403.7E8 - Random Testing Driver Change List Form - Iowa Drug and Alcohol Testing Program

School District Contact Person:  _________________________________________________  Date:  __________________________

School District:  _____________________________________________________________  Phone:  __________________________

Address:  ___________________________________________________________________________________________________

Social Security Number and Name (first and last).  Example 111-22-3333, John Doe.

                    Additions                                                                          Deletions

SSN                               Name                                            SSN                               Name

__________________________________          ______________________________________

__________________________________          ______________________________________

__________________________________          ______________________________________

__________________________________          ______________________________________

Please list all qualified drivers who must be tested under the federal regulations.  Make copies of this form if you need additional space.  Changes must be made in writing.  Telephone changes cannot be accepted.

Changes must be received the last business day of the prior quarter to be effective for the quarter.  Random selection list updates cannot be data entered for a new month if this form is received on or after the first of the new quarter.

IDAPT participants please fax or mail to:          

                                                                        Medical Enterprises

                                                                        200 Essex Ct.

                                                                        Omaha, NE 68114

                                                                        FAX:  (402) 393-8946