The next module that we will be discussing and considering today have to do with the MRO staff's relationships with the various service agents that were mentioned in the first module of this course, specifically those relationships with the employers, with the collectors, and with the laboratory, because those are really the three entities, if you will, that MRO staff members are most likely to have interaction with and communications with on an ongoing basis, some more so than others in relationship to various types of cases that you would be handling. So let's review and I think perhaps dig a little bit deeper into the relationship with the employer. The MRO is a service agent for the employer with responsibilities obviously for specific tasks that are related to drug testing. The term service agent is what the DOT uses for any entity or person that implements or administers or assists an employer with the drug testing process. So the rule, the regulation, is really kind of divided, if you will, into being written for three different entities. It's a rule that is written first for employers. Here employers are your responsibilities. It's also a regulation that is intended for employees, for donors, for individuals that are subject to drug testing and subject to alcohol testing. So you will find in various sections of the rule, those times when you've been reading it or looking at it as a reference, that it will say you as the employee are considered to have refused to test if you do these things, right? You will find phrasing in that regulation that says you as the employer must do such and such. You must contact previous employers to determine if the individual has had a prior positive drug test, for example. And then you will find lots of sections of the Part 40 rule that are specific to service agents. You as the borrower must. You as the collector must. You as the collector shall. You as the laboratory shall. So everything that is not an employee or a donor or an employer is a service agent. So that, again, is the gamut of what we mentioned in our first module. So the medical review officer, therefore, as a service agent for an employer, and even when that medical review officer is an employee of the employer, meaning that a company has an internal medical review officer who is part of a medical department or other segment of that company's business structure, the MRO is specifically in that instance a specific service agent for that employer in those tasks. So there needs to be some type of a service agreement. Here are the tasks that as your service agent, as your medical review officer, I am going to perform or we are going to perform for you. In many instances with a freestanding MRO or third-party administrator or large occupational health service providers, that's in the form of a contract with the employer in terms of, again, agreed upon pricing, tasks, all of that kind of thing. And employer-based MROs may simply have it in their job description that in addition to being the medical director of the company who is responsible for this, this, and this, part of that job description of the medical director is that they will serve as the medical review officer for non-DOT results or for DOT drug test results or for all test results or maybe for all test results except for pre-employments, which may be handled outside of the company because they are not yet employees of the company. The MRO's role is also certainly consultative. There is a big element in the DOT regulation as it has evolved over the 20 years really has included more and more gatekeeper-type roles of the medical review officer and as being really an expert in this very specific area of test result review and interpretation and reporting for the employer. And so the medical review officer's role as a gatekeeper is not only quality assurance, but it is also, says the Department of Transportation, as being an advocate for public safety. So the medical review officer, and thereby your role as a staff member, is really dual-hatted. Yes, you are there to make sure that the rights of the employee are driven and are retained so that they have the interview, that they do have the right to a split-specimen analysis and all of that kind of thing. So you are an advocate for the employee's rights and for the responsibilities of the employer under the program, but you are also an advocate for public safety. And that is the role that the DOT sees for you in terms of that ultimately you are a piece of protecting the public safety by having a drug testing program that is internally consistent that does its best to deter and detect users of prohibited substances. Okay, what do we know about employer MRO or employer protocols? Again, in terms of federal testing for DOT, HHS, and the Nuclear Regulatory Commission, most of the MRO process and interface with the employer is established by that regulation. Now, there are some things that are not established by regulation that are left up to the employer and the medical review officer to work out. Now, in some instances, this is not going to be as complex for an internal or in-house MRO department as it is for the company that contracts out that service or arranges that service with an outside medical review officer or service agent. Need to address billing and payment issues. For example, about split specimen reconfirmations. Because the regulation says that the donor is entitled, right, to a split specimen reconfirmation on any verified, alterated, substituted, or positive test result. Who pays for that is not specified by the rule. All the regulation says is that you as the medical review officer cannot deny that right to the employee pending getting the money up front from the employee, right, or in terms of making certain that you are going to be paid for that service. So consequently, you need to develop that with your employer client in terms of how are split specimen reconfirmations