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<br />r <br />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 />L <br /> <br />~~ <br />~' <br />ii <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 />TYPE OF TEST <br />Non-DOT <br />DOT <br />(Supervisor) at <br />TEST REASON <br />Reasonable Suspicion <br />Post Accident <br />Other (please specify) <br />(Phone Number). <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)704-497-4020 <br />• Pamela Dubois (Deputy County Manager)704-906-9839 <br />17 <br />F-11 <br />HR reviewed 1/23/2009 <br />Page 198 of 320 <br />J <br />Ll <br /> <br /> <br />C <br />0 <br /> <br />n <br />7 <br /> <br />