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FORM B <br />CABARRUS COUNTY GOVERNMENT <br />DRUG AND ALCOHOL TESTING AUTHORIZATION FORM <br />STEP 1: Employee's Supervisor completes Step 1 & gives to Employee to take to test collection site. <br />Advise applicant/employee: Picture ID is required. <br />Applicant / Employee Name: <br />You are to report immediately for testing to: <br />You must report NO later than am /pm date <br />(Failure to report by time indicated without a valid explanation will be considered a test refusal.) <br />Day and Time of Testing: <br />Employee Reports to collection site: <br />Weekdays: 8:00 am — 4:30 pm * <br />Employee Health Center (EHC) <br />(closed for lunch 11:30 am —1:00 pm and CMC -NE holidays) <br />845 Church St, Suite 101, Concord, NC <br />704 - 783 -3174 fax 704 - 786 -0711 <br />Weekdays: 11:30 am —1:00 pm and 4:30 pm — 6:30 pm ** <br />Carolinas Health Care Urgent Care — Cabarrus <br />Sat/Sun /EHC Holidays: 8:00 am — 6:30 pm ** <br />888 Church St N, Concord, NC <br />(closed Thanksgiving, Christmas Eve, and Christmas) <br />704 - 786 -6122 <br />Daily: 6:30 pm — 8:00 am <br />Carolinas Medical Center — NorthEast <br />Thanksgiving, Christmas Eve, and Christmas <br />Emergency Care, 920 Church St N, Concord, NC <br />*For applicants only: Must report to the clinic by 4:00 pm. <br />* *Urgent Care is open until 8:00 pm for Workers' Comp Injury Treatment. Drug & alcohol testing services end at 6:30 pm. <br />If the collection site has questions call: <br />Date and time employee notified of test: <br />TESTING AUTHORITY TYPE OF TEST <br />(Supervisor must check one box in each of these three columns.) <br />NON -DOT DRUG <br />DOT -FTA <br />DOT -FMCSA <br />ALCOHOL <br />BOTH <br />** *Transportation must be provided for reasonable suspicion <br />(Supervisor) at <br />TFCT RFARON <br />Pre - Employment <br />Promotion to Safety- Sensitive Position <br />Random <br />Post - Accident <br />Reasonable Suspicion * ** <br />Other (specify ) <br />STEP 2: Collection Site Staff complete Step 2 & return form to Employee after test. <br />This is your authorization to perform the specified Drug and /or Alcohol Testing on the identified applicant /employee. <br />Donor Arrived at Collection Site: Date: Time: AM /PM <br />Identity Verified: [ ] yes [ ] no Specimen Collected: [ ] yes [ ] no <br />Collector's Name & Signature: <br />STEP 3: Emalovee: After test. return form to supervisor. Supervisor: Complete Step 3 and return to HR. <br />(phone number). <br />Returned to: Date: Time: AM /PM <br />Return Completed Form to Human Resources <br />Cabarrus County Human Resources, P.O. Box 707, Concord, NC 28026 -0707 <br />Phone: 704 - 920 -2200 Fax: 704 - 920 -2250 www.cabarruscounty.us HR Revised 7/20/11 <br />19 <br />Attachment number 1 <br />F -6 Page 130 <br />