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| Date: ____________ Time: ____________ Client Company: ______________________________ | ||
| Outcomes Customer Service Rep: ____________________________________________________ | ||
| Caller: ____________________________________________________________________________ | ||
| Location: ___________________________ Outcomes Acct. #: _____________________________ | ||
| Employee Name: _________________________________ Phone: __________________________ | ||
| Position: ___________________________________ Department: __________________________ | ||
| Supervisor: ______________________________________ Phone: __________________________ | ||
| Other Contact: ___________________________________ Phone: __________________________ | ||
| Work Performance Issues: [ ] Yes [ ] No | ||
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Please describe:
___________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ (Please attach supporting documentation.) |
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| Employee referred as the result of a DOT positive alcohol or drug screen? [ ] Yes [ ] No | ||
| Is this a request for a Fitness for Duty Evaluation? [ ] Yes [ ] No | ||
| Type of referral: | Emergency | [ ] |
| Formal | [ ] | |
| Mediation | [ ] | |
| CISM | [ ] | |
| Notes:
____________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ |
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| Supervisor Signature: ______________________________________________________________ | ||
| Case Manager: __________________________ Submitted to CM on Date: __________________ | ||
| Referred To: ______________________________________________________________________ | ||
| Authorization No. & Date: __________________________________________________________ | ||
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Follow-Up Notes:
__________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ |
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