Montana Professional Assistance Program, Inc.
Monitoring Leave of Absence
Request Form

I, , MPAP Participant # , hereby declare that I shale be away from the area of my primary residence for the purpose of

Vacation
Conference
Training
Personal Time Off
Other (please Specify below)

My destination and/or itinerary is as follows:

         
I shall be away from:  
  
 
(Date)
    
(Time)
through:  
 
 
(Date)
     (Time)

I hereby request permission to suspend the requirement for me to check in daily for the purpose of random urine drug screening. I understand that I shall be required to resume daily check- in on the day following my return.

I further understand that I shall require MPAP Staff approval of this request before suspending daily check- in requirement. I understand that submission of the form does not automatically guarantee permission to deviate from the protocol. This decision shall be made on a case-by-case basis.

Submitted this day of

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