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State Drug-Free Worksheet for Private Entities
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* Indicates required question
Name of the Entity as it should appear throughtout the Policy & Forms:
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Your answer
Abbreviated Name of the Entity as it should appear throughout the Policy & Forms:
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(such as "ATC" rather than "American Trucking Company, Inc.")
Your answer
Type of Entity:
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(examples -- Company, Organization, Agency, League, Association, Corporation, Firm, Group, Department, Practice, Partnership, Enterprise)
Your answer
Mailing Address:
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(Include City, State & Zip)
Your answer
Phone number for the Entity:
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Your answer
Fax number for the Entity:
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Your answer
Name of the Entity's "Desginated Employer Representative":
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(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 "Desginated Employer Representative":
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Your answer
Entity's Alternate "Designated Employer Representative":
*
Your answer
Name of Entity's certified Medical Review Officer (MRO):
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(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
EAP Provider:
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(Provide all contact information)
Your answer
If you have any DOT regulated covered employees, what DOT Agency covers you?
Your answer
For what State(s) should this policy be developed?
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Your answer
When do you plan to implement the program?
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(Date)
Your answer
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