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Split Specimen Cancellation Notification (49 CFR Part 40.187 & Appendix D)

Note: Information is required only for those tests where donor requested test of split

Medical Review Officer Information
Collection Site Information
Primary Specimen Laboratory
Split Specimen Laboratory
Date split laboratory reported or certified split specimen result
(e.g. name of drug, adulterant, etc.)
Reason for split specimen failure-to-reconfirm result
(e.g. notified employer of failure to reconfirm and requirement for recollection)
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