TREATMENT AUTHORIZATION FORM
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 ________________________
Title
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
Exhibit RIVERSIDE UNIFIED SCHOOL DISTRICT
version: July 17, 2018 Riverside, California