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t*4*.4**

(Tlte instrttctiorts./or contpleting this ftirm ure on tlte back of Copy 3)

STEP 1: TO BE COM ALCOHOLTECHN

A: Employee Name(Print)

B: SSN or Ernployee ID No.

C: Employer Name

Street

E'J

City, State, ZIP

DER Name and

Telephone No.(Area Code & Phone Number)

D: Reason fol Test: f] Random E Rcasonablc Susp. EReturn toDuty ! Follol'.up [] Pre-en4loyrnent

STEP2: TO BE COMPLETED ItY EMPLOYEE

I certify that I am about to subrnit to alcohol testing required by U.S. f)epartment of 'llansportationregulations and that the identifying infomration provitled on the form is true and correct.

>i/,.,,- -2",-(1-. Aq ;3 A0-/

Signature of Employee //' Date Month / -Day / Year

LJ.S. Department of Tlansportation (DOT)Alcohol Testing Form

RET rr.rs ff24fi56ftlqTE 6S*e3-21TEIiT t'10 . E! t I

In#6S*e'3rEP1AB Ir.t+ 1fr685a

SEF:EENII.{Egi3lg! IIIE. BAA AUT0 2B ' 46 i

I

.-BEIC,

IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII

H

{

h

X*Jilr'

n

a

Ito

Form DOT F 1380 (Rev.5/2008)

COPY 1 - OHIGINAL. FORWARDTOTHE EMPLOYER

STEP3: TO BE COMPLETED BYALCOHOLTECHNICIAN(If the technician conducting the screening test is not the same technician who lvill be conducting theconfirmation test, each technician must complete their own form,) I certify that I have conductedalcohol testing on the above named individual in accordance with the procedures established in the U.S.I)epartrnent of Transportation regulations, 49 CFR Part 40, that I am qualified to operate the testingdcvice(s) identified. and that the results are as recorded.\l\JTECHNICIAN: mBAI E SrT DLVICE: E S,tt-lVn $UXe,tTH* ls-MinuteWait: EYcs E No

/' /\'SCREENINGTES'l':fF,,r'BREATHDEVI('Er'vrirtitttltr.sl,tt6q'!t1l1ry1t11lSif lltrrt.ttitty,,lttitt'irUJ!lt'.titlt(tl tt, lrint.l

Tcst # Tcsting Device Narnc Device Serial # OB Lot # & Dxp. Date Activ:rtion Tirlc Rcading Time

CONFIRMATION TEST: Results MUST be alfixed to each cop1, oJ this.form or printed directly onto tlte form.

's Namc (First, M,I., Last)

Signature of Alcohol I'echnician

(Area Code & Numbertq 1>31> r

ffiSTEP 4: TO BE COMPLETED BY EMPLOYEE IF TEST RESULT IS O.O2 OR HIGHERI certify that I have subrnitted to the alcohol test, the results of rvhich are accurately recorded on this form.I understand that I must not drive, perform safety-sensitive duties, or operate heavy equipment because theresults are 0.02 or greater.

Signature of Enrployee Date Month / Day / Year

OMB No. 2105-0529\ Afliix \tith'l amper livideut'['ape

(Tlrc instructions for contpleting tlris form ore on tlte back of Copy 3 )

STEP 1: TO BE ALCOHOLTECH

A: Employee Name(Print) ( M.I., Last)

621B: SSN or Employee ID No.

C: Ernployer Name

Street d a4ao

City, State, ZIP

DER Name and

I'elephone No,DER Name

D: Reason lbrTest: E Random ! ReasonableSusp.

DER (Area Code & Phone

f]RctulntoDutl' E Follou'up ! Ple.cnrplovment

aackl r.n,

STEP2: TO BE COMPLETED BY EMPLOYEE

I certify that I am about to subnrit to alcohol testing required by U.S, Departrnent ofTransportationregulations and that the identitying information provided on thc fbrrr is true and correct.

Signature of Employee

fI.S. Department of Tfansportation (DOT)Alcohol Testing Form )>

I

rArt

6!

