Substance Abuse Screening Verification Form

THE CORPUS CHRISTI REGIONAL TRANSPORTATION AUTHORITY SUBSTANCE ABUSE SCREENING VERIFICATION

Applicants Name:

SSN:

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.

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):

** 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:
II-A. 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?

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 the 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 he employee complete the return-to-duty process?

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 Completing information in Section II-A:

Title:

Phone #:

Date:

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

Where would you like to go?

THE CORPUS CHRISTI REGIONAL TRANSPORTATION AUTHORITY SUBSTANCE ABUSE SCREENING VERIFICATION

Section II: To be completed by the previous employer and returned by mail or fax to the new employer: