RANDOM WALK-IN SCHEDULING

EMPLOYERS, FILL THIS SECTION OUT IF YOUR EMPLOYEE(S) HAVE BEEN SELECETED FOR THEIR RANDOM TESTING. THIS WILL PROMPT US TO CREATE A BARCODE AUTHORIZATION FOR A WALK-IN FACILITY.

Company Name

Name of person filling out the form

First Name

Last Name

Default zip code

Walk-in Donor scheduling

Employee(s) Information

(Provide Name, phone #, Zip code if not the same as above)

Email for barcode authorization

Do any of the selections need rescheduling?

No

Reschedule employee(s)

Employee(s) That need rescheduling: