immunization and certification requirements document

Transcription

Distance Degrees and Programs Office
Pharmacy & Pharmaceutical Sciences Bldg.
12850 E. Montview Blvd., Room V20-1116
Aurora, CO 80045
Mail Stop (C238-V20)
303-724-3582 office
303-724-3732 fax
[email protected]
[email protected]
www.ucdenver.edu/pharmacy
Immunization and Certification Requirements
The University of Colorado mandates all students in health care professions whose training includes
clinical settings and patient contact complete standard immunization requirements. Students enrolled
in the North American-Trained PharmD (NTPD) Program and International Trained PharmD (ITPD)
Program will have assignments throughout their didactic coursework and rotations which will require
direct patient interaction. As such, all students will complete immunization and certification
requirements as listed in this document and it the student’s responsibility to maintain the
requirements throughout their enrollment in the program. Failure to adhere to the deadlines listed
below will result in a hold placed on the student’s account, preventing the student from registering in
future courses, planning and/or beginning rotations.


Upon Admission – See Pages 2-3
o
ITPD Students – Students will complete all the requirements before starting
their Live Summer Session I.
o
NTPD Students – Students admitted for the 2017 spring semester will have six
weeks from the start of the fall semester to submit their immunization and
certification requirements. Therefore, the deadline for students admitted for the
2017 spring semester is Wednesday, March 1. Students who do not meet this
deadline will have an administrative hold placed on their account. The hold
prevents students registering for courses in an upcoming semester, and the hold
will be removed once the DDP Office receives the immunization and certification
requirements.
Prior to Rotations – Introductory and Advance Pharmacy Practice Experiences
(IPPEs and APPEs) – See Pages 2-6
o
All Students – All requirements must be updated the semester prior to the rotation start
date and remain current throughout the remainder of the rotation. Saturday, October 1
is the deadline for students to update to their requirements if the student is starting a
rotation during the 2017 spring semester. Wednesday, March 1 is the deadline for
students to update to their requirements if the students is starting a rotation during the
2017 summer semester.
Students will collect and upload the requirements, except for the criminal background check, into
E*Value. Please contact the Distance Degrees and Programs Office ([email protected] for
NTPD students or [email protected] for ITPD students) if you cannot access your E*Value
account.
Immunization and Certification Requirements - Complete at Admission and Prior to Rotations


Criminal Background Check
o Students Residing in the United States – You’ll fill out and return to the DDP
Office the Background Check Release form and the Address Verification form.
o
Students Residing in Canada – You’ll fill out and return to the DDP Office the
Background Check Release form, the Canadian Form, and the Address Verification
form.
o
Students Residing outside the United States and Canada – You’ll fill out and
return to the DDP Office the Background Check Release form and the Address
Verification form.
o
The DDP Office will contact you to confirm the cost of the background check. You
may view current costs as listed on the tuition and fees website page.
o
Note: Students with any arrest records or convictions, please follow the Student
Ethics and Conduct Code policy and submit the paperwork underneath Appendix C.
Immunizations
o Complete and return the attached SOP Student Immunization Form signed by you
and your medical provider.
o
In addition to the signed form, you’ll submit the supporting documentation for any lab
results, such as titers done in lieu of immunization, to meet the requirements.
Ministry of health letters are not considered acceptable forms of documentation
unless provided in addition to the signed immunization form.
o
We accept serum titer results indicating immunity in lieu of being revaccinated if
childhood vaccination records are not readily available.
o
NOTE: Please read the specific instructions on page two of the SOP Student
Immunization Form for:
 Measles, Mumps, Rubella (MMR)
 Hepatitis B
 Polio
 Tuberculin Skin Test
 Varicella

HIPAA and Bloodborne Pathogens (BBP) Exams
HIPAA and Security – Retake annually
HIPAA and Privacy – Retake annually
Bloodborne Pathogens (BBP) – Retake annually
o
To complete your HIPAA and BBP requirements, you will utilize the online training
offered by Pharmacist’s Letter and by following the steps listed below:
 You will create a student account with Pharmacist’s Letter to complete the
online training.
 If you already have a separate Pharmacist’s Letter account, you will need to
set up a student account in order for the Skaggs School of Pharmacy and
Pharmaceutical Sciences to track your progress as a student.
 You’ll create your student account at www.studentpharmacists.com.
 When creating your account, list your first and last name on record with the
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


Skaggs School of Pharmacy and Pharmaceutical Sciences and your
UCDenver email address and anticipated graduation date.
After you create your account, Pharmacist’s Letter will connect you to the
online training courses and corresponding exams within 24-48 hours. You
will need to check your account again to see if you are connected to the
courses and exams.
Once you complete the courses and receive a 90% or above on each of the
exams, you’ll print out a certificate confirming your passing grade and upload
the certificate into E*Value.
If you have problems accessing the website or creating your account, you’ll
contact Pharmacist’s Letter at [email protected].
BLS / CPR
o All students must have a current and/or renewed certification, and students will
provide a copy of their current BLS/CPR (basic life support) or BCLS (basic cardiac
life support) for adults, infant and child certification card.
o
Students do not need to take an ACLS course, only a BLS course. However, the
DDP Office will accept ACLS training certification.
o
Students must be certified through live onsite training course specific for healthcare
professionals. Most courses include AED training. Online/cognitive training
courses are not accepted.
o
Students may find courses offered through American/Canadian Heart Association or
American/Canadian Red Cross websites. Please note: some rotation sites will
require American Heart Association CPR BLS courses to have been completed.

CU Student Orientation Information
o The Student Orientation Materials website page provides students with quick links to
the available resources. Students will read through the information on this website
page, and fill out the form that is located on the bottom of the website page.

Declaration Statement
o The declaration statement confirms your agreement to follow University of Colorado
Skaggs School of Pharmacy and Pharmaceutical Sciences and the Distance
Degrees and Programs policies and procedures. You’ll sign and upload the attached
Declaration Statement form into E*Value.

FERPA Form
o The FERPA form provides the Office of Experiential Programs, who coordinates the
IPPE and APPE rotation site placement, and the DDP Office the permission to
provide a copy of your immunization records, background check, and drug test to the
rotation site. You’ll sign and upload the attached FERPA form into E*Value.

Professional Liability Insurance (Canadian Students Only)
o Canadian students must provide a copy of their Professional Liability Insurance rider
if residing in Canada.

Cultural Competency Training – The cultural competency training discusses cultural
awareness, and the training is completed by students and preceptors. To access the training
materials, follow these steps:
o Log into E*Value and click on “Evaluations.”
o Then, click on “To Be Completed,” and you should see a requirement called “Training
– Cultural Competency.”
3
o
Click on “Edit Evaluation” to review the directions on the training and linked materials
within E*Value before completing the evaluation.
Additional Immunization and Certification Requirements – Complete Prior to both IPPE and
APPE Rotations

Intern License
o Students completing rotations in Colorado – See instructions below within the
Immunization and Certification Requirements for Colorado Rotations section.
Students should complete this 4-6 months prior to starting the rotation.
o
Students completing rotations in states other than in Colorado – The state
where you are completing your rotation may require you to have an intern license.
You are responsible for checking and applying for an intern license, if needed. This
should be completed 4-6 months prior to starting the rotation. Please refer to the
NABP website learn about each state’s application process:
http://www.nabp.net/boards-of-pharmacy/.

