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PEC APD Form
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Alcohol & Drug Policy Violation Referral Form
Alcohol & Drug Policy Violation Referral Form
*
denotes required field
Select one
Did the violation occur at (or for employment at) a work site in Alberta?
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Yes
No
Select one
Where did the violation occur?
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At Work
Off Work
Select a date
Date of incident giving rise to referral:
*
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Type first name of worker
First Name of Worker:
*
Type last name of worker
Last Name of Worker:
*
Type phone number of worker (xxx-xxx-xxxx)
phone number should be xxx-xxx-xxxx
Worker's Phone Number (xxx-xxx-xxxx):
*
Worker's Address:
RSAP ID:
Union Member ID# required
Union Member ID#:
*
(listed on the upper right hand corner of Dispatch Slips. Enter "NA" if unknown.)
Referring Organization Contact Information
Type legal name of organization
Legal Name of Organization (please avoid abbreviations):
*
Type name of the individual making referral
Name of Individual Making Referral:
*
Type position of the individual making referral
Position:
*
Type email of the individual making referral
email must be in format name@domain.xyz
Email 1:
*
Email 2:
Email 3:
Type phone number of organization (xxx-xxx-xxxx)
phone number should be xxx-xxx-xxxx
Phone Number:
*
Project / Dispatch Information
Type name of project
Name of Project:
*
Type name of employing contractor
Name of contractor employing / who intended to employ individual referred (if different from referring organization):
Select a dispatch date
Date of Dispatch:
*
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Select a work start date
Work Start Date:
*
RadDatePicker
RadDatePicker
Open the calendar popup.
Calendar
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Select one
The individual was employed (or intended to be employed) under the following Alberta Collective Agreement:
*
Construction Agreement
Local 424 Maintenance Agreement
General Presidents Maintenance Agreement
National Maintenance Agreement
Other (explain)
Is the contractor making contributions to the Rapid Site Access Program (RSAP) for the work in question?
Yes
No
Unsure
Select one
Was the testing performed in accordance with the Alcohol & Drug Work Rule (Canadian Model)?
*
Yes
No
N/A
Select at least one
This referral is in respect to:
*
Site access test
Site access - Site transfer
Site access - Name hire
Post Incident
Reasonable cause
Follow-up test
Camp infraction
Transportation infraction
Possess or offer for sale
Disclosure to employer
Disclosure to union
Random (Owner Requirement)
Select at least one
Reason for violation:
Positive alcohol and drug test
Refusal to test
Evidence of substitution or tampering
Failure to provide adequate sample
Please attach copy of the Dispatch Slip & A+D Test Results if applicable and available.
You may upload a maximum of two PDF documents; for multi-document submissions, please combine your documents into a single file before uploading.
Contractor / Union: additional comments relevant to the case management of this file:
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