Form Ucb-474 - Medical Report To Determine Unemployment Insurance (Ui) Eligibility (Page 4 of 6) in pdf

Form Ucb-474 - Medical Report To Determine Unemployment Insurance (Ui) Eligibility Page 4

UNEMPLOYMENT INSURANCE (UI) DRUG REPORT: OBTAINING AND SEALING THE SPECIMEN

Name

Return to

Social Security Number

Hearing No.

Date Sent

Date Due

Phone Number

Fax Number

The purpose of this form is to resolve an UI eligibility claim for the above claimaint. The information provided here will be shared

with department personnel and the parties involved in the disputed claim.

What type of specimen was obtained?

What was the date and time the specimen was obtained?

What procedures were used to identify the claimant?

Did the claimant observe the specimen being sealed?

Yes

Did the claimant initial or sign the label on the speciment container?

Yes

Provide any other information concerning the specimen (its obtaining and/or handling).

CERTIFICATION is required by an individual who can attest to the accuracy of the information provided.

I hereby certify, with full knowledge of the penalty of fine and/or imprisonment, as provided in Section 943.39

of the Wisconsin Statutes, that this report, together with any attached documents, truly and correctly sets forth

the above matters.

Signature

Printed Name

Title

Name of Laboratory or Clinic:

Address:

Phone Number (_________) __________________ Date:

Supporting documents may be attached. However, you must still sign this form.

3.30

April 2000

Form Ucb-474 - Medical Report To Determine Unemployment Insurance (Ui) Eligibility Page 4