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4!9 <br />CONTROLLED SUBSTANCE /ALCOHOL SCREENING PROCEDURES CHECKLIST <br />JOB RELATED ACCIDENTS INVOLVING EMPLOYEES <br />STEP <br />PROCEDURE <br />✓ <br />1 <br />In the case of a minor injury, the supervisor determines necessity for <br />controlled substance /alcohol screening (all accidents involving motor <br />vehicles /mobile equipment require testing) for employee involved. <br />2 <br />Supervisor makes sure that the employee does understand the City of Paris's <br />policy concerning on the job accidents, and the supervisor has a copy of the <br />policy to review with the employee, if necessary. <br />(It is imperative that the employee understands that.he/she could be terminated <br />for refusal to test.) <br />3 <br />Supervisor has employee read the "Informed Consent Release of Liability <br />Medical Optimization Form, Consent Form for Substance Testing" and <br />answers any questions the employee might have. The employee then signs of <br />the document and includes the date and time. (A consent and release'form is <br />required for each employee tested.) <br />4 <br />Supervisor transports (except in the case where emergency care is necessary) <br />the employee to St. Joseph's Hospital. (At no time should the employee be allowed <br />to drive to the testing facility.) <br />5 <br />Supervisor completes the authorization sheet. The authorization sheet and the <br />screening results form are given to the testing facility for completion. (These <br />forms will be mailed to the Personnel Department after. completion.) During <br />regular business hours (8:00 a.m. — 5:00 p.m., Monday through Friday, excluding <br />holidays) list the Personnel Department, 784 -9243, as contact. After hours or on a <br />holiday or weekend, request an approximate time it will take to receive test results <br />and utilize this information to determine which supervisor should be contacted and <br />be very precise regarding who to contact so that the results can be obtained as <br />quickly as possible. <br />6 <br />Supervisor delivers the signed Informed Consent and Release of Liability <br />Medical Optimization Form to the Personnel Department after leaving the <br />testing facility. If the accident takes place after hours, the release should be <br />turned into Personnel no later than 12:00 noon on the next normal business day <br />* *A . R E M I N D E R - THIS TESTING IS AND MUST REMAIN CONFIDENTIAL <br />INFORMATION ** <br />82 Revised 01 -25 -05 <br />