Employer’s Authorization for Examination and/or Treatment Employee Date MM slash DD slash YYYY Type of Service/Treatment Needed: Non-DOT Physical DOT Physical UA Dipstick Non-DOT Drug Screen DOT Drug Screen Ergonomic Testing Random Drug Screen Hearing Screen Work STEPS Breath/Alcohol Testing Spirometry X-Rays Respirator Fit Testing Treatment for work injury Other Other Work Injury Date MM slash DD slash YYYY Work Injury Type Reason for Service/Treatment Pre-employment Random Post Accident Follow Up Reasonable Suspicion/Case Return to Duty Re-Cert On-the-job-injury Other Other Employer PhoneEmail Contact Today's requested service authorized by: MessageNameThis field is for validation purposes and should be left unchanged. Δ
