If any substance is observed or indicated to be present, the substance observed or indicated must be removed prior to starting the 15 minute observation. Within the form, the employee gives the employer permission to test their urine, hair, blood, or any other physical sample for indicators of substