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CABARRUS COUNTY GOVERNMENT <br />DRUG TESTING AUTHORIZATION <br />STEP 1: To Be Completed By Employee's Supervisor <br />Please complete and sign this form. Send it with Applicant/Employee to collection sites. Designate the reason for testing, <br />the time and date. Advise donor to bring picture identification (ID). Do not give medical information to collector. <br />Applicant / Employee Name: <br />IS TO REPORT IMMEDIATELY FOR TESTING TO: Employee Health Center, 845 Church Street, Concord, NC <br />DATE: <br />TIME: <br />Collection Site Staff: This is your authorization to perform the specified Drug and/or Alcohol Testing on the identified <br />applicant/employee. If you have any questions, please call: <br />(Supervisor) at (phone number). <br />TYPE OF TEST <br />Non -Dot ❑ <br />DOT ❑ <br />TEST REASON <br />❑ Random <br />❑ Post Accident <br />❑ Other (please specify) <br />❑ Reasonable Suspicion <br />❑ After Hours <br />(Report to CMC -NE Emergency Room) <br />STEP 2: To Be Completed by Collection Site Staff <br />(Please return to Employee) <br />Donor Arrived at Collection Site: Date: Time: AM/PM <br />Identity Verified: [ ] yes [ ] no <br />Collector's Signature: <br />Returned to: <br />Specimen Collected: [ ] yes [ ] no <br />STEP 3: To Be Completed by Cabarrus County Supervisor <br />(After Employee Returns from Collection/Testing Site) <br />Date: Time: AM/PM <br />Supervisor's Name <br />RETURN COMPLETED FORM TO HUMAN RESOURCES <br />Revised 11/29/00; 8/1/07; 4/20/09 <br />21 <br />Attachment number 1 <br />F -5 Page 115 <br />