U.S. DEPARTMENT OF TRANSPORTATION

**DRUG AND ALCOHOL TESTING MIS DATA COLLECTION FORM**

**INSTRUCTION SHEET**

This Management Information System (MIS) form is made-up of four
sections: employer information; covered employees (i.e., employees
performing DOT regulated safety-sensitive duties) information; drug
testing data; and alcohol testing data. The employer information needs
only to be provided once per submission. However, you must submit a
separate page of data for each employee category for which you report
testing data. If you are preparing reports for more than one DOT agency
then you must submit DOT agency-specific forms.

Please type or print entries legibly in black ink.

***[TIP]{.underline}** \~ Read the entire instructions before starting.
Please note that USCG-regulated employers do not report alcohol test
results on the MIS form.*

**Calendar Year Covered by this Report**: Enter the appropriate year.

######## [Section I. Employer]{.underline}

######## 

######## 1. Enter your company's name, to include when applicable, your "doing business as" name; current address, city, state, and zip code; and an e-mail address, if available.

2\. Enter the printed name, signature, and complete telephone number of
the company official certifying the accuracy of the report and the date
that person certified the report as complete.

3\. If someone other than the certifying official completed the MIS
form, enter that person's name and phone number on the appropriate lines
provided.

4\. If a Consortium/Third Party Administrator (C/TPA) performs
administrative services for your drug and alcohol program operation,
enter its name and phone number on the appropriate lines provided.

5\. DOT Agency Information: Check the box next to the DOT agency for
which you are completing this MIS form. Again, if you are submitting to
multiple DOT agencies, you must use separate forms for each DOT agency.

a\. If you are completing the form for FMCSA, enter your FMCSA DOT
Number, as appropriate. In addition, you must indicate whether you are
an owner-operator (i.e., an employer who employs only himself or herself
as a driver) and whether you are exempt from providing MIS data.
Exemptions are noted in the FMCSA regulation at 382.103(d).

b\. If you are completing the form for FAA, enter your FAA Certificate
Number and FAA Antidrug Plan / Registration Number, when applicable.

c\. If you are completing the form for RSPA, check the additional box(s)
indicating your type of operation.

d\. If you are completing the form for FRA, enter the number of
observed/documented Part 219 "Rule G" Observations for covered
employees.

e\. If you are submitting the form for USCG, enter the vessel ID number.
If there is more than one number, enter the numbers separately.

######### Section II. Covered Employees

1\. In Box II-A, enter the total number of covered employees (i.e.,
employees performing DOT regulated safety-sensitive duties) who work for
your company. Then enter, in Box II-B, the total number of employee
categories that number represents. If you have employees, some of whom
perform duties under one DOT agency and others of whom perform duties
under another DOT agency, enter only the number of those employees
performing duties under the DOT agency for whom you are submitting the
form. If you have covered employees who perform multi-DOT agency
functions (e.g., an employee drives a commercial motor vehicle and
performs pipeline maintenance duties for you), count the employee only
on the MIS report for the DOT agency regulating more than 50 percent of
the employee's safety sensitive function.

\[Example: If you are submitting the information for the FRA and you
have 2000 covered employees performing duties in [all]{.underline}
FRA-covered service categories -- you would enter "2000" in the first
box (II-A) and "5" in the second box (II-B), because FRA has five
safety-sensitive employee categories and you have employees in all of
these groups. If you have 1000 employees performing safety-sensitive
duties in three FRA-covered service categories (e.g., engine service,
train service, and dispatcher/operation), you would enter "1000" in the
first box (II-A) and "3" in the second box (II-B).\]

***[TIP]{.underline}** \~ To calculate the total number of covered
employees, add the total number of covered employees eligible for
testing during each random testing selection period for the year and
divide that total by the number of random testing periods. (However, no
company will need to factor the average number of employees more often
than once per month). For instance, a company conducting random testing
quarterly needs to add the total of covered employees they had in the
random pool when each selection was made; then divide this number by 4
to obtain the yearly average number of covered employees. It is
extremely important that you place all eligible employees into these
random pools. \[As an example, if Company A had 1500 employees in the
first quarter random pool, 2250 in the second quarter, 2750 in the third
quarter; and 1500 in the fourth quarter; 1500 + 2250 + 2750 + 1500 =
8000; 8000 / 4 = 2000; the total number of covered employees for the
year would be reported as,"2000".*

*If you conduct random selections more often than once per month (e.g.,
you select daily, weekly, bi-weekly), you do not need to compute this
total number of covered employees rate more than on a once per month
basis. Therefore, employers need not compute the covered employees rate
more than 12 times per year.\]*

2\. If you are reporting multiple employee categories, enter the
specific employee category in box II-C; [and]{.underline} provide the
number of employees performing safety-sensitive duties in that specific
category.

\[Example: You are submitting data to the FTA and you have 2000 covered
employees. You have 1750 personnel performing revenue vehicle operation
and the remaining 250 are performing revenue vehicle and equipment
maintenance. When you provide vehicle operation information, you would
enter "Revenue Vehicle Operation" in the first II-C box and "1750" in
the second II-C box. When you provide data on the maintenance personnel,
you would enter "Revenue Vehicle and Equipment Maintenance" in the first
II-C box and "250" in the second II-C box.\]

***[TIP]{.underline}** \~ A separate form for each employee category
must be submitted. You may do this by filling out a single MIS form
through Section II-B and then make one copy for each additional employee
category you are reporting. \[For instance, if you are submitting the
MIS form for the FMCSA, you need only submit one form for all FMCSA
covered employees working for you -- your only category of employees is
"driver." If you are reporting testing data to the FAA and you employ
[only]{.underline} flight crewmembers, flight attendants, and aircraft
maintenance workers, you need to complete one form each for category --
three forms in all. If you are reporting to FAA and have
[all]{.underline} FAA categories of covered employees, you must submit
eight forms.\]*

*Here is a full listing of covered-employee categories:*

##### **FMCSA** (one category): Driver

***FAA** (eight categories): Flight Crewmember; Flight Attendant; Flight
Instructor; Aircraft Dispatcher; Aircraft Maintenance; Ground Security
Coordinator; Aviation Screener; Air Traffic Controller*

***RSPA** (one category): Operation/Maintenance/Emergency Response*

***FRA** (five categories): Engine Service; Train Service;
Dispatcher/Operation; Signal Service; Other \[Includes yardmasters,
hostlers (non-engineer craft), bridge tenders; switch tenders, and other
miscellaneous employees performing 49 CFR 228.5 (c) defined covered
service.\]*

***USCG** (one category): Crewmember*

***FTA** (five categories): Revenue Vehicle Operation; Revenue Vehicle
and Equipment Maintenance; Revenue Vehicle Control/Dispatch;
CDL/Non-Revenue Vehicle; Armed Security Personnel*

### [Section III. Drug Testing Data]{.underline}

This section summarizes the drug testing results for all covered
employees (to include applicants). The table in this section requires
drug test data by test type and by result. The categories of test types
are: Pre-Employment; Random; Post-Accident; Reasonable Suspicion /
Reasonable Cause; Return-to-Duty, and Follow-Up.

The categories of type of results are: Total Number of Test Results
\[excluding cancelled tests and blind specimens\]; Verified Negative;
Verified Positive; Positive for Marijuana; Positive for Cocaine;
Positive for PCP; Positive for Opiates; Positive for Amphetamines;
Refusals due to Adulterated, Substituted, "Shy Bladder" with No Medical
Explanation, and Other Refusals to Submit to Testing; and Cancelled
Results.

