H:\Original forms\Car
son Address Forms\FRM Global Authorization Consent-10.29.14 final.doc
AUTHORIZATION & CONSENT FORM
Test Authorized by DER/CER:
Print Name: _______________________________________________
(Sign) ____________________________________________________
(Signature indicates that your company is assuming responsibility for payment of
charges for services.)
Service Request Date: ___________________________________
Tel.: _______________________ Fax: ____________________
Time of Notification: ________________ am/pm
Am
erican Substance Abuse Professional Drug Solutions, Inc. (ASAP)/Occupational Safety Councils of America (OSCA)
Corporate Office: 455 East Carson Plaza Dr, CA 90746
Toll Free: (866) 699-ASAP (2727) Fax #: (562)624-2724
1- Company Name 2 - Company Account # 3- P.O. # or Work Location
4- Employee First Name 5- M.I. 6- Last Name
7- Social Security # 8- Date of Birth (mm/dd/yyyy) 9- Employee Telephone #
10- Employee Address: _______________________________________________ 11-Email Address:_____________________________________________________
Street
___________________________________________________________
City
____________________ ________________
State
Zip Code
Please select the consortium the employee is testing under
LACC NASAP STGT ASAPCC Hair Testing
CONSENT TO TEST & AUTHORIZATION FOR THE RELEASE OF INFORMATION PERTAINING TO
DRUG AND ALCOHOL TESTING, TRAINING, OSHA CLEARANCE, SSV AND CERTIFICATION STATUS
DRUG AND ALCOHOL TESTING:
I am applying for participation in the ASAP/OSCA Contractor Drug Testing Consortium (ASAPCC), and/or the Los Angeles Clean Card (LACC), and/or the North
American Substance Abuse Program (NASAP/ASAP), as well as all ASAP/OSCA-affiliated and other reciprocal contractor consortiums under the sponsorship of the
Company Member indicated above.
I also allow the Medical Review Officer (MRO) verifying my drug test result to report a safety or medical qualification issue disclosed
during the review of my drug test result to my employer’s Designated Employer Representative (DER). If, in the MRO’s judgment, a likely safety risk or medical qualification
issue exists, a medical evaluation to assess my fitness to work may be recommended if I am performing safety sensitive job functions.
I agree, upon acceptance, to abide by all consortium policies and rules.
The policy/policies under which I am testing have been made available to me by my employer. I consent to the tests required, including alcohol and urine drug
testing, and/or alternate specimen drug testing. I authorize ASAP Drug Solutions, Inc. (ASAP/OSCA) to coordinate the testing and reporting of results to the
Contractor Company Member/Employer or Owner requesting the testing. I authorize my test statuses in the consortium databases to be released to Contractor
Company Members requesting verification for employment purposes and Owner member Companies on whose premises I seek to work or am currently working.
Under the NASAP Policy, if applicable, the NASAP Policy was made available to me by my employer. I further authorize ASAP/OSCA to disclose a summarized
event record of my drug and alcohol test to the Houston Area Safety Council (HASC) and if required under the Policy, to release and receive my NASAP drug and
alcohol test information, records of substance abuse professional evaluations, rehabilitation, and compliance with NASAP, to the other approved third-party
administrators (TPA) of the NASAP.
TRAINING and SECURITY:
I authorize ASAP/OSCA to release information regarding my identity and; all applicable certifications on safety and craft training and testing; and Occupational
Safety and Health Administration (OSHA) certifications in the LACC/ASAPCC/ASAP/OSCA-affiliated databases to any Contractor Company Member requesting
verification of such status; and to Owner Companies on whose premises I seek to work or am currently working. ASAP may release information regarding the above
statuses to the Houston Area Safety Council and third party administrators as designated by specific Owner/Contractor program policies.
RESPIRATOR CLEARANCE, FIT TESTING, AND AUDIOMETRIC:
I authorize CareOnSite Medical Services and its affiliates to release the results of my respirator clearance evaluations, and/or respirator fit testing, and/or audiometric
testing to ASAP/OSCA and the Employer requesting this testing. I authorize ASAP/OSCA to release information about my certifications and clearance statuses to
any ASAPCC, LACC, NASAP & other ASAP/OSCA-affiliated Contractor Company Members requesting verification of such statuses; and to LACC, ASAPCC,
NASAP, and ASAP/OSCA-affiliated Owner Companies on whose premises I seek to work or am currently working, for the purpose of verifying compliance with
OSHA (Occupational Safety and Health Administration) workplace requirements and determining my eligibility to work at participating Owner sites.
I have the right to revoke this authorization at any time by written notification to ASAP Drug Solutions, Inc.(ASAP), and/or Occupational Safety Councils of
America (OSCA) at 455 East Carson Plaza Dr, Carson, CA 90746. Revocation is only effective after it is received in writing and logged by ASAP/ OSCA. I
understand that revocation of this authorization will result in the removal of my participation from the ASAP/OSCA program database. This authorization shall
expire five (5) years after the date of this form. As a result of this authorization, there is the potential for information disclosed to an authorized recipient to be subject
to re-disclosure by the authorized recipient without specific consent. I understand that I am entitled to receive a copy of this authorization upon request. A photostatic,
facsimile, or electronic copy of this authorization is as valid as the original.
I have read and understand this authorization and hereby
consent do not consent to the above testing and release of information.
Signature: _____________________________________________ ___________
(Applicant/Employee) Date
Collection Site Use Only
Donor I.D. Verified: ____________________
Donor Arrival Time: ____________________
If the employee is testing at one of the following preferred collection sites, please fax to
one of the following fax numbers:
COS/Carson: (888) 276-7710 COS/Long Beach: (562) 624-2725
COS/Martinez: (925) 335-5060
ISS/Anacortes: (360) 299-1244
ISS/Ferndale: (360) 922-0858
OSCA
OCCUPATIONAL SAFETY
COUNCILS OF AMERICA
Please select the test type:
Pre-employment Random Pre-access Follow-up
Post-Accident/Incident Reasonable Suspicion/For Cause
Other_______________
Specialty Welding and Turnarounds LLC
