DOT Drug-Free Policy Worksheet
You have requested a worksheet in order for your entity to receive a proposal to develop a Drug Free Workplace Policy and/or Forms. Please answer the following questions and fax the completed worksheet back to (334) 521-7017, attention Tommy Eden at the law firm of Constangy, Brooks & Smith, LLP. You will be sent an engagement letter to confirm the work requested prior to drafting your customized Drug Free Workplace Program. If you have questions call attorney Tommy Eden at (334) 246-2901 or fill in form and e-mail teden@constangy.com you may view Tommy’s Blog at www.AlabamaAtWork.com.
Name of the Entity as it should appear throughout the Policy & Forms: *
Your answer
Abbreviated Name of the Entity as it should appear throughout the Policy & Forms: *
(such as "ATC" rather than "American Trucking Company, Inc.")
Your answer
Type of Entity: *
(examples -- Company, Organization, Agency, League, Association, Corporation, Firm, Group, Department, Practice, Partnership, Enterprise)
Your answer
Mailing Address: *
(Include City, State & Zip)
Your answer
Phone Number: *
Your answer
Fax Number: *
Your answer
Name of the Entity's "Desginated Employer Representative": *
(This should be the person in charge of implementing the program, overseeing employee education, arranging for testing and keeping records of the Entity's compliance with Drug-Free Workplace rules. It is generally the Personnel Director, Administrator or your Entity's equivalent)
Your answer
Title of the Entity's "Designated Employer Representative": *
Your answer
Address of the Entity's "Designated Employer Representative": *
Your answer
Phone number of the Entity's "Designated Employer Representative": *
Your answer
Email address of the Entity's "Designated Employer Representative": *
Your answer
Name of the Entity's "Alternate Designated Employer Representative": *
Your answer
Name of the Entity's certified Medical Review Officer (MRO): *
(a licensed physician, MD or DO, who is responsible for receiving and reviewing laboratory results generated by an employer's drug testing program and evaluating medical explanations for certain drug test results)
Your answer
Address of the Entity's certified Medical Review Officer (MRO): *
Your answer
Phone number of the Entity's certified Medical Review Officer (MRO): *
Your answer
Name of the Entity's EAP Provider: *
(provide all contact information -- must have if PHMSA regulated)
Your answer
Name of the Lab used by the Entity:
Your answer
Address of the Lab used by the Entity:
Your answer
Number of DOT covered employees: *
Your answer
Under what DOT agency(s) regulations do your covered employees work? *
Your answer
Do you also want additional a state specific "Company Authority" policy? *
If yes, what state?
Your answer
When do you plan to implement the program? *
(date)
Your answer
Alcohol Testing Site(s) & Specimen Collection Site(s):
Your answer
Name of Entity's Substance Abuse Professional (SAP): *
Your answer
Address of Entity's Substance Abuse Professional (SAP):
Your answer
Phone number of Entity's Substance Abuse Professional (SAP):
Your answer
Name of Entity's Consortium/Third Party Administrator (C/TPA):
Your answer
Address of Entity's Consortium/Third Party Administrator (C/TPA):
Your answer
Phone number of Entity's Consortium/Third Party Administrator (C/TPA):
Your answer
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