### FRA MODEL POLICY FOR COMPLIANCE WITH ALCOHOL/DRUG USE REGULATIONS

###### 

###### (For Railroads With Less than 16 Hours of Service Employees

**And No Joint Operations)**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
recognizes that there is a problem of substance abuse, both in drugs and
alcohol, in today's society. As an employer who is subject to
governmental regulations and seeks to promote the safety of its
employees and the public, willingly complies with federal regulations
that are designed to restrict and prohibit the unauthorized use of drugs
and alcohol on its property. This company will comply with the United
States Department of Transportation (DOT) and Federal Railroad
Administration (FRA) regulations and all statutes and regulations
administered by the FRA in implementing the required Part 219 Drug and
Alcohol Program.

In accordance with the applicable Federal regulations, this railroad
prohibits persons who perform work covered by the Federal Hours of
Service Laws (see 49 U.S.C. §§ 21101-21108) from being under the
influence and/or possession of illegal substances and/or under the
influence of alcohol while on duty or within four hours of reporting for
covered service. Additionally, controlled substance use is prohibited at
any time [**on or off duty**,]{.underline} except as allowed in 219.103.

This program applies to all employees who are subject to the Federal
hours of service laws (i.e. operating employees or covered service
employees, including contractors and volunteers). Covered service
employees are required to be in compliance with the applicable sections
of Part 219 when they are on duty and are required to perform or are
available to perform covered service.

This railroad has a total of \_\_\_\_\_\_ hours of service employees
(including volunteers and contractors who perform hours of service
functions).

The following classes or crafts of employees are subject to the hours of
service laws on this railroad, and to applicable sections of Part 219:

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

#### 

###### APPLICATION OF PART 219

Part 219 subparts **D (for cause testing)**, **E (voluntary referral &
co-worker report policies)**, **F (pre-employment testing)** and **G
(random testing)** **[do not apply]{.underline}** (and cannot be
implemented using Federal authority) at this time because the railroad
does not employ more than 15 covered service employees as defined 49
U.S.C. 21103, 21104, or 21105, and/or the railroad does not operate on
tracks of another railroad (or otherwise engage in joint operations with
another railroad) except as necessary for purposes of interchange.

Employer-authority programs that mirror the Federal programs are not
prohibited as long as Federal authority and Federal forms are not used.
For employer-authorized testing, non-Federal testing forms must be used.

#### PROHIBITED CONDUCT UNDER PART 219 SUBPART B

###### "Rule G" or Equivalent

## 

## Alcohol and Drug Use Prohibited (219.101):

\- No employee may use or possess alcohol or any controlled substance
while assigned by a railroad to perform covered service. No employee may
report for covered service, or go or remain on duty in covered service
while under the influence of or impaired by alcohol or having .02
(Federal violation at .04 or more) or more alcohol concentration in
their breath or blood.

\- No employee may report for covered service, or go or remain on duty
in covered service while:

-   Under the influence of or impaired by alcohol; or

-   Having 0.02 (Federal violation at 0.04 or more) or more alcohol
    concentration in their breath or blood; or

-   Under the influence of or impaired by a controlled substance.

\- No employee may use alcohol for whichever is the lesser of the
following periods:

-   Within four hours of reporting for covered service; or

-   After receiving notice to report for covered service

\- No employee tested under Part 219 whose test results indicates an
alcohol concentration of 0.02 or greater but less than 0.04 may perform
or continue to perform covered service functions for a railroad, nor may
a railroad permit the employee to perform or continue to perform covered
service, until the start of the employee\'s next regularly scheduled
duty period, but not less than 8 hours following administration of the
test.

**[Prohibition on Abuse of Controlled Substances
(219.102)]{.underline}:**

No employee who performs covered service may use a controlled substance
at any time, whether on duty or off duty, except as permitted by
219.103.

**[Use of Prescribed or Over-the-Counter Drugs (219.103)]{.underline}:**

Part 219 subpart C does not prohibit the use of a controlled substance
(on Schedules II through V of the controlled substance list) prescribed
by a medical practitioner, or possession incident to such use, if:

-   The treating medical practitioner or a physician designated by the
    railroad has made a good faith judgment, with notice of the
    employee's assigned duties and on the basis of the available medical
    history, that use of the substance by the employee at the prescribed
    or authorized dosage is consistent with the safe performance of the
    employee\'s duties;

-   The substance is used at the dosage prescribed or authorized; and

-   In the event the employee is being treated by more than one medical
    practitioner, at least one treating medical practitioner has been
    informed of all medications authorized or prescribed and has
    determined that use of the medications is consistent with the safe
    performance of the employee\'s duties (and the employee has observed
    any restrictions imposed with respect to use of the medications in
    combination).

Part 219.103 does not restrict any discretion available to the railroad
to require that employees notify the railroad of therapeutic drug use or
obtain prior approval for such use. This railroad's policy regarding
notification of use is:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

#### TRAINING

**[Supervisor Training (219.11 (g))]{.underline}:**

Each supervisor responsible for covered employees (except a working
supervisor within the definition of co-worker under this part) must have
at least two hours of training in the recognition of signs and symptoms
of alcohol and drug influence, intoxication and misuse consistent with a
program of instruction to be made available for inspection upon demand
by FRA. Such a program shall, at a minimum, provide information
concerning the acute behavioral and apparent physiological effects of
alcohol and the major drug groups on the controlled substances list. The
program should also cover supervisor responsibilities for "Rule G"
observations under Part 217 and subsequent action such as reasonable
suspicion testing.

The program must also provide at least one hour training on the
qualifying criteria for post-accident testing contained in subpart C of
Part 219, and the role of the supervisor in post-accident decisions and
collections described in subpart C and Appendix C to Part 219.

**[Employee Training]{.underline}:**

This railroad will provide educational materials that clearly explain
the requirements of Part 219, and the railroad's policies, prohibitions,
and procedures with respect to meeting those requirements. A copy of
this plan and any other educational materials will be distributed to
each covered service employee and to each person subsequently hired for
or transferred to a covered service position. This railroad will also
provide written notice to representatives of employee organizations of
the availability of this information per 219.23.

**[Railroad Contact]{.underline}:**

The following person is designated by this railroad to answer employee
questions about the educational materials

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Phone: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

##### PREVIOUS EMPLOYER CHECK

Effective September 2001, a gaining employer must check on the drug and
alcohol testing record of employees it is intending to use to perform
hours of service duties. This railroad will, after obtaining an
employee's written consent, request information from DOT-regulated
employers who have employed the employee during any period during the
two years before the date of the employee's application or transfer into
covered service. A copy of the employee release form is attached as
Appendix A to this policy. (49 CFR 40.25)

An employee will also be asked whether he or she tested positive (or
refused to test) on any Federal pre-employment drug or alcohol test
administered by a DOT employer to which the employee applied for, but
did not obtain covered service work during the past two years.

With respect to any employee who violated a DOT drug and alcohol
regulation, documentation of the employee's successful completion of DOT
return-to-duty requirements (including Federal follow-up tests) must be
provided to this railroad.

##### CIRCUMSTANCES FOR TESTING COVERED SERVICE EMPLOYEES

# [FRA Post-Accident Toxicological Testing:]{.underline}

[**Part 219 subpart** **C** **requires**]{.underline} this railroad to
collect certain employee's urine, blood and/or breath specimens (tissue
in the event of a fatality) after qualifying FRA Post-Accident events.
This railroad will provide training on the qualifying criteria for
post-accident testing contained in subpart C of this part, and the role
of the supervisor in post-accident collections described in subpart C
and Appendix C to Part 219. The duration of such training will not be
less than 1 hour, as previously addressed. Post-accident events are as
follows:

> **[Major Train Accident]{.underline}:** Any train accident (i.e., a
> rail equipment accident involving damage in excess of the current
> reporting threshold, \$7,700 in 2006) that involves one or more of the
> following:

-   A fatality

-   A release of hazardous material lading from railroad equipment
    accompanied by an evacuation; or

-   A reportable injury resulting from the hazardous material release
    (e.g., from fire, explosion, inhalation, or skin contact with the
    material); or

-   Damage to railroad property of \$1,000,000 or more.

