Staffuptransportation

    Section I. To be completed by the new employer, signed by the employee, and transmitted to the previous employer:


    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.


    I-A.






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

    Complete the following for any accidents included on your accident register (§390.15(b)) that involved the applicant in the 3 years prior to the application date shown above, or check † here if there is no accident register data for this driver.

    Date

    Location

    # Injuries

    # Fatalities

    Hazmat Spill

    1

    2

    3

    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?

    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 a previous employer report a drug and alcohol rule violation to you?

    6. If you answered “yes” to any of the above items, did the 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).
    II-B.

    Name of person providing information in Section II-A:
    Title:
    Phone:
    Date:
    [multistep step4 "https://staffuptransportation.com/step5/"]