Preventive worksite screening request

To request a preventive screening at your worksite, please complete the form below once you have determined the time, date, location and number of employees who wish to be screened. Submit the form at least six weeks prior to your requested screening date. We will contact you to confirm your request.

Worksite name:

Contact name:

Phone:

Email:

Address:

City:

State:

Zip code:

Screening location:

Include room name/number and directions, if necessary.

Screening provider:

This is my worksite's first screening.

Request same provider as last year or last screening.

Request a different provider from the one that did last screening.

Reason:

Special requests or comments:

Requested screening date:

Requested start time:

Expected number of participants:

How would you like to receive your confirmation letter and screening materials?

Standard mail

Serving those who serve South Carolina

Preventive worksite screening request

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