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CCRTA Board of Directors
Substance Abuse Screening Verification Form
THE CORPUS CHRISTI REGIONAL TRANSPORTATION AUTHORITY SUBSTANCE ABUSE SCREENING VERIFICATION
I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer, listed in Section 1 –B, to the employer listed in Section 1-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:
Alcohol test with a result of 0.04 or higher;
Verified positive drug tests;
Refusals to be tested;
Other violations of DOT agency drug and alcohol testing regulations;
Information obtained from previous employers of a drug and alcohol rule violation;
Documentation, if any, of completion of the return-to-duty process following a rule violation.
Max. file size: 500 MB.
MM slash DD slash YYYY
New Employer Name:
Designated Employer Representative:
Previous Employer Name:
Designated Employer Representative (if known):
** APPLICANT PLEASE COMPLETE THIS SECTION ONLY **
Section II: To be completed by the previous employer and returned by mail or fax to the new employer:
In the two years prior to the date of the employee’s signature (above), for DOT-regulated testing~
1.Did the employee have alcohol test with a result of 0.04 or higher?
2.Did the employee have verified positive drug tests?
3.Did the employee refuse to be tested?
4.Did the employee have other violations of DOT agency drug and alcohol testing regulations?
5.Did the previous employer report a drug and alcohol rule violation to you?
6.If you answered “yes” to any of the above items, did he employee complete the return-to-duty process?
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).
Name of Person Completing information in Section II-A:
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NOTE: Failure to furnish information required by 49 CFR Part 40, Section 40.25 within 14 days will result in the applicant being removed from any safety sensitive position. The applicant will be notified.
Return Form to CCRTA, Attn: HR Department, 5658 Bear Lane Corpus Christi, TX 78405 or Fax to 361.289.2765
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