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  1. Provider  
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  2. Referral  
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  3. Practice  
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  4. Education  
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  5. License/Certification  
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  6. Insurance  
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  7. Work History  
  8. EAP Counselor  
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  9. Disability Provider  
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  10. FFD Specialist  
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  11. Provider Profile  
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  12. Attestation  
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  13. W-9  

10. FITNESS FOR DUTY ASSESSMENT SPECIALIST NETWORK ONLY
 
Are you interested in participating in the Fitness for Duty specialty network? Yes No
If yes, go on.
Do you meet the minimum VO criteria for your licensure level AND the criteria for the specialty FFD network? Yes No
If yes, complete the following for the Fitness for Duty specialty network in its entirety.
 
 
Check the box for the discipline that applies to you and answer the questions for that discipline.
 
A. Psychiatrist or Addictionist
 
1. Are you a member of the American Academy of Psychiatry and the Law? Yes No
2. Do you hold current and valid ASAM certification? Yes No
3. Do you have at least 2 years of experience engaged in Fitness for Duty (FFD) evaluations? Yes No
4. Have you evaluated clinical cases where fitness for duty and/or substance abuse was the primary issue? Yes No
 
B. Psychologist
 
1. Do you hold ABBP certification? Yes No
2. Do you have at least 2 years of experience engaged in Fitness for Duty (FFD) evaluations? Yes No
3. Have you evaluated clinical cases where fitness for duty and/or substance abuse was the primary issue? Yes No
 
C. All Fitness for Duty Assessment Specialist applicants complete the following:
1. Are you willing to function as part of an FFD team assigned to one or more specific locations? Yes No N/A
2. Are you able to schedule and perform a face-to-face FFD evaluation within 24 hours if requested, provide feedback immediately after the evaluation if requested (with the exception of psychological testing results), and complete and return an FFD form to ValueOptions within 3 business days? Yes No N/A
3. Are you willing to engage in on-going dialogue with ValueOptions care managers on an as-needed basis? Yes No N/A
4. Are you willing to testify in legal/court proceedings when requested? Yes No N/A
5. Have you performed at least 25 evaluations where substance abuse and/or FFD was an issue during the last 2 years? Yes No N/A
6. Are you familiar with alcohol and drug testing policies and procedures? Yes No N/A
7. Are you familiar with workplace issues? Yes No N/A
8. Do you have experience working with and evaluating employees who are in federally regulated safety sensitive jobs? Yes No N/A
9. If you are a psychologist have you utilized psychological tests as part of your FFD evaluation process? Yes No N/A
10. If you perform psychological testing are you able to schedule it within 72 hours of a request, and send a completed written report to ValueOptions within 3 business days after completion of the testing? Yes No N/A
11. Are you eligible or do you hold NCAC, ICADC or state-level addictions treatment certification/licensure? Yes No N/A
12. Are you willing to allow ValueOptions to request a criminal background check on you? Yes No N/A
 
D. Indicate in the grid below your level of experience (number of cases) with each of the issues identified:
Trigger for a Fitness for Duty Evaluation Number of cases seen where this was the primary cause for evaluation
...In the last 2 years ...In my career
Positive test on a random drug/alcohol screen
Positive drug/alcohol test result where test was administered for reasonable cause
Unusual/aberrant/bizarre behavior in the workplace
Return to work post-critical incident
Sub-standard work performance
Absenteeism
Pre-employment screening
Change in job responsibilities to a level involving potential for increased safety hazard(s)
Column Totals
 
E. Check the settings in which you have performed Fitness for Duty evaluations:
Industry Fire, Police, Safety Military Oil, Mineral, Forestry
Health Care Utilities (Water, Gas, Electric, etc.) Other (specify):
 
  
 
 

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