Date:

Operator's IOCS ID

Inspection Unit's IOCS ID

Operator Evaluated

Name and Title of Company Official

Address

Telephone No.

Location of Inspection

Person(s) Interviewed

Inspector's Name

Type of Facility: \_\_\_ Gas Transmission Pipeline \_\_\_ Hazardous
Liquid Pipeline

\_\_\_ Gas Distribution System \_\_\_ Liquefied Natural Gas

**[Alcohol Misuse Plan and Policy developed by]{.underline}: [Alcohol
Misuse Testing Program administered by]{.underline}:**

\_\_\_\_\_\_ Operator \_\_\_\_\_\_ Operator

\_\_\_\_\_\_ Contractor \_\_\_\_\_\_ Contractor

\_\_\_\_\_\_ Consortium \_\_\_\_\_\_ Consortium

**[Contractor records maintained by]{.underline}: [Specimen collection
conducted by]{.underline}:**

\_\_\_\_\_\_ Operator \_\_\_\_\_\_ Operator Personnel On-Site

\_\_\_\_\_\_ Contractor \_\_\_\_\_\_ Operator Personnel Off-Site

\_\_\_\_\_\_ Consortium \_\_\_\_\_\_ Contractor Personnel On-Site

\_\_\_\_\_\_ Contractor Personnel Off-Site

+----------------------+-------------------------+--------------------+
|                      |                         |                    |
+----------------------+-------------------------+--------------------+
| §199.202 Alcohol     |                         |                    |
| misuse plan          |                         |                    |
+----------------------+-------------------------+--------------------+
| **COMPLIANCE**       | **CRITERION**           | **GUIDANCE**       |
+----------------------+-------------------------+--------------------+
| ** YES  NO  N/A** | Does the inspection     |                    |
|                      | unit/location have      |                    |
| §199.202             | available a copy of the |                    |
|                      | company's written       |                    |
|                      | alcohol misuse          |                    |
|                      | prevention plan?        |                    |
+----------------------+-------------------------+--------------------+
| §199.203 Alcohol     |                         |                    |
| testing procedures   |                         |                    |
+----------------------+-------------------------+--------------------+
| **Covered Under      |                         |                    |
| Headquarters         |                         |                    |
| Inspection**         |                         |                    |
+----------------------+-------------------------+--------------------+
| §199.205 Definitions |                         |                    |
+----------------------+-------------------------+--------------------+
| ** YES  NO  N/A** | Is sufficient           | Plan should        |
|                      | terminology contained   | contain            |
| §199.205             | in the Alcohol Misuse   | definitions for    |
|                      | Prevention Plan?        | *"accident,        |
|                      |                         | alcohol,           |
|                      |                         | confirmation test, |
|                      |                         | covered employee,  |
|                      |                         | covered function,  |
|                      |                         | screening test."*  |
+----------------------+-------------------------+--------------------+
| §199.207 Preemption  |                         |                    |
| of State and local   |                         |                    |
| laws                 |                         |                    |
+----------------------+-------------------------+--------------------+
| **Covered Under      |                         |                    |
| Headquarters         |                         |                    |
| Inspection**         |                         |                    |
+----------------------+-------------------------+--------------------+
| §199.209 Other       |                         |                    |
| requirements imposed |                         |                    |
| by operators         |                         |                    |
+----------------------+-------------------------+--------------------+
| **Covered Under      |                         |                    |
| Headquarters         |                         |                    |
| Inspection**         |                         |                    |
+----------------------+-------------------------+--------------------+
| §199.211 Requirement |                         |                    |
| for notice           |                         |                    |
+----------------------+-------------------------+--------------------+
| ** YES  NO  N/A** | Does the plan address   |                    |
|                      | procedures for          |                    |
| §199.211             | notification to         |                    |
|                      | employees prior to      |                    |
|                      | conducting alcohol      |                    |
|                      | testing?                |                    |
+----------------------+-------------------------+--------------------+
| §199.213 Starting    |                         |                    |
| date for alcohol     |                         |                    |
| testing programs     |                         |                    |
+----------------------+-------------------------+--------------------+
| ** YES  NO  N/A** | Does the plan specify   | Large operators    |
|                      | the starting date for   | (more than 50      |
| §199.213             | the Alcohol Testing     | covered employees) |
|                      | Program?                | implement January  |
|                      |                         | 1, 1995. Small     |
|                      |                         | operators (50 or   |
|                      |                         | fewer covered      |
|                      |                         | employees)         |
|                      |                         | implement on       |
|                      |                         | January 1, 1996.   |
+----------------------+-------------------------+--------------------+

