Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Application For Voluntary Drug-Free Workplace Program Form. This is a Arkansas form and can be use in Workers Comp.
Loading PDF...
Tags: Application For Voluntary Drug-Free Workplace Program, HS-36-A, Arkansas Workers Comp,
Form HS-36-A
ARKANSAS WORKERS’ COMPENSATION COMMISSION
Ark. Code Ann. §1114-101 & AWCC
Rule 36
Rev. 7-1-2010
HEALTH & SAFETY DIVISION
HS36-A
324 Spring Street, Little Rock, AR 72201
Mail: P. O. Box 950, Little Rock, AR 72203-0950
501-682-3930 / 1-800-622-4472
Application for Voluntary Drug-Free Workplace Program
Application Type: ‘Initial/first time application
‘Renewal (Approval no._______)
‘ Termination of Participation
Company Information
1) Company name:
2) Address:
3) City:
4) State
6) FEIN:
7) NAICS:
5) Zip:
8) Effective date of drug-testing program:
9) Company contact:
10) Telephone no.: (
11) Title:
12) e-Mail:
13) Workers’ compensation insurance (WCI) status: ‘Self-insured
)
‘Purchase (WCI)
14) Insurance carrier or third party administrator (TPA):
15) Average number of employees during the most recent calendar year:
15a) Full-time:
15b) Part-time:
Drug Testing Program
Program Manager or Third Party Administrator 16) Name:
17) Address:
18) City:
19) State:
20) Zip:
21) Telephone no.
22) E-Mail:
Testing Lab: 23) Name:
24) Address:
25) City
26) State:
27) Zip:
28) Telephone no.: (
29) Certification No. (enter lab certification no; only one is required) SAMHSA:
MRO:
30) Name:
32) City:
36) MRO certification no.:
)
CAP-FUDTAP:
Other:
31) Address:
33) State:
34) Zip:
35) Telephone no.: (
)
37) If not certified MRO, other qualifying certification (please attach explanation describing
how this meets the Rule 36 requirements for an MRO):
HS-36-A
American LegalNet, Inc.
www.FormsWorkFlow.com
(38) Summary Statistics
Please attach the most recent year-end summary report from your testing laboratory or a letter certifying that no tests were
required to be performed and why (no hires, no accidents, etc.).
Employer Certification (complete for all applications)
I certify the above information is, to my best knowledge, true and accurate. I further certify that I understand submitting false
information on this application may constitute workers’ compensation fraud (Ark. Code Ann. §11-9-106). I certify that at each of
the above mentioned locations a drug-free workplace program has been put in place which is in full compliance with the
requirements of AWCC Rule 36.
(39)__________________________________________________________________________
Signature of Owner/Officer and Title
________________________
Date
(40)__________________________________________________________________________ _________________________
Notary/Date and State of Commission
Date
The completed and notarized application should be sent to:
Voluntary Drug-Free Workplace Program
Health and Safety Division
Arkansas Workers’ Compensation Commission
P.O. Box 950
Little Rock, AR 72203-0950
HS-36-A
American LegalNet, Inc.
www.FormsWorkFlow.com
