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: __________________________
------------------------------------------------------------------------------------------------------------
|
Approved: 12/11/95 |
Reviewed: |
Revised: 2/9/09; 4/8/13; 10/14/19; 2/10/20; 2/14/22 |