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<br />DRAFT <br /> <br />ST. JOSEPH'S HOSPITAL <br /> <br />OTHER FACILITY: <br /> <br />DATE: <br /> <br />TIME: <br /> <br />TO: TESTING FACILITY <br /> <br />LETTER OF AUTHORIZATION <br />CONTROLLED SUBSTANCE AND ALCOHOL SCREENING FORM <br /> <br />This letter will serve as authority to perform a controlled substance and alcohol abuse <br />screening. Please expedite all testing and report verbal results to contact person listed below. <br /> <br />This document must be received by the testing facility as authorization to administer test, and <br />testing must be administered within 24 HOURS of date/time listed on this paperwork. <br /> <br />The 24-hour time frame does not apply to post-accident, injury, random, or reasonable <br />suspicion controlled substance and alcohol screening. Employees must be tested as soon as <br />possible for post-accident, injury, random screening, and reasonable suspicion. D.O. T. <br />guidelines must be followed for public safety and safety-sensitive employees and random <br />screening. <br /> <br />This position is classified as public safety or safety-sensitive (D.O.T.). <br />NoD <br /> <br />YesD <br /> <br />NAME: <br /> <br />POSITION: <br /> <br />DEPTIDIV: <br /> <br />FOR VERBAL CONFIRMATION OF <br />RESULTS - TESTING FACILITY <br />PLEASE CONTACT: <br /> <br />CITY OF PARIS <br /> <br />Name <br /> <br />Screening Authorized By <br /> <br />Contact Number <br /> <br />Title <br /> <br />82 <br /> <br />Rev. 10/27/04 <br />