***[TIP]{.underline}** \~ Do not enter data on blind specimens submitted
to laboratories. Be sure to enter all pre-employment testing data
regardless of whether an applicant was hired or not. You do not need to
separate reasonable suspicion and reasonable cause drug testing data on
the MIS form. \[Therefore, if you conducted only reasonable suspicion
drug testing (i.e., FMCSA and FTA), enter that data; if you conducted
only reasonable cause drug testing (i.e., FAA, RSPA, and USCG); or if
you conducted both under FRA drug testing rules, simply enter the data
with no differentiation.\] For USCG, enter any "Serious Marine Incident"
testing in the Post-Accident row. For FRA, do not enter post accident
data (the FRA does not collect this data on the MIS form). Finally, you
may leave blank any row or column in which there were no results, or you
may enter "0" (zero) instead. Please note that cancelled tests are not
included in the "total number of test results" column.*

**Section III, Column 1. Total Number of Test Results** \~ This column
requires a count of the total number of test results in each testing
category during the entire reporting year. Count the number of test
results as the number of testing events resulting in negative, positive,
and refusal results. Do not count cancelled tests and blind specimens in
this total.

\[Example: A company that conducted fifty pre-employment tests would
enter "50" on the Pre-Employment row. If it conducted one hundred random
tests, "100' would be entered on the Random row. If that company did no
post-accident, reasonable suspicion, reasonable cause, return-to-duty,
or follow-up tests, those categories will be left blank or zeros
entered.\]

**Section III, Column 2. Verified Negative Results** \~ This column
requires a count of the number of tests in each testing category that
the Medical Review Officer (MRO) reported as negative. Do not count a
negative-dilute result if, subsequently, the employee underwent a second
collection; the second test is the test of record.

\[Example: If forty-seven of the company's fifty pre-employment tests
were reported negative, "47" would be entered in Column 2 on the
Pre-Employment row. If ninety of the company's one hundred random test
results were reported negative, "90" would be entered in Column 2 on the
Random row. Because the company did no other testing, those other
categories would be left blank or zeros entered.\]

**Section III, Column 3. Verified Positive Results \~ For One Or More
Drugs** \~ This column requires a count of the number of tests in each
testing category that the MRO reported as positive for one or more
drugs. When the MRO reports a test positive for two drugs, it would
count as one positive test.

\[Example: If one of the fifty pre-employment tests was positive for two
drugs, "1" would be entered in Column 3 on the Pre-Employment row. If
four of the company's one hundred random test results were reported
positive (three for one drug and one for two drugs), "4" would be
entered in Column 3 on the Random row.\]

**■ Section III, Columns 4 through 8. Positive** (for specific drugs) \~
These columns require entry of the by-drug data for which specimens were
reported positive by the MRO.

\[Example: The pre-employment positive test reported by the MRO was
positive for marijuana, "1" would be entered in Column 4 on the
Pre-Employment row. If three of the four positive results for random
testing were reported by the MRO to be positive for marijuana, "3" would
be entered in Column 4 on the Random row. If one of the four positive
results for random testing was reported positive for both PCP and
opiates, "1" would be entered in Column 6 on the Random row and "1"
would be entered in Column 7 of the Random row.\]

***[TIP]{.underline}** \~ Column 1 should equal the sum of Columns 2, 3,
9, 10, 11, and 12. Remember you have not counted specimen results that
were ultimately cancelled or were from blind specimens. So, Column 1 =
Column 2 + Column 3 + Column 9 + Column 10 + Column 11 + Column 12.
Certainly, double check your records to determine if your actual results
count is reflective of all negative, positive, and refusal counts.*

*An MRO may report that a specimen is positive for more than one drug.
When that happens, to use the company example above (i.e., one random
test was positive for both PCP and opiates), the positive results should
be recorded in the appropriate columns -- PCP and opiates in this case.
There is no expectation for Columns 4 through 8 numbers to add up to the
numbers in Column 3 when you report multiple positives.*

**Section III, Columns 9 through 12. Refusal Results** \~ The refusal
section is divided into four refusal groups -- they are: Adulterated;
Substituted; "Shy Bladder" \~ With No Medical Explanation; and Other
Refusals To Submit to Testing. The MRO reports two of these refusal
types -- adulterated and substituted specimen results -- because of
laboratory test findings.

