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FORM C <br />CABARRUS COUNTY GOVERNMENT <br />DRUG TESTING AUTHORIZATION <br />(Out of Town) <br />STEP 1: To Be Completed By Employee's Supervisor <br />Please complete and sign this form. Send it with Employee to collection site. Designate the reason for testing, the time and <br />date. Advise donor to bring picture identification (ID). <br />Employee Name: <br />IS TO REPORT IMMEDIATELY FOR TESTING TO: <br />DATE: <br />TIME: <br />Collection Site Staff: Please accept this as your authorization to perform the Specified Drug/and or Alcohol Testing on <br />the identified employee. If you have any questions, please call: <br />(Supervisor) at <br />(Phone Number). <br />TYPE OF TEST TEST REASON <br />Non -DOT ❑ ❑ Reasonable Suspicion <br />DOT ❑ ❑ Post Accident <br />❑ Other (please specify) <br />STEP 2: Please fax MRO copy of chain -of- custody to <br />704- 783 -1573 (Steven St. Clair, MD, MPH, MRO) <br />STEP 3: Please send results of tests to Medical Review Officer: <br />Steven St. Clair, MD, MPH, MRO <br />Northeast Occupational Medicine Services <br />707 Memorial Blvd, Concord, NC 28025 <br />704 - 783- 1791(Tel) 704- 783 -1573 (Fax) <br />Billing Info: Cabarrus County, Attn: Human Resource Dept., P. O. Box 707, Concord, NC 28027 <br />If procurement authority is required — please contact the following in this order: <br />• Supervisor/Department Head <br />• Tony Harris (Safety& Risk Manager) 704 -453 -6641 <br />• Johanna Ray (Health & Wellness Manager) 497 -4020 <br />• Pamela Dubois (Deputy County Manager) 906 -9839 <br />HR reviewed 4/20/2009 <br />22 <br />Attachment number 1 <br />F -5 Page 116 <br />