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