When an individual does not provide enough urine at the collection site,
the MRO conducts or causes to have conducted a medical evaluation to
determine if there exists a medical reason for the person's inability to
provide the appropriate amount of urine. If there is no medical reason
to support the inability, the MRO reports the result to the employer as
a refusal to test: Refusals of this type are reported in the "Shy
Bladder" \~ With No Medical Explanation category.

Finally, additional reasons exist for a test to be considered a refusal.
Some examples are: the employee fails to report to the collection site
as directed by the employer; the employee leaves the collection site
without permission; the employee fails to empty his or her pockets at
the collection site; the employee refuses to have a required shy bladder
evaluation. Again, these are only four examples: there are more.

**■ Section III, Column 9. Adulterated** \~ This column requires the
count of the number of tests reported by the MRO as refusals because the
specimens were adulterated.

\[Example: If one of the fifty pre-employment tests was adulterated, "1"
would be entered in Column 9 of the Pre-Employment row.\]

**■ Section III, Column 10. Substituted** \~ This column requires the
count of the number of tests reported by the MRO as refusals because the
specimens were substituted.

\[Example: If one of the 100 random tests was substituted, "1" would be
entered in Column 10 of the Random row.\]

**■ Section III, Column 11. "Shy Bladder" \~ With No Medical
Explanation** \~ This column requires the count of the number of tests
reported by the MRO as being a refusal because there was no legitimate
medical reason for an insufficient amount of urine.

\[Example: If one of the 100 random tests was a refusal because of shy
bladder, "1" would be entered in Column 11 of the Random row.\]

**■ Section III, Column 12. Other Refusals To Submit To Testing** \~
This column requires the count of refusals other than those already
entered in Columns 9 through 11.

\[Example: If the company entered "100" as the number of random
specimens collected, however it had five employees who refused to be
tested without submitting specimens: two did not show up at the
collection site as directed; one refused to empty his pockets at the
collection site; and two left the collection site rather than submit to
a required directly observed collection. Because of these five refusal
events, "5" would be entered in Column 11 of the Random row.\]

***[TIP]{.underline}** \~ Even though some testing events result in a
refusal in which no urine was collected and sent to the laboratory, a
"refusal" is still a final test result. Therefore, your overall numbers
for test results (in Column 1) will equal the total number of negative
tests (Column 2); positives (Column 3); and refusals (Columns 9, 10, 11,
and 12). Do not worry that no urine was processed at the laboratory for
some refusals; all refusals are counted as a testing event for MIS
purposes and for establishing random rates.*

**Section III, Column 13. Cancelled Tests** \~ This column requires a
count of the number of tests in each testing category that the MRO
reported as cancelled. You must not count any cancelled tests in Column
1 or in any other column. For instance, you must not count a positive
result (in Column 3) if it had ultimately been cancelled for any reason
(e.g., specimen was initially reported positive, but the split failed to
reconfirm).

\[Example: If a pre-employment test was reported cancelled, "1" would be
entered in Column 13 on the Pre-Employment row. If three of the
company's random test results were reported cancelled, "3" would be
entered in Column 13 on the Random row.\]

**TOTAL Line. Columns 1 through 13** \~ This line requires you to add
the numbers in each column and provide the totals.

### 

### [Section IV. Alcohol Testing Data]{.underline}

This section summarizes the alcohol testing conducted for all covered
employees (to include applicants). The table in this section requires
alcohol test data by test type and by result. The categories of test
types are: Pre-Employment; Random; Post-Accident; Reasonable Suspicion /
Reasonable Cause; Return-to-Duty, and Follow-Up.

The categories of results are: Number of Screening Test Results;
Screening Tests with Results Below 0.02; Screening Tests with Results
0.02 Or Greater; Number of Confirmation Test Results; Confirmation Tests
with Results 0.02 through 0.039; Confirmation Tests with Results 0.04 Or
Greater; Refusals due to "Shy Lung" with No Medical Explanation, and
Other Refusals to Submit to Testing; and Cancelled Results.

