Review Officer Northfield

amazon

TF

Step */* — Chain of custody

Specimen ID AMZ01113301 Lab ID Quest Diagnostics

Lab Account # 11078876

Lab PanelID 25901N

Oral Fluid Drug Test Form

Donor's information

ID 101*******

Last Name Jones

First Name Kathyleen

ID Verified Y Photo 1D

Reason for Test ¥ Pre-Employment

Daytime Phone Number 925-***-****

Date of Birth 11/20/1964

Collection Information

Monitor's Name Kayla Major

Collection Date and Time 08/02/2022 10:55

Employer Medical Review Officer

Amazon Janelle Jaworski MD

2021 7th Ave 13 Screen

Seattle, WA 98122 9501 Northfield Blvd

Denver, CO 80238

PH: 866-***-****

FAX: 855-***-****

Email: ******@********.***

I certify that I provided my specimen; that have not adulterated it in any manner;

that have sealed each specimen tube with the tamper-evident seal(s); that the

Information and number provided on this form and on the label affixed to each

specimen tube are correct.

Donor's name Kathyleen Jones

Donor's signature os WT

i

Contact this candidate