ' f , / , ; f ' ) l r ~ I . . . ~ ; . ~av'rme ~ n o n eI JO :.-> : S \ l l ) ~ o r ~ ; 9 1 J ) ~ m o . r . : ' -Mo. . O a y. .. Year T . . . . :., . . . . , : . , . . .. . . . Cj

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fUCUDOI l e s l u g l l O r m

The instructions fo r completing this form areon the back o f Copy 3

EP TO BE COMPLETED BY ALCOHOL TECHNICIAN

.

------

RBT Il..l 01 bDATE 08 09 1TEST NO. 01

ID6570AS 1l 1 04391

S ~ E E N I H G-G/2h3L TH

) 000 AUTO 15 ;----------

Affix orPrint ScreeninqResulfs Her'e Oh with Tamper E {.;itleiJtTape

b l 'none Number~ K j l l a m e

DERNameand

Telephone No.

Employer NameStreetCity, ST ZIP

SSNor Employee i l l No. _

Reason for the Test: 0 Random 0 Reasonable Susp

0 Return to Duty 0 Follow-up 0 Pre-employment

Employee Name L:t2 ,h ~ U ~( pr in t) ( Fir st , M . I. , L as t)

EP 2: TO BE COMPLETED BY EMPLOYEE

ertify that I am about to submit to alcohol testing and that the identifying information provided on then is true..and c o r r ~

- _ _ _ _ _ _ _ - - 0 ~ _ 0 _ _

. AffIXor Print Confirmation Results HereAffix with Tamper Evident Tape

nature'ofEmployee Date Month Day Year?

EP 3: TO BE COMPLETED BY ALCOHOL TECHNICIAN

the technician conducting the screening test is no t the same technician who will be conducting thefirmation test, each technician must complete their own form). I certify that I have conducted alcoholing on the above named individual and that I am qualified to operate the testing device(s) identified,

that the results are as recorded.

ECHNICIAN: ~ T T DEVICE: 0 SALIVA IS-Minute Wait: 0 Yes

REENING TEST: For BRE TH DEVICE write ill he spacebelow if the testing drtVice is 1JQ1 desiglled to m:i J1 J

Testing Device Narne Device Serial Qll Lot Exp Date ActivationTime Reading Time Result

NFIRMATION TEST: Result MUST be affIXed to each copy ofthisfonn or printed directly onto theform.. .T .T .. . -

MARKS:A/ji.xor PrintAdditionalResults Here

Affix with Tamper EvidentTape

GU RDI N MEDI L

ohol T e c h n i c i l l l ~C-omnanv Company Street AddressST LOUIS,MO 63146

~ R I N ~ - T ) - A l - c o - ; j i ( r l - - - - ~ - e c - h n i - c - i a n - s - N - a m - e - ( F - i r - s t - ,M-.l-. -L-as-t Company Ci ty, S ta te , Zip Phone Number

nature of AlCohol Technician - Date Month Day Year '

EP 4: TO BE COMPLETED BY EMPLOYEE IF TEST RESULT IS 0.02 OR IDGHER

ertify that I have submitted to the alcohol test, the results of which are accurately recorded on thisn. I understand that I must no t drive, perform safety-sensitive duties, or operate heavy equipmentause the results are 0.02 or greater.

nature o f Employee Date Month Day Year


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THAT WILL PROTECT AGAINSTCOPY COUNTERFEIT AND ALTERATION. BACK OF T IS DOCUMENTLISTS VAfllOUS SECURITVFEATURES

NO REf. ~ { : :

s i g n a t ~ r E

~ ~~ ~ ~ ~ ~~ ; ~t: . ~ : ~ : . : ~ ~

Signed b ~ ; ; t

: < S U 6 s t t t u R o ~ ~ p e ~ ~ r K i H e ~ : }j:f C o l l ~ b ; Q r ~ t i 1 g,Physician:

;:; : : : ; : :: . ;.. .. . :: : : :.:

~

~ . :~


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Patient: WILSON DARREN DMR :Acct DaBContusion is th e medical term for a bruise.being struck in the face.

r --N o r t h v v e s t

ea t th a re

A facial contusion can be caused by a fall or by

The skin, muscles and other soft tissues of the face may become swollen and painful. Yo u ma yhave other injuries, like cuts or scrapes. The bones under your face might be bruised.

Th e doctor does not believe you, have injured essential organs, like your eyes, brain or spine.

pply ice to the face to help with pain and swelling. Place some ice cubes in are-sealableplastic bag like Ziploc). Add some water. Seal the bag. Put a thin washcloth between the bagand the s ~ n Apply the ice bag for at least 20 minutes. Do this at least 4 times per day. It sokay to apply ice longer or more often. NEVER APPLY ICE DIRECTLY TO THE SKIN. Alwayskeep a washcloth between the ice pack and your body. Swelling may increase overnight whenyour head is down and gravity causes fluids to pool in your face. This should improve within afe w hours after you are awake with your head up. Try sleeping with extra pillows to keep yourhead high.

Use Acetaminophen Tylenol) or Ibuprofen Advil or Motrin) to decrease pain and inflammation.Th e physician will decide if you need a prescription medication.

If your nose bleeds, pinch it closed for 15 ,minutes. If that does not stop the bleeding, thenreturn here or to the closest Emergency Department.

If you have a cut that requires stitches, then you will receive additional wound care instructions.

One concern after a facial injury is the possibility of other injuries to the head or neck. Thedoctor has determined that you do not have any other serious injuries and that it is safe for youto go home. If you develop symptoms of a head or neck injury, return immediately to thenearest Emergency Department.

YO U SHOULD SEEK MEDICAL TIENTION IMMEDIATELY, EITHER HERE OR T THENE REST EMERGENCY DEPARTMENT, NY OF THE FOLLOWING OCCURS:

Your headaches are severe or become worse. You vomit repeatedly. You are lethargic or difficult to awaken or you feel confused or seem intoxicated drunk).

You have trouble with coordination or balance, feel dizzy, pass out, or have difficultyspeaking or slurred speech.

Your vision changes or your pupils are unequal in size.

DatelTime: 8 9 2 143:36 PM Page 2


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.1 .

o r \ h v v e s t ea l th a re

Patient: WILSON DARREN D:MR. :Acct :DOB:Medication Reconciliation:THIS IS A LIST OF THE MEDICATIONS THAT YOU WERE ON

II Patient not currently taking any medications.

THESE ARE THE MEDICATIONS YOU WERE GIVEN THE EMERGENCY ROOM: NAPROSYN ORAL 500mgs PO

THESE ARE THE PRESCRIPTIONS THAT YOU WERE GIVEN TODAY:t l New: Naprosyn 500mg; Twenty 20); Take one by mouth twice daily as needed fo r pain,

with food l New ; Collaborating physician:

* *I f side effects develop such as a rash difficulty breathing or a severe upset stomachstop the medication and call your doctor or the mergency Department

I WILSON DARREN D understand the instructions an d will arrange for follow-up care.

atient Signature

Representative Signature

taff Signature

DatefTime: 8/9120143:36 PM Page 4


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Patient: WILSON DARREN DlV R :

c ct

DOB:

Attach utritional Screening

Date Time: 8 9 20143:36 P

e r t h v v e s tH e a l t h a t e

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mo v wilson darren wilson drug testing results

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