Figment Group Inc.

If you say NO to any of these, contact your Testing Site to have them correct the error (if correctable) and send you a copy of the affidavit to attach to your copy of the results.

• Does the top of the form say (DOT)?
• Is the information correct in Step 1?
  • Employee Name
  • Employee’s SS# or ID #
  • Employer Name & Address
  • DER’s Name & Phone #
  • Reason for Test
• Did the donor sign and date in Step 2?
• Was the following information completed in Step 3?
  • Technician information (i.e. BAT or STT)
  • Device (i.e. Saliva or Breath)
  • Screening Test Information (if not printed out and attached to the Alcohol Testing Form)
    • Test #
    • Testing Device Name
    • Device Serial # (Breath Test) or Lot # & Expiration Date (Saliva Test)
    • Activation Time
    • Reading Time
    • Result
  • Alcohol Technician’s Company, Address & Phone#
  • Alcohol Technician’s Printed Name, Signature & Date

Confirmation Test  (Required if the result of the Screening test was 0.02 or higher).

• Was a Confirmation Test Completed?
• Was there a 15-Minute Wait between the Screening and Confirmation Tests?
  • The yes box next to 15-Minute Wait in Step 3 must be marked
• Are the Confirmation Test results attached (The results for a Confirmation Test must be printed out and attached to the Alcohol Testing Form)?
• If the result of the Confirmation Test was 0.02 or higher, did the donor sign and date Step 4?

If your collection site is making errors frequently, contact Figment Group at 219-326-8880 and we will assist you in finding a new collection site.