Code No. 403.10E4
DRUG/ALCOHOL TEST NOTIFICATION FORM
Date: _______________________________________________________________________
Name (print): _______________________________________________________________
Social Security Number: _____________________________________________________
The above named employee is to have the following test done:
Drug __________ Alcohol __________ Both Drug and Alcohol ____________
Type of Test: _______________________________________________________________
Time Sent by District: ______________________________________________________
School District Contact Person, Vicki Palmer, 712-484-2291
Time Arrived at Collection Site: ____________________________________________
Collection Site Person: _____________________________________________________
Time Test Was Completed:_____________________________________________________ _____________________________________________________________________________
Collection Site Person: _____________________________________________________
I understand I am to go directly to the collection site located at:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Employee's Signature: _______________________________________________________
Date: _______________________________________________________________________
Revised 7-17-23