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Implementation Guidelines - Federal Transit Administration - U.S. ...

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_____________________________<br />

________________________<br />

Employee Signature Date<br />

_____________________________<br />

Print Name<br />

_____________________________<br />

________________________<br />

Agency Representative Signature Date<br />

_____________________________<br />

Print Name<br />

SUBSTANCE ABUSE PROFESSIONAL REFERRAL<br />

I acknowledge that I have received a referral to a Substance Abuse Professional as required by<br />

FTA regulations and as adopted by this agency in ____________________________________<br />

(Name of System)<br />

________________________ Substance Abuse Policy dated____________________________<br />

The cost of this service will be paid by:____________________________________________<br />

Substance Abuse Professional referral:<br />

Name _______________________________<br />

Address ______________________________<br />

City/State _____________________________<br />

Phone ________________________________<br />

Alternate Substance Abuse Professional referral:<br />

Name _________________________________<br />

Address _______________________________<br />

City/State ______________________________<br />

Phone _________________________________<br />

I have received a copy of this referral:<br />

Chapter 9. Substance Abuse<br />

Professionals, Rehabilitation, and<br />

Treatment<br />

9-13 August 2002

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