407.5E3 Drug and Alcohol Testing Notification Form

 

Employee Name: ______________________________________________________

Driver's License #___________________________________    State of Issue:______________________

The above named employee is to have the following type of test done:

_____DRUG _____ALCOHOL_____DRUG AND ALCOHOL

 

Date/Time Sent by District: _________________ /________________________

District Contact Person: _______________________________________

 

Date Arrived at Collection Site: _______________________     Time Test Completed: _________________________

Site Contact Person:__________________________________ 

 

I understand I am to go directly to the collection site located at:

Spirit Lake School, District Office,              2701 Hill Ave., Spirit Lake, IA 51360,          (712)-336-2820

 

Employee Signature: __________________________________ Date: __________________________

 

 

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Approved: 12/11/95

Reviewed:

Revised: 2/9/09; 4/8/13; 10/14/19; 2/10/20; 2/14/22