> **[Impact Accident]{.underline}:** An impact accident (i.e., a rail
> equipment accident defined as an \"impact accident\" in 219.5) that
> involves damage in excess of the current reporting threshold,
> resulting in:

-   A reportable injury; or

-   Damage to railroad property of \$150,000 or more.

> **[Fatal Train Incident]{.underline}:** Any train incident (involving
> the movement of on-track equipment) that involves a fatality to any
> on-duty railroad employee (covered or non-covered service, including a
> contractor). This type does not have to meet the reportable property
> damage threshold.
>
> **[Passenger Train Accident]{.underline}:** Reportable injury to any
> person in a train accident, (i.e., a rail equipment accident involving
> damage in excess of the current reporting threshold) involving a
> passenger train.

[Testing Decision]{.underline}: For an accident that meets the criteria
for a Major Train Accident, [all crewmembers of all trains]{.underline}
must be tested. For an Impact Accident, Fatal Train Incident, or
Passenger Train Accident, the railroad must exclude an employee if the
responding railroad representative can immediately determine, on the
basis of specific information, that the employee had no role in the
cause(s) or severity of the accident/incident (considering any such
information immediately available at the time). For a fatal train
incident, the fatally injured employee cannot be excluded from being
tested.

For all four types of accidents, in any case where an operator,
dispatcher, signal maintainer or other covered service employee is
directly and contemporaneously involved in the circumstances of the
accident/incident, those employees must also be required to provide
specimens.

[Exceptions from Testing]{.underline}: No test may be required in the
case of a collision between railroad rolling stock and a motor vehicle
or other highway conveyance at a rail/highway grade crossing. No test
may be required in the case of an accident/incident the cause and
severity of which are wholly attributable to a natural cause (e.g.,
flood, tornado, or other natural disaster) or to vandalism or
trespasser(s), as determined on the basis of objective and documented
facts by the railroad representative responding to the scene.

[Collection of Urine and Blood Specimens]{.underline}: Employee
specimens will be collected at a medical facility, i.e., hospital,
clinic, physician\'s office, or laboratory where toxicological specimens
can be collected according to recognized professional standards.
Specimen collections will be accomplished using the FRA Post-Accident
Toxicological Testing Kit. Specimens will be tested at FRA's contracted
post-accident testing laboratory, currently NWT in West Valley City,
Utah.

[Implied Consent]{.underline}: Employee(s) required to participate in
body fluid testing under subpart C of Part 219 (post-accident
toxicological testing) consent to taking of specimens, their release for
toxicological analysis under pertinent provisions of this part, and
release of the test results to the railroad\'s Medical Review Officer by
promptly executing a consent form, if required by the medical facility.
The employee is not required to execute any document or clause waiving
rights that the employee would otherwise have against the employer, and
any such waiver is void. The employee may not be required to waive
liability with respect to negligence on the part of any person
participating in the collection, handling or analysis of the specimen or
to indemnify any person for the negligence of others. Any consent
provided consistent with this section may be construed to extend only to
those actions specified in this section.

Any railroad employee who performs service for a railroad is deemed to
have consented to removal of body fluid and/or tissue specimens
necessary for toxicological analysis from the remains of such employee,
if such employee dies within 12 hours of an accident or incident
described in subpart C of Part 219 as a result of such event. This
consent is specifically required of employees not in covered service, as
well as employees in covered service.

###### REFUSAL TO TEST

Failure to remain available following an accident or casualty as
required by company rules (i.e., being absent without leave) is
considered a refusal to participate in testing, without regard to any
subsequent provision of specimens. An employee who has been transported
to receive medical care is not released from duty for purposes of this
section. Nothing in this section prohibits the subsequent testing of an
employee who has failed to remain available for testing as required
(i.e., who is absent without leave); but subsequent testing does not
excuse such refusal by the employee timely to provide the required
specimens.

