"Substance Abuse Professional Referral Form - Employee Not Present" - Ohio

Substance Abuse Professional Referral Form - Employee Not Present is a legal document that was released by the Ohio Department of Transportation - a government authority operating within Ohio.

Form Details:

  • Released on January 1, 2016;
  • The latest edition currently provided by the Ohio Department of Transportation;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Ohio Department of Transportation.

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CONFIDENTIAL
SUBSTANCE ABUSE PROFESSIONAL REFERRAL
EMPLOYEE NOT PRESENT
If the employee is not present to sign the Substance Abuse Professional Referral letter, send this form to
the employee utilizing certified mail.
Employee/Applicant Full Name:__________________________________________________________
Employee/Applicant Identification Number: ________________________________________________
This letter serves to notify that the aforementioned individual was in violation of DOT drug and alcohol
regulations (49 CFR Part 655 and/or 40) on __________________________________. In accordance
Date
with 49 CFR Part 655.62, this agency is required to advise the individual of the resources available for
evaluating and resolving problems associated with prohibited drug use and/or alcohol misuse.
The following Substance Abuse Professional(s) is available for the individual:
Name: ________________________________________________________________________
Address: ______________________________________________________________________
City/State: _____________________________________________________________________
Phone: ________________________________________________________________________
Alternate Substance Abuse Professional Referral:
Name: ________________________________________________________________________
Address: ______________________________________________________________________
City/State: _____________________________________________________________________
Phone: ________________________________________________________________________
_______________________________________________
_________________________________
Agency Representative Full Name, Title
Telephone Number
_______________________________________________
Agency Name
_______________________________________________
_________________________________
Agency Representative Signature
Date
1/2016
CONFIDENTIAL
SUBSTANCE ABUSE PROFESSIONAL REFERRAL
EMPLOYEE NOT PRESENT
If the employee is not present to sign the Substance Abuse Professional Referral letter, send this form to
the employee utilizing certified mail.
Employee/Applicant Full Name:__________________________________________________________
Employee/Applicant Identification Number: ________________________________________________
This letter serves to notify that the aforementioned individual was in violation of DOT drug and alcohol
regulations (49 CFR Part 655 and/or 40) on __________________________________. In accordance
Date
with 49 CFR Part 655.62, this agency is required to advise the individual of the resources available for
evaluating and resolving problems associated with prohibited drug use and/or alcohol misuse.
The following Substance Abuse Professional(s) is available for the individual:
Name: ________________________________________________________________________
Address: ______________________________________________________________________
City/State: _____________________________________________________________________
Phone: ________________________________________________________________________
Alternate Substance Abuse Professional Referral:
Name: ________________________________________________________________________
Address: ______________________________________________________________________
City/State: _____________________________________________________________________
Phone: ________________________________________________________________________
_______________________________________________
_________________________________
Agency Representative Full Name, Title
Telephone Number
_______________________________________________
Agency Name
_______________________________________________
_________________________________
Agency Representative Signature
Date
1/2016