ABCDEFGHIJKLMNOPQRSTUVWXYZAAABACADAE
1
TimestampName of the Entity as it should appear throughout the Policy & Forms:Abbreviated Name of the Entity as it should appear throughout the Policy & Forms:Type of Entity:Mailing Address:Phone Number:Fax Number:Name of the Entity's "Desginated Employer Representative":Title of the Entity's "Designated Employer Representative":Address of the Entity's "Designated Employer Representative":Phone number of the Entity's "Designated Employer Representative":Email address of the Entity's "Designated Employer Representative":Name of the Entity's "Alternate Designated Employer Representative":Name of the Entity's certified Medical Review Officer (MRO):Address of the Entity's certified Medical Review Officer (MRO):Phone number of the Entity's certified Medical Review Officer (MRO):Name of the Entity's EAP Provider:Name of the Lab used by the Entity:Address of the Lab used by the Entity:Number of DOT covered employees:Under what DOT agency(s) regulations do your covered employees work?Do you also want additional a state specific "Company Authority" policy?If yes, what state?When do you plan to implement the program?Alcohol Testing Site(s) & Specimen Collection Site(s):Name of Entity's Substance Abuse Professional (SAP):Address of Entity's Substance Abuse Professional (SAP):Phone number of Entity's Substance Abuse Professional (SAP):Name of Entity's Consortium/Third Party Administrator (C/TPA):Address of Entity's Consortium/Third Party Administrator (C/TPA):Phone number of Entity's Consortium/Third Party Administrator (C/TPA):
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100