ADC Testing Centers: SCREENING FORM
Print out then fill in this form for each individual to be tested. Fax or mail the completed form to the ADC Center of your choice (see below.)
ALL INFORMATION TO BE FILLED OUT BY EMPLOYER:
COMPANY INFORMATION
COMPANY ____________________________________________________________
ADDRESS ___________________________________________________________
CITY / STATE / ZIP ____________________________________________________
CONTACT ____________________________________________________________
SIGNATURE___________________________________________________________
PHONE_________________________________ FAX __________________________
E-MAIL ______________________________________________________________
EMPLOYEE / APPLICANT INFORMATION
NAME ______________________________________________________________
SSN ___________________________________________ MALE ___ FEMALE ___
ADDRESS___________________________________________________________
CITY / STATE / ZIP ____________________________________________________
PICTURE ID REQUIRED - YES ___ NO ___
INDICATE TEST TO BE PREFORMED (PLEASE CHECK ONE)
___ PRE-EMPLOYMENT
___ RANDOM
___ POST-ACCIDENT
ACCIDENT DATE / LOCATION _______________________________________
___ SINGLE PANEL
___ 2 PANEL
___ 3 PANEL
___ 5 PANEL
___ 8 PANEL
___ 10 PANEL
___ DOT
___ ALCOHOL TEST
___ HAIR FOLLICLE
___ BACKGROUND
___ CREDIT
___ MARIJUANNA (THC)
___ COCAINE
___ OPIATES
___ PCP
___ AMPHETAMINES
___ METHAMPHETAMINES
___ BENZODIAZEPINES
___ BARBITURATES
___ TRICYCLICS (ANTI-DEPESSANTS)
TO BE FILLED OUT BY ADC COMPANY REPRESENATIVE:
ADC TESTING CENTER: ___ PORTLAND, OR ___ VANCOUVER, WA
NAME OF TESTER____________________________________________________
ADC EMPLOYEE SIGNATURE __________________________________________
TIME___________ TEST TEMP _______ NEGATIVE _____ POSITIVE PENDING_____
POSITIVE TO BE CONFIRMED ___ YES ___ NO _____________________________
CONFIRMATION WAIVED ____________________________________________
Portland, Oregon Clinic
Holladay Park Professional Building
1020 NE Second Avenue - Suite 310
Portland, OR 97232
Fax: 503 234-8384
jcprtlnd@aol.com
Walk-in Hours: 9:00 am to 4:00 pm Monday thru Friday
Other days / hours by appointment
Click Here for Driving Directions and Map
Vancouver, Washington Clinic
SR 500 Commerce Center Building
5501 NE 109th Court - Suite E
Vancouver, WA 98662
Phone: 360 256-0322
Fax: 360 256-0611
Walk-in Hours: 9:00 am to 4:30 pm Monday thru Friday
Other days / hours by appointment
Click Here for Driving Directions and Map
