Download Acct. No. 8858 Non Uniform Personnel (City of Little Rock) DOT

Acct. No. 8858 Non Uniform Personnel (City of Little Rock) DOT
COLLECTION SITE INFORMATION
Name:
Employee I.D. #
Do Not Use Social Security Number
DATE
TIME
SIGNATURE
Supervisor Notification
Employee Notification
Collection Site Arrival
Collection Site Departure
Employee
Collection Site
Collection Site
Note: Failure to produce a sufficient quantity sample will require the employee to drink up to 40 fluid
ounces of liquid distributed reasonably over a period of up to three hours or until the employee
provides a sample of sufficient quantity.
The employee MUST remain in the testing area during this period.
Leaving the testing area will be classed as a refusal to test = Positive result.
Drug Screen Collector or Breath Alcohol Technician Please Note:
This form (PE 138), Employer Copy of Drug Test Custody & Control Form (Copy 4), and Breath
Alcohol Testing Form (where applicable) to be returned with the employee.
SUPERVISOR’S NAME: _______________________________________________________________________
TESTING REQUIRED
1
DOT (CDL) DRUG SCREEN (NIDA-5 Split Sample)
2.
DOT (CDL) BREATH ALCOHOL TEST
3. REASON FOR TEST (Check One)
Pre-Employment
Post-Accident
Random
Return to duty
Reasonable Suspicion/Cause
Follow-Up
FOR FURTHER REFERENCE, SEE SECTION X, PERSONNEL POLICY PROCEDURE MANUAL
DRUG TESTING COLLECTION SITE
The designated collection site for urine samples and breath alcohol testing required under the City of
Little Rock drug-testing policy from 8:00 AM through 4:30 PM Monday through Friday is: MLA LITTLE
ROCK, 9601 Lille Drive, Suite 108, Medical Towers I, Little Rock, AR 202-6522 (This is the office building
connected with Baptist Hospital in Little Rock)
Other than the times listed above, the collection site is BAPTIST HOSPITAL, LITTLE ROCK, 9601
Interstate 630, Exit 7. Little Rock, Arkansas, 202-2000. Enter the hospital main lobby; you will see an
Information desk. There will be a hallway to the left. Follow the hallway till you reach the sign on the
right that says Lab., enter there.
YOU MUST HAVE A PICTURE ID, YOUR AUTHORIZATION FORM, AND YOU CLR COLLECTION
SITE FORM.
PE138