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REFERRAL FOR SAP EVALUATION
All fields are required

Date _____________________Employer_________________________________

Address ____________________________City ___________State___ Zip ______

Designated Employer Representative (DER)_____________________________

Phone number_______________________E-mail_________________________

Fax _______________________Is this a confidential fax? __________________

Employee Name ____________________________SSN #__________________

Date of birth _______________Occupation /Job Title_______________________

Operating Admin.: ___ FMCSA  ___ FAA  ___ FRA  ___ FTA  ___ RSPA  ___USCG

Briefly describe safety-sensitive duties of employee:
___________________________________________________________________
___________________________________________________________________

Briefly describe any work performance issues:
___________________________________________________________________
___________________________________________________________________

Describe any previous positive drug or alcohol tests:
___________________________________________________________________

Current status of employee (suspended, terminated, working non-safety-sensitive duties)
___________________________________________________________________

Reason for most recent drug/alcohol test:        Date of test/refusal: ____________
        __ Random
        __ Reasonable suspicion (documentation must be attached)
        __ Post-accident (documentation must be attached
        __ Return-to-duty requirement (previous test results attached)
        __ Follow-up (post treatment)
        __ Pre-employment
        __ Employee refused to submit to testing

Substances found:
         __ Cannabis or THC ____________________
         __ Cocaine ___________________________
         __ Amphetamine _______________________
         __ Opiates ____________________________
         __ PCP ______________________________  
         __ Alcohol (BAC) _______________________
         __ Other _____________________________ (specify)

Name of Medical Review Officer (MRO) ___________________________________

MRO Phone __________________________MRO Fax ______________________

DER Signature ____________________________________ Date _____________

Fee for SAP services must be paid in advance

Who will be responsible for payment?_____________________________________

Print out, complete and fax this form to Cynthia Fravel at (970) 204-7881


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Cynthia Fravel, LPC, CAC II, NCAC I    
Phone: (970) 495-4852    Fax: (970) 204-7881