REFERRAL FOR SAP
EVALUATION
DER should print out, complete and fax to the number at the end of form.
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
Describe safety-sensitive duties of employee:
___________________________________________________________________
___________________________________________________________________
Describe in detail any work performance issues:
___________________________________________________________________
___________________________________________________________________
Describe any previous positive drug or alcohol tests:
___________________________________________________________________
Current status of employee:
___________________________________________________________________
Reason for most recent drug/alcohol test:
__ 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 ______________________________
__ Other
_____________________________ (specify)
Name of Medical Review Officer (MRO) ___________________________________
MRO Phone __________________________MRO Fax ______________________
DER Signature ____________________________________ Date _____________
Fee
for entire SAP Return-To-Duty process is $375.00 - must be paid in advance.
Who will be responsible for payment?_____________________________________
Fax
completed form to: Cynthia Fravel at (970)
204-7881