going to be handled in DOT tests. Now for those of you that do a lot of non-DOT work, I can tell you that in our practice it's exactly the opposite. For DOT testing, we offer the split specimen. We don't tell the employee anything about payment. It is in the contract with the employer that they will be billed for the split specimen reconfirmation. For our non-DOT clients, however, it's exactly the opposite. Barring maybe one or two where it's a part of a collective bargaining agreement, all of those non-DOT employer clients specify to us you can offer the split specimen reconfirmation and you should do so on every verified positive, adulterated, or substituted result. However, the employee, the donor, even if that's an applicant or a candidate, must submit payment to you, the medical review officer, before you do the split specimen analysis. So it's very different from how DOT has to be handled. Now there are some employers who, as I said, because of a collecting bargaining agreement or whatever, they'll say we're going to pay for the split specimen reanalysis. We have a very large employer that does that. They don't even have a collective bargaining unit, but because they do a lot of DOT testing, they want to apply the same standard for the non-DOT testing that they do of their employees and consequently they pay for the split specimen reanalysis. Now there are some DOT regulated employers who, while they must pay the bill to us as the medical review officer or to the laboratory, they ultimately will seek reimbursement from the employee, and the DOT rule allows them to do that. It's hardest, obviously, for them to do that from a candidate or an applicant. This is a person that they are not going to hire now, assuming that their reconfirmation came back as reconfirmed. So they're going to send the person a letter saying we're not hiring you, and by the way, send me $150 for your positive test that failed to reconfirm. Also luck getting that one. So for employers in the DOT arena, certainly on applicant testing, they're very likely to have to bear that expense as a part of cost of doing business. Shy bladder examinations. You need to set that up with employers, and you're probably thinking, well, how often is that going to happen? Let me tell you. It happens more than you think, number one, and number two, if you don't have a procedure and an understanding with your employer as to how that's to be handled, set up beforehand, it can get really messy. I was just handling a case like this last week, for example, where I don't know why it was not adequately communicated to this employer, but this employer believed, because they were part of a consortium of smaller employers in, this was actually in central Pennsylvania, that the fact that they had an employee who had a shy bladder, could not produce a specimen, an adequate specimen, given three hours timeframe and up to 40 ounces of fluid, and then the collector called the DER and said, Joe Schmo cannot produce a specimen. The DER then said, well, send them over to the hospital then, and so they send them over to the hospital. The hospital had no clue what they were to do. The guy said he was there for a DOT test. They thought it was a DOT physical exam, of course. So the whole situation got to the point where this guy finally ended up, I think, being seen like two different times, finally then did get the MRO staff involved. The MRO staff said, no, no, no, they need to go to an occupational health physician or if he's under the care of a urologist, he can be seen by that urologist, but the medical review officer has to communicate to that referring physician, you know, what the shy bladder examination is. It's not a DOT physical, it's not a pre-placement exam, etc. All was said and done, got this guy evaluated, and then lo and behold, this small employer that was a member of this consortium, in this case it was a public employer, a township, came back and said, what do you mean we have to pay $200 for that emergency room visit and $135 for that examination that was done at the occupational health clinic two days later? No, we don't have to pay that. We only have to pay $35 for our drug test and we're a member of the consortium and that's all we have to pay. No understanding, okay, that the shy bladder examination process, okay, is outside of the normal, if you will, you know, billing, the normal process for DOT drug testing. Now which probably brings up a good point, who is responsible for paying for the shy bladder examinations that are done by physicians as part of that DOT process? Is it the employer or is it the employee? What's your thought? In reality, the rule is silent on that and in talking with the Department of Transportation about it, there really is a kind of, again, that's something you have to work out ahead of time, that most people believe that if the employee is told, is directed by the employer to go to an occupational health provider, to someone other than his or her own physician whose care they are under, whether that's a urologist or an internist or a primary care physician, that if the employee is directed by the employer to get that examination at an occupational health clinic or some, or referred specifically to a urologist that the MRO staff and the employer have identified, the employer is responsible for paying for that. If it is acceptable to the MRO that the employee be seen and get a report from his primary care or other specialists that he is under the care of, then that would be the employee's cost for that examination. That becomes a tricky thing. But also as the medical review officer, don't forget it is your responsibility and thereby as a staff member to make sure that whenever you are working with the DER on trying to set up this whole shy bladder examination process, that the MRO has an obligation to tell the referring physician what they are expected to do, in terms of the kind of report. Because who is the