***COMMENTS***

+----------------------+--------------------------+-------------------+
| §199.215 Alcohol     |                          |                   |
| concentration        |                          |                   |
+----------------------+--------------------------+-------------------+
| **COMPLIANCE**       | **CRITERION**            | **GUIDANCE**      |
+----------------------+--------------------------+-------------------+
| ** YES  NO  N/A** | Does the plan address    | Covered employees |
|                      | prohibited alcohol       | cannot report or  |
| §199.215             | concentrations?          | remain on duty    |
|                      |                          | with an alcohol   |
|                      |                          | concentration of  |
|                      |                          | 0.04 or greater.  |
+----------------------+--------------------------+-------------------+
| §199.217 On-duty use |                          |                   |
+----------------------+--------------------------+-------------------+
| ** YES  NO  N/A** | Does the plan address    |                   |
|                      | what the policy is for   |                   |
| §199.217             | on-duty use?             |                   |
+----------------------+--------------------------+-------------------+
| §199.219 Pre-duty    |                          |                   |
| use                  |                          |                   |
+----------------------+--------------------------+-------------------+
| ** YES  NO  N/A** | Does the plan address    |                   |
|                      | what the policy is on    |                   |
| §199.219             | pre-duty use?            |                   |
+----------------------+--------------------------+-------------------+
| §199.221 Use         |                          |                   |
| following an         |                          |                   |
| accident             |                          |                   |
+----------------------+--------------------------+-------------------+
| **Covered Under      |                          |                   |
| Headquarters         |                          |                   |
| Inspection**         |                          |                   |
+----------------------+--------------------------+-------------------+
| §199.223 Refusal to  |                          |                   |
| submit to a required |                          |                   |
| alcohol test         |                          |                   |
+----------------------+--------------------------+-------------------+
| ** YES  NO  N/A** | Does the plan address    |                   |
|                      | the policy for employees |                   |
| §199.223             | who violate one of the   |                   |
|                      | prohibitions of the      |                   |
|                      | alcohol rule or who      |                   |
|                      | refuse to take a test?   |                   |
+----------------------+--------------------------+-------------------+
| §199.225 Alcohol     |                          |                   |
| tests required       |                          |                   |
+----------------------+--------------------------+-------------------+
| ** YES  NO  N/A** | **Post-Accident          |                   |
|                      | Testing**                |                   |
| §199.225             |                          |                   |
|                      | Does the plan address    |                   |
|                      | what the policy is on    |                   |
|                      | post-accident testing?   |                   |
+----------------------+--------------------------+-------------------+

***COMMENTS***

+----------------------+-------------------------+--------------------+
| §199.225 Alcohol     |                         |                    |
| tests required       |                         |                    |
+----------------------+-------------------------+--------------------+
| **COMPLIANCE**       | **CRITERION**           | **GUIDANCE**       |
+----------------------+-------------------------+--------------------+
| ** YES  NO  N/A** | **Reasonable            | A covered employee |
|                      | Suspicion**             | with an alcohol    |
| §199.225             |                         | concentration of   |
|                      | Does the plan address   | 0.02 or greater    |
| ** YES  NO  N/A** | what the policy is for  | but less than 0.04 |
|                      | determining reasonable  | can be either      |
| §199.225             | suspicion?              | retested until     |
|                      |                         | they have an       |
| ** YES  NO  N/A** | Does the plan address   | alcohol test       |
|                      | what the policy is for  | result below 0.02, |
| §199.225             | reasonable suspicion    | or can wait 8      |
|                      | testing?                | hours and return   |
| ** YES  NO  N/A** |                         | to continuing a    |
|                      | **Follow-Up Testing**   | covered function.  |
| §199.225             |                         |                    |
|                      | Does the plan address   |                    |
|                      | follow-up testing?      |                    |
|                      |                         |                    |
|                      | **Retesting**           |                    |
|                      |                         |                    |
|                      | Does the plan address   |                    |
|                      | retesting?              |                    |
+----------------------+-------------------------+--------------------+
| §199.227 Retention   |                         |                    |
| of records           |                         |                    |
+----------------------+-------------------------+--------------------+
| **Covered Under      |                         |                    |
| Headquarters         |                         |                    |
| Inspection**         |                         |                    |
+----------------------+-------------------------+--------------------+
| §199.229 Reporting   |                         |                    |
| of alcohol testing   |                         |                    |
| results              |                         |                    |
+----------------------+-------------------------+--------------------+
| **Covered Under      |                         |                    |
| Headquarters         |                         |                    |
| Inspection**         |                         |                    |
+----------------------+-------------------------+--------------------+
| §199.231 Access to   |                         |                    |
| facilities and       |                         |                    |
| records              |                         |                    |
+----------------------+-------------------------+--------------------+
| **Covered Under      |                         |                    |
| Headquarters         |                         |                    |
| Inspection**         |                         |                    |
+----------------------+-------------------------+--------------------+
| §199.233 Removal     |                         |                    |
| from covered         |                         |                    |
| function             |                         |                    |
+----------------------+-------------------------+--------------------+
| ** YES  NO  N/A** | Does the plan specify   |                    |
|                      | provisions on removal   |                    |
| §199.233             | from covered functions  |                    |
|                      | for violations of       |                    |
|                      | alcohol misuse plan?    |                    |
+----------------------+-------------------------+--------------------+

***COMMENTS***

+----------------------+-------------------------+--------------------+
| §199.235 Required    |                         |                    |
| evaluation and       |                         |                    |
| testing              |                         |                    |
+----------------------+-------------------------+--------------------+
| **COMPLIANCE**       | **CRITERION**           | **GUIDANCE**       |
+----------------------+-------------------------+--------------------+
| ** YES  NO  N/A** | Does the plan address   |                    |
|                      | the requirement for a   |                    |
| §199.235             | referral or evaluation, |                    |
|                      | following an employee   |                    |
|                      | engaging in prohibited  |                    |
|                      | conduct?                |                    |
+----------------------+-------------------------+--------------------+
| §199.237 Other       |                         |                    |
| alcohol-related      |                         |                    |
| conduct              |                         |                    |
+----------------------+-------------------------+--------------------+
| ** YES  NO  N/A** | Does the plan address   |                    |
|                      | provisions where an     |                    |
| §199.237             | employee has an alcohol |                    |
|                      | concentration of 0.02   |                    |
|                      | or greater but less     |                    |
|                      | than 0.04?              |                    |
+----------------------+-------------------------+--------------------+
| §199.239 Operator    |                         |                    |
| obligation to        |                         |                    |
| promulgate a policy  |                         |                    |
| on the misuse of     |                         |                    |
| alcohol              |                         |                    |
+----------------------+-------------------------+--------------------+
| **Covered Under      |                         |                    |
| Headquarters         |                         |                    |
| Inspection**         |                         |                    |
+----------------------+-------------------------+--------------------+
| §199.241 Training    |                         |                    |
| for supervisors      |                         |                    |
+----------------------+-------------------------+--------------------+
| ** YES  NO  N/A** | Do supervisors making   | At least 60        |
|                      | the reasonable          | minutes of         |
| §199.241             | suspicion               | training is        |
|                      | determinations have the | required on the    |
|                      | required training?      | physical,          |
|                      |                         | behavioral, speech |
|                      |                         | and performance    |
|                      |                         | indicators of      |
|                      |                         | probable alcohol   |
|                      |                         | misuse.            |
+----------------------+-------------------------+--------------------+
| §199.243 Referral,   |                         |                    |
| evaluation, and      |                         |                    |
| treatment            |                         |                    |
+----------------------+-------------------------+--------------------+
| ** YES  NO  N/A** | Does the plan provide   |                    |
|                      | that employees who      |                    |
| §199.243             | engage in prohibited    |                    |
|                      | conduct shall be        |                    |
| ** YES  NO  N/A** | advised of available    |                    |
|                      | resources to evaluate   |                    |
| §199.243             | and resolve problems    |                    |
|                      | associated with alcohol |                    |
|                      | misuse?                 |                    |
|                      |                         |                    |
|                      | Does the inspection     |                    |
|                      | unit/location have      |                    |
|                      | access to names,        |                    |
|                      | addresses, and phone    |                    |
|                      | numbers of SAPs,        |                    |
|                      | counselors and          |                    |
|                      | treatment programs?     |                    |
+----------------------+-------------------------+--------------------+

***COMMENTS***

+----------------------+-------------------------+--------------------+
| §199.245 Contractor  |                         |                    |
| Employees            |                         |                    |
+----------------------+-------------------------+--------------------+
| **COMPLIANCE**       | **CRITERION**           | **GUIDANCE**       |
+----------------------+-------------------------+--------------------+
| ** YES  NO  N/A** | Does the operator       |                    |
|                      | maintain or have access |                    |
| §199.245             | to records concerning   |                    |
|                      | contractor employees?   |                    |
| ** YES  NO  N/A** |                         |                    |
|                      | Does the inspection     |                    |
| §199.245             | unit/location           |                    |
|                      | adequately evaluate     |                    |
|                      | contractor records?     |                    |
+----------------------+-------------------------+--------------------+

***COMMENTS***