Call Today: (575) 746-3404
Home
About
Services
Forms
New Customer or Update Form for Artesia Drug & Alcohol Screening Only
Release of Information for Drug and/or Alcohol Test
Authorization for Employee to Test
Intake Form For Counseling or SAP Services (Password Protected)
Blog
Contact
Marty Petsonk Counseling
Authorization for Employee to Test
Authorization for Testing
Company Name:
Date of Arrival:
Employee Name:
SSN#:
Employee Day Phone #:
Evening Phone #:
Line Space
Form Fox Account:
Yes
No
Account #:
Line Space
Line Space
Select Type of Test
DOT u/a
DOT Breath Alcohol:
Jurisdiction:
FMCSA
PHMSA
FAA
FRA
FTA
USCG
Line Space
non-DOT (Lab Run Test):
Panels:
5 Panel
10 Panel
Add K2/Spice
Line Space
non-DOT u/a ("Rapid" Dip Test):
Panels:
5 Panel
10 Panel
Add K2/Spice
Line Space
non-DOT Oral Fluid Test:
Panels:
5 Panel
10 Panel
Add K2/Spice
Line Space
Hair box
Hair Test (0 - 90 days - 5 Panel) - (K2/Spice Optional):
Line Space
Line Space:
Other:
Line Space:
Reason for Test:
Pre-Employment
Random
Post Accident
Return-to-Duty (Observed):
Follow-up (Observed)
Reasonable Suspicion
Other (Specify)
Other:
Line Space:
ADAS will only provide the result(s) of test(s) to the Authorized Company Contact(s) on file as provided to ADAS in your Company Protocol or as provided in the New Company/Update Form found under "Forms" in the "Home" page.
Line Space:
Line Space
Name of Authoritzed Person Requesting Test(s):
Title:
Line Space:
Phone #:
Line Space:
Line Space
Line Space
Line Space
Line Space
Thanks for completing the form.
Any questions or problems call the office, (575) 746-3404. Thanks!
Oops, there was an error sending your message.
Please try again later
Follow Us
Call Us Now!
Built by Vivial
|
Privacy Policy
Share by:
