Return to Duty & Consent Form

Return to Duty & Consent Form

Complete this form to authorize services and consent to the necessary drug testing and record sharing.
Applicant Information
Are you an owner-operator with your own DOT number?
DOT number
How did you hear about us?
Full legal name

First NameMiddle NameLast Name
Driver's license number
State or province of issue
Date of birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
Substance Abuse Counselor Information
SAP Counselor Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Website
Consent, SMS, Upload, and Acknowledgments

We are currently setting this up for future reference & contact.
Do you agree to receive calls and ortext/SMS messages from the Hope Diagnostics Lab?
Upload a clear and legible copy of your license

Cancelof
I understand that all drug tests will be observed, meaning a person of the same sex watches the urine leave the body and enter a cup.
I understand that Hope Diagnostics Lab will receive a copy of my test results and will serve as my C/TPA in the Clearinghouse. We recommend a non-DOT drug test for drivers, and it is an additional cost to the driver, as we want to ensure the driver fully understands the seriousness of a failed test during this process. If the driver is confident they will pass the DOT test, they may decline the non-DOT test.
Consent and affirmation
Should be Empty:

Return to Duty & Consent Form

Applicant Information

Substance Abuse Counselor Information

Consent, SMS, Upload, and Acknowledgments