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BCABEAP Alcohol & Drugs Policy Violation Referral Form

For assistance, please contact Sara Scott (905-684-2244) at the BCA. Please fill in the form below.

Fields displayed in bold text are required.

Referring Organization Contact Information

Date of Incident:
First Name of Worker:
Last Name of Worker:
Worker Home Phone:
Worker Cell Phone:
Worker Home Address:
RSAP ID:
Legal Name of Organization
(please avoid abbreviations):
Name of individual making referral:
Position:
Email 1:
Email 2:
Email 3:
Phone Number:

Project / Dispatch Information

Name of Project:
Name of contractor employing or who intended to employ individual referred (if different from referring organization):
Date of Dispatch:
The work in question is:
Construction
Maintenance
Fabrication
Other

If "other", please explain:
Is the contractor making contributions and sending data to the Boilermaker Contractors of Alberta Employee Assistance Program (BCABEAP)?
Yes
No
Unsure
Is the contractor making contributions to the Rapid Site Access Program (RSAP) for the work in question?
Yes
No
Unsure

Was the testing performed in accordance with the Canadian Model Alcohol and Drug Work Rule? (i.e. breath alcohol with confirmation plus 5 panel urine-based laboratory analysis with MRO review of non-negative results)

Yes
No
NA

This referral is in respect to:

Site access test
Site access - Site transfer
Site access - Name hire
Post incident
Reasonable cause
Follow-up test
Camp Infraction
Travel Infraction
Possess or offer for sale
Random (Owner Requirement)

Reason for violation:

Positive alcohol & drug test
Refusal to test
Evidence of substitution or tampering
Failure to provide adequate sample
Not applicable - Self referral
Not applicable - Camp or Travel Infraction

Self disclosure?

Yes
No

Please attach copy of the Custody Control Form, Dispatch Slip & A&D Test Results if applicable & available

If submitting multiple documents, please combine into a single PDF file before uploading. Files in .zip format are not permissible. Maximum file size: 1MB.

Contractor / Union: additional comments relevant to the case management of this file:

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