C/TPA - Corporate Quote Request

Type Industry:
Company Name:

Contact: Contact Title:
Telephone:
Cell phone:
Facsimile:
Email:

 

Type of Program:
Scope of Program:  
  Number States:
  Number Locations:
  Number Providers:
  Number Employees:


Test Pool Size Per Type:
  Non-Regulated or State-Regulated Program:
  DOT Look-alike:
  Drug Panels Tested:


  Rregulated Program:
  DOT Agency Annual Random Testing Rate Random Test Pool
   Drug Alcohol  
  FAA 25% 10%
  FMCSA 50% 10%
  FRA 25% 10%
  FTA 50% 10%
  PHMSA 25% N/A
  USCG 50% N/A


Volume of All Categories of Drug Testing(estimated):
  Regulated: Per Year:   Per Month:
  Non-Regulated: Per Year:   Per Month:


On-Site Collections:
  Frequency:


 
Supervisor Training:
Program Policy :
Laboratory Preference :
Other Needs: