Implementation Guidelines - Federal Transit Administration - U.S. ...
Implementation Guidelines - Federal Transit Administration - U.S. ... Implementation Guidelines - Federal Transit Administration - U.S. ...
Suggested Format: “Release of Information Form -- 49 CFR Part 40 Drug and Alcohol Testing” Section I. To be completed by the new employer, signed by the employee, and transmitted to the previous employer: Employee Printed or Typed Name: ________________________________________________________________ Employee SS or ID Number: _____________________________________________________________________ I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer, listed in Section I-B, to the employer listed in Section I-A. This release is in accordance with DOT Regulation 49 CFR Part 40, Section 40.25. I understand that information to be released in Section II-A by my previous employer, is limited to the following DOT-regulated testing items: 1. Alcohol tests with a result of 0.04 or higher; 2. Verified positive drug tests; 3. Refusals to be tested; 4. Other violations of DOT agency drug and alcohol testing regulations; 5. Information obtained from previous employers of a drug and alcohol rule violation; 6. Documentation, if any, of completion of the return-to-duty process following a rule violation. Employee Signature: __________________________________________________ Date: ____________________ I-A. New Employer Name: __________________________________________________________________________ Address: _____________________________________________________________________________________ _____________________________________________________________________________________ Phone #: _______________________________________ Fax #: _______________________________________ Designated Employer Representative: ______________________________________________________________ I-B. Previous Employer Name: _______________________________________________________________________ Address: _____________________________________________________________________________________ _____________________________________________________________________________________ Phone #: _______________________________________ Designated Employer Representative (if known): _____________________________________________________ Section II. To be completed by the previous employer and transmitted by mail or fax to the new employer: II-A. In the two years prior to the date of the employee’s signature (in Section I), for DOT-regulated testing ~ 1. Did the employee have alcohol tests with a result of 0.04 or higher? YES ____ NO ____ 2. Did the employee have verified positive drug tests? YES ____ NO ____ 3. Did the employee refuse to be tested? YES ____ NO ____ 4. Did the employee have other violations of DOT agency drug and alcohol testing regulations? YES ____ NO ____ 5. Did a previous employer report a drug and alcohol rule violation to you? YES ____ NO ____ 6. If you answered “yes” to any of the above items, did the employee complete the return-to-duty process? N/A ____ YES ____ NO ____ NOTE: If you answered “yes” to item 5, you must provide the previous employer’s report. If you answered “yes” to item 6, you must also transmit the appropriate return-to-duty documentation (e.g., SAP report(s), follow-up testing record). II-B. Name of person providing information in Section II-A: _______________________________________________ Title: ___________________________________________ Phone #: ________________________________________ Date: ___________________________________________ Chapter 6. Types of Testing 6-29 August 2002
1) Accident Report Number: 2) Location of Accident: Example Post-Accident Drug and Alcohol Test Decision Documentation Form 3) Accident Date: Time: 4) Report Date: Time: 5) Name of Employee: 6) Identification Number: 7) Position: 8) Result of Accident: (Check all that apply) Fatality Disabling Damage* to One or More Vehicles (Bus, Van, Paratransit) Remove from revenue service (Fixed guideway vehicles only) Injury Requiring Immediate Transport to Medical Facility Employee Other Vehicle Passenger Other, Specify: 9) Was the employee sent for a post-accident test? Yes No 10) If No, Explain: 11) 12) 13) 14) 15) Decision to Test: FTA Authority Company Authority Type of Test: Drug Supervisor Making Determination: Notification of Test: Date: Test Conducted: Drug: Date: Alcohol: Date: Yes Yes Alcohol Time: 16) Did the alcohol test occur more than 2 hours from the time of the accident? Explain: No No Time: Time: Yes No Chapter 6. Types of Testing 6-31 August 2002
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Suggested Format: “Release of Information Form -- 49 CFR Part 40 Drug and Alcohol Testing”<br />
Section I. To be completed by the new employer, signed by the employee, and transmitted to the previous<br />
employer:<br />
Employee Printed or Typed Name: ________________________________________________________________<br />
Employee SS or ID Number: _____________________________________________________________________<br />
I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by<br />
my previous employer, listed in Section I-B, to the employer listed in Section I-A. This release is in accordance with DOT<br />
Regulation 49 CFR Part 40, Section 40.25. I understand that information to be released in Section II-A by my previous employer,<br />
is limited to the following DOT-regulated testing items:<br />
1. Alcohol tests with a result of 0.04 or higher;<br />
2. Verified positive drug tests;<br />
3. Refusals to be tested;<br />
4. Other violations of DOT agency drug and alcohol testing regulations;<br />
5. Information obtained from previous employers of a drug and alcohol rule violation;<br />
6. Documentation, if any, of completion of the return-to-duty process following a rule violation.<br />
Employee Signature: __________________________________________________ Date: ____________________<br />
I-A.<br />
New Employer Name: __________________________________________________________________________<br />
Address: _____________________________________________________________________________________<br />
_____________________________________________________________________________________<br />
Phone #: _______________________________________ Fax #: _______________________________________<br />
Designated Employer Representative: ______________________________________________________________<br />
I-B.<br />
Previous Employer Name: _______________________________________________________________________<br />
Address: _____________________________________________________________________________________<br />
_____________________________________________________________________________________<br />
Phone #: _______________________________________<br />
Designated Employer Representative (if known): _____________________________________________________<br />
Section II. To be completed by the previous employer and transmitted by mail or fax to the new employer:<br />
II-A. In the two years prior to the date of the employee’s signature (in Section I), for DOT-regulated testing ~<br />
1. Did the employee have alcohol tests with a result of 0.04 or higher? YES ____ NO ____<br />
2. Did the employee have verified positive drug tests? YES ____ NO ____<br />
3. Did the employee refuse to be tested? YES ____ NO ____<br />
4. Did the employee have other violations of DOT agency drug and<br />
alcohol testing regulations? YES ____ NO ____<br />
5. Did a previous employer report a drug and alcohol rule<br />
violation to you? YES ____ NO ____<br />
6. If you answered “yes” to any of the above items, did the<br />
employee complete the return-to-duty process? N/A ____ YES ____ NO ____<br />
NOTE: If you answered “yes” to item 5, you must provide the previous employer’s report. If you answered “yes” to item 6, you<br />
must also transmit the appropriate return-to-duty documentation (e.g., SAP report(s), follow-up testing record).<br />
II-B.<br />
Name of person providing information in Section II-A: _______________________________________________<br />
Title: ___________________________________________<br />
Phone #: ________________________________________<br />
Date: ___________________________________________<br />
Chapter 6. Types of Testing 6-29 August 2002