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Alcohol & Drug Policy Violation Referral Form

Alcohol & Drug Policy Violation Referral Form

* denotes required field
 
Did the violation occur at (or for employment at) a work site in Alberta? *

Where did the violation occur? *

Date of incident giving rise to referral: *
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First Name of Worker: *
Last Name of Worker: *
Worker's Phone Number (xxx-xxx-xxxx): *
Worker's Address:
RSAP ID:
Union Member ID#: *(listed on the upper right hand corner of Dispatch Slips. Enter "NA" if unknown.)
 
Referring Organization Contact Information
Legal Name of Organization (please avoid abbreviations): *
Name of Individual Making Referral: *
Position: *
Email 1: *
Email 2:
Email 3:
Phone Number: *
 
Project / Dispatch Information
Name of Project: *
Name of contractor employing / who intended to employ individual referred (if different from referring organization):
Date of Dispatch: *
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Work Start Date: *
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The individual was employed (or intended to be employed) under the following Alberta Collective Agreement: *




Is the contractor making contributions to the Rapid Site Access Program (RSAP) for the work in question?


Was the testing performed in accordance with the Alcohol & Drug Work Rule (Canadian Model)? *


  This referral is in respect to: *










  Reason for violation:



Please attach copy of the Dispatch Slip & A+D Test Results if applicable and available.

You may upload a maximum of two PDF documents; for multi-document submissions, please combine your documents into a single file before uploading.
Contractor / Union: additional comments relevant to the case management of this file: