U.S. DEPARTMENT OF TRANSPORTATION DRUG AND ALCOHOL TESTING MIS DATA
COLLECTION FORM

Calendar Year Covered by this Report: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
OMB No. 2105-0529

# I. Employer:

Company Name:

Doing Business As (DBA) Name (if applicable):

#######  Address:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ E-mail: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 

Name of Certifying Official: Signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

##  Telephone: (\_\_\_\_\_)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date Certified: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Prepared by (if different):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Telephone: (\_\_\_\_\_)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

C/TPA Name and Telephone (if applicable):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
(\_\_\_\_\_)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

## Check the DOT agency for which you are reporting MIS data; and complete the information on that same line as appropriate:

\_\_\_ FMCSA -- Motor Carrier: DOT #:
­­­\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Owner-operator: (circle
one) YES or NO Exempt (Circle One) YES or NO

\_\_\_ FAA -- Aviation: Certificate \# (if applicable):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Plan / Registration \#
(if applicable):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_ PHMSA -- Pipeline: (Check) Gas Gathering\_\_ Gas Transmission\_\_
Gas Distribution\_\_ Transport Hazardous Liquids\_\_ Transport Carbon
Dioxide\_\_

\_\_\_ FRA -- Railroad: Total Number of observed/documented Part 219
"Rule G" Observations for covered employees:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_ USCG -- Maritime: Vessel ID \# (USCG- or State-Issued):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
(If more than one vessel, list separately.)

\_\_\_ FTA -- Transit

**II. Covered Employees**: **(A) Enter Total Number Safety-Sensitive
Employees In All Employee Categories:**

**(B) Enter Total Number of Employee Categories**:

**(C)**

###### III. Drug Testing Data:

<table style="width:100%;">
<colgroup>
<col style="width: 16%" />
<col style="width: 8%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 4%" />
</colgroup>
<tbody>
<tr class="odd">
<td rowspan="2">Type of Test</td>
<td rowspan="2"><blockquote>
<p>Total Number Of Test Results [Should equal the sum of Columns 2, 3,
9, 10, 11, and 12]</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Verified Negative Results</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Verified Positive Results ~ For One Or More Drugs</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Positive For</p>
<p>Marijuana</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Positive For</p>
<p>Cocaine</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Positive For</p>
<p>PCP</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Positive For</p>
<p>Opiates</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Positive For</p>
<p>Amphetamines</p>
</blockquote></td>
<td colspan="4">Refusal Results</td>
<td rowspan="2"><blockquote>
<p>Cancelled Results</p>
</blockquote></td>
</tr>
<tr class="even">
<td><blockquote>
<p>Adulterated</p>
</blockquote></td>
<td><blockquote>
<p>Substituted</p>
</blockquote></td>
<td><blockquote>
<p>“Shy Bladder” ~ With No Medical Explanation</p>
</blockquote></td>
<td><blockquote>
<p>Other Refusals To Submit To Testing</p>
</blockquote></td>
</tr>
<tr class="odd">
<td>Pre-Employment</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Random</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Post-Accident</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Reasonable Susp./Cause</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Return-to-Duty</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Follow-Up</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>TOTAL</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

**IV. Alcohol Testing Data**:

<table>
<colgroup>
<col style="width: 17%" />
<col style="width: 11%" />
<col style="width: 11%" />
<col style="width: 11%" />
<col style="width: 10%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 6%" />
</colgroup>
<tbody>
<tr class="odd">
<td rowspan="2">Type of Test</td>
<td rowspan="2"><blockquote>
<p>Total Number Of Screening Test Results [Should equal the sum of
Columns 2, 3, 7, and 8]</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Screening Tests With Results Below 0.02</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Screening Tests With Results 0.02 Or Greater</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Number Of Confirmation Tests Results</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Confirmation Tests With Results 0.02 Through 0.039</p>
</blockquote></td>
<td rowspan="2"><blockquote>
<p>Confirmation Tests With Results 0.04 Or Greater</p>
</blockquote></td>
<td colspan="2">Refusal Results</td>
<td rowspan="2"><blockquote>
<p>Cancelled Results</p>
</blockquote></td>
</tr>
<tr class="even">
<td><blockquote>
<p>“Shy Lung” ~ With No Medical Explanation</p>
</blockquote></td>
<td><blockquote>
<p>Other Refusals To Submit To Testing</p>
</blockquote></td>
</tr>
<tr class="odd">
<td>Pre-Employment</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Random</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Post-Accident</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Reasonable Susp./Cause</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Return-to-Duty</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Follow-Up</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>TOTAL</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

+-----------------------------------------------------------------------+
| **PAPERWORK REDUCTION ACT NOTICE (as required by 5 CFR 1320.21)**     |
|                                                                       |
| According to the Paperwork Reduction Act of 1995, no persons are      |
| required to respond to a collection of information unless it displays |
| a valid OMB control number. The valid OMB control number for this     |
| information collection is 2105-0529. The Department of Transportation |
| estimates that the average burden for this report form is 1.5 hours.  |
| You may send comments regarding this burden estimate or any           |
| suggestions for reducing the burden to: U.S. Department of            |
| Transportation, Office of Drug and Alcohol Policy and Compliance,     |
| Room 10403, 400 Seventh Street, SW, Washington, D.C. 20590; OR Office |
| of Management and Budget, Paperwork Reduction Project, 725            |
| Seventeenth Street, NW, Washington, D.C. 20503.                       |
+-----------------------------------------------------------------------+

  -----------------------------------------------------------------------
  Title 18, USC Section 1001, makes it a criminal offense subject to a
  maximum fine of \$10,000, or imprisonment for not more than 5 years, or
  both, to knowingly and willfully make or cause to be made any false or
  fraudulent statements of representations in any matter within the
  jurisdiction of any agency of the United States.

  -----------------------------------------------------------------------