HomeMy WebLinkAboutFlorida Municipal Insurance Trust Application -2002 11 12w
. TLORIDa- 1lt1DiICIp1~L IN80R31NGE TRUST FLG 09-1
{Revised 2/97)
]i1PPLICI-TION TOR DRUG-~'A~ NOR1CPLi1CS PRA![ CIt1EDIT PIiOG~711t
Name of Member: City of Winter. Springs -(EMIT 64$")
Date PrograM Implemented: July 8, 1996
2002/2D03
I. TESTING:
-Drug .testing has been conducted in the following areas:
® Job applications ® Routine fitness for ditty
® Reasonable suspicion ~ Follow-up to Employee Assistance Program
II. NOTICE OT N~ER'$ DRUG TESTING POLICY:
® Copy to all employees prior ~ Show notice of drug testing on vacancy
to testing announcements
® Posted on employer's premises ® Copies available in personnel office or
other suitable locations.
® Copy to job applicants prior to
testing- NSA No notice required because the employer
had a drug testing program in place prior
® General notice given 60 days to July 1, 1990
prior to testing •~.:;
III . EDOC]ITION : , .
® Resource file on Providers ® Educat~gn "'
® Employee Assistance Program
IV. N1~ OT M$DIClii. REVIEIP OlTICER D.b:.T.. Stop 'Medical Review. Officer,.. Jock Sneedon,
MD, 9484 S, 0$T,,Orlando, FL 32837 (40.7)•:857-557
' ~ ~:
A. Name of approved Agency for Health Care A~i.ni.stration Lab or United States
Department of Health and Human Services Certified La~oratary;
American Medical Laboratories
B. Phone #: ( 407 ) 857.-81:8:8
C. Address: 8549 Parkline Slvd., Orlando Fi, 328:09
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SPECI]IL NOTE: 71LL ITE1L$ ldvST H~ COLdPLIED 11IT8 IN OR~ TO HE $LIGIB~ ~ THE. CREDIT.
Any person who.]cnowingly and with intent to injure, defraud, or degei~~~'any insurer files
a statement of claim or an application containing lse, ~?lete, or misleading
information is guilty of a'felony of the. third degr e. ,,
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City of Winter Springs Noyember;l2, 2002 '' -~
Member Name Date * El"acted dff#e'1al o~~ ther Offic al
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THE ABOVE SIGNED CERTIFIES THAT THiS INFORMATION I.S A TRUE AND FACTUAZ DEPICTION OF TIiEIR
CURRENT PROGRAM.
*Appli ation must be signed by an elected o€ficial or other official.:..
ANDRF,~K~Lt~EWp~Q-L
Mrcos~oN ~-.cc
~" November 12, 2002 -~ ~~
o ary ub c's Signature Date
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CHECKLIST FOR WRITTEN POLICY ON DRUG TESTING
Your policy must cover each of these points.
1. A general statement of policy. -
2. The type of testing required...
3. What can happen to an employee with a positive confirmed: result,
or one who refuses to take the test.
4. Reference the drug testing statute and rules.
5. Test results must be confidential.
6. A procedure for the employee to report the use of drugs which
may affect the result of a drug test.
7. A list of the most common drugs or medication, by brand name,
common name, and chemical name, which can alter a drug test.
8. Name, address, and .telephone number of local rehabilitation .
programs.
9. The individual's rights to explain the drug test results to you within
five days and if you do not accept their explanation, the fact they
can contest the results with the Judge of Compensation Claims.
10. A statement that-the applicant is responsible for notifying the
laboratory if he or she takes -legal action' over the drug test.
11. A list of all drugs for which you will test, by brand name, common
name, and chemical name.-
12. A statement of any rights the individual has under a collective
bargaining agreement or other laws or contracts.
13. Notification -the individual can consult a testing laboratory for
additional information about medication that will affect a drug test
result.
14. Notice that you require a drug test- must be posted. on all- help.
wanted advertisements and job vacancies.
15. -You must post the entire policy on your premises where the public
can inspect it during regular. business hours.
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e STATE OF FLORIDA
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AGENCY FOR HEALTH CARE ADMINISTRATION
JE8 BUSH, GOVERNOR . RUBEN J. KING-SWAW, JR., SECRETARY
Licensed Laboratories Authorized to Perform Drug Free Workplace Testing Under Chapter 112, Florida Statutes
integrated Regional Laboratories Q Quest Diagnostics Clinical Laboratories .
