Conservative Care Occupational Health

CONSORTIUM PROFILE/DER FORM

Company Name*:

DOT Authority Number:

Full Mailing Address*:

Full Physical Address*:

Phone*:

Fax:

Email*:

Please mark all types of testing that apply to your company:

NON-DOT:

lab-based testing

Instant Testing

DOT:

FMCSA

FAA

FRA

FTA

PHMSA

USCG

Number of employees in each category:

DOT:

NON-DOT:

Designated Employer Representative (DER) Information

*Defined as an employee of the company who has the authority to immediately remove an individual from duty upon the receipt of a positive drug or alcohol test result. {These are the individuals who are designated to receive drug test results. CCOH as well as Department of Transportation (DOT) requires a primary and secondary DER with a 24 hour telephone number(s). If you have more than 2 DERs, please include their name and contact information in the Additional DERs field below. In the event that we are unable to contact the primary DER, we will immediately attempt to contact the secondary DER. CCOH will not release results to anyone who is not listed as a DER.}

Primary DER Name:

Title:

Work Phone:

Mobile Phone:

Home Phone:

Email Address:

Fax:

Secure:

Yes

No

Preferred method of receiving results (select only one):

Email

Online Access+

Secondary DER Name:

Title:

Work Phone:

Mobile Phone:

Home Phone:

Email Address:

Fax:

Secure:

Yes

No

Preferred method of receiving results (select only one):

Email

Online Access+

Additional DERs:

*Please provide Conservative Care Occupational Health, as soon as possible, with a copy of your drug and alcohol testing policy/policies as well as a list(s) of all current employees indicating their full names, social security numbers, and DOT or NON-DOT designation. The preferred format for this list is an excel document via email to Conservative Care Occupational Health Consortium Manager.

I,, being the Owner/Manager of the company listed above, give my permission for the person(s) listed above to receive results for drug and alcohol testing. If at any time the information on this form is no longer accurate I will contact Conservative Care Occupational Health as soon as possible to update this information.

Signature*

Title*

Date

Please sign your name above and save signature, and then submit the form below.

Select Location*