MedWay OHS, Inc. TPA DOT UDS/BAT Consortium Registration – Med Way Onsite Health Solutions, Inc

Arlington: 817-506-7998

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MedWay OHS, Inc. TPA DOT UDS-BAT Consortium Registration

* This form will record your name, please fill your name.(Required)

1. What is the legal name of your company or business? *(Required)

2. What is the legal business address for your company? *(Required)

3. What is the mailing address for your company? *(Required)

4. What is your company’s DOT number? *(Required)

5. How many years has your business been in operation? *(Required)

6. Number of DOT employees *(Required)

7. Number of Non-Regulated employees to be enrolled in drug/alcohol consortium *(Required)

1-10

11-50

51-99

100+

8. Primary contact name *(Required)

9. Primary contact phone number *(Required)

10. Primary contact email address *(Required)

11. Number of DOT employee drug/alcohol violations within the past 5 years *(Required)

12. Number of non-regulated employee drug/alcohol violations within the past 5 years *(Required)

13. Do you currently have a DOT random drug and alcohol program in place? *(Required)

Yes

14. Do you currently have a random drug/alcohol program in place for nonregulated employees? *(Required)

Yes

15. What is the frequency of testing for non-regulated employees? *(Required)

N/A

Weekly

Bi-weekly

Monthly

Quarterly

We only test for post accident and reasonable suspicion

16. Methodology of testing (select all that apply) *(Required)

Urine lab based

Instant urine

Oral Fluid lab based

Oral fluid instant

Hair strand

Breath Alcohol

None of the above

Other

17. Do you currently have written DOT and non-regulated drug/alcohol testing policies established? *(Required)

Yes

18. Preferred method of contact *(Required)

Phone

Text

Employees

Name	DOB	Phone	Driver License No.	State License is issued	Actions

There are no Entries.

For corporate(Required)

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