Application: Working Partners® Technical Assistance Clinic WIA WV May 24 & 25, 2021

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* 1. Name

First Name

Last Name

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* 2. Title

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* 3. E-mail

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* 4. Company Name (full name as registered with the State of Ohio including commas, etc.)

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* 5. Company Address

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

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* 6. County

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* 7. Phone Number

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* 8. Type of Industry (e.g., construction, service, manufacturing, retail, government)

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* 9. Do you regularly perform work outside Ohio?

Yes

No

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* 10. Number of full-time employees

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* 11. Number of part-time employees

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* 12. Do you have unionized employees?

Yes

No

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* 13. Do you have employees mandated for drug and alcohol testing under ANY DOT administration? (e.g., FAA, DMCSA, PHMSA)

Yes

No

Not sure

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* 14. Do you currently have a drug-free workplace policy?

Yes

No

Not sure

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* 15. Do you currently drug test applicants or current employees?

Yes

No

Not sure

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* 16. Following an employee's first positive alcohol or drug test, you believe in (check one):

Termination

Assistance and return-to-work

Not sure