F-1 Visa
o A F-1 visa (educational visa) is required for students traveling from outside of United
States to complete a rotation in any US-based rotation site. The University of
Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences will sponsor the
F-1 visa while completing a rotation at any US-based site. We will contact you well in
advance of the rotation start date to begin processing the paperwork for the F-1 visa.
An updated CV or resume is required to complete the paperwork.

Immunization Training (submit prior to APPE rotations only)
o Rotation sites are requiring students to administer immunizations during their
rotation. Students will complete the immunization training prior to starting Advanced
Pharmacy Practice Experiences (APPE). Instructions on how to complete this
requirement are located in the Immunization Training policy.

Rotation Sites in the Alberta Canadian Province – Alberta SPA Agreement
o Students planning a rotation in the Alberta Canadian province will complete the
Alberta SPA agreement paperwork, which relates to liability while on rotation. This
paperwork needs to be signed by the University of Colorado Skaggs School of
Pharmacy and Pharmaceutical Sciences and the Alberta Health Services. Students
will receive this paperwork during the rotation planning process.

Additional Site Requirements
o A rotation site may request additional requirements which must be submitted prior to
the start of the rotation, and the DDP Office will notify you of any additional site
requirements as provided by the rotation site.
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Additional Immunization and Certification Requirements for Colorado Rotations
Students who will complete either their IPPE and/or APPE rotations in Colorado will also complete
these requirements. Unless otherwise noted below, these requirements are due by the deadline listed
on page one of this document.

Intern License
o Students who do not have a registered, Colorado RPh license must have a Colorado
intern license prior to starting any Colorado rotation(s).
o
Students may apply online at:
https://www.colorado.gov/pacific/dora/Pharmacy_Applications
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
o
Students will need to apply for their intern license four to six months in advance
of starting their rotation. Any Canadians or ex-US citizens must also complete Social
Security Number Affidavit. Scroll to this below.
o
Please Note: Students need to submit the online portion following the directions as
listed on the DORA website. Students will send an email to the DDP Office after
submitting the online application. Then, the DDP Office will send a separate letter to
verify if the student is in good standing.
o
Colorado intern licenses will expire on October 31, 2017. Students who received
a Colorado intern license for a rotation completed earlier in the year will need to
renew the Colorado intern license for any rotation that begins on or after November
1, 2017.
Drug Test
o Students need to complete the Drug test the Wednesday prior to the start of
their Colorado rotation.
o
Review the attached drug test facilities form: Drug Test Facilities-CO Rotation. All of
the facilities listed on this form accept walk-in appointments. In order to complete the
drug test, students will pick up the drug test form from the DDP Office at the
University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences
and bring the form to the drug test site.
o
The cost of the drug test is $65 USD check or money order made payable to the
University of Colorado Denver. The test must be paid for and the results from the
drug test submitted to the DDP Office prior to the rotation start date.
Name Badge
o Students need to obtain their name badge the Wednesday prior to the start of
their Colorado rotation.
o

Students will need a special UC Denver photo ID for all Colorado rotations. We will
direct you to the coordinator via e-mail to have the badge made before the rotation
starts. The authorization for the photo ID is only good for 30 days. Please bring
Government ID when obtaining your name badge.
Name Tag
o The name tag is different from the name badge, and the Colorado State Board of
Pharmacy and most sites require that students wear a name tag on their lab coat.
5
o
The name tag can be purchased at the Anschutz Medical Campus bookstore for
under $10. Students should contact the Anschutz Medical Campus bookstore
three weeks prior to the start of their rotation to make an appointment on the
Wednesday before their rotation start date to obtain their name tag.
Anschutz Medical Campus Bookstore: Phone: 303-724-2665
Hours: Monday – Friday 8:00am – 5:00pm MST
o
The Colorado State Board of Pharmacy requires the information listed below on each
name tag:
 CU Logo
 Student’s First and Last Name
 The phrase “Intern Pharmacist”
 Student’s License Number
o
The name tag should look like this:
CU Logo
Student’s First and Last Name
The phrase Intern Pharmacist here
Intern license number OR pharmacy license number here
o

