Crucial Pointe Employer Partnership Request
Thank you for your interest in partnering with Crucial Pointe Training & Medical Services. This form is used to gather preliminary information regarding your organization’s occupational health, drug testing, and workforce support needs. Once submitted, a representative from our office will review your information and contact you regarding next steps, service options, and onboarding. Please complete all applicable sections below.
Company Information
Company Name
*
Industry Type
*
Please Select
Trucking
Transportation
Staffing Agency
Healthcare
Home Health
Manufacturing
Construction
Security
Education/Daycare
Government
Other
Number of Employees
*
Website
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Contact
Contact Person Name
*
Title/Position
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Services Needed
Which services are you interested in?
*
CPR/BLS Certification
Workplace Safety Training
DOT Drug Testing
Non-DOT Drug Testing
Random Drug Testing Programs
Post-Accident Testing
Reasonable Suspicion Testing
Return-to-Duty Testing
Follow-Up Testing
Rapid Drug Testing (Coming Soon)
Hair Testing (Coming Soon)
Oral Fluid Testing (Coming Soon)
Breath Alcohol Testing/BAT (Coming Soon)
I-9 Verification
Background Checks
Estimated Monthly Testing Volume
*
1-5
5-10
10-20
20+
How would you like to onboard your employees?
*
As Needed (Individual scheduling)
Scheduled Onboarding Days
Not Sure, I need guidance
Timeline
*
Asap
Within 2 Weeks
Within 30 days
Future Planning
Program Details
What type of testing program does your company currently utilize?
*
DOT
Non-DOT
Both
Unsure
Do you currently work with another testing provider?
*
Yes
No
Would your company be interested in mobile collections?
*
Yes
No
Possibly
Would your company potentially require after-hours testing services?
*
Yes
No
Possibly
Billing & Authorized Requesters
Preferred Billing Method
*
Pay Per Service
Invoice Billing
Unsure / Need Guidance
Who will be authorized to request testing services on behalf of your company?
*
CPR/BLS Needs
Do you need CPR/BLS certification services?
*
Yes
No
Perferred CPR Option
*
Group Class
Individual Blended Learning
Not Sure
Estimated Number of Employees Needing Certification
*
1-5
5-10
10-20
20+
Additional Information
Please briefly describe your company’s onboarding, compliance, or testing needs.
*
I understand submission of this form does not establish a contractual agreement.
*
Yes
I consent to being contacted regarding occupational health and workforce support services.
*
Yes
Submit
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