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Riverside USD |  E  4212.41  Personnel

Employee Drug Testing   

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Inland Empire Occupational Medicine

3579 Arlington Avenue, Suite 300

Riverside, CA 92505

Tel 951-341-9333

Fax 951-341-9330

Patient Name: ___________________________ Position applied for: _________________

Today's Date: ___________________________ Time Received by IEOM ________ am/pm

Employer: Riverside Unified School District Authorized by: _____

Human Resources Print Name

3380 Fourteenth Street

Riverside, CA 92501

951-788-7135 ________________________


SERVICES REQUESTED (Check all boxes that apply):

Please call for an appointment at 951-341-9333

__ Drug Screen - Non-DOT

__ Random Drug Screen - DOT

__ Functional Capacity Exam (FCE)

(Please wear work-out clothing and tennis shoes)

__ Pre-employment physical

__ T.B. Skin Test

BILLING: __ Applicant/Employee (Must pay at time of service.)

I understand that it is my responsibility to pay for the required drug test, functional capacity exam, and physical examination and/or TB test.

Applicant's Signature: ________________________Date: ______________

__ RUSD (Human Resources)

__ RUSD (Nutrition Services Dept.)

__ RUSD (Risk Management)

__ RUSD (Special Education)

__ I understand that my employment with Riverside Unified School District is contingent upon me taking and passing the mandatory drug test and/or physical examination (as well as passing the fingerprint background check). The drug test requirement must be fulfilled within 48 hours of the offer of employment as stated below.

Tentative offer of employment made on: ________________(Not a start date with the District)

Applicant's Signature:__________________________________Date:__________________

White Original ----Clinic Yellow--Employer


version: July 17, 2018 Riverside, California