Most rotation sites still require a name tag as a way to distinguish their employees
from the students. Students should check with their preceptor to determine their
site’s current requirements prior to ordering their name tag from the Anschutz
Medical Campus Bookstore.
White Lab Coat
o Students will need to wear a white lab coat while on rotation. The length of the lab
coat will be the short “student” style. Students may purchase a lab coat at the
Anschutz Medical Campus Bookstore the Wednesday prior to starting the
rotation.
Anschutz Medical Campus Bookstore: Phone: 303-724-2665
Hours: Monday – Friday 8:00am – 5:00pm MST
Attachments
SOP Student Immunization Form
Background Check Release Form
Canadian Form
Address Verification Form
FERPA Form
SSN Affidavit Form
Drug Test Facilities – CO Rotation
6
The University of Colorado Denver Anschutz Medical Campus
2016-17 STUDENT IMMUNIZATION CERTIFICATION FORM
Student’s Name
Last,
First
Telephone number
VARICELLA:5
Titer date:
If needed, Date of 1st vaccine:
Date of 2nd vaccine:
MI
Date of Birth
Street address
City, State, Zip
Degree/Program
TDAP/TD: (circle one) TDAP or TD (must be within the last 10 years.)
Date current TDAP/TD shot received:
/
/ ___
email address
Please submit the completed form in E-Value:
The following immunizations are required of all entering Anschutz Medical Campus Students.
Please see the guidelines listed on the back of this form. Please list the dates, immunizations
or titers were received for the following required immunizations. Should you have any
questions, please email [email protected] or [email protected].
MEASLES, MUMPS, RUBELLA (MMR): 1
Date of 1st Measles Vaccine:
Date of Titer:
Date of 1st Mumps Vaccine:
Date of Titer:
Date of 1st Rubella Vaccine:
Date of Titer:
HEPATITIS B: 2
Hep B: 1st)
and/or Positive Hep B titer)
Date:
Result: Positive
Negative
/
/ ___
/
/ ___
Date of 2nd Measles Vaccine:
Titer Result: Positive
Date of 2nd Mumps Vaccine:
Date of 2nd Rubella Vaccine:
Negative
Negative
Negative
INFLUENZA: Required Seasonal Immunization: (August – October 15)
Date:
/
/ ___
FOR INTERNATIONAL STUDENTS outside Canada and United States: three documented
doses of TD are required. Primary vaccination of previously unvaccinated adults consists of
three doses of adult tetanus-diphtheria toxoid (Td): 4-6 weeks should separate the first and
second dose; the third dose should be administered 6-12 months after the second.
TO BE COMPLETED BY STUDENT - I understand that if my immunizations are not current,
or in progress while in attendance at Anschutz Medical Campus, I may be subject to academic
restrictions and may not be able to complete program/degree requirements. I authorize
Anschutz Medical Campus to disclose this form and/or other information related to my
immunization records to any clinical agency or other such entity in connection with my
placement or participation in clinical internships, practica, affiliations and other programs
related to my course of study.
Student Signature Required: ________________________________________________
2nd)
Contact Number:
3rd)
Titer Result: Titer Result: Positive
POLIO: list the dates of the four-shot childhood series.3
1)
2)
3)
Date Signed:
Negative
TO BE COMPLETED BY CERTIFYING OFFICIAL
Print Name (MD, DO, NP, PA, RN):
4)
Date of polio booster ____________________ Date of Titer ______________________
Title:
Signature of person listed above:
Contact Number:
TUBERCULIN SKIN TEST (within the past year) (Required Mantoux PPD): 4
Date of 1st PPD:
Result Positive
Negative
Date of
2nd
PPD:
Result:
Positive
Negative
TB QuantiFERON Gold
Result
TB T-Spot: _____________________ Result
Positive
Positive
Negative
Negative
2016-17 Student Immunization Certification Form
Revised 5/31/2016
Date Signed:
FOR ANSCHUTZ MEDICAL CAMPUS USE ONLY:
Signature of Campus Official reviewing form:
Date Reviewed:
Page 1 of 2
The University of Colorado Denver Anschutz Medical Campus
2016-17 STUDENT IMMUNIZATION CERTIFICATION FORM
IN THE EVENT OF AN OUTBREAK, EXEMPTED PERSONS WILL BE SUBJECT TO EXCLUSION FROM SCHOOL AND QUARANTINE
Please be advised, by signing a waiver, students may be subject to academic restrictions regarding lab and/or clinical placement and may be unable to complete their program/degree requirements.
Medical Exemption: The physical condition of the above-named person is such that immunization would endanger life or health, or is medically contraindicated due to medical conditions.
Physician’s Name (please print):
Date Signed:
Physician’s Signature:
Contact Number:
Email Address:
Personal Exemption: Parent or guardian of the above-named person or the person himself/herself is an adherent to a personal belief opposed to immunizations.
Relationship and printed name of person signing this form:
Signature of Person Signing this form:
MUMPS, RUBELLA (MMR): The State of Colorado requires 2 MMRs. There
must be documented evidence of shots or serologies. Measles, mumps and rubella require
individual titers; there is no one titer for all three. List either the two dates of the MMRs
received, or the individual titer dates and results. The first MMR must have been received on
or after your first birthday, and there must be at least 28 days between the first and second
MMR. If received prior to your first birthday or there is less than 28 days between the two
MMRs received, you are required to have another MMR or show proof of positive titers.
Date Signed:
Contact Number:
1MEASLES,
2HEPATITIS
4TUBERCULIN
SKIN TEST (Required Mantoux PPD): If you have never had a PPD or your
current PPD is more than one-year-old, you are required to have the two-step method of
testing done. The two-step requires placement of two separate PPD skin tests 7-14 days
apart. All skin tests need to be read within 48-72 hours or another test is required. A single
TB skin test administered after the initial exposure may elicit a negative response. The
immune reaction wanes over time. Giving a second test stimulates the immune system to
respond and may respond positively, indicating that the person was previously infected or
exposed. It is important to differentiate between old and new infection. Please list the dates
and a result for all PPDs received. After the initial two-step PPD, an annual PPD test is
required.
B: If you are in the process of receiving your Hep B immunizations for the first
time, you are required to have the three-shot series and provide the date and result of a
positive titer 1-2 months after the third dose. If you are have completed your Hep B
immunizations more then one year ago, please provide the date vaccines were received or
the titer date and result. (Please note that although you may have previously had your Hep B
immunizations and it may not be required as part of the admissions process to obtain a titer;
however, it may be requested later as some clinical sites now require proof of titers before
students may begin rotations at their facilities). If the 3-dose series is needed, then the doses
should be in a 0, 1, 6-month interval and then a titer done 1-2 months after the last dose. If
immunity is not present, then another 3-dose series must be done followed by another titer. If
after 6 doses no immunity is present, then the student is considered a “non-responder” and no
further testing or immunization is required.
International students who have received the Bacille Calmette‐Guerin Vaccine (BCG) will
submit a physician’s report of a negative chest x‐ray, since the PPD will appear as a false
positive.
3POLIO:
5VARICELLA:
list the dates of the four-shot childhood series. For adults who had 1 or 2 IPV doses,
and no documentation of childhood series, they will need to complete a total of three
injections. Therefore, if they had one, they would need to receive an additional two adult
catch-up injections; if they had 2, they would receive one additional adult catch-up injection.
If the PPD is positive (10mm and above), a negative chest x-ray is required, along with a copy
of the physician’s report. A negative chest x-ray is valid for two years.
Instead of a PPD, it is acceptable to provide negative QuantiFERON gold blood test results.
The QuantiFERON gold blood test will need to be completed annually.
Please list the date of the titer and result. A negative titer requires two
vaccines placed one month apart. Or, if vaccines are required, list the dates they were
received.
International students are required to complete the 3 dose series or positive titer.
2016-17 Student Immunization Certification Form
Revised 5/31/2016
Page 2 of 2
BACKGROUND DISCLOSURE AND AUTHORIZATION
In connection with my application for employment/training or continued employment/training with the University
of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences (SSPPS) or the “University”, and/or my
application for admission or continued enrollment at the University, I understand that the University may request
“consumer reports” and/or “investigative consumer reports” (collectively “Background Check Reports”) on me
pursuant to the Fair Credit Reporting Act.
I understand that the Background Check Reports will be obtained by the University from HireRight, Inc.
(“HireRight”), a consumer reporting agency that is located at 2100 Main Street, Suite 400, Irvine, CA
92614. HireRight can be contacted at 800-400-2761, option 3. Any such Background Check Reports may
contain information bearing on my character, general reputation, personal characteristics, mode of living and
credit standing. The types of information that may be obtained include but are not limited to: credit reports (for
certain employment positions only), social security number verification, criminal records checks, public court
records checks, driving records checks, educational records checks, verification of employment positions held,
workers compensation records, personal and professional references checks, licensing and certification checks,
etc. The information contained in these Background Reports may be obtained by HireRight from private and/or
public record sources, including sources identified by me in my job and/or enrollment application or through
