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
