Background Check and Drug Test Order Request
Date form was submitted
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/
Month
/
Day
Year
Date
Name
*
Last Name
First Name
UIW Identification Number
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Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
UIW Email Address
*
Confirmation Email
What is your status with UIWSOM?
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OMS I or OMS II student (returning from a LOA)
OMS III Student
OMS IV Student
Returning MBS student
Which service(s) do you need to order?
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Both (Background Check and Drug Test)
Background Check only
Drug Test only
Please provide a detailed explanation for the requested service(s). OMS III and OMS IV students: Please be sure to include the details for the clinical rotation that is requiring the updated background check and/or drug screen.
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Submit
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