Fjo

x4

[Eir'qi;.f;:tT="-l,.1'?lfitik]Essr

r..E'iEru""ut,nu

. BBE fiuTl:r tr3'"16

-Mro

I

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x

i

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nq

t

E

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J

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IIIIIIIIIIIItIIII!IIIIIIIIIIIIIIIIIIIIIII

.lII

Form DOT F 1380 (Rev.5/2008)

COPY 3.ALCOHOL TECHNIGIAN RETAINS

STEP3: TO BE COMPLETED BYALCOHOLTECHNICIAN(If the technician conducting the screening test is not the same technician lvho rvill be contlucting the

confirmation test, each technician must complete their orvn form.) I certify that I have conductedalcohol testing on the above named individual in accordance with the procedures established in the U.S.Department of Tfansportation regulations, 49 CFR Part 40, that I am qualified to operate the testingdevice(s) identified, and that the results are as recorded.

TECHNICIAN: E BAr tr Srr DEVICE: E Slt-tVl E UnpAtU* Is-Minute Wait: E Yes E No

SCRBENING TEST: (For BfiTATH DEVICD' r'rite irt the spute bclovv oll! i.f tlrc testing rlet,ice is uAttlcsigna(l to pLiJtl.)

'l'est # Testing Device Namc Dcvice Serial # O& Lot # & Exp. Date Activation'l'iIne Readiltg Tinrc

CONI'IRMATION TEST: Rcsult,\ MUST he uffired to eaclt copl, of tltis.foun or printetl tliectb, ottto thc.fbnn.

's Name (First, M.I., Last)

STEP 4: TO BE COMPLETED BY EMPLOYEE IF TEST RESULT IS O.O2 OR HIGHERI certify that I have submitted to the alcohol test, the results oflvhich are accurately recorded on this fornt.I understand that I must not drive, perfbrm safety-sensitive duties, or operate heavy equipment because theresults are 0.02 or greater.

Signature of Ernployee Date Month / Day / Year

OMB No. 2105-0529A,Lffi* \Yith Tamper Bvident Tape

FEDERAL DRUG TESTING

cF05674060SPECIMEN ID NO,

CUSTODY AND CONTROL FORM

ilililrilllllllillllllllll

B4g3 eurvrra Roao dfr'-:::.-.=. :.1 ::-:: (Cnl

ACCESSION NO.

CLIENT NO. DUK.DOT1,15OOB99B

STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATWE

Name, Address, I. Site Location B. MRO Name, Phone No, and Fax No,

TOXICOLOGY TESTINGHAPEVILLE535 N CENTML AVE

HAPEVILLE, GA 30354Phone#: (404)761-4040 / Fax#: nullnull

C. Donor SSN, Employee LD, No., or CDL State and No.

DRS:DAWKINS & GLASS (MRO1247)

CADUCEUS USA535 N CENTML AVEHAPEVILLE, GA 30354Phone#: (404)76I-4040 I Fax#i (404)761-4008

GA05829782LD.SpecifyTestinsAuthority: IHHsIr.rnc SpecifyDoTAsency: f]rNcsaEt*Er* Etto InnNsn fuscc

E. Reason forrest:npre-emptoymend-lRandomf]Reasonable Suspicion/Cause [teost Accident!Return to Duty !fottow-up!Other (specifu)-

F. Drug Tests to be Performed' fiftrc, Coc, PCP, oPI, AMP ! ftrc & coC only

w215! o*,"r (specify)

G. Collection Site Address: Caduceus USA - Hapeville Collection Site Code: Collector Contact Info: Phone (404)761-4040

535 N Central Ave DUK.O012 Fax

Other

(404)761-4008

Hapeville, GA 30354-1603hapeville@cad uceusoccmed'co

STEP 2: COMPLETED BY COIIECTOR (make remarks when appropriate). URINE ORAL FLUID

STEP3:collectoraffixes"ea@seal(s).Donorinitialsseal(s)'DonorcompletessTEP5oncopy2(MRocopy)

STEP 5: COMPLETED BY DONOR

COLLECTION: fl sptit l-l sinste I tlonu Provided, Enter Remark.

