403.10E8 Random Testing Driver Change List Form

Code No. 403.10E8

RANDOM TESTING DRIVER CHANGE LIST FORM IOWA DRUG AND ALCOHOL TESTING PROGRAM

Nicole Koric, Riverside Community School District Contact Person

Date: _________________________

Riverside Community School District

Phone: 712-484-2291

P .0. Box 218, Carson, Iowa 51525

Social Security Number and Name (first and last).

Example 111-22-3333, John Doe.

Additions

SSN _________________________  Name _________________________________________

                                                                           SSN       Name  _____________________________

Deletions

SSN _________________________  Name  ________________________________________

                                                                                SSN        Name  _______________________

Please list all qualified drivers who must be tested under the federal regulations. Make copies of this form if you need additional space. Changes must be made in writing. Telephone changes cannot be accepted. Changes for a month must be received the last business day of the prior month to be effective for the month. Random list updates cannot be data entered for a new month if this form is received on or after the first of the new month.

Revised 7-17-2023