Background Check and Drug Test Supplemental Information

Background Check and Drug Test Supplemental Information
Date form was submitted*

YearMonthDay
Date
*This form is only for submitting information due to your Background Check and/or Drug Test reports coming back with a discrepancy. The link to order a Background Check and/or Drug Test is Background Check/Drug Test Ordering Link.
Name*

Last NameFirst Name
UIW Identification Number*
Phone Number*
Please enter a valid phone number.
UIW Email Address*

Confirmation Email
Select UIWSOM Program*

DOMBS
Select DO Classification*

OMS-IOMS-IIOMS-IIIOMS-IV
Which items is this supplemental information for?*

Background CheckDrug Test
*** DRUG Test Discrepancy***

If you take prescription medication that may have caused your positive results, please contact Pre-Check so they can assist you with resolving the positive results before completing this form. Only complete this form is they are unable to resolve the issue and your report still reads "Positive" for the item.

Email: studentcheck@precheck.com
Phone: (866) 961-6587
If your "Positive" results were due to a prescription, have you contacted Pre-Check and provided them the opportunity to help you resolve the discrepancy?*

Yes, but they were unable to resolve itNo, my discrepancy was not related to a prescription
Why did/will the Background Check or Drug Test have a discrepancy?*
Attach a PDF copy of your results. (Required if the background check or Drug Test test has already been completed)

Cancelof
Background Check: Provide details about the case/issue and any additional information/statement you would like to include. Please be sure to include the status of the case/issue (i.e closed, still open, etc.)*
Prescription Information: Please provide the diagnosis, date of diagnosis, name of medication prescribed, dosage, frequency of use, and the name and telephone of the doctor/medical facility treating you for the medical condition.*
Upload a copy of the prescription or picture of the medication bottle and/or letter from the physician detailing diagnosis and prescription information*

Cancelof
Upload additional supporting documentation, if needed

Cancelof
I confirm the information I provided is true and accurate.*

Confirm
Should be Empty: