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April 20, 2009 (Regular Meeting) <br />Non-Dot ^ <br />DOT ^ <br />^ Random <br />^ Post Accident <br />Page 1330 <br />^ Reasonable Suspicion <br />^ After Hours <br />(Report to CMC-NE Emergency Roam) <br />^ Other (please specify) <br />STEP 2: To Be Completed by Collection Site Staff <br />(Please return to Employee) <br />Donor Arrived at Collection Site <br />Identity Verified: [ ] yes [ <br />Collector's Signature: <br />STEP 3: To Be Completed by Cabarrus County Supervisor <br />(After Employee Returns from Collection/Testing Site) <br />Returned to: Date: Time: AM/PM <br />Supervisor's Name <br />RETURN COMPLETED FORM TO HUMAN RESOURCES <br />Date: Time: AM/PM <br />] no Specimen Collected: [ ] yes [ ] no <br />Revised 11/29/00; 8/1/07; 4/20/09 <br />FORM C <br />CABARRUS COUNTY GOVERNMENT <br />DRUG TESTING AUTHORIZATION <br />(Out of Town) <br />STEP l: To Be Completed By Employee's Supervisor <br />Please complete and sign this form. Send it with Employee to collection <br />site. Designate thereason for testing, the time and date. Advise donor to <br />bring picture identification (ID). <br />Employee Name: <br />IS TO REPORT IMMEDIATELY FOR TESTING T0: <br />DATE: <br />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 (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 />709-783-1573 (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) 709-783-1573 (Fax) <br />Billing Info: Cabarrus County, Attn: Human Resource Dept., 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) 709-953-6641 <br />• Johanna Ray (Health & Wellness Manager)704-497-4020 <br />• Pamela Dubois (Deputy County Manager)709-906-9839 <br />HR reviewed 4/20/2009 <br />FORM D <br />CABARRUS COUNTY GOVERNMENT <br />