Corporate Substance Abuse Programs, Inc.

WORKPLACE DRUG TESTING QUESTIONNAIRE

Name of Company:
Contact Person:
Title:
Address:
City:
State:
Zip:
Telephone Number:
Fax Number:
EMail Address:
Number of Employees:

Are you subject to any federal drug-testing regulations (e.g., D.O.T. regulations)? Yes No
Do you have a written policy regarding drug usage? Yes No
Do you currently perform drug tests of any kind? Yes No
Do you require pre-employment drug screening? Yes No
Do you require random drug screening? Yes No
Do you require on-site testing? Yes No
What illegal controlled substances (drugs) do you want to test for? (Please check below) Amphetamines, cocaine, opiates, marijuana, phencyclidine (5-drug panel) Amphetamines, cocaine, opiates, marijuana, phencyclidine, barbiturates, methaqualone, benzodiazepines, methadone, propoxypene (10-drug panel) Ecstasy Adulterants
Drug testing method: Urine Hair
Do you want to test for alcohol? Yes No
Alcohol testing method: Breath Saliva Blood Urine
Do you desire an employee assistance program? Yes No
Do you desire employee educational materials? Yes No