DOT - CITY OF LITTLE ROCK



CITY OF LITTLE ROCK NON-DOT, NON-UNIFORM ACCT NO: 8858

COLLECTION SITE INFORMATION

|Name: |Employee I.D. # |

| |Do Not Use Social Security Number |

| |DATE |TIME |SIGNATURE |

|Supervisor Notification | | | |

|Employee Notification | | |Employee |

|Collection Site Arrival | | |Collection Site |

|Collection Site Departure | | |Collection Site |

Note: Failure to produce a sufficient quantity sample will require the employee to drink up to 40 fluid ounces of liquid distributed reasonably over a period of up to three hours or until the employee provides a sample of sufficient quantity.

The employee MUST remain in the testing area during this period.

Leaving the testing area will be classed as a refusal to test = Positive result.

Drug Screen Collector or Breath Alcohol Technician Please Note:

This form (PE 138), Employer Copy of Drug Test Custody & Control Form (Copy 4), and Breath

Alcohol Testing Form (where applicable) to be returned with the employee.

SUPERVISOR’S NAME: _______________________________________________________________________

TESTING REQUIRED

1 NON-DOT DRUG SCREEN (AML-5 Split Sample)

2. NON-DOT BREATH ALCOHOL TEST

3. REASON FOR TEST (Check One)

Pre-Employment Random Reasonable Suspicion/Cause

Post-Accident Return to duty Follow-Up

FOR FURTHER REFERENCE, SEE SECTION X, PERSONNEL POLICY PROCEDURE MANUAL

DRUG TESTING COLLECTION SITE

The designated collection site for urine samples and breath alcohol testing required under the City of Little Rock drug-testing policy from 8:00 AM through 4:30 PM Monday through Friday is: MLA LITTLE ROCK, 9601 Lille Drive, Suite 108, Medical Towers I, Little Rock, AR 202-6522 (This is the office building connected with Baptist Hospital in Little Rock)

Other than the times listed above, the collection site is BAPTIST HOSPITAL, LITTLE ROCK, 9601 Interstate 630, Exit 7. Little Rock, Arkansas, 202-2000. Enter the hospital main lobby; you will see an Information desk. There will be a hallway to the left. Follow the hallway till you reach the sign on the right that says Lab., enter there.

YOU MUST HAVE A PICTURE ID, YOUR AUTHORIZATION FORM, AND YOU CLR COLLECTION SITE FORM.

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