BC 2011 04 18 Regular - Laserfiche WebLink

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April 18, 2011 (Regular Meeting) Employee Name: IS TO Page 391 REPORT IMMEDIATELY FOR TESTING TO: DATE: TIME: Collection Site Staff: Please accept this as your authorization to perform the Specified Drug /and or Alcohol Testing on the identified employee. If you have any questions, please call: (Supervisor) at (Phone Number). TYPE OF TEST TEST REASON Non -DOT ❑ ❑ Reasonable Suspicion DOT ❑ ❑ Post Accident ❑ Other (please specify) STEP 2: Please fax MRO copy of chain -of- custody to 704 - 783 -1573 (Steven St. Clair, MD, MPH, MRO) STEP 3: Please send results of tests to Medical Review Officer: Steven St. Clair, MD, MPH, MRO Northeast Occupational Medicine Services 707 Memorial Blvd, Concord, NC 28025 704 - 783- 1791(Tel) 704 - 783 -1573 (Fax) Billing Info: Cabarrus County, Attn: Human Resource Dept., P. 0. Box 707, Concord, NC 28027 If procurement authority is required - please contact the following in this order: • Supervisor /Department Head • Tony Harris (Safety& Risk Manager) 704 - 453 -6641 • Johanna Ray (Health & Wellness Manager) 497 -4020 • Pamela Dubois (Deputy County Manager) 906 -9839 HR reviewed 4/20/2009 FORM D CABARRUS COUNTY GOVERNMENT OBSERVATION OF SUSPECT BEHAVIOR Supervisor's Name: Employee's Name: Job Title: Description of Work: Managerial Office /Clerical Driver Other: How long has the employee worked for CABARRUS COUNTY GOVERNMENT: How long have you supervised the employee? Was the employee involved in an accident or near - accident? Yes No If yes, Description: Date and Time: Extent of Injury to persons /Property: Employee's Actions: OBSERVATIONS: Speech: Mumbled Slurred Condition of Clothes: Disorderly Eyes: _Sleepy _Blood Shot Alert Attitude or Demeanor: Talkative Nervous Depressed Profane Confused Incoherent Stuttering Soiled Rumpled Orderly Glassy Watery Dilated Closed Hyperactive Hostile Irritable Drows Pleasant Wide Mood Swings