AUTHORIZATION FORM

The University of Arkansas for Medical Sciences, Department of _______________

gives permission to have _________________________, _______________________ ,
                                                                       (Employee)                             (Social Security Number)                                    

________________ tested by:
(Position)

On all Pre-Employment and Random test, an AML-10 will be performed. 
On For Cause test, either the AML-10 or another panel/test may be selected 
and performed on a Split Sample.

4 Check Appropriate Test:

q AML-10 (amphetamine & methamphetamine, barbituates, benzodiazepines, 
cocaine metabolites, methadone, methaqualone, opiates- codeine & morphine, 
propoxyphene, PCP, THC) – SPLIT Sample

q Other ____________________(e.g. hydrocodone, fentanyl, demerol, stadol, alcohol)

4 Check Appropriate Reason for Test:

q Pre-employment q Random q Post Accident q Reasonable Suspicion

______________________________________________ ______________________
Department Head/Supervisor (print)                                       Date

______________________________________________ ______________________
Department Head/Supervisor (signature)                        Telephone #

_________________________
Pager # Slot #

Upon Completion of this form:

1. Make sure the employee/applicant has a map to the collection facility. 
   In the event the applicant is out of the Central Arkansas area, please 
   contact AML for an alternate collection facility (202-1561).
2. If the employee is clearly impaired, escort the employee and/or make 
   arrangements for UAMS Police to take the employee to the testing facility.
3. Samples for pre-employment testing should be collected within 24 hours of
    notification. Samples for random and for cause testing must be collected 
   within 2 hours of notification (wait until it is reasonable for the employee to 
   get to the collection facility within 2 hours prior to notification).
4. Fax this form to both of the following locations:

AML                               HUMAN RESOURCES

Fax: 202-7382              Fax: 296-1825

Attn: Carolyn              Attn: Paulette Lawson