University of Missouri - Columbia by wulinqing


									                                      University of Missouri - Columbia
                                        COMMERCIAL DRIVERS
                                            REQUEST FORM
To:        Collection Site
From:      Human Resource Services
           c/o Peggy Spiers
           University of Missouri - Columbia (Account Number 365111)
           1095 Virginia Avenue, Rm. 101
           Columbia, MO 65211-1340

The following individual is a University of Missouri - Columbia employee or pre-employee and is being tested under federal
guidelines of the Department of Transportation. Your assistance in helping the University carry out this process is
appreciated. Breath Alcohol test results are to be reported to Peggy Spiers, Manager, Human Resource Services, (573)884-
7274. Please forward this completed form, the sample, and the "Federal Drug Testing Custody and Control Form" to the
testing laboratory indicated below. Please provide a copy of this completed form to the employee/pre-employee to take back
to their supervisor.

                                              TESTS TO BE PERFORMED
               __Urine Dot 5 Panel          __Breath Alcohol Test BAT Result _____ gm/210L

                                                REASON FOR TEST
__ Pre-Employment       __ Post-Accident (Complete "Post Accident Documentation" form)                      __ Follow-UP
__ Return to Duty       __ Reasonable Cause (Complete "Reasonable Cause" form)                              __ Random
__ Other (Specify):______________________________________________________________

Employee Name: ______________________                     Social Security Number: ______________________
Department: _____________________                Supervisor: ____________________               Phone: _____________

Date/Time Notified To Report To Test Collection Site:           Date: ______                      Time: ______ am/pm
Supervisor Signature: ___________________________________________                                 Date: ____________
Date/Time Arrival At Test Collection Site:                      Date: ______                      Time: ______ am/pm
Collector Signature: ____________________________________________                                 Date: ____________

If more than two (2) hours of time lapses between the time the employee was notified by the supervisor to report to the test
collections site and the time the employee reports to the site, the supervisor of the employee must document the

Note: For post-accident testing, please also complete the "Post Accident Report" form.
Collection Site:                                          Testing Facility:                    Medical Review Officer:
___ The Walk In Medical Clinic                            Medtox Laboratories                  Dr. Belz
    900 Rain Forest Parkway                               402 W. County Rd. D                  Tox Review
    Columbia, MO 65202                                    St. Paul, MN 55112                   P.O. Box 1403
    (573) 449-2216 (Closed Fridays)                       (651)636-7466                        Ozark, Mo 65721
___ Collection sites for employees outside Columbia       (800)832-3244
    area will be provided by employee's supervisor.


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