URINE: Collector reads urine temperature within 4 minutes, Temperature between 90o and 100oF? E Yes fl NoJnter Remart n observea, rnter nemart<

ORALFLUID: SptitType: !serial ]concurrent l-l subaiuit.o Each Device Within Expiration oatel fl ves I lo ] votrr. Indicato(s) observed

REMARKS:

CUSTODY - INITIATED BY COLLECTOR AND COMPLETED BY TEST FACILITY

SPECTMEN BOTTLE(S)/TUBE(S) RELEASED TO:

Eups Erearx-gtua

to me by the dmor idqtilid in tlte ceftilication section on Copy 2 of this forn was colected btuleLI tEliEry qryib ndd in a$ordance with appliable federal requhefitents.

, V * -E6ignature of Collector AM

Shantol Williams 91231202I B:52 EDT PM X

provided on this Fm and on the lbel dtfixed to each specinen bottle/tube is correct.

Sharon Stanley 91231202tDate (Mo/Day/Yr)

}h^ h..L ^f t,^I,r .^^I] /.^h\, <\ _ NN NNT DPN\/IDF THIS INFOPMATTON ON THF BACK OF ANY OTHER COPY OF THE FORM. TAKE COPY 5 WTTH YOU,

Email address:

(PRINT) Donor's Name (First, IYI, Last)

Daytime Phone t'to. 7707447268 Evening Phone No. 7707447268 Date of Birth Il30lL972(l4olDay/Yr)

STEP 6; COMPLETED BY MEDICAL REVTEW OFFICER - PRIMARY SPECIMEN XI URINE ORAL FLUID

E rurcerlvr E posmvr for:

In accordance with applicable federal rcquiements, my verification is:

E oturrE nerusal ro TEST because - check reason(s) below:

E eoulrrnerED (adulterant/reason) :

Esuesrnumo

E rrsr cANCELLED

E ornrR:REMARKS:

xSiqnature of 14edical Review Officer

ttSTEP 7r COMPLETED BY MEDICAT REVIEW OFFICER - SPLIT SPECIMENln accordance with appliable federal requirements, my verilication for the split srecimen (if tested) is:

E nrcorunRNro for:

E rRrrro ro RECoNFIRM for:

REMARKS:

xMof Medical Review Officer

n rrsr cANcELLED

COPY 2 . MEDICAL REVIEW OFFICER COPY

FEDEML DRUG TESTING CUSTODY AND CONTROL FORM

lll I I ll I lllll lll lll ll lllllll lllcF0567406SPECIMEN ID NO,

0CLIENT NO. DUK.DOTl. 15OOB99B

8433 Quivira RoadLenexa, KS 66215

ACCESSION NO.

(mSTEP 1: COMPTETED BY COLLECTOR OR EMPTOYER REPRESENTATIVE

A, Employer Name, Address, I.D. No.

TOXICOLOGY TESTINGHAPEVILLE535 N CENTML AVE

HAPEVILLE, GA 30354Phone#: r4O4)761-4040 / Fax#: nullnull

C. Donor SSN, Employee LD. No., or CDL State and No'

D. Specify Testing Authority: I HnS ! r'rnC

Site Location S. MRO l"lame, Address, Phone No. and Fax No.

DRS:DAWKINS & GLASS (MRO1247)

CADUCEUS USA535 N CENTML AVE

HAPEVILLE, GA 30354Phone#: (404)76t'4040 I Fax#: (404)761-4008

GA05829782L

F. Drug Tests to be Performed:

G. Collection Site Address: Caduceus USA - HaPeville

535 N Central Ave

Haoeville, GA 30354-1603

! otut (specify)

Collection Site Code: Collector Contact Info:

DUK.0012Phone

Fax

Other

@o4t.76L-4040(404)761-4008

hapeville@caduceusoccmed'co

,'..,ffiEr* Et* Eltto lnHrvsn [uscc

E. Reason forTest:Ipre-employmend-lRandom!Reasonabte suspicion/cause Ieost Accident[-lReturn to Duty !rottow-up!other (specify)=--