report from the examining physician going to come to? The MRO, not to the DER, not to the donor. So there is a requirement in the rule that the MRO shall communicate to the selected referring physician the following things. He has to tell them that it was a DOT drug test, that they were afforded three hours to produce an adequate specimen, that they were offered up to 40 ounces of fluid, and if you have the information, you as the MRO staff or the medical review officer has the information from the custody and control form from the collector that they refused to take any liquids or they did consume 40 ounces or they only consumed 10 ounces, that is important information to the referral physician to have because claims of dehydration, claims of whatever, right, can be substantiated or unsubstantiated in many cases based on the facts that you're able to provide the referral physician because the referral physician was not there, generally speaking, when the shy bladder event took place. Now, what else? You have to also tell the examining physician that there are specific things in the regulation that can be considered legitimate medical explanations for a shy bladder. Dehydration is not one of them. Situational anxiety about urinating when other people are around or when told to do so or to handle one's own urine, those kinds of things are not considered preexisting documented medical conditions that preclude the person from providing a specimen. So the instructions that you or the MRO provide to that referral physician, either in a form or in a procedural letter of instruction, if you will, need to include the language either paraphrased from Part 40 or we just provide it to them verbatim. It says here are the conditions that are acceptable, that your failure to find or document any preexisting condition will result in a refusal to test for this individual, which is a violation of DOT rules. Because we don't want to get back a report that says he's cleared to return to duty. What does that mean? Or the worst thing is I ask the patient to provide a urine specimen and he did so. It was normal specific gravity, normal creatinine, normal protein and normal glucose. Thank you very much. That helps me not at all, right, in terms of making this determination. So again, what is a best practice here? I know there may be some MROs where the physician MRO personally calls and talks to the examining physician prior to the examining physician seeing the donor. We do not do that, nor does the regulation imply that there must be that direct physician to referral or examining physician contact. So what our MRO practice has developed is essentially a letter of instruction to that referring physician. We do need to know, we as the MRO and MRO staff, need to know what doctor is going to be seeing that donor because the doctor that is going to be doing the examination has to be acceptable to whom? The employer? The donor? Who? The medical review officer, right? That's what the rule says. So the medical review officer then, we would know which doctor is going to perform this examination and therefore can send this letter of instruction. You know, you're going to be seeing Donna Smith. She had what is called a DOT shy bladder on an attempt to collect a DOT urine specimen for a drug test on such and such a date. You know, she was afforded three hours, was offered 40 ounces of fluid, drank, according to the documentation, 30 ounces of fluid, provided no specimen. And then we actually also provide an exam form. That's not required probably, but it's just simpler for us to get this back. We have some semblance of consistency, you know, for them to check off on males, for example, things like large prostate, whether or not they did a rectal, you know. If they did any type of tests relative to a float study or anything like that, not required, but at least if it is there. We stress the fact that this examination should not include a drug test. That's not what they're there for. They're there to document, if you will, okay, the existence of a medical condition so that we can determine either this is a cancelled test with a bona fide medical explanation for the inability to produce a urine specimen or it is a refusal to test. There is no documented medical condition, either preexisting psychological or preexisting physiological condition. Okay. Yes. That's okay. Our MRO, like I said before, we are a small facility, is our occupational health physician. And we haven't had many cases of this, but in one case we have another physician that we deal with, too, and he was there. In one case we had our MRO had to actually see the patient. Is that okay? Yes. Her question essentially is, can the medical review officer serve as the examining physician for a shy bladder determination and then essentially would be taking the basis of his own findings, right, and making the final test result determination? And that is permitted by the regulation. And likewise, if, for example, a person is at a clinic, maybe at your facility, getting a collection done, right, and the three hours expires, they have not been able to provide a specimen, when the collector, let's say you're serving as the collector or another person on your staff is serving as the collector, contacts the DER, is it permissible for that collector to say to the DER, we have a physician who is here now who could go ahead and do the shy bladder examination, and that is also permissible. Okay, it doesn't have to be a urologist. As I said, it doesn't have to be approved by the DER as long as, again, either you are the MRO of record on that or you were able to have the DER, say, contact the MRO who's listed on this custody and control form is Dr. Kenneth Chase, okay, contact them and ask if it is okay for this shy bladder examination to take place right now here at such and such hospital because Dr. Jones is available. Okay, so those are variations of that. And really, that's