Shy Bladder After Hours Billing Protocol

Shy Bladders/Quantity Not Sufficient Protocol (QNS). DOT Rule 49 CRF Part 40 Section 40.65
In the event of a shy bladder, the DOT drug testing protocol requires the donor to stay and try to provide a sufficient specimen within a 3-hour time frame.
If this wait time extends past the closing time for Drug Free Business's normal business hours, a flat fee of $150 will be billed for after-hours collections. This will cover a wait-time for our collectors of up to 3 hours after closing. (currently 3 p.m.) This will apply to NON-DOT as well as DOT collections performed at our Bothell, WA collection site.
Company Name*
Billing Address*
Street Address Address Line 2 City State ZIP Code
Billing Contact Name:
First Last
Billing Phone
Billing Contact Email
Name of Designated Employer Representative (DER):*
Person responsible for your drug testing program
DER Phone
DER fax:
Needed so we can fax back Employer's copy of custody & control form
DER's Email
By completing and submitting this form your company hereby acknowledges responsibility for payment in full.
Name of person submitting this form*
First Last
Comments
This field is for validation purposes and should be left unchanged.