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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
#: ____________________________________ Fax #:
_________________________________________
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:
___________________________________________
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