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* 1. Center Name

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* 2. Region

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* 3. Your Name

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* 4. Your Title

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* 5. Your Email Address

Reporting Period : If you are filling this form out between October 1 and 10, 2023 -  the correct corresponding reporting period is July-September 2023.

The reporting period is the 3 month period prior to when the report is due.

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* 6. Reporting Period

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* 7. Number of Alcohol Tests on Suspicion

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* 8. Number of Tests Positive

The Center ID is a 2 letter, 3 number combination.

This ID also used to complete the Annual Program Description Report (Ex. AB123)

If you do not know your Center ID, e-mail Leah Pan at Leah.Pan@humanitas.com

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* 9. Center ID

Thank you for submitting the quarterly Alcohol Report.

A confirmation will be sent within the next 15 minutes to the e-mail address supplied above containing the submitted responses.

If you have any questions or concerns, contact Leah Pan at Leah.Pan@humanitas.com.

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