[]rHc, coc, PCP, oPI, AMP ! rHc & coc onlv

w215

STEP 2: COMPTETED BY COLLECTOR (make remarks when appropriate)' URINE ORAL FLUID

lsseai(s).DonorcompletessTEP5onCopy2(MRocopy)

OF CUSTODY - INITIATED BY COLLECTOR AND COMPLETED BY TEST FACILITY

STEP 5: COMPLETED BY DONOR

STEP 3:STEP 4:

URINE: Collector reads urine temperature within 4 minutes. Temperature between 90o and 100'F? Elyes E No, rnter nemark Ll observed, Enter Remark

Volume Indicator(s) ObservedEach Device Within Expiration Date?oRALFLUID: SplitType: I lseriat I lConcurrent

SPECIMEN BOTTLE(S)/TUBE(S) RELEASED TO:

uPS fl nedrx

El otf,er CRL Courier

@ dt copy 2 of thb forn was collecte4 latule4

nod in afiordailce wlth applicable federal rcquhenents.

T-WEsignatureof collector AM

Shantol Williams 912312021 B:52 EDT PM X

tinanymanner;eachspecinenbottle/tubeu#dwassea/edwithatao1per-evjdentseatinmypresence;andthattheinformation

Sharon StanleY 9l23l2o2rDate (Mo/Day/Yr)

Email address: Daytime phone No. 7707447268 Evenins Phone uo. 7707447268 Date of Birth 1130t197.2(Mo/Day/Yr)

rhaha.!^fv^,,r.^nvr.6nvs) -DoNorpRovIDErHts$troR[4aTIONONTHEBAC(OFANYOTHERCOPYOFTHEFORM,TAKECOPY5WtrHYSirp o: coMpLETED By MEDTcAL REVTEw oFFrcER - PRTMARY SPEcTMEN XI URINE ORAL FLUID

]n accordance with appticabb federal requirements, my veritication is:

! rurcnrlvr E posrrrvr for:

E oturcn rusr cANCELLEDn nrrusnr ro TEST because - check reason(s) below:

E nouLrrnqrED (adulterant/reason) :

Esuss[rurcof] ornrn:

REMARKS: ll-DaelEoEaY/Tl

xSiqnature of Medical Review Officer

STEP 7: COMPLETED BY MEDICAL REVIEW OFFICER - SPLIT SPECIMEN

In accordance with appticable federal requlrements, my verilication for the split srycimen (if tested) is:

E nrcoNFIRuro for:

E rntrro ro RECoNFiRM for:

REMARKS:

xofficer

f]rcsr cANCELLED

COPY3_COLLECTORCOPY

None Provided, Enter Remark.

FEDEML DRUG TESIING CUSTODY AND CONTROL FORM

ill I I ll I illll lll lll ll lllllll lllcF05674060SPECIMEN ID NO, CLIENT NO. DUK'DOT1.1sOOBggB

STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE

64uu uurvrra Hoao .

-\

-=i3i3,:.S::-:: (CRL

ACCESSION NO.

A. Employer Name, Address, I.D. No.

TOXICOLOGY TESTINGHAPEVILLE535 N CENTML AVEHAPEVILLE, GA 30354Phone#: (404)76t-4040 / Fax#: nullnull

C. Donor SSN, Employee I.D' No', or CDL State and No,

Location Name, Address, Phone No. and Fax No.

DRS:DAWKINS & GLASS (t\4RO1247)

CADUCEUS USA535 N CENTML AVEHAPEVILLE, GA 30354Phone#: (404)76t-4040 I Fax#: (404)76t'4008

GA05829782LD.SpecifyTestingAuthority:[rrHs[r'rnc,o...ffiFMf]FME]frAflPHMSA[uscc

Collection Site Code: Collector Contact Info:

DUK.0012Phone (404)761-4040

Fax (404)761-4008

Other hapeville@caduceusoccmed.co

E. Reason for Test:!pre-employmendlRandom[Reasonable Suspicion/Cause []nost Accident IReturn to Duty !nottow-uo!other (specify)--

