University of Missouri - Columbia
COMMERCIAL DRIVERS
CONTROLLED SUBSTANCE AND ALCOHOL TESTING
REQUEST FORM
To:
From:
Collection Site
Human Resource Services
c/o Peggy Spiers
University of Missouri - Columbia (Account Number 365111)
1095 Virginia Avenue, Rm. 101
Columbia, MO 65211-1340
The following individual is a University of Missouri - Columbia employee or pre-employee and is being tested under federal
guidelines of the Department of Transportation. Your assistance in helping the University carry out this process is
appreciated. Breath Alcohol test results are to be reported to Peggy Spiers, Manager, Human Resource Services, (573)8847274. Please forward this completed form, the sample, and the "Federal Drug Testing Custody and Control Form" to the
testing laboratory indicated below. Please provide a copy of this completed form to the employee/pre-employee to take back
to their supervisor.
__Urine Dot 5 Panel
TESTS TO BE PERFORMED
__Breath Alcohol Test
BAT Result _____ gm/210L
REASON FOR TEST
__ Pre-Employment
__ Post-Accident (Complete "Post Accident Documentation" form)
__ Return to Duty
__ Reasonable Cause (Complete "Reasonable Cause" form)
__ Other (Specify):______________________________________________________________
Employee Name: ______________________
Department: _____________________
__ Follow-UP
__ Random
Social Security Number: ______________________
Supervisor: ____________________
Date/Time Notified To Report To Test Collection Site:
Date: ______
Supervisor Signature: ___________________________________________
Date/Time Arrival At Test Collection Site:
Date: ______
Collector Signature: ____________________________________________
Phone: _____________
Time: ______ am/pm
Date: ____________
Time: ______ am/pm
Date: ____________
If more than two (2) hours of time lapses between the time the employee was notified by the supervisor to report to the test
collections site and the time the employee reports to the site, the supervisor of the employee must document the
reason:_________________________________
Note: For post-accident testing, please also complete the "Post Accident Report" form.
Collection Site:
___ The Walk In Medical Clinic
900 Rain Forest Parkway
Columbia, MO 65202
(573) 449-2216 (Closed Fridays)
___ Collection sites for employees outside Columbia
area will be provided by employee's supervisor.
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Testing Facility:
Medtox Laboratories
402 W. County Rd. D
St. Paul, MN 55112
(651)636-7466
(800)832-3244
Medical Review Officer:
Dr. Belz
Tox Review
P.O. Box 1403
Ozark, Mo 65721