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April 18, 2011 (Regular Meeting) <br />Employee Name: <br />IS TO <br />Page <br />REPORT IMMEDIATELY FOR TESTING TO: <br />DATE: TIME: <br />Collection Site Staff: Please accept this as your authorization to perform <br />the Specified Drug /and or Alcohol Testing on the identified employee. If you <br />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 <br />to : <br />704 - 783 -1573 (Steven St. Clair, MD, MPH, MRO) <br />STEP 3: Please send results of tests to Medical Review <br />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., <br />P. 0. Box 707, <br />Concord, NC 28027 <br />If procurement authority is required - please contact the following in this <br />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 />FORM D <br />CABARRUS COUNTY GOVERNMENT <br />OBSERVATION OF SUSPECT BEHAVIOR <br />Supervisor's Name: <br />Employee's Name: <br />Job Title: <br />Description of Work: Managerial Office /Clerical <br />Other: <br />How long has the employee worked for CABARRUS COUNTY GOVERNMENT: <br />How long have you supervised the employee? <br />Was the employee involved in an accident or near - accident? Yes <br />If yes, Description: <br />Date and Time: <br />Extent of Injury to persons /Property: <br />Employee's Actions: <br />OBSERVATIONS: <br />Speech: Mumbled <br />Condition of Clothes: <br />Eyes: _Sleepy B1 <br />Alert <br />Attitude or Demeanor: <br />_Nervous _Depressed <br />No <br />_Slurred _Confused _Incoherent _ Stuttering <br />_Disorderly _Soiled _Rumpled _Orderly <br />Dod Shot Glassy Watery Dilated Closed <br />Talkative Hyperactive Hostile _Irritable <br />Profane Drows Pleasant Wide Mood Swings <br />Driver <br />A -1 Page 294 <br />