F. Drug Tests to be Performed, [rHc, CoC, PCP, oPI, AMP ! rHc & CoC only

w215flot ur" (specify)

G. Collection Site Address: Caduceus USA - Hapeville

535 N Central Ave

Hapeville, GA 30354-1603

STEP 2: COMPLETED BY COLLECTOR (make remarks when appropriate)' URINE ORAL FLUID

STEP3:Collectoraffixes,""1.oonorinitialsseal(s)'DonorcompletessTEP5oncopy2(MRocopy)

STEP 5: COMPLETED BY DONOR

uRrNE! Collector reads urine temperature within 4 minutes. Temperature between 90o and loooF? |xI v.r I No, Enter Remark Ll observed, Enter Remark

Volume Indicato(s) ObservedEach Device Within Expiration Date? | lvesORAL FLUID: Split TYPe:

cUsToDY-INITIATEDBYcoLLEcToRANDcoMPLETEDBYTESTFACIIITYSPECIMEN BOfiLE(S)/TUBE(S) RELEASED TO:

flups E redrx@ iction on copy 2 of this Fornl wds collected, lakled,

A tniOetipry SEru4 ndeet in a@tdance with applicdble Fedefil requirentents'

T)Gignature of Collector AM

Shantol Williams 912312021 B:52 EDT PM X

ffbthecollectol;thatIhaVenotadulteDteditinanymanner;eachspeclnenbottte/tubeufdwa5sealedwlthatamper.eVidentsealinmypre5ence;andthattheinfomatlon

Sharon SlanleY

Email address:

(PRINT) Donor's Name (First, 1"11, Last)

Daytime phone no. 7707447268 Evenins Phone No. 7707447268 Date of uirth tl30lt972(Mo/Day/Yr)

Ih^ hA'' ^f I'^, ,r '^^\/ /.^N, q\ _ NO NNT PROVIDF THIS TNFORN1ATION ON THE BACK OF ANY OTHER COPY OF THE FORM. TAKE COPY

STiP O, COMPLETED BY MEDICAL REVIEW OFFTCER - PRIMARY SPECIMEN XI URINE ORAL FLUID

In accordance with apptiable fedenl requirements, my verlfication is:

E rurcarrvr flposntvr for:

E ollurrE rrsr cANCELLEDE Rrrusnl ro rEST because - check reason(s)

E RoulrrnnrED (adulterant/reason):below:

E suasrrrurroI orHrR:

REMARKS:

x llDete (Mo/Dav/Yr)

STEP 7: COMPLETED BY MEDICAT REVIEW OFFICER - SPLIT SPECTMEN

In accordance with appticable federal requiement, my verilication for the split specimen (if tested) is:

! RrcorunRptro ror:

E rnrlro ro RECoNFIRM for:

Officer

REMARKS:

E resr cANCELLED

COPY4-EMPLOYERCOPY

None Provided, Enter Remark.

NAME: D:ArBi 07 -71-z/

S}il ri*f*;,iillr*-r. in weight, fatigue, behavior changes, change in energy level, change in appetitq and

iiiir,i,, sleeping habits

SKIN: Any history of allergies, psoriasis, eczema, prurihrs, bruising, rash, moles, hair loss, changes in nails or dryness?

YES o(No

HBENT: Any history of headaches, head fi'auma, dizziness, vision changes, pain, diplopia, cataracts, glaucoma, earaches, infections,hearing loss, tinnitus, vertigo, nosebleeds, sinus pain, altered smell, difficuhy breathing, sore throat, mouth lesions, epistaxis, hoarseness,rrriglaines or sore gums? YES o( NO .;

CARDIOVASCUL,{R: Any history of chest pain, dyspnea, palpitations, orthopnea, cough, fatigue, cyanosis,-e-demq, pallor,claudication, phlebitis or surgery? YES (r NO i

HEMATOPOIETIC: Any history of bruising, lymph node swelling, pallor, bleeding, recurrent infections or toxic exposure?