***[TIP]{.underline}** \~ Be sure to enter all pre-employment testing
data regardless of whether an applicant was hired or not. Of course, for
most employers pre-employment alcohol testing is optional, so you may
not have conducted this type of testing. You do not need to separate
"reasonable suspicion" and "reasonable cause" alcohol testing data on
the MIS form. \[Therefore, if you conducted only reasonable suspicion
alcohol testing (i.e., FMCSA, FAA, FTA, and RSPA), enter that data; if
you conducted both reasonable suspicion and reasonable cause alcohol
testing (i.e.., FRA), simply enter the data with no differentiation.\]
RSPA does not authorize "random" testing for alcohol. Finally, you may
leave blank any row or column in which there were no results, or you may
enter "0" (zero) instead. Please note that USCG-regulated employers do
not report alcohol test results on the MIS form: Do not fill-out Section
IV if you are a USCG-regulated employer.*

**Section IV, Column 1. Total Number of Screening Test Results** **\~**
This column requires a count of the total number of screening test
results in each testing category during the entire reporting year. Count
the number of screening tests as the number of screening test events
with final screening results of below 0.02, of 0.02 through 0.039, of
0.04 or greater, and all refusals. Do not count cancelled tests in this
total.

\[Example: A company that conducted twenty pre-employment tests would
enter "20" on the Pre-Employment row. If it conducted fifty random
tests, "50' would be entered. If that company did no post-accident,
reasonable suspicion, reasonable cause, return-to-duty, or follow-up
tests, those categories will be left blank or zeros entered.\]

**Section IV, Column 2. Screening Tests With Results Below 0.02** \~
This column requires a count of the number of tests in each testing
category that the BAT or STT reported as being below 0.02 on the
screening test.

\[Example: If seventeen of the company's twenty pre-employment screening
tests were reported as being below 0.02, "17" would be entered in Column
2 on the Pre-Employment row. If forty-four of the company's fifty random
screening test results were reported as being below 0.02, "44" would be
entered in Column 2 on the Random row. Because the company did no other
testing, those other categories would be left blank or zeros entered.\]

**Section IV, Column 3. Screening Tests With Results 0.02 Or Greater**
\~ This column requires a count of the number of screening tests in each
testing category that BAT or STT reported as being 0.02 or greater on
the screening test.

\[Example: If one of the twenty pre-employment tests was reported as
being 0.02 or greater, "1" would be entered in Column 3 on the
Pre-Employment row. If four of the company's fifty random test results
were reported as being 0.02 or greater, "4" would be entered in Column 3
on the Random row.\]

**Section IV, Column 4. Number of Confirmation Test Results** \~ This
column requires entry of the number of confirmation tests that were
conducted by a BAT as a result of the screening tests that were found to
be 0.02 or greater. In effect, all screening tests of 0.02 or greater
should have resulted in confirmation tests. Ideally the number of tests
in Column 3 and Column 4 should be the same. However, we know that this
required confirmation test sometimes does not occur. In any case, the
number of confirmation tests that were actually performed should be
entered in Column 4.

\[Example: If the one pre-employment screening test reported as 0.02 or
greater had a subsequent confirmation test performed by a BAT, "1" would
be entered in Column 4 on the Pre-Employment row. If three of the four
random screening tests that were found to be 0.02 or greater had a
subsequent confirmation test performed by a BAT, "3" would be entered in
Column 4 on the Random row.\]

**Section IV, Column 5. Confirmation Tests With Results 0.02 Through
0.039** \~ This column requires entry of the number of confirmation
tests that were conducted by a BAT that led to results that were 0.02
through 0.039.

\[Example: If the one pre-employment confirmation test yielded a result
of 0.042, Column 5 of the Pre-Employment row would be left blank or
zeros entered. If two of the random confirmation tests yielded results
of 0.03 and 0.032, "2" would be entered in Column 5 of the Random row.\]

**Section IV, Column 6. Confirmation Tests With Results 0.04 Or
Greater** \~ This column requires entry of the number of confirmation
tests that were conducted by a BAT that led to results that were 0.04 or
greater.

