Form Lb-1111 - Drug Free Workplace Program Application
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1Tennessee Bureau of Workers’ Compensation
220 French Landing Drive, I-B
Nashville, TN 37243-1002
DFW.Program@tn.gov
Phone: 615-532-1321
FAX: 615-253-5265
Email:
DRUG FREE WORKPLACE PROGRAM APPLICATION
1. This application must be complete, legible and signed or it
will be RETURNED.
2. This application must be resubmitted anytime the employer changes insurance carriers.
3. This form must be submitted to the Bureau. Please include the completed original copy of this form plus one
photocopy, a
copy of PROOF OF COVERAGE and two pre-addressed, stamped envelopes:
a.
One addressed to your Workers’ Compensation Insurance Carrier and
b.
.
One addressed to the employer named below
4.
THIS APPLICATION MUST BE RENEWED ANNUALLY.
Circle one:
New application
Renewal application
Changed Insurance Carrier
Company Name _________________________________________________________________ FEIN: ___________________________________
Mailing Address __________________________________________________________ City _____________________ State & Zip _____________
Business Address _________________________________________________________ City ____________________ State & Zip______________
Phone #_____________________________ Fax #______________________________ Email ___________________________________________
Name of Substance Abuse Program Administrator _______________________________________________________________________________
Nature of Business ____________________________________________________ Total # of FT & PT employees___________________________
Workers’ Compensation Insurance Carrier _____________________________________________________________________________________
__________________________________________________
Lab Certification (circle one): SAMHSA
CAP-FUDTAP Other
Name of Testing Laboratory ______________________________________________City _____________________State________ ZIP _________
Name of Medical Review Officer (MRO)_________________________________________________ Phone # ______________________________
Date you conducted or plan to conduct an annual minimum two-hour of Workplace Substance Abuse Recognition training for supervisory
personnel._________________________________
Have all employees hired prior to the date of this application been informed of your company’s drug free program policies?
Yes
No
Have all employees hired prior to the date of this application been provided at least one hour of substance abuse training?
Yes
No
________________________
Effective date of your program
Renewal applicants only:
Number of tests performed in past 12 months for each of the following:
Job Applicants:
Total __________ Positive _________
Routine Fitness for Duty: Total_________ Positive _________
Post work accident: Total _________ Positive _________
EAP Follow-up:
Total ________ Positive _________
Random (optional): Total _________ Positive _________
Reasonable Suspicion
Total ________ Positive _________
I hereby certify that all provisions and requirements of the Tennessee Drug-Free Workplace Program as established by T.C.A. have
been met and implemented.
________________________________________________________________________________________________________
Owner/Officer’s Signature and title
Printed name
Date
________________________________________________________________________________________________________
Bureau of Workers’ Compensation Representative Signature
Title
Accepted Date
LB-1111 (REV 5/16)
RDA 10183
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