UDS Authorization


1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Urine Drug Screen (UDS) Authorization

Name:    Date of Birth:

Center for Family Development Recovery Program utilizes urine testing in order to objectively determine whether recent substance use has occurred. Urine drug screens (UDS) can serve as a motivator to assist individuals in meeting their substance use goals.

Center for Family Development requires a UDS at the time of assessment, and thereafter individuals will be tested during the course of services. UDS results will be utilized to further develop service recommendations. If an individual refuses to do a UDS or is unable to produce the sample, it will be assumed the sample would have been positive. The integrity of urine samples is an essential element of the Recovery Program. As such, UDSs are monitored closely and observed as needed.

I understand that I may be required to provide unscheduled/random urine samples. If I fail to provide a random urine sample, it will be assumed the sample would have been positive. Information on how to access my random UDS dates will be provided to me via email or hard copy.

I understand that if I receive public funding or am in the DUII program, CFD must report the number of positive UDSs I produce as required by the State of Oregon for the Measures and Outcomes Tracking System (MOTS). I acknowledge that dilute UDSs are recorded in MOTS as positive.

Urine samples will be sent to the lab for analysis.

By signing below, I acknowledge that:

  • I have read this form and understand its contents.
  • I understand the information on dilute urine samples and false positive UDS results.
  • If I am not carefully monitoring my liquid intake before providing a urine sample, I could provide a dilute urine sample.
  • If I am enrolled in CFD's DUII Program, a positive UDS result without a valid prescription or a UDS result of "specimen is dilute" will restart the time for my documented substance abstinence.
  • I agree to have urine samples analyzed for purposes of determining my use of substances.
  • I acknowledge that I may ask for copies of my UDS results in the future and that my signature acts as approval for this release.

My signature affirms that I have read and understand this form and have had the opportunity to ask questions.

This document is being signed by:

If you are signing as the Personal Representative, please complete the following section; otherwise, proceed to signing the form.

Full legal name of Personal Representative:

Relationship to client:

Definition of Personal Representative:
For Adults: A person with legal authority to make healthcare decisions on behalf of the adult. Supporting documentation required.
For Youth: A parent, guardian, or other person acting in the place of a parent with legal authority to make healthcare decisions on behalf of the minor child. Supporting documentation may be required.

Leave this empty:

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Signature Certificate
Document name: UDS Authorization
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February 2, 2024 1:22 pm PDTUDS Authorization Uploaded by Do Not Reply - donotreply@c-f-d.org IP 192.111.94.1
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February 2, 2024 2:35 pm PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 192.111.94.2
February 2, 2024 2:57 pm PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 192.111.94.2
February 2, 2024 3:01 pm PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 192.111.94.2
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