preferable, to be honest with you, because the sooner that person can be seen in relationship to when the event occurred, the better it is. Now, how long does the reg allow between the time that the person could not urinate and when they are supposed to have this medical examination done? Do you know the time frame? It is five days, five business days. And again, we have these circumstances all the time. I don't know why. The collector called the DER on Friday and said, Mr. Jones couldn't provide a specimen for his DOT test. And the DER is hassled and doing whatever and says, okay, fine, send him back. And then, come next Thursday, calls the... remembers to call the MRO and says, oh, man, Joe didn't get his drug test last Thursday. He couldn't urinate. Can I just send him in today? No, you can't just send him in today. And we're now almost at the end of time that we have to, you know, get this arranged. So then everybody is scrambling to get the examination done. All right, what about DNL isomer analysis? Why would I have this up here under things that you need to address with your employer clients? Or in the case of an in-house MRO that you need to make sure that you have internal procedures for how you're going to do them. A DNL isomer analysis refers to what? Does anybody know? It is when you're dealing with a positive methamphetamine result. It is an additional test that the laboratory can do. They're authorized to do it under DOT and other federal rules, okay? It is an additional test that they can do that would help the medical review officer to provide the best interpretation of a methamphetamine positive result, particularly when the donor has indicated in the interview in response to a question that any good MRO is going to ask with a methamphetamine positive, and that is, do you use a solid inhaler? What's a solid inhaler? Like a Vicks inhaler. Not something you squirt in your nose and not something that you take for asthma like an Advair or that kind of an inhaler, but a solid inhaler that is used or sniffed for congestion. The MRO is going to ask that because that is the only over-the-counter medication that contains methamphetamine. Now, I don't want everybody to be running out there to get a Vicks inhaler thinking that they can get high by sniffing a Vicks inhaler. That's the point of the additional analysis. The methamphetamine ingredient in Vicks solid inhaler or other CVS or Walgreens brand of inhalers, okay, contains the L form, what we call the Levo form of methamphetamine. It is not psychoactive. It is not a controlled substance. But the test that we have in the laboratory is not specific for the D form of methamphetamine. It will show any cluster that is the ions of methamphetamine, okay? So why do you have to know this? This sounds way too technical for what an MROA should know, but here's where you all come into this. The laboratory is not going to routinely do the DNL isomer analysis. They will charge extra for it. So here we go. Who's going to bear this cost? Should it be the MRO or should it be the employer? Under DOT, the who bears all the costs associated with the drug test? The employer with the drug test itself, okay? Additional stuff such as examinations, reconfirmations, or whatever. But for collecting, analyzing, and reporting and reviewing a DOT drug test, that's the employer's expense. That's the cost of being a DOT-regulated employer. It's probably a few cents on my airline ticket, right, because they have to comply with FAA drug testing rules. But here you need to make sure that the employer knows that if you as the medical review officer or the medical review officer you work for needs a DNL isomer analysis for a methamphetamine positive, that the employer is going to see additional charge on their invoice from you. Or in the case of an in-house medical review officer, that the MRO knows in terms of a budget standpoint that the laboratory is going to charge an additional amount for that analysis. Now, is it possible to set up that the laboratory does these automatically on methamphetamine positives? Yes. And that is certainly my advice to you. One of the ugliest MRO cases that I know, legal cases, that was brought against an MRO was the untenable situation for the MRO where he had a methamphetamine positive. It was on a driver and the CDL holder. And the driver alleged that he probably had taken some Vicks. He wasn't sure, yada, yada. The MRO staff member sent a special request to the laboratory to do the DNL isomer analysis. And that took seven days before the laboratory re-ran the specimen to do the DNL and to give a report to the MRO. The report got back. The MRO wasn't there. I think he was gone for a couple of days. And so anyway, a whole ten days had elapsed, okay, between the time that the MRO had done the interview. And wouldn't you know it, on that tenth day, this guy was in a fatal crash and killed two people. And the post-accident test, of course, was again positive. And the DNL report came back as 90% D. What did that mean? It wasn't a Vicks inhaler at all. Because if it had been a Vicks inhaler, it would have been at least 80% L and only 20% D. So the guy was a meth head, right, essentially, had conned the MRO. The MRO, though, was doing the right thing, okay, in terms of making sure that the guy's story about a Vicks inhaler, right, could be disproven, ordered the analysis, but then all this time. So you really want to protect, if you can, yourselves from possible litigation, and protect the public and protect the employer, et cetera, by having a standing order. We have a couple of labs that will not do standing orders on them. I get so frustrated with them. And it is really a difficult situation. But if you can at all, you should try to get D. It is not necessary to do DNL isomers on the amphetamines, and don't let the laboratory try to tell you, well, yes, we'll sell you that, but we're going to do them on all the amphetamine positives also. That's