Cedars Medical Center; Toxicology Dept.' 801 E. Dixie Avenue
1400 N.W. 12~' Avenue ~ Leesburg, FL 34748
Miami, FL 33136 (352)787-9006
(305)325-5810 Kirit T. Patel, M.D., Director-
James Robb, M.D., Director ~ License Number: T002
License Number- T001
Toxicology Testing Service, [nc. Labcorp Occupational Testing Services
5426 N:W. 79~' Avenue 1904 Alexander Drive
Miami, FL 33166 Research Triangle Park, NC 27709
(305) 593-1595 (919)572-6900
Terry D. Hall, Ph.D., Director Francis Esposito, M:D., Director
License Number: 3'003 License Number: T005
LabCorp Occupational Testing Services Laboratory Corporation of America, Inc.. •
4022 Willow Lake Blvd. 5610 LaSalle Street
Memphis, TN 38118 Tampa, FL 33607 -
(800) 223-6339 (813)289-5227
Lance C. Presley, Ph.D., Director W. Allen Taylor, Ph.D:, Director "
'License Number: T006 License Number: T009
Diagnostic Services, Inc. PharmChem Laboratories, Inc.
12700 Westlinks Dr. 1505-A O'Brien Drive
Fort Myers, FL 33913 , Menh Park, CA 94025
(941)561-8208 (800)446-5177
.Robert M. White, Sr., Ph.D., Director J. Meeker, Ph.D., Director
License Number: TO11 License Number: T014
American Medical Laboratories, Inc. Quest Diagnostics Clinical Laboratories
14225 Newbrook Drive 3175 Presidential Drive
•P.O. Box 10841 Atlanta, GA 30340
Chantilly, VA 20153 (77052-1590
(703) 802-7190 R.H. Barry Sample, Ph.D., Director
_ Anthony G. Costantino, Ph.D., Director License Number: T017
License Number. TO15
MedTox Laboratories, Inc. Quest Diagnostics, Inc.
402 W. County Road D 7470 Mission Valley Road
St. Paul, MN 55112- San Diego, CA 92108
(651) 636-7466 (61986-3200
Jennifer Collins, Ph.D., Director Anthony D'Addanio, Ph.D., Director
License Number:. T019 License Number: T025
2727 Mahan Drive Mail Stop #32 Visit ANCA Online at
Tallahassee, FL 32308 ~~'~w.~`. www.fdhc..rtate.jl.us
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Licensed DFW Laboratories
Doctors Laboratory, Inc. Alabama Reference Laboratory, Inc.
2906 Julia Drive 536. South Decatur Street
. P.O. Box 2658 P.O. Box 4600
Valdosta, GA 31602 Montgomery. AL 36103-4600
(912) 244-4468 ~ (334)263-5745
Byron S. Davis, M.D., Ph.D.,Director Charles Thomas Huber, Ph.D., Director
License Number: T026 License Number: T027
Lab One, Inc.. Clinical Reference Laboratory, Inc.
10101 Renner Blvd. 8433 Quivira Road
Lenexa, KS 66219 Lenexa, KS 66215
(913) 577-I S 17 (80045-691.7
Michael A. Peat, Ph.D., Director Stan Kammerer, Ph.D., Director
Licease`Number: T029 License Number. T035
Mercy Hospital Forensic Toxicology Lab Kroll Laboratory Specialist, Inc.
3663 South Miami Avenue 1111Newton Street
Miami, FL 33133 Gretna, LA 70.053
(305) 285-2693 - (800) 433-3823
.Jose A. Hernandez, M.D., Director Leon Glass, Ph.D., Director
License Number: T038 License Number: T039
Advanced Technology Network Psychemedics Corporation
3560 Air Center Cove # 101 5832 Uplander Way.
Memphis, TN 38118 Culver City, CA 90230..
(88890-1150 (800)522-7424
Stuart C. Bogema, Ph.D., Director Michael I. Schaffer, Ph.D., Director .
License Number: T041 License Number: T042
Associated Pathologists Laboratories
4230 South Burnham Avenue#212
Las Vegas, NV 89119
(702)733-7866
Raymond C. Kelly, Ph.D., DABFT
License Number: T043
Revised December 5, 2000
FLC UNOERWRITIM~
FE8 0 6.2001
RFC;