EmailMe Form - Random Testing Program Registration

Employer/Company Name

Testing Protocol Information

What program will your company be participating in?

Stand-Alone Testing Pool (recommended for over 20 employees)

Consortium Testing Pool (recommended for under 20 employees)

What type of Random Drug Testing will we be performing? (check all that apply)

DOT

Non DOT

For DOT, what agency will we be testing under? *

FAA (Aviation)

FMCSA (Motor Carrier)

FRA (Railroad)

FTA (Transit)

PHMSA (Pipeline & Hazardous Materials)

USCG (Coast Guard)

Other

*The agency selected will determine the annual minimum drug and alcohol random testing rates established within DOT Agencies and the USCG for 2019. If registering for the consortium, it is imperative your company is combined with other companies within the same agency. For more information of random testing rates visit: https://www.transportation.gov/odapc/random-testing-rates.

For Non DOT, select the desired testing rate:

10%

25%

50%

Other

For Non DOT, will we be performing Breath Alcohol Tests?

Yes

No

If Yes, select the desired testing rate:

10%

25%

50%

Other

Add recipients to receive the Random Selection List

Name

First Last

Email

Add Additional Recipient

Name

First Last

Email

Add Additional Recipient

Name

First Last

Email

Add Recipients to Receive the Results

Same as above

Add New Recipient

Name

First Last

Email

Add Additional Recipient

Name

First Last

Email

Add Additional Recipient

Name

First Last

Email

Employee Rosters

Upload an Active Employee Roster for each Random Testing Pool. Please provide two separate rosters for DOT and NonDOT employees.

File Upload

Add Another Roster

File Upload

Add Another Roster

File Upload

Designated Employer Representative

The Designated Employer Representative will be the main point of contact for questions regarding Random Testing.

Employer Representative

First Last

Email

Signature of Authorized Employer Representative

Clear