an expense that the employer should not have to bear. It's not at all necessary. There's a heck of a lot more amphetamine positives than there are methamphetamine positives today, especially with drugs like Adderall being so frequently prescribed. Okay, so that's DNL isomer analysis. Additional specimen validity testing. I would tell you that probably 20% of the invalids that are reported by drug testing laboratories today are because the laboratory believes there is an adulterant in the specimen but does not do the necessary confirmation testing to confirm it and report it as adulterated. Why don't they? Quite frankly, it's horrendously expensive. Adulterants change their formulas every year. There are now at last count, I think, probably 16 different commercial adulterant products that include various varieties of halogens and oxidizing agents or iodine-based agents. And so to develop and validate the confirmation, either tandem mass spec with liquid chromatography or GC mass spec, gas chromatography mass spec, to definitively identify those specific adulterants is a costly and time-consuming process. And so basically what the laboratories have done is that they have developed screening tests that will identify like halogens and iodine compounds, etc., that are going to interfere or that are potential masking agents. But because they have not validated and invested in the confirmation technique, they can't report that as adulterated. So it comes out as invalid. Now, most of the certifying scientists at laboratories where that is their normal practice will tell the medical review officer in discussing that invalid result that it looks to us like this is probably a halogen interferon or adulterant. We don't have the means to test for it, to confirm it. Now, there are, and we have these conversations every month it seems, so somewhere with some laboratory, there are laboratories that do specialize in that. And so we'll get somebody at Quest that will say to us, I do think this is one of those new iodate or iodine-based masking agents. And Medtox Laboratory, for example, has developed a confirmation test for it. Why don't we send it off there? Well, here's the catch, of course. Is Medtox going to do that for free? No. Okay. So you basically have to work out with your employers, again, as a medical review officer and as an MRO department, are we going to pursue these? Or are we going to call this one invalid, canceled, no medical explanation, recollect under direct observation immediately? I can tell you what most of our employers do. What would you guess? Yeah, they just say cancel the test. I don't want to pay $250 or $100 or whatever it is, right, to send it off to Medtox or to El Soli or to USDTL that, you know, that tend to be laboratories that specialize in this kind of more esoteric type of testing for the rarer compounds. So just cancel the test and I'll send the guy back in tomorrow and maybe we'll get lucky, you know, through direct. Because most adulterants like that are added to a specimen. That's how they're done. It's not something they've taken internally. It's not, you know, but it is something that they have manipulated at the time of collection. So if a true direct observation is done, they're not going to be able to use the same, you know, methods or the same steps for being able to introduce the adulterant into the urine. Okay, so that's the additional specimen validity testing. Remember, for those of you that, again, may have taken a course like this a number of years ago or that have been involved in testing over a long period of time, both the Department of Transportation and the Department of Health and Human Services have joined the Nuclear Regulatory Commission in requiring a standard specimen validity testing panel of all federal tests. That became a reality by the rules about three years ago, maybe a little bit more than that. The standard specimen validity testing that must be done on all federal urine specimens at the laboratory today consists of, first thing they do is what? Creatinine, right? If the creatinine is less than what? 20, they do a what? A specific gravity. They also, creatinine, and if it trips the creatinine cutoff, then a specific gravity measurement is done. Those are two of the specimen validity measures. The third one is pH must be done on every specimen. Then they must do a screening test for at least one oxidant or oxidizing agent. The laboratory can choose which oxidizing agents they would like to screen for. Most of them use a general oxidizing or oxidate screen. Many of those are triggered at nitrites. As the principal, you know, adulterant in that category that is found today. So you have essentially a four, if you will, right? Specimen validity panel minimum. The creatinine, and if that is below cutoff of 20, a specific gravity. The pH, which is a test of the urine's acidity or alkaloid or base properties, and then the oxidizing agent. Creatinine and specific gravity, then, are the two measurements under specimen validity that are used to determine what two types of test results. Dilute and what other category? Adult, no. Substituted, right? Creatinine and specific gravity are used to determine whether it meets the definition of substituted or whether it meets the definition of dilute. pH, on the other hand, would be a category or a measurement that may define a specimen as what? Adulterated, that is correct. Because a pH of less than three is adulterated, and a specimen with a pH of greater than 11 is adulterated. Oxidizing agents would also be a measurement that would be included in the adulterated category. So you would find things like nitrites greater than 500, that's an adulterated specimen, and that would be based on the screening test for the oxidants and then a confirmatory test specifically for nitrite. Now, the specimen validity measures also may contribute to a specimen being called invalid. So if you have creatinine and specific gravity, for example, that are inconsistent, they don't meet the definition of normal, they don't fall into the dilute category, and they don't fall into the substituted criteria, then they will be reported as invalid. Specific gravity and creatinine are inconsistent. They're inconsistent with being normal, they're inconsistent with us being able to say this is not human urine, it is substituted, and they are inconsistent, right, with it being considered a dilute specimen by definition. Likewise, pH, I said that if the pH is less than what? Three or greater than 11, right, it is adulterated. However, if it is outside of the normal range, right, then, but not yet, so acid or so base that it has been manipulated or externally adulterated, then it is called invalid. So you will find that you will get an invalid specimen pH 3.5. Anything that is between 3 and 4.5 is going to be invalid, and anything that is between 9 and 11, right, is going to be invalid. Now there are a variety of reasons why specimens can be invalid in the pH range, and you'll have an opportunity to discuss that in one of the other modules that we'll be doing in today's course. Okay, need to determine the DER contact procedures, the result reporting methods, the negative dilute recollections, etc. The DER contact procedures, remember, that has to be, for DOT results, you have to have a procedure that says that the MRO is going to make X number of attempts, or you are going to make X number of attempts to get the individual by phone to have them talk with the medical review officer, right, in a 24-hour period, and that number of attempts is what currently? Do you know? Three. You must make three attempts to contact the donor over a 24-hour period, preferably on the same business day or starting on the next business day when you receive the laboratory result, and if at the end of that third attempt over a 24-hour period you are not successful in the donor returning the call to the medical review officer if a message has been left, etc., or for the medical review officer to have reached the donor, then you must do what? Do you cancel the test? Do you report as a no contact? No. You contact the DER and you say, we are having difficulty reaching Donna Smith. The medical review officer needs to talk with her. Well, what does he have to talk with her about? I'm not at liberty to say, but we do need, we have tried to reach her over the past 24 hours. Do you have an alternate phone number, or can you get in touch with her and have her call Dr. Chase, Dr. Ferguson, Dr. Hartenbaum at the following number, and then give that number? Okay, so then you also have to say to that DER, I need to know when you have contacted Donna Smith, because that you put in your MRO case notes, right, as a staff member that says, I called the DER on Thursday morning at 1030 to tell her to get in touch with Donna Smith and have Donna Smith call Dr. Hartenbaum. At 12 noon, the DER left me a voicemail message that said that she had contacted Donna Smith and given her Dr. Hartenbaum's number to call. So that time and that day, if you will, that the DER let you know that Donna Smith knows she has to contact Dr. Hartenbaum about a test result, becomes the 72-hour clock, okay? So now, 72 hours, or three business days essentially from when the DER lets you know, all right, that they have contacted the donor, then if you have not heard from the donor, then you call it a no contact, or you report it as positive, adulterated, or substituted, whatever the laboratory result was. Now, what if Donna Smith, in this case, was an applicant? The numbers that were provided on the CCF, nobody ever called back on one, the other one, this number is out of service, okay? And you have contacted the DER and said, well, they don't work here, that's an applicant, I'll try to see if the HR person can get in touch with them. HR person, probably when the applicant saw the number coming up from the MRO or whatever, or the MRO staff member left a message, please call this office about your recent test, end of story, then they said, oh, well, I'm not getting that job, right? So why would they even attempt to have communication with the HR person or whatever? So in that instance, if the DER or the DER's representative is not able to contact the donor to say, you know, call the MRO or come into my office now, I'll close the door, give you some privacy, and you talk to the MRO right now, then you can report that test out without donor interview after 10 days from the receipt of the result from the laboratory. So you have these kind of time clocks that you need to have in your procedures. I guess that's what I'm trying to get across in this particular session, is that you have the 24-hour time clock, which represents the time over which you or the medical review officer must do what? Attempt to contact the donor, right? And then at the end of that period of time, you have a 72-hour, right, or three-day clock that starts once you have asked the DER for assistance, and the DER has confirmed that they have told the donor to get in touch with the medical review officer. And then you have this 10-day clock, right, that you can report a result without any donor interview when neither the medical review officer or his or her staff member or the DER or the employer representative has been able to reach the donor. And that 10 days goes from the time that the non-negative result was reported to the medical review officer by the laboratory 10 days out. You then verify based on the laboratory result without any change to the result based on a donor interview. Okay, question? We are going to take a break, and let's go ahead and take a break right now. I was going to try to get through this slide, but that's okay. We'll take a break right now. Thank you.

Medical Review Officer

drug testing

employers

collectors

laboratories

service agreement

employee's rights

specimen validity testing

communication