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Please fill out the information to the best of your knowledge. The Personal Experience Field for is to be marked 'YES', if indeed, you have personal experience any type of drug testing with this company. The comments field is reserved for any additional comments that you will to make concerning this company. This would be a good place to indicate and experience with this company concerning their drug testing practices. As always, we do not record any personal information concerning this submittal.

Name of Company	*
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Business Type	Select Business Type Manufacturing Finance/Banking Insurance/Legal Government Education Health Care Wholesale/Retail Trade Transportation Utilities/Petroleum/Gas Architecture/Engineering Agriculture Non-Profit Consultant Software Developer Web Hosting Service Internet Service Provider Internet VAR Bell, National, Carrier Local Telco or Cable Co Computer/Software Mfg Network/Comm Equip Mfg Cable TV Broadcast TV/Radio Publishing Entertainment Industry Advertising/Public Relations Mining Unknown *
Drug Test Used	Select Test Urine Blood Hair Saliva Sweat Urine/Blood Roche Test Cup American Bio Medica Test Cup Other Test/Indicate in Comments *
Frequency of Test	Select Frequency Pre-Employment Only Random - Every 30 Days Random - Every 30 Day to 3 Months Random - Every 3 to 6 Months Random - Every 6 months to 1 year *
Personal Experience	Pick One Yes No *
Laboratory	Other
Testing characteristics	Requires ID Split Sample Temp Check Dye in Toilet Faucets Sealed Door Closed Door Cracked Door Open
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