403.7E4 - Drug/Alcohol Test Notification Form

Date

 

Name (print)                                                                                       Social Security Number

 

 

The above named employee is to have the following test done:

 

_Drug Type of Test:

_Alcohol

 

_Both Drug and Alcohol

 

Time Sent by District School District Contact Person (Phone)

 

 

Time Arrived at Collection Site                                             Collection Site Person

 

 

Time Test Was Completed                                                     Collection Site Person

 

I understand I am to go directly to the collection site located at:

                  

                                                                                                                   (address of collection site)

 

 

 

Employee's Signature                                                             Date

 

 

 

 

Approved: November 1995      
Reviewed: January 2017, May 2020