SAP Request - Jen Hargrove
Please complete the following to request a SAP evaluation with Jen Hargrove
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Email *
Evaluation Request Information
A SAP return to duty evaluation consists of three parts.  For information on the process, please see the documents linked below.  Text Jen at 417-343-4083 if you have any questions.



Date of SAP evaluation request *
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Are you wanting to pay in full or 2 separate payments? 
 *
Client Information
Please provide the following.  This is needed to complete the DOT paperwork for the SAP evaluation.
Name *
Personal Address *
Last four of Social Security Number *
Phone Number (please provide a number that you are ok with SAP texting to set up appointment) *
Violation Information 
It is important in this section to provide the information as seen in Clearinghouse if you are a driver.  If you are not a driver please provide the information as you were told, or as seen in the letter if one was sent to you.
What DOT agency do you work under? (please check all that apply) *
Required
What was the date of the test (put n/a if you are unsure) *
MM
/
DD
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YYYY
What was the date that the violation was confirmed (this can be found in the Clearinghouse for drivers or the letter you may have received) *
MM
/
DD
/
YYYY
What type of test was it? *
What was the violation? *
Required
If the violation was testing positive for an illicit substance, what substance(s) was it positive for? *
Required
Have you registered and assigned Jen Hargrove as your SAP in the Clearinghouse?  (this step must be done before we can meet for our initial evaluation) *
Clearinghouse Directions
If you have not had a chance to register for the Clearinghouse and assign Jen Hargrove as you SAP, here are links to two direction sheets that can help.


Client Availability
Please share your availability to do a Telehealth evaluation - we will use Zoom Telehealth.
What days are you available to meet this week? (check all that apply) *
Required
What times of day are you available to meet this week? (check all that apply) *
Required
A copy of your responses will be emailed to the address you provided.
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