Making a Formal Supervisor Referral for DFWP/DOT Issues

In addition to performance problems, employees can be referred to The Village EAP as a result of violations of Drug Free Workplace Policy (DFWP) or Department of Transportation (DOT) violations, if either of these apply to your company. Procedures for this are listed below.

1. Call The Village EAP before beginning the referral process—1-800-627-8220.
2. Open and print the DFWP/DOT referral form.
3. Complete the top section of this form with the identifying information requested. Include the employee social security number.
4. Indicate if referral represents a violation of your company’s Drug Free Workplace Policy (DFWP) or a violation of DOT rules and regulations. Please forward a copy of your DFWP.
5. For both DFWP and DOT violations, indicate if there was a positive drug screen, the date of the positive screen, and the substance detected in the drug screen. If the violation did not involve a drug screen, please describe the nature of the violation. It is very important to include information regarding the employee’s current status with the company. Indicate the conditions for continued employment. Village EAP staff can assist you with this.
6. In the section "EMPLOYEE SIGNATURE AND RELEASE OF INFORMATION," have the employee print their name where directed, and sign and date the form in the appropriate blanks. Be sure to explain this section of the form to the employee, i.e., their signature indicates both their understanding of the situation and allows for the release of information. Information to be released is described in this section of the form. The items listed are the only information which will be released by us back to the employer. No personal information obtained during assessment or treatment will be released.
7. Sign the form in the space designated for “Supervisor Signature.” This provides confirmation that you have explained the relevant policies and procedures, and that the employee has indicated his/her understanding.
8. Fax the completed form to The Village EAP for processing. Our fax number is (701) 451-5058.
9. We will notify you in writing about the status of the referral and the employee’s compliance with treatment recommendations. No other information will be released to you without the employee’s written consent.