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or have the collection facility contact ScreenSafe at 877-727-3369. <br />DO NOT LEAVE THE COLLECTION FACILITY <br />Date of Birth <br />For the Medical Review Officer, to <br />release the results only to ScreenSafe <br />and/or the EAP. <br />For the EAP to release records for the <br />initial visit for Substance Abuse <br />Treatment to ScreenSafe. <br />Signature <br />_._ DIANA PfECA/LU 153 INFORMiED AF AN CHANCE NN YOUR ADDRES'S <br />PLEASE REMEMBER IT iS YOUR. RESPO IBILITY TO d4EEP NORTHERN 114ti,.W.,-m,,,,�, _- _ _, <br />OR PHONE NUMBER <br />REMEMBER NORTHERN INDIANA NECA LU 153 OFFERS A FULLY INDEPENDENT PROFESSIONAL EAP NEUVAtiiENUE FOR YC9I AND YOUR <br />FAMILY. <br />CONTACT THE EAP TOLL -FREE;,, q R9OURS,'7 DAYS „WEEK AT THEIR HOTLINE NUMBER 800 731-6501., <br />The following is a copy of the reminder letter that will be sent to members who for whatever <br />reason have come in to be tested. <br />to ScreenSafe, Inc. <br />2364 Essington Rd. Suite 128, Joliet, IL 60435 <br />Number/Bar Code 8030376S <br />P: 877-727-3369 F: 815-676-2210 <br />Screen <br />www.ScreenSafeinc.com <br />Dear., <br />Authorization for a Urine Drug Screen billed <br />Form Fox Users Quest Account <br />Test Code 65105N Non -DOT Random Drug <br />Your name has been randomly selected for required testing for the NECA & IBEW 153 Substance Abuse Program. <br />According to the Substance Abuse Policy, all participants shall report to one of the testing facilities listed below <br />only during the hours of operation. Please arrive with a full bladder and try not to drink excessive amounts of <br />fluids just prior to your arrival. You may also be required to take a breath alcohol tests. If you fail to report to one <br />of the testing facilities within ten (10) days from the date of this notification letter, you will be placed into the <br />ineligible pool. According to the Substance Abuse Policy you will receive a $35.00 participation stipend for <br />submitting to the testing. <br />Northern Indiana NECA/Local Union 153 information: <br />It is your responsibility to notify Northern Indiana NECA/Local Union 153 of any address and/or phone <br />number changes. <br />• Northern Indiana NECA/Local Union 153 offers a fully independent, professional Employee Assistance <br />Program (EAP) for you and your family. <br />Page 22 of 3' <br />