interviews or correspondence with my past or present coworkers, neighbors, friends, associates, current or former
employers, educational institutions or other acquaintances.
The nature and scope of any investigative consumer reports that may be requested is explained above. You are
nonetheless entitled to request more information about the nature and scope of such reports by submitting a
written request to the University at: University of Colorado Skaggs School of Pharmacy and Pharmaceutical
Sciences Office, 12850 E. Montview Blvd, Mail Stop C238, Suite 1116, Denver, Colorado, 80045.
Information about HireRight’ s privacy
www.hireright.com/Privacy-Policy.aspx.
practices
is
available
at
I acknowledge that the University has with this form provided me a summary of my rights under the Fair
Credit Reporting Act in a form issued by the Federal Trade Commission and entitled “Summary of Your Rights
under the Fair Credit Reporting Act” located at http://www.ftc.gov/bcp/conline/pubs/credit/fcrasummary.pdf.
If I am presently a resident of California, Maine, Minnesota, New York, Oklahoma, or Washington State, I have
reviewed the additional state law disclosure information attached.
Costs associated with the required background check are the responsibility of the student and/or
employee. Background checks are completed based upon residencies within the past seven years. Due to the
variable nature of an individual student’s residencies, the resulting background check cost will vary. The Distance
Degrees and Programs Office (DDP) Office will relay final background check costs to each student on an
individual basis via email. Upon receipt, payment in full in U.S. dollars must be submitted directly to the DDP
Office at 12850 E Montview Blvd, Mail Stop C238, Aurora CO 80045.
Please send this document to:
University of Colorado School of Pharmacy
12850 E. Montview Blvd, Mail Stop C238, Suite 1116, Denver, Colorado, 80045.
By my signature below, I expressly authorize and instruct HireRight to perform and release to the University a
Background Check Report(s) on me at the request of the University in conjunction with my job and/or enrollment
application. I understand that if the University hires and/or admits me, my consent will apply throughout
my employment and/or enrollment to the extent permitted by law, unless I revoke or cancel my consent by sending
a signed letter or statement to the University and to HireRight.
I understand that, to the extent allowed by law, information contained in my job and/or enrollment application or
otherwise disclosed by me before, during or after my employment and/or enrollment, if any, may be utilized for
the purpose of obtaining Background Check Reports.
I also understand that in the event I am applying for admission or continued admission to the university, (1)
successfully completing the university’s background investigation is a prerequisite to clinical rotations at
hospitals/other Affiliates, AND (2) Clinical rotations are a required component of my degree program and that if
the results of this background Investigation render me unable to complete clinical rotations, the university may
not permit me to enter/continue in its educational program.
By my signature below, I also authorize the disclosure to HireRight of information concerning my employment
history, earning history, education, credit history, credit capacity and credit standing, motor vehicle history and
standing, criminal history, and all other information HireRight deems pertinent by any individual, corporation or
other private or public entity, including without limitation the following: employers; learning institutions;
including colleges and universities; law enforcement agencies; federal, state and local courts; the military;
credit bureaus; motor vehicle records agencies; and other applicable sources.
I further acknowledge that a telephone facsimile (FAX) or photographic copy of this release will be as valid as
the original.
I understand that any false statements or deliberate omissions on this document or any other document I
file with University may be grounds for disqualification from employment/admission or, if discovered after
I have been admitted or employment begins, could result in discipline up to and including my termination
of employment/enrollment.
For residents of California, Maine, Minnesota, New York, Oklahoma, and Washington State only: You will
be provided with a free copy of any consumer reports or investigative consumer reports on you if you check the box
below.
□ I wish to receive a free copy of any Background Check Report on me that is requested.
Last Name
First
_______Middle
___________
Program Name____________________________________________________________________________
Social Security #
Date of Birth (for ID purposes only)
Present Address
City/State/Zip
Signature _________________________________________________Date_____________________________
Please respond to the following questions in the most complete and accurate manner possible. Do not identify
convictions for which the criminal record has been expunged or sealed by the court. For purposes of the
following questions, a “conviction” means guilty verdict, guilty plea or Nolo Contendere (“No Contest”) plea.
Have you ever been convicted of a felony?
No______
Yes______
If yes, please give details including date, state/county court in which conviction was entered, type of felony, etc.
_______________________________________________________________________________________
Have you ever been convicted of a misdemeanor? No______
Yes______
If yes, please give details including date, state/county court in which conviction was entered, type of misdemeanor,
etc.________________________________________________________________________________________
I have read the Background Investigation Consent and Release form and understand my rights.
ADDITIONAL STATE LAW NOTICES
If you currently live in the state of California, New York, Oklahoma, Minnesota, Maine, or Washington State, please
review these additional notices.
CALIFORNIA: Under section 1786.22 of the California Civil Code, you may view the file maintained on you by HireRight during normal business hours. You may also obtain a copy of this file, upon submitting proper identification and paying the costs of duplication services, by appearing at HireRight’ s offices in person, during normal business hours and on reasonable notice, or by mail. You may also receive a summary of the file by telephone, upon submitting proper identification. HireRight has trained personnel available to explain your file to you, including any coded information. If you appear in person, you may be accompanied by one other person, provided that person furnishes proper identification. NEW YORK, OKLAHOMA, and MINNESOTA: You have the right, upon request, to be informed of whether or
not a consumer report was requested. If a consumer report is requested, you will be provided with the name and
address of the consumer reporting agency furnishing the report. You may inspect and receive a copy of the report by
contacting that agency.
MAINE: You have the right, upon request, to be informed of whether an investigative consumer report was requested,
and if one was requested, the name and address of the consumer reporting agency furnishing the report. You may
request and receive from the Company, within five business days of our receipt of your request, the name, address and
telephone number of the nearest unit designated to handle inquiries for the consumer reporting agency issuing an
investigative consumer report concerning you. You also have the right, under Maine law, to request and promptly
receive from all such agencies copies of any such reports.
WASHINGTON STATE: If we request an investigative consumer report, you have the right, upon written request
made within a reasonable period of time after your receipt of this disclosure, to receive from us a complete and accurate
disclosure of the nature and scope of the investigation we requested. You also have the right to request from the
consumer reporting written summary of your rights and remedies under the Washington Fair Credit Reporting Act.
Rev. UCD SSPPS 8/2015
Document Type
Type de Document
International Release Form
Formulaire d’Autorisation International
Your Name
Votre nom
Canada – CPIC Compliant General Consent
Canada – CPIC- Consentement Général Conforme
If you have not already submitted this form to your employer, please complete the requirements in the table below and email all documents to
[email protected] or fax it to (877) 797-3442 in the US and Canada or +1 (949) 224-6064 if outside of the US and Canada. If you
have questions, please email [email protected]. If returning this form by email, please attach scanned images that are less than
15MB.
Si vous n’avez pas déjà fait parvenir ce formulaire à votre employeur, prière de compléter les champs obligatoires dans le tableau ci-dessous et faire
parvenir tous les documents à [email protected] ou par télécopieur au (877) 797-3442 aux États-Unis et du Canada ou au +1 (949)
224-6064 à l’extérieur des États-Unis et du Canada. Pour toute question, prière d’envoyer un courriel à [email protected]. Si vous
retourner ce formulaire par courriel, veuillez attacher des images numériques de moins de 15MB au total.
Below are the requirements set forth by the CPIC (Canadian Police Information Centre) to request a Criminal Records Check. Please make
sure that all information and documents listed in this checklist are included and legible before submitting. All incomplete and illegible requests
will be returned.
Vous trouverez ci-dessous les exigences stipulées par le Centre d’Information de la Police Canadienne (IPC) pour faire une demande de
recherche et divulgation du casier judiciaire. Veuillez vous assurer que toute l’information et les documents apparaissant sur la liste ci-dessous
sont inclus et lisibles avant de soumettre la demande. Toute demande incomplète ou illisible sera retournée.
Completed Cover
Sheet

