Drug and Alcohol Testing Program
TITLE OF FORM: Drug/Alcohol Test Referral Form
This form can be used for many purposes. It is a referral form that you will use whenever you need
to send a driver to a clinic for drug and/or alcohol testing. These will include any test that is not part
of the random program and must be conducted at a clinic:
•
•
Pre-Employment
•
Reasonable Cause •
Return-To-Duty
Post-Accident
•
•
Follow-Up
Other testing, even Non-DOT
1. Use this form. Fill out the employee information.
2. Indicate the name of the collection facility. Preferred Alliance is currently working with the
following local clinics. There are clinics all over California. If you need to send an employee to a
clinic outside of the local area, call for a clinic location.
In Merced:
Patient’s First
394 E. Yosemite Ave. Suite 200
Merced, Ca. 95340
(209) 383-3990
In Turlock:
Work Wellness of Emanuel
825 Delbon Ave.
Turlock, Ca. 95282
(209) 669-2333
3. Check the box indicating the test you want performed.
Important: If Pre-employment - check the DOT-NIDA DRUG PANEL box only.
For all other DOT tests check the appropriate box.
• If you are requesting both Drug and Alcohol tests, check both the DOT-NIDA DRUG PANEL
box and the Alcohol Breathalyzer box.
• If you are requesting a test for controlled substances only, then check the DOT-NIDA DRUG
PANEL box.
• If you are requesting a test for alcohol only, then check the Alcohol Breathalyzer box.
• If you are using this form for drug testing of other employees (e.g. custodians) then check the
NON-DOT box.
4. Check the reason you are requesting the test be performed. (Choose only one Reason)
5. Sign the form authorizing the test.
6. Send the employee with a collection box, a Custody and Control Form, a mailing label and this
referral form to the collection site. You should have these collection kits and materials on site.
If you need a collection kit, chain of custody form and mailing label; or the location of the nearest
collection site, call Linda Ploof at Preferred Alliance (877) 272-5227. Direct Line: 209-858-3239 or email at lploof@HSBA.com
Keep a copy of this completed form in the employee's DOT file. These files should be kept in a
secured file separate from personnel files.
FILL OUT THIS FORM ON YOUR COMPUTER. If you’re filling this form out on the computer,
merely tab to move from blank to blank. When you’re finished, print the form and obtain the
signatures. When prompted to save the document, you may choose no – the form remains a
blank for the next time you use it. If you would like to save it, you should save it as a different
file name. If you have any questions, please contact Terri Prichard at 209-389-4054 or
tprichard@mcoe.org
Drug and Alcohol Testing Program
Drug/Alcohol Test Referral Form
Employee Name
Social Security Number:
Name of District:
District Contact Phone Number:
Employee must report to the following collection site:
Name of Collection Site:
Address:
**Employee must bring a photo Identification**
This employee/applicant is required to submit to the following test(s):
Please check the appropriate test:
DOT-NIDA DRUG PANEL
NON-DOT
ALCOHOL BREATHALYZER
REASON FOR TEST
Please check one:
PRE-EMPLOYMENT (DRUG-NIDA PANEL ONLY)
POST ACCIDENT
RANDOM
REASONABLE SUSPICION
RETURN-TO-DUTY
FOLLOW-UP
Authorized by:___________________________________ Date _______________
Signature of District Official