RANDOM SELECTION LOG Random Coordinator's Name * (Your Name) Today's Date * MM DD YYYY Company or individual Name * Select the following * NON-DOT DOT (DEPARTMENT OF TRANSPORATION) Company or individual test frequency * MONTHLY QUARTERLY BI-WEEKLY YEARLY OTHER Select the following * On-site Walk-in ******** 1st Quarter Picks ******** (JANUARY) Date selected (If applicable) MM DD YYYY (FEBRUARY) Date selected (If applicable) MM DD YYYY (MARCH) Date selected (If applicable) MM DD YYYY Total Number of individuals selected this quarter ******** 2nd Quarter Picks ******** (APRIL) Date selected (If applicable) MM DD YYYY (MAY) Date selected (If applicable) MM DD YYYY (JUNE) Date selected (If applicable) MM DD YYYY Total Number of individuals selected this quarter ******** 3rd Quarter Picks ******** (JULY) Date selected (If applicable) MM DD YYYY (AUGUST) Date selected (If applicable) MM DD YYYY (SEPTEMBER) Date selected (If applicable) MM DD YYYY Total Number of individuals selected this quarter ******** 4th Quarter Picks ******** (OCTOBER) Date selected (If applicable) MM DD YYYY (NOVEMBER) Date selected (If applicable) MM DD YYYY (DECEMBER) Date selected (If applicable) MM DD YYYY Total Number of individuals selected this quarter Other deatils Subject Thank you!