**For all types of Federal testing, an employee who refuses to cooperate
in providing specimens as required by Parts 219/40 "has refused to test"
and must be withdrawn from covered service and must be deemed
disqualified for covered service for a period of nine (9) months**. The
requirement of disqualification for nine (9) months does not limit any
discretion on the part of the railroad to impose additional sanctions
for the same or related conduct.

A refusal to test also includes failure to provide a sufficient amount
of urine when directed, and it has been determined through a required
medical evaluation, that there was no adequate medical explanation for
the failure; providing an adulterated or substituted urine specimen. See
219.107 and 49 CFR Parts 40.191 and 40.261.

###### RAILROAD'S RESPONSIVE ACTION TO A POSITIVE FRA TEST

A covered service employee who has tested positive on an FRA test must
be immediately removed from covered service. Prior to or upon
withdrawing the employee from covered service, the railroad must provide
notice to the employee of the reason for this action. If the employee
denies that the test result is valid evidence of alcohol or drug use
prohibited by 219.101 or 219.102, the employee may demand and must be
provided an opportunity for a prompt post-suspension hearing. [See
219.104 (c) for the hearing provisions]{.underline}.

Even if the railroad does not wish to keep the employee in its
employment, it must provide the above hearing (if requested) and at a
minimum provide the employee with a list of qualified Substance Abuse
Professionals.

The employee may not return to duty in any DOT-covered service unless
he/she has complied with the return to service provisions described
here. Before the employee is returned to covered service, he/she must be
evaluated by a Substance Abuse Professional (SAP), complete any required
education and/or treatment, be recommended for return to duty by the
SAP, have a negative Federal drug and/or alcohol return to duty test,
and be subject to Federal follow-up testing for up to 5 years, per the
SAP's recommendations.

###### RAILROAD'S RESPONSIVE ACTION TO A POSITIVE FEDERAL 

###### ALCOHOL TEST 0.02 TO 0.039

As previously discussed, a test result of 0.02 to 0.039 is a positive
alcohol test for which the railroad may take further action under its
company policy. However, since it does not reach the level of a Federal
violation (0.04 or more) there are no Federal sanctions which may be
taken other than the employee's removal from covered service for a
minimum of 8 hours.

The following is this railroad's company policy for additional railroad
action for a 0.02 to 0.039 Federal alcohol test result, if applicable:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

######  

###### NEGATIVE ALCOHOL TEST RESULT

If an employee tested under the provisions of this part has a test
result indicating an alcohol concentration below 0.02, the test [must be
considered negative]{.underline} and is not evidence of alcohol misuse.
A railroad may not use a federal test result below 0.02 either as
evidence in a company proceeding or as a basis for subsequent testing
under company authority.

###### EMPLOYEE ASSISTANCE

(Provide info concerning the effects of alcohol misuse on an
individual's health, work and person life; signs & symptoms of an
alcohol problem; and available methods of evaluating the misuse of
alcohol, and the names, addresses and telephone numbers of substance
abuse professionals or EAP & counseling and treatment programs.)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

####### ADDITIONAL RAILROAD POLICIES

(As applicable, include information on additional railroad policies with
respect to the use or possession of alcohol and drugs, including any
consequences for an employee found to have a specific alcohol
concentration, that are based on the railroad's authority independent of
Part 219).

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

###### COMPANY POLICY TESTING PROGRAMS

(Identify whether this railroad is conducting pre-employment, random
testing, etc. under [company]{.underline} authority. If so, note that
all such testing will be conducted using non-DOT forms).

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

APPENDIX A

Suggested Format: "Release of Information Form \-- 49 CFR Part 40 Drug
and Alcohol Testing"

**[Section I]{.underline}. 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]{.underline}. 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:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_