Alcohol & Drug Policy Violation Referral Form

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* denotes required field

Did the violation occur at (or for employment at) a work site in Alberta? *
Yes
No

Where did the violation occur? *
At Work
Off Work

Date of incident giving rise to referral: *

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First Name of Worker: *

Last Name of Worker: *

Worker's Phone Number (xxx-xxx-xxxx): *

Worker's Address:

RSAP ID:

Union Member ID#: *(listed on the upper right hand corner of Dispatch Slips. Enter "NA" if unknown.)

Referring Organization Contact Information

Legal Name of Organization (please avoid abbreviations): *

Name of Individual Making Referral: *

Position: *

Email 1: *

Email 2:

Email 3:

Phone Number: *

Project / Dispatch Information

Name of Project: *

Name of contractor employing / who intended to employ individual referred (if different from referring organization):

Date of Dispatch: *

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Work Start Date: *

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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

Was the testing performed in accordance with the Alcohol & Drug Work Rule (Canadian Model)? *
Yes
No
N/A

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)

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: