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Pilot Application Form

The following application must be filled in to be a DARRPP participant. Contractors that are part of an association or group using the same processes only need to submit one application as long as your data can also be entered as a group. Please choose and enter a user name and id, then the required information as per the questions below.

Click here for instructions on how to complete this application form.



Required: Business contact information

Username:
Password:
Password Confirm:
   
Name of contact:
Name of organization:
Mailing address:
Contact phone number:
Cell phone number:
Contact email address:
Organization info:
 
# of employees






Optional

Scope of participation

The scope of our participation in the pilot project is limited to the following worksites:

attach additional page(s) if necessary - additional page attached:



Please describe the key components of your A&D policy & processes that you will have in place as part of this pilot and attach a copy of your policy. If you use the COAA Guidelines for your policy, please indicate this and do not attach.




safety sensitive position definition and how it will be applied. Include examples of safety sensitive positions, # of positions identified as safety sensitive and total # of workers identified as safety sensitive


Describe testing process including tests to be used, who will do collections, # of drugs screened for:


Describe assessment, case management and treatment process for workers who test positive (confirmed). If the process differs for workers who are assessed as dependant vs. non-dependant, please indicate both processes.


EAP & treatment program in place:


Privacy controls regarding A&D information:


If owner company, indicate what you will require of your contractors: