9400 Gateway Drive, Suite D Reno, NV 89521 800.788.3210

natacs.aero

Employee/Donor Name (Full Name) Employee/Donor Social Security/ID Number

Employer Name Employer (Contact) Name & Title

Employer Address: Employer (Contact) Phone #:

MRO (CCF) Fax #: 913.469.4029 Employer (Contact) Fax #:

(*ATF) Fax #: 866.768.2881

*Required for collection payment verification

Company Authorization (Signature):

Donor - You must have a photo ID and REMAIN at the testing site until the testing process is completed.

Collector - Ensure the CORRECT Custody and Control Form (CCF) is used and is accurately completed

by the Donor and Collector.

Check test type and reason for test: FAA FMCSA FRA FTA PHMSA USCG NonDOT

*Drug – Urine Drug Collection Breath/Saliva-Alcohol Collection & Test DOT DOT

Pre-Employment Non-DOT

Pre-Employment Non-DOT

DOT DOTRandom

Non-DOT Random

Non-DOT DOT DOTReasonable

Suspicion Non-DOT Reasonable

Cause Non-DOT DOT DOT

Post Accident Non-DOT

Post Accident Non-DOT

DOT(Direct Observation) DOT Return to Duty

Non-DOT Return to Duty

Non-DOT DOT(Direct Observation) DOT

Follow Up Non-DOT

Follow Up Non-DOT

Collector CCF & ATF Distribution Instructions:Immediately following each collection, please fax/mail Employer's & MRO's Copy of the CCF & ATF

*Substances for which testing must be conducted. Each individual will be tested for evidence of marijuana, cocaine, opioids, phencyclidine (PCP), and amphetamines.

Request & Authorization for Drug and/or Alcohol Collection/Testing Services

2018.01

Lab Account # - _________________

CONSEQUENCES UNDER THE RULE

REFUSAL TO SUBMIT TO TESTING

Employers are required to notify the FAA within 2 working days of any instance in which a Part 61, Part 63, or Part 65 airman certificate holder refused to submit to a required drug or alcohol test. (Generally, this applies to individuals who perform flight crewmember, flight instruction, aircraft dispatcher, aircraft maintenance, or air traffic control duties)

Notification of refusals should be sent to:

Or by Fax to:

FAA, Office of Aerospace Medicine Drug Abatement Division, AAM-800Independence Ave., SWWashington, DC 20591

2 0 2 . 2 6 7 . 5 2 0 0

Refusal to submit to a required drug or alcohol test. A covered employee must not refuse to submit to any required drug or alcohol test. A certificate holder must not permit an employee who refuses to submit to such a test to perform or continue to perform safety-sensitive functions.

Refusal to submit means that a covered employee has engaged in conduct including but not limited to that described in 49 CFR 40.261 and 49 CFR 40.191, or has failed to remain readily available for post-accident testing as required.

A SINGLE POSITIVE DRUG/ALCOHOL TEST RESULT

If an employee is determined to have one verified positive drug test result, he/she will be immediately removed from performing safety-sensitive functions.

If an employee holds a Part 67 Airman’s Medical Certificate is determined to have one verified positive drug test result, an alcohol test result of 0.04 or greater alcohol concentration, or a refusal to submit to a drug and/or alcohol test required by the U.S. DOT, he/she will be reported to the Federal Air Surgeon (via the address listed above) within 2 working days after the result is verified.

No Covered employee who is required to hold an airman medical certificate under Part 67 in order to perform a safety-sensitive duty may perform that duty following an alcohol violation, verified positive drug test result or a refusal to test until the covered employee obtains an airman medical certificate issued by the Federal Air Surgeon dated after the alcohol test result, verified drug test result or refusal to test date.

CONFIRMED ALCOHOL TEST RESULT OF 0.02 BUT LESS THAN 0.04

Immediate removal from safety-sensitive functions, until: a) the employee’s alcohol concentration measures less than 0.02; or b) the start of the employee’s next regularly scheduled duty period, but not less than 8 hours following the administration of the test

CONFIRMED ALCOHOL TEST RESULT OF 0.04 OR GREATER

No covered employee shall perform safety-sensitive functions if the employee has engaged in conduct prohibited by 120.19 or 120.37 or an alcohol misuse rule of another DOT agency.

PERMANENT DISQUALIFICATION FROM SERVICE

1. Two Verified Drug and/or Alcohol Violation An employee who has verified positive drug test results on two drug tests required by 14 CFR--PART 120 and conducted after September 19, 1994 ispermanently precluded from performing for an employer the safety-sensitive duties the employee performed prior to the second drug test. The bar on two-time violators applies to both persons who have gone through rehabillation and those, who, after evaluation, were determined not to need treatment.

An employee who violates 120.19 or 120.37, or Who engages in alcohol use that violates another misuse provision of 120.19 or 120.37 and had previously engaged in alcohol use that violates the provisions of 120.19 or 120.37 after becomingsubject to such prohibitions is permanently precluded from performing for an employer the safety-sensitive duties the employee performed before such violation.

2. On-Duty Use of a Prohibited Drug An employee who has engaged in prohibited drug use during the performance of a safety-sensitive function after Spetember 19, 1994 is permanently precluded from performing that safety-sensitive function for an employer.

Performing (a safety-sensitive function): An employee is considered to be performing a safety-sensitive function during any period in which he or she is actually performing, ready to perform, or immediately available to perform such function.

2018.01

DAA

BILLING INFORMATION

- Urine Collections FAX Copy of COC after collection to 913.469.4029- Breath Alcohol FAX Copy of the ATF after collection to 866.768.2881

ESCREEN PAYS urine drug collections, BATs-must have the paperwork for payment.

Billing address for eScreen, Inc transactions:

INCLUDE SSN OR CHAIN OF CUSTODY # on invoices.

eScreen Inc. PO Box 25902 Overland Park, KS 66225-5902 FAX INVOICES: 913.327.1185

MRO – Dr. Stephen Kracht 8140 Ward Pkwy Suite 275Kansas City, MO 64114

Phone: 888.382.2281 Fax: 913.469.4029

Please call 800.881.0722, option 6 for eScreen Accounting, and for general questions, call NATA Compliance Services at 800.788.3210.

2018.01