Workforce Integrity Network

City*

County*

State*

Zip Code*

City*

County*

State*

Zip Code*

Corporate Website

http://

Phone*

Fax*

Organizational Structure*

Sole proprietorship Partnership Corporation Other

Federal Tax ID Number (FEIN)*

How many additional or secondary sites do you currently operate or maintain (not counting primary)?*

List all states where you currently operate (i.e. TN, NY, etc.)*

Corporate Officer*

Title*

Copy from Main Mailing Address

Mailing Address*

City*

County*

State*

Zip Code*

Is this email addresss both private and secure, available for receipt of sensitive information?

Yes No

Office Phone*

Mobile Phone*

Is this a secure fax, available to receive sensitive information?*

Yes No

Please indicate the most preferred reporting method for this contact

ON DEMAND EMAIL* FAX*

Please indicate all reports which this contact is to receive

Test Results Invoices Random Selections

Primary DER*

Title*

Copy from Main Mailing Address

Mailing Address*

City*

County*

State*

Zip Code*

Is this email addresss both private and secure, available for receipt of sensitive information?*

Yes No

Office Phone*

Mobile Phone*

Is this a secure fax, available to receive sensitive information?*

Yes No

Please indicate the most preferred reporting method for this contact

ON DEMAND EMAIL* FAX*

Please indicate all reports which this contact is to receive

Test Results Invoices Random Selections

Secondary DER*

Title*

Copy from Main Mailing Address

Mailing Address*

City*

County*

State*

Zip Code*

Is this email addresss both private and secure, available for receipt of sensitive information?*

Yes No

Office Phone*

Mobile Phone*

Is this a secure fax, available to receive sensitive information?*

Yes No

Please indicate the most preferred reporting method for this contact

ON DEMAND EMAIL* FAX*

Please indicate all reports which this contact is to receive

Test Results Invoices RandomSelections

Is the Primary DER the person responsible for all matters related to Billing & Payables?*

Yes No

Billing Contact*

Title*

Copy from Main Mailing Address

Mailing Address*

City*

County*

State*

Zip Code*

Is this email addresss both private and secure, available for receipt of sensitive information?*

Yes No

Office Phone*

Mobile Phone*

Is this a secure fax, available to receive sensitive information?*

Yes No

Please indicate the most preferred reporting method for this contact

ON DEMAND EMAIL* FAX*

Please indicate all reports which this contact is to receive

Test Results Invoices Random Selections

Is the Primary DER the person responsible for the oversight of your random testing program?

Yes No

Random Program Contact*

Title*

Copy from Main Mailing Address

Mailing Address*

City*

County*

State

Zip Code*

Is this email addresss both private and secure, available for receipt of sensitive information?*

Yes No

Office Phone*

Mobile Phone*

Is this a secure fax, available to receive sensitive information?*

Yes No

Please indicate the most preferred reporting method for this contact

ON DEMAND EMAIL* FAX*

Please indicate all reports which this contact is to receive

Test Results Invoices Random Selections

Please provide the TOTAL number of ALL peronnel which your company currently employs at ALL sites

Of those, how many serve in a DOT regulated capacity (i.e. DOT mandated)?

How many DO NOT serve in a DOT regulated capacity (i.e. Non-DOT madated)?

FMCSA

USCG

FAA

PHMSA

FRA

NRC

Please provide the estimated TOTAL number of ALL collection sites that your company currently utilizes:

Does your company require collection sites to perform after-hours or emergent collection services?

Yes No

Does your company require collection sites to provide on-site or mobile collection services?

Yes No

Who is responsible for the re-ordering of testing supplies (Chain of custody forms, kits, etc.)?

Company Vendor

Please indicate those services which you currently receive from an outside vendor, and the name of the supplier for each

Examples:

Laboratory: CRL

Medical Review Officer: Dr. Jane Dow

Instant Test Devices: XYZ DrugDetect

Laboratory

Training/Material

Third-Party Administrator

Medical Review Officer

Instant Test Devices

Other

What is your estimated annual testing volume (including all tests, both drug & alcohol)?

Does your company currrently employ a written drug & alcohol testing policy?

Yes No

When was your company's policy last reviewed for continued compliance?

What is your company's policy in regards to those testing positive?

Terminated Retained/SAP

Would you like WIN to provide you with info to obtain such a policy?

Yes No

Have all employees received the appropriate drug & alcohol awareness training?

Yes No

Have all supervisors received the appropriate reasonable suspicion training?

Yes No

Please indicate those types of specimens which you currently perform and enter the estimated annual volume beide each:

Drug Testing (Lab)

Drug Testing (Instant)

Alcohol Testing (Breath)

Oral Fluid Testing

Hair Testing

Other

Please indicate those types of drug & alcohol testing which you currently perform and the estimated annual volume of each

Pre-Employment

Random

Post-Accident

Reasonable Suspicion

Follow Up

Other

Please indicate the estimated annual volume for each disposition beside each category below:

Negative

Positive

Dilute/Adulterated

Requires Direct Observed Collection

Other

Has all information been fully and accurately completed?

Yes No

Is the Corporate Officer, Primary and Secondary DERs listed as three (3) different individuals?

Yes No

Does each contact have the necessary email address listed, as is required?

Yes No

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Please indicate those services which you currently receive from an outside vendor, and the name of the supplier for each

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