YES (1 NO

GASTROINTESTINAL:: any history of weight loss, appetite changes, dysphagia, food intolerance, nausea, vomiting, change in

bowel habits, ulcers, gallbladderproblems, colitis, hernias, constipations, excess flatulence, surgeries, rectal bleeding,.g,hange in stool colorhemorrhoids, anorexia, regurgitation, bloating, clay stools or anal fissures? YES or QO .'

NEUROLOG:IC: Any history of headaches, clizziness, veftigo, head injury, seizures, tremors, weakness, numbne-ss,,(nglittg, laintirrg,melnol)loss,syncope,sleepchanges,paralysis,paresthesiaormusclestrengthchanges? YES of'NO.-.1

GENITOURINARY: Any history of frequency, urgency, nocturia, hematuria, change in urine color, hesitaucy, pqlyuria, flank pain,

discharge, dribbling, incontinence, retention, chronic UTI, STD, libido change, or GU surgery? YES d( NO ';

MUSCULOSKELETALI Rny history of weakness, leg cramps, joint pain, muscle pain, swelling, stiffiress, redness, limitedlIoVcIneIlt,trauma,audiblecracking/crutrching,lossofstrength,arthritis,fracture,dislocationsorweightchange?

YES ori NO ;

ENDOCRINE: Any history of excess hunger, excess thirst, abnormal hair distribution, delayecl puberty, development, temperattrrcintolerance, change in sex characteristics, flushing, nervousness, obesity or sexual dysfunction? YES g,; NOi

Srnoking:Alcohol use:

Caffeine use:

Substance abuse::

Marital Status:Activities:Education:

years.

PSYCHIATRIC: Any history of nervousness, tension, change in affect, depression, anxiefy, anention, volition, hal[ucinations ol suicit

PAST MEDICAL HISTORY

Any history of childhood diseases, accidents, injuries, blood transfusions or immunization problems? VfS orl(O,)

PAST SOCIAL H]ISTORY

packs/day x -=-- Years.

_drinks/day x _ years.cups/day x years.

type:Widowed Separated

or NOor NO

>F)F*>F+*)r***,l<)r{r{<***+**,fi,l.OFFICIAL USE ONLY BELOW***>k**'l*(*}t*{<*.*'F***}t*{<**)t

- BIP '-- HT

-------\). -MA YV Reviewed By CA

WT

addreri: 5 3( { 7t:1ot^'"Citv. Stut., ZiP, (;' I I e;, '

Date of InHome Phone: '

Date of Birth:Cell/ Other Phone:

Driver's License #: r '

Company Dept/Job Site:

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Reason for Visit Physical Drug Screen Work Related Injury Follow-up Visit Private Pay Primary Care

Signature:

Notice of Privacy Sfatemenf -. n..^^+:^^^ ^,. rha rrqrc anrl r'your narne and signature inclicate that you have received a copy of caduceus' Notice of Pt'ivacy Practices on the date and tinre

indicated. If you have any questions regarding trre rnrormation in caouceusi Notice of Privacy Practices' you may contact our

Corporate Office at (404) 161-4040Date/Tirne:-

Name (Please Print):

Signature:

The informatio, provided is correot to the best of my knowledge. I will not hold .ADUCEU^', its health p'oviders' or its

employees respo,sible for any errors ot o*irSorr",iluiffi;; h?;t;li"'i' t"i'pt"ii''g ttt" infoi'mation on this fonn' You mav

.ontu.i my empioyer to verify the purposes of rny visit' if necessaty' ^ ^ - .t I

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If you were injured, please complete the below:

Social securityNumber: Lt*r': "<:t t/i.tt'l'l

Please list additional Medicine you are taking below:

Describe how You were injured:

Using these

figures, pleose

circle the

oreas you qre

injured.

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Supervisor/Contact Person :

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COVID-1 9 DailY Screening

Please answer by circling YES or NO, the following questions concerning symptoms

within the past 24 hours.

Have you experienced symptoms of cough? Ves l@

Have you experienced symptoms of runny nose? Ve@

Temperature in Degrees Fahrenheit: wm-22*/