SAP Intake Assessment
Section 1 is required information for compliance reporting
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Email *
Enter your Email Address again *
Your Name *
Best phone number to reach you *
Your Social Security Number (last 4 digits minimum requirement)
 *
Reporting authority for your credentials *
Date of Violation (Positive Test or Failure to Report)
 *
MM
/
DD
/
YYYY
Reason stated on results for violation *
Reason you took that DOT test *
Have you had any prior Drug/Alcohol violations? *
Your Employer (or pre employment) Company Name at the time of the violation
 *
Street Address for Company at time of Violation
 *
Contact Name for employer at time of Violation (Usually the safety person who sent you for the test)
 *
Email Address for Contact person noted above (safety person at employer at time of violation)
 *
Please let me know how you found out about my SAP service (ex employer referred, friend referred, search engine etc . This is not required for reporting but is appreciated)
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