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COMPANY DEMOGRAPHICS
Company Name:
Address:
City:     State:     Zip:
Phone:     Alt. Phone:     Fax Number:
# of Employees:

WORKER'S COMPENSATION INFORMATION
Insurance:
Policy #:     Policy Expiration:  "mm/dd/yyyy"
Address:
City:     State:     Zip:
Phone:     Alt. Phone:


Provide service with verbal or written authorization only?   Yes No
 Injury to the employee:
  Post-Injury? Yes No As per authorization request
  Type of Drug Test: Collection using 
Quick Test with confirmation no confirmation
Drug Screen using our lab? NON-NIDA NIDA
  Post-Injury BAT? Yes No
 
 Accident / Collision to the employee:
  Post-Accident Drug Test? Yes No As per authorization request
  Type of Drug Test: Collection using 
Quick Test with confirmation no confirmation
Drug Screen using our lab? NON-NIDA NIDA
  Post-Accident BAT? Yes No
 
 Physicals: Yes No
  Type of Physicals: REGULAR DOT SPECIAL PACKAGE
  Drug Test required: Yes No As per authorization request
  Type of Drug Test Collection using 
Quick Test with confirmation no confirmation
Drug Screen using our lab? NON-NIDA NIDA
 
 Requirements for Special Package Physical:
  Routine Physical   BAT   PPD   Jamar Test
  Biodex   Customized FT   Back X-Ray   Chest X-Ray
  PFT   Nerve Pace   HEP B Vaccine   HEP B Titer
  Tetanus Vaccine   EKG   Treadmill   Blood Chem
  Hgb/Hct/HBC   Urinalysis   Blood Lead   Mask fitting
  Hair Drug Test

Give Original Copy of Regular or DOT Physical to Applicant/Employee?   Yes No
 
Original Copy:   Mail Fax Courier
 
Drug Screen Result:   Mail Fax Call applicant if positive
 
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