\[Example: Because the one pre-employment confirmation test yielded a
result of 0.042, "1" would be entered in Column 6 of the Pre-Employment
row. If one of the random confirmation tests yielded a result of 0.04,
"1" would be entered in Column 6 of the Random row.\]

***[TIP]{.underline}** \~ Column 1 should equal the sum of Columns 2, 3,
7, and 8. The number of screening tests results should reflect the
number of screening tests you have no matter the result (below 0.02 or
at or above 0.02, plus refusals to test), unless of course, the tests
were ultimately cancelled. So, Column 1 = Column 2 + Column 3 + Column
7 + Column 8. Certainly, double check your records to determine if your
actual screening results count is reflective of all these counts.*

*There is no need to record MIS confirmation tests results below 0.02:
That is why we have no column for it on the form. \[If the random test
that screened 0.02 went to a confirmation test, and that confirmation
test yielded a result below 0.02, there is no place for that confirmed
result to be entered.\] We assume that if a confirmation test was
completed but not listed in either Column 5 or Column 6, the result was
below 0.02. In addition, if the confirmation test ended up being
cancelled, it should not have been included in Columns 1, 3, or 4 in the
first place.*

**Section IV, Columns 7 and 8. Refusal Results** \~ The refusal section
is divided into two refusal groups -- they are: Shy Lung \~ With No
Medical Explanation; and Other Refusals To Submit to Testing. When an
individual does not provide enough breath at the test site, the company
requires the employee to have a medical evaluation to determine if there
exists a medical reason for the person's inability to provide the
appropriate amount of breath. If there is no medical reason to support
the inability as reported by the examining physician, the employer calls
the result a refusal to test: Refusals of this type are reported in the
"Shy Lung \~ With No Medical Explanation" category.

Finally, additional reasons exist for a test to be considered a refusal.
Some examples are: the employee fails to report to the test site as
directed by the employer; the employee leaves the test site without
permission; the employee fails to sign the certification at Step 2 of
the ATF; the employee refuses to have a required shy lung evaluation.
Again, these are only four examples; there are more.

**■ Section IV, Column 7. "Shy Lung" \~ With No Medical Explanation** \~
This column requires the count of the number of tests in which there is
no medical reason to support the employee's inability to provide an
adequate breath as reported by the examining physician; subsequently,
the employer called the result a refusal to test.

\[Example: If one of the 50 random tests was a refusal because of shy
lung, "1" would be entered in Column 7 of the Random row.\]

**■ Section IV, Column 8. Other Refusals To Submit To Testing** \~ This
column requires the count of refusals other than those already entered
in Columns 7.

\[Example: The company entered "50" as the number of random specimens
collected, however it had one employee who did not show up at the
testing site as directed. Because of this one refusal event, "1" would
be entered in Column 8 of the Random row.\]

***[TIP]{.underline}** \~ Even though some testing events result in a
refusal in which no breath (or saliva) was tested, there is an
expectation that your overall numbers for screening tests (in Column 1)
will equal the total number of screening tests with results below 0.02
(Column 2); screening tests with results 0.02 or greater (Column 3); and
refusals (Columns 7 and 8). Do not worry that no breath (or saliva) was
tested for some refusals; all refusals are counted as a screening test
event for MIS purposes and for establishing random rates.*

**Section IV, Column 9. Cancelled Tests** \~ This column requires a
count of the number of tests in each testing category that the BAT or
STT reported as cancelled. Do not count any cancelled tests in Column 1
or in any other column other than Column 9. For instance, you must not
count a 0.04 screening result or confirmation result in any column,
other than Column 9, if the test was ultimately cancelled for some
reason (e.g., a required air blank was not performed).

\[Example: If a pre-employment test was reported cancelled, "1" would be
entered in Column 9 on the Pre-Employment row. If three of the company's
random test results were reported cancelled, "3" would be entered in
Column 13 on the Random row.\]

**TOTAL Line. Columns 1 through 9** \~ This line requires you to add the
numbers in each column and provide the totals.