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ST. JOSEPH'S HOSPITAL OTHER FACILITY: <br />DATE: TIlVIE: <br />TO: TESTING FACILITY <br />LETTER OF AUTHORIZATION <br />CONTROLLED SUBSTANCE AND ALCOHOL SCREENING FORM <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 />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 />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 />This position is classified as public safety or safety - sensitive (D.O.T.). Yes ❑ <br />No ❑ <br />NAME: <br />POSITION: <br />DEPT/DIV: <br />FOR VERBAL CONFIRMATION OF <br />RESULTS - TESTING FACILITY <br />PLEASE CONTACT: <br />Name <br />CITY OF PARIS <br />Screening Authorized By <br />Contact Number Title <br />83 Revised 01 -25 -05 <br />