Include Applicant Name
Page Couverture

Incluant le nom du candidat
Completed CPIC
Form


All sections of the form must be completed.
The “Identity Verification for CPIC Search/es” section of the CPIC Form must be signed by either an authorized
representative of the employer (the organization requesting the background report) or a notary public.

Toutes les sections du formulaire doivent être complétées
 La section “Vérification De L'identité Pour Recherche(S) CPIC” du formulaire de l’IPC doit être signé soit par un
représentant autorisé de l’employeur (l’organisation qui fait la demande de vérification de casier judiciaire) ou par
un notaire public.
Formulaire de l’IPC
complété
Copies of 2
forms of ID
1.Acceptable Identification: (Must be valid and not expired)
 Driver’s License (issued by Canadian Province or Territory)
 Foreign Driver’s License
 Canadian Passport
 Foreign Passport
 Canadian Citizenship Card
 Permanent Resident (PR) Card
 Certificate of Indian Status
 Firearms Acquisition Certificate (FAC)
 Canadian National Institute of the Blind (CNIB) Identification Card
 Federal, provincial, or municipal employee identification card
 Military Family Identification Card (MFID)
 Provincial ID Card
 International Student Identity Card
2.Acceptable as a second piece of ID, in support of the above piece:
 Photo healthcare card (Ontario & Quebec ONLY)
 Birth Certificate
 Baptismal Certificate
 Hunting/Fishing/Boating Licence
 LCBO Card
 Hospital Card / Blood Donor Card
 Immigration Papers
 Student Identity Card (Canadian & International)
 Addressed mail from Revenue Canada indicating the subject’s name, date of birth, and current address (Note Black out Social Insurance
Number prior to forwarding)
 Other ID cards issued by Provincial Ministries
 Copy of an recent pay stub / Copy of an Income Tax stub
 Provincial Health Cards
The information, photos and signatures on both ID’s must be viewed and verified in- person by either an authorized representative of the employer
or notary public. (Please see the identification section of the CPIC form.)
Copies de 2
pièces
d’identités
1.













Pièces d’identité acceptables: (Doit être valide et non expiré)
Permis de conduire (émis par une province ou un territoire canadien)
Permis de conduire étranger
Passeport canadien
Passeport étranger
Carte de citoyenneté canadienne
Carte de résidence permanente (RP)
Certificat du statut d’Indien
Autorisation d’acquisition d’armes à feu (AAAF)
Carte d’identité de l’Institut national canadien pour les aveugles (INCA)
Carte d’identité d’employé fédéral, provincial ou municipal
Carte d’identité de famille militaire (CIFM)
Carte d’identité d’employé fédéral, provincial ou municipal
Carte d’étudiant international
2. Acceptable en tant que seconde pièce d’identité, accompagné d’une des pièces ci-dessus :
 Carte d'assurance maladie avec Photo (Ontario et Québec seulement)
 Certificat de naissance
 Certificat de Baptême/pêche/navigation
 Carte du LCBO
 Carte d’Hôpital/Carte de donneur de sang
 Documents d’immigration
 Carte d’étudiant (Canadienne et Internationale)
 Envoi postal provenant de Revenu Canada indiquant le nom de l’individu, la date de naissance et l'adresse actuelle
(REMARQUE : Prière de cacher ou noircir le numéro d’assurance sociale avant de le transmettre)
 Autres cartes d’identité émises par les ministères provinciaux
 Copie d’un relevé de paye récent/Copie d’un relevé fiscal
 Carte d’Assurance Maladie émises par une province ou un territoire canadien
L’information, photos et signatures contenues sur les deux pièces d’identité doivent être vues et vérifiées en personne par un représentant
autorisé de l’employeur ou un notaire public. (Voir la section identification du formulaire CPIC).
INFORMED CONSENT FORM (CANADA) Criminal History Searches
CONSENTEMENT ÉCLAIRÉ (CANADA) Recherche d’Antécédents Criminels
PLEASE PRINT (to be completed by applicant)
EN LETTRES D’IMPRIMERIE (à remplir par le candidat)
Surname (Provide previous name/s if applicable):
Nom de famille (Indiquez le ou les noms utilisés avant la candidature le cas échéant):
First Name:
Prénom:
Second Name:
Deuxième nom:
Maiden Name or Other Surnames Used (if applicable):
Nom de jeune fille ou autres noms utilisés (le cas échéant):
Place of Birth (If other than Canada note date of entry to Canada):
Lieu de naissance (si hors du Canada, veuillez aussi noter la date
d’entrée au Canada):
Date of Birth:
Date de naissance:
Current Address/Adresse actuelle:
Number/Numéro:
Street/Rue:
City/Province/Country:
Ville/Province/Pays:
Dates:
Apt/Unit:
App./Unité:
Postal Code:
Code Postal:
(YY-MM-DD)
(AA-MM-JJ)
Sex:
Sexe:
Note: provide previous addresses (last Canadian address) if you did not reside at the above address for more than five years
Remarque : fournissez les adresses précédentes (dernières adresses Canadiennes) si vous ne résidez pas à l’adresse ci-dessus depuis plus de cinq ans
Number/Numéro:
Street/Rue:
Apt/Unit:
App./Unité:
Postal Code:
Code Postal:
Dates:
Number/Numéro:
Street/Rue:
Apt/Unit:
App./Unité:
Postal Code:
Code Postal:
Dates:
AUTHORIZATION FOR REQUESTED SEARCH(ES) (Notary Or Representative Of Employer / Organization To Complete)
AUTORISATION POUR LA/LES RECHERCHE(S) DEMANDÉE(S) (À Remplir Par Le Notaire Ou Représentant De L'employeur / Entreprise)
Acceptable: Driver’s Licence, Birth Certificate, Passport, Permanent Residency Card
Acceptable : permis de conduire, acte de naissance, passeport, carte de résident permanent
NOT Acceptable: SIN Card, Invalid / Expired ID
NON Acceptable : carte d'assurance sociale, pièce d'identité non valable ou expirée
IDENTIFICATION TYPE
TYPE D'IDENTIFICATION
ID NUMBER
Nº D'IDENTIFICATION
1.
IDENTIFICATION TYPE
TYPE D'IDENTIFICATION
ID NUMBER
Nº D'IDENTIFICATION
2.
WITNESSING APPLICANT’S IDENTIFICATION/ TÉMOIN POUR L'IDENTIFICATION DU CANDIDAT
I verify that I have witnessed two pieces of the Applicant’s Identification, one of which is government issued with a photograph and the Applicant’s signature, and attached
a copy of each in a legible format.
J'atteste avoir vérifié deux pièces d'identité du candidat, dont une est délivrée par un gouvernement, sur lesquelles se trouve une photo et la signature du candidat, et joint
une copie de chacune dans un format lisible.
Notary or Employer / Organization Name:
Nom du Notaire ou Employeur / Organisation:
Witness Name:
Nom du témoin:
Witness Signature:
Signature du témoin:
* Witness must be either (i) a Notary, or (ii) a representative of the Company engaging HireRight to conduct the Criminal Record Check on its behalf. The Witness must
verify the Applicant’s identity by comparing the signature on the Applicant’s government issued photo identification to the Applicant’s signature below. The
Witness’s signature above confirms that the Witness has verified the identity of the Applicant by means of two (2) pieces of government identification and has
verified that the signature of the Applicant’s photo identification matches the Applicant’s signature on this Consent Form.
* Le témoin doit être soit (i) un Notaire ou, (ii) un représentant de l’Entreprise désignant HireRight pour effectuer la vérification du Casier Judiciaire en son nom. Le témoin
doit vérifier l’identité du candidat en comparant la signature se trouvant sur la pièce d’identité avec photo et délivrée par un gouvernement à la signature du
candidat ci-dessous. La signature du témoin ci-dessus confirme que le témoin a vérifié l’identité du candidat au moyen de deux (2) pièces d’identité délivrées
par un gouvernement et que la signature du candidat sur la pièce avec photo correspond à la signature du candidat sur ce formulaire de consentement.
HireRight Canada - Informed Consent – Criminal Record Searches – Rev 04/2014
HireRight Canada - Consentement éclairé - Recherche d’Antécédents Criminels – Rev 04/2014
Page 1 of 2
INFORMED CONSENT FORM (CANADA) Criminal History Searches
CONSENTEMENT ÉCLAIRÉ (CANADA) Recherche d’Antécédents Criminels
AUTHORIZATION AND WAIVER TO RELEASE CRIMINAL RECORD AND CRIMINAL/POLICE INFORMATION
I am aware and give consent to the release of a Criminal Record or any Criminal/Police Information by the processing Police Service to Canadian Employment Screening
to disseminate and transmit the results electronically (or in hard copy) to HireRight, for further dissemination and transmission to the employer/prospective employer
designated below.
I hereby release and forever discharge all members and employees of the processing Police Service from any and all actions, claims and demands for damages, loss or
injury howsoever which may hereafter be sustained by myself, as a result of the disclosure of information by the processing Police Service to Canadian Employment
Screening and HireRight.
AUTORISATION DE DIVULGATION DU CASIER JUDICIAIRE ET AUTRE INFORMATION POLICIERE ET QUITTANCE
En connaissance de cause, je consens à la divulgation d'un casier judiciaire ou de tout renseignement d'ordre criminel ou policière par les services de police traitant la
demande à Canadian Employment Screening aux fins de diffusion et transmission électronique (ou sur papier) des résultats à HireRight, pour des fins de diffusion et
transmission subséquente à mon employeur/ employeur potentiel.
Par la présente, je tiens indemne et libère à jamais tous membres et employés des services de police ayant effectués la vérification, relativement à toute actions,
réclamations ou demande d’indemnité pour tous dommages, pertes, dommages corporels à ma personne, occasionnés par la divulgation d’information par les services
de police à Canadian Employment Screening et HireRight.
REASON FOR THE CONSENT/ RAISON DU CONSENTEMENT
Description of Position
Description du poste
Name of Employer / Organization Requiring the Criminal Record Verification [“COMPANY”]
Nom de l'employeur/ Organisation demandant la recherche du casier judiciaire [“COMPAGNIE”]
SEARCH AUTHORIZATION AND DECLARATION
By signing this form, I certify that the information set out by me in this application is true and correct to the best of my ability.
I understand that a search of the RCMP National Repository of Criminal Records and CPIC Investigative Data Bank will be conducted based on the name(s) and date of
birth I have provided above.
By my signature below, I authorize the processing Police Service to conduct a name-based criminal record verification on me and to disclose criminal record information
pertaining to me to COMPANY through Canadian Employment Screening and HireRight, which are obtaining information about me on behalf of COMPANY. I consent to
the storage or dissemination of such information to or at a location outside of Canada by or to Canadian Employment Screening, HireRight and COMPANY.
I understand that the information is collected and disclosed according to applicable Canadian privacy laws, including but not limited to the Federal Privacy Act, MFIPPA,
PIPA, PIPEDA and Quebec Privacy Laws, each to the extent applicable. It may also be subjected to applicable International laws, i.e. U.S. Patriot Act.
AUTORISATION DE RECHERCHE ET DÉCLARATION
En signant ce formulaire, j'atteste que l’information que j’ai fournie dans ce formulaire est exacte et véridique au meilleur de mes connaissances.
Je comprends qu'une recherche auprès du Dépôt National des Casiers Judiciaires tenue par la GRC et de la Banque de Données d’Enquête CIPC sera effectuée d’après
le(s) nom(s) et date de naissance que j'ai fournie ci-dessus.
Par ma signature ci-dessous, j’autorise les Service de Police traitant la demande à effectuer une vérification nominale de mon potentiel casier judiciaire et à divulguer ces
informations relatives au Casier Judiciaire me concernant à COMPAGNIE par l’intermédiaire de Canadian Employment Screening et HireRight, lesquels obtiennent de
l’information me concernant de la part de COMPAGNIE. Je consens à l’enregistrement ou diffusion de cette information aux bureaux situés hors du Canada par ou à
Canadian Employment Screening, HireRight et COMPAGNIE.
Je comprends que les renseignements sont recueillis et divulgués conformément à la Loi sur la protection des renseignements personnels applicable, incluant mais non
limitée à LAIMPVP, la LPRPDE et les lois québécoises relatives à la protection des renseignements personnels, chacune dans la mesure applicable. Ils peuvent
également être assujettis aux lois internationales applicables, par exemple la Patriot Act aux États-Unis.
Date
Signature of Applicant / Signature du candidat
HireRight Canada - Informed Consent – Criminal Record Searches – Rev 04/2014
HireRight Canada - Consentement éclairé - Recherche d’Antécédents Criminels – Rev 04/2014
Page 2 of 2
Address Verification Form
University of Colorado
Skaggs School of Pharmacy and Pharmaceutical Sciences
Distance Degrees and Programs
International-Trained PharmD and
North American-Trained PharmD
Programs
In addition to the Background Check Release Form, Hire Right, the university’s provider of background check services will require a list of home addresses from the past seven years. Please list all places where you have lived over the past seven years beginning with your current address. Name:
Email Address:
Passport Number: __________________________Country of Passport:________________ Current Address Street Address:
City:
Country:
From Date:
Building/House # _________
State:_
_Mail Code:
To Date:
Previous Address(es)– using the above format, please list all addresses over the past seven years. Please use additional pages if necessary. Distance Degrees and Programs Office
North American-Trained PharmD Program
Aurora, CO 80045
303-724-3582 office
303-724-3732 fax
[email protected]
[email protected]
Declaration
I understand there are policies and procedures designed to assist and provide guidance to students
completing within the North American-Trained PharmD (NTPD) Program and the InternationalTrained PharmD (ITPD) didactic and experiential training requirements. These policies and
procedures are intended to optimize the learning experience and ensure the on-going success of
both Programs. I have reviewed a copy of these policies and procedures located on the following
website pages:
1.) Policies and Procedures – This page defines program and the University of Colorado Skaggs
School of Pharmacy and Pharmaceutical Sciences specific policies and procedures,
including the Student Bulletin, Student Advancement and Appeals policy, and Student Ethics
and Conduct Code.
2.) Experiential Training – This page links to specific policies and procedures pertaining to the
experiential training requirements for both programs.
As a student of the University of Colorado Skaggs School of Pharmacy and Pharmaceutical
Sciences, I will abide by the policies and procedures pertaining to the Distance Degrees and
Programs and the School. I understand the Distance Degrees and Programs Office and the School
reserves the right to modify the policies and procedures at any time.
Students and preceptors will be notified of any changes in the documents. Questions about the
policies and procedures will be directed to the Academic and Experiential Program Coordinator.
Your signature below indicates you have received, read and understand the Distance Degrees and
Programs’ policies and procedures.
_________________________
Student Signature
_________________________
Printed Name
_________________________
Date
_________________________
Student ID Number
Last Updated: June 20, 2014
Distance Degrees and Programs Office
Aurora, CO 80045
303-724-3582 office
303-724-3732 fax
[email protected]
[email protected]
I understand that at the post-secondary level, pursuant to the Family Educational Rights and
Privacy Act of 1974 (FERPA) and University policy, no individual person possesses the inherent right
to inspect my education records, including my immunization records, background check and drug
test results. However, education records may be released with my written consent.
By signing this form, I,______________________ give my permission for the Distance Degrees and
Programs Office and Office of Experiential Programs at the University of Colorado Skaggs School of
Pharmacy and Pharmaceutical Sciences to provide a copy of my immunization records, background
check, and drug test to the hospital or community pharmacy sites at which I will receive clinical
training if necessary to comply with the requirements of the hospital or community pharmacy site.
I understand that this permission will allow the Distance Degrees and Programs Office and Office of
Experiential Programs to release this information to the specified parties until I revoke this permission
or am no longer enrolled in a program at the University of Colorado Skaggs School of Pharmacy and
Pharmaceutical Sciences.
_____________________________
Signature
_____________________________
Date
Colorado Department of Regulatory Agencies
Division of Professions and Occupations
1560 Broadway, Suite 1350
Denver, CO 80202
Phone: (303) 894-7800
SOCIAL SECURITY NUMBER AFFIDAVIT
LICENSEE/APPLICANT INFORMATION
First:
Name: Last:
Date of Birth (mm/dd/yyyy):
Middle:
Daytime Telephone Number: (
Suffix:
)
PO Box or Street, City:
Physical
Address:
State or Foreign Country, Zip or Postal Code:
Mailing
Address:
PO Box or Street, City:
(if different than
Physical Address)
State or Foreign Country, Zip or Postal Code:
Profession or Occupation:
License, Certification, or Registration Number:
(leave blank if this is a new application)
1. I am applying for or renewing a professional or occupational license, certification, or registration in the
State of Colorado for the profession or occupation identified above.
2. I do not have a social security number and (check one of the following):
I am not physically present in the United States.
I am a non-immigrant in the United States on a student visa.
I am a non-immigrant P-1 individual athlete in the United States on an authorized stay pursuant to
Title 8, Section 214.2(p) of the Code of Federal Regulations and Section 214(a)(2)(B) of the Federal
Immigration and Nationality Act.
3. I am the person identified above and the information contained herein is true and correct to the best of my
knowledge. I understand that under Colorado law, providing false information is grounds for denial,
suspension, or revocation of a license, certification, registration, or permit.
ATTESTATION
I state under penalty of perjury in the second degree, as defined in C.R.S. 18-8-503, that the information
contained in this application is true and correct to the best of my knowledge. In accordance with C.R.S. 18-8501(2)(a)(l), false statements made herein are punishable by law and may constitute a violation of the practice
act.
Signature
Social Security Number Affidavit
Date
08/2012
The link ed image cannot be display ed. The file may hav e been mov ed, renamed, or deleted. Verify that the link points to the correct file and location.
Assigned Collection Site For
University of Colorado Skaggs School of Pharmacy
San Luis Valley Reg Med Occup Hlth
Name
Address
2115 Stuart Ave
Concentra Medical Center
Quest Diagnostics-Aurora South
State Zip
CO
81101
Phone
719-589-8110
10355 East Iliff Avenue
Aurora
15235 E 38th Ave
Aurora
1411 S. Potomac Street, Suite 290 Aurora
CO
CO
CO
80247
80111
80012
303-755-4955
303-340-3053
303-283-0838
Wiz Quiz
1701 Chambers
2260 S Xanadu Way Suite 270
Aurora
Aurora
CO
CO
80011
80014
303 537-5057
Wiz Quiz
3300 28th St
Boulder
CO
80301
303-541-9090
Quest Diagnostics-Boulder PSC
1653 28th Street
Boulder
CO
80301
303-444-4344
Tomahawk Truck Stop Cdl Physical and
Drug Testing
12060 Sable Blvd
Brighton
CO
80601
303-659-8895
Quest Diagnostics-Broomfield PSC
799 US Highway 287, Suite F
Broomfield
CO
80020
303-466-2391
CCOM Cannon City
1338 Phay Avenue; CCOM BLDG.
Canon City
CO
81212
719-285-2800
Mon-Fri 9am-3pm and 6:15-8:15 pm
Verify hours prior to test. Mon-Fri
9:00AM-5:00PM
Sat 10:00AM-12:00PM
Mon-Fri 8:00AM-8:00PM
Sat 10:00AM-6:00PM
Mon-Fri 1:30PM-3:00PM
Sun Mon Tue Wed Thu Fri 8:00AM6:00PM
Centennial
CO
80112
303-792-7368
Wiz Quiz
11877 E Arapahoe Rd Centennial
CO 80112
2305 E. Arapahoe Road, Suite 147
Centennial
CO
80122
303-738-1140
Wiz Quiz
Keefe Memorial Hospital
20971 E Smoky Hill Rd 105B
602 N 6th W
Centennial
Cheyenne Wells
CO
CO
80015
80810
303-400-3172
719-767-5661
Colorado Health Services
327 E. Pikes Peak Avenue
2322 S. Academy Blvd.
5320 Mark Dabling Blvd. Bldg 7
Suite 100
1715 N Weber St Suite 140
Colorado Springs
Colorado Springs
Colorado Springs
CO
CO
CO
80903
80916
80918
Colorado Springs
CO
1011 N. Mildred Road
641 E. Main St. Unit B
469 Breeze St.
750 Hospital Loop
209 4th Street, Suite A-z
420 East 58th Avenue, Suite 111
Cortez
Cortez
Craig
Craig
Dacono
Denver
1730 Blake Street, Suite 100
Denver
Quest Diagnostics-Colorado Springs
Web
Compliance Drug & Alcohol Testing
Four Corners Drug Testing
McKey Chiropractic
The Memorial Hospital
Wiz Quiz - Dacono
City
Alamosa
Hours
Mon-Fri
Mon-Fri
Mon-Fri
Mon-Fri
Mon-Fri
DA Walkin NonYes
X
Electronic
No
Yes
Yes
Yes
X
X
X
No
No
Yes
Yes
X
Yes
Yes
X
No
Yes
X
Yes
Yes
X
Yes
No
X
Yes
Yes
X
No
Yes
X
No
Yes
X
Yes
No
Yes
X
X
Yes
No
719-633-6565
719-390-1727
719-592-1584
Sat 10:00AM-12:00PM
Mon 1:00PM-6:00PM
Sat-Sun 8:00AM-12:00PM
80907
719-636-3707
Yes
X
Yes
CO
CO
CO
CO
CO
CO
81321
81321
81625
81625
80514
80216
970-565-9515
970-564-1443
970-824-4444
970-826-2270
303-833-2924
303-292-2273
Mon-Fri
Mon-Fri
Mon-Fri
Mon-Fri
Mon-Fri
Mon-Fri
Yes
Yes
Yes
No
Yes
Yes
X
X
X
X
X
X
Yes
Yes
No
No
No
No
CO
80202
303-296-2273
Yes
X
No
8:00AM-10:00AM
1:00PM-3:00PM
8:00AM-5:00PM
8:00AM-8:00PM
10:00AM-3:30PM
8:30AM-4:30PM
8:00AM-4:30PM
8:00AM-5:00PM
8:00AM-5:00PM
7:30AM-5:00PM
7:00AM-5:00PM
Yes
Yes
Yes
Yes
No
No
Mon-FRI 8:00AM-6:00PM
Drug Testing Services, Inc.
8/31/2016
5855 Stapleton Drive North Unit
A130
1212 S. Broadway, Suite 150
1780 S. Bellaire St. Suite 302
Denver
CO
80216
303-371-7444
Yes
X
No
Denver
Denver
CO
CO
80210
80218
303-777-2777
303-830-8092
Yes
Yes
X
X
No
Yes
Midtown Occupational Health Services
2420 W 26th AveBldg D, Suite 200 Denver
CO
80211
303-831-9393
Yes
X
No
Quest Diagnostics-Denver Main Lab
695 S. Broadway
CO
80209
303-899-6750
Yes
X
Yes
Drug & Alcohol Testing Associates, Inc.
570 Turner Drive, Unit A
Durango
CO
81303
970-382-9206
Sat 8:00AM-12:00PM
Yes
X
No
Four Corners Drug Testing
278 Sawyer Dr., #4
Durango
CO
81301
970-259-6414
Yes
X
Yes
Englewood
CO
80110
720-833-9800
Mon 12:30PM-4:30PM
Fort Collins
CO
80526
970-223-9833
Sat-Sun 8:00AM-11:45AM
Mon-Fri 8:00AM-8:00pm
Sat
8:00-4:00PM Sun 10:00-4:00PM
Yes
X
Yes
No
Yes
Yes
Yes
X
No
No
No
No
730 W. Hampden Avenue, Suite
200
Quest Diagnostics-Ft. Collins Richmond 1100 Haxton Dr Suite 110
Rocky Mountain Drug Testing
Denver
Yes
No
High Country Health
Concentra
Grand Valley Occupational Medicine
CHAMPS @ Greeley Medical Clinic
360 Peak one Dr Suite 260
770 Simms Street, Ste 100
2004 N 12th Street
1900 16th St
Frisco
Golden
Grand Junction
Greeley
CO
CO
CO
CO
80443
80401
81501
80631
970-668-5584
303-239-6060
970-256-6490
970-350-2471
Medical Services
7257 W 4th Street, Suite #3
9330 South University Blvd. Ste
100
Greeley
Highlands Ranch
CO
CO
80634
80126
970-351-7447
303-346-3627
Quest Diagnostics-Quebec PSC
8671 S. Quebec Street, Suite 240
Highlands Ranch
CO
80130
720-344-5242
Yes
X
Yes
Specimens Unlimited-Mobile Only
Plains Medical Center
30950 County Road 6.5
820 1st St
Lamar
Limon
CO
CO
81052
80828
719-336-5176
719-775-2367
No
No
X
No
No
Quest Diagnostics-Balsam PSC
Quest Diagnostics-Longmont PSC
20 W Dry Creek Cir, Ste 100
Littleton
6179 S Balsam Way, Suite 240
Littleton
2130 Mountain View Ave. Suite 208 Longmont
CO
CO
CO
80120
80123
80501
303-798-1009
303-904-9926
303-682-9322
Yes
Yes
Yes
X
X
X
No
Yes
Yes
The OIKOS Co
Drug Testing Inc.
Quest Diagnostics-Northglenn PSC
2529 N. Lincoln Ave., Suite C
26 South Stough Avenue
11310 N. Huron St Ste 220
Loveland
Montrose
Northglenn
CO
CO
CO
80538
81401
80234
970-227-9583
970-249-1113
720-929-2433
Yes
Yes
Yes
X
X
X
Yes
No
Yes
CCOM Pueblo
EmergiCare
4112 Outlook Blvd Suite 255
4117 North Elizabeth
Pueblo
Pueblo
CO
CO
81008
81008
719-562-6300
719-545-0788
Yes
Yes
X
X
No
No
Quest Diagnostics-Pueblo Lake Ave
PSC
1910 Lake Ave
Pueblo
CO
81004
719-566-3518
Yes
X
Yes
Rangely District Hospital
A1 Drug & Alcohol Screening
The Drug Testing Place Inc.
Steamboat Medical Group
225 Eagle Crest Drive
1433 Airport Rd.
1530 Railroad Ave, Suite A
1475 Pine Grove Rd, Ste 102
Rangely
Rifle
Rifle
Steamboat Springs
CO
CO
CO
CO
81648
81650
81650
80487
970-675-5011
970-274-2023
970-625-3033
970-879-0203
Sterling Regional Medical Ctr (SRMC)
615 Fairhurst St
Sterling
CO
80751
970-521-3128
Drug Techs LLC
500 E. 84th Ave. Suite B14
51 W 84th Ave #304
Thornton
Thornton
CO
CO
80229
80260
303-287-7070
303-650-4151
Sat 8:00AM-12:00PM
Sat 8:00AM-12:00PM
Sat 8:00AM-2:00PM
Sat 9:00AM-2:00PM
Sun 9:00AM-12:00PM
Mon-Fri 9:00AM-11:00AM
8/31/2016
Yes
No
Yes
Yes
Yes
Yes
No
No
Yes
No
Yes
No
Yes
Yes
X
No
Yes

immunization and certification requirements document

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