Mercy HealthWorks
DRUG AND ALCOHOL TESTING
PROGRAM FEDERAL COVER SHEET
Date of Testing: ____________________
Employee Name: ____________________________________________________________________________________
Employee Social Security Number: ________________________ Phone: _______________________________________
Company Name: ____________________________________________________________________________________
Company Address: __________________________________________________________________________________
Designated Employer Representative (DER): _____________________________ Phone: __________________________
Alternate Designated Employer Representative: ___________________________ Phone: __________________________
Test(s) to be taken:
□ Drug Test
□ Breath Alcohol Test
Reason for Test:
□ Pre-Employment
□ Random
□ Post Accident
□ Return to Duty
□ Follow-Up
□ Reasonable Suspicion
I N S T R U C T I O N S
Employer: Complete this form in full and attach to a Federal drug testing Custody and Control Form to be taken to the
collection site by the employee. This form must be used whenever an employee reports for any drug and/or alcohol testing
Employee: After you have completed your drug and/or alcohol test, you will be given the employee copy of the Custody
and Control Form. Keep the employee copy for your records.
COLLECTION SITE PERSONNEL: This employee is reporting for a drug and/or breath alcohol test as indicated above.
They will have a Federal Custody and Control Form with Dr. John W. Barnes listed as the MRO. Always perform a split
sample drug collection. Use the standard DOT Alcohol Testing Form provided by your facility for the alcohol test.
Collection Site Supplies: For testing kits and shipping supplies, please contact Shawn @ Medical Enterprises, Inc
at 1-402-393-8826. Ext 114 or E-Mail
Positive Alcohol Test: Contact the DER listed above immediately if the individual is found to have an alcohol concentration
of 0.02 or greater.
Custody and Control Form: Please email the MRO (Copy 2) of the custody and control form to the Medical Enterprises,
Inc./MRO office
Alcohol Testing Form: Please send a copy of the alcohol testing form to the Medical Enterprises, Inc./MRO office at:
Mail: Mail the employer copy of the drug testing Custody and Control Form and/or Alcohol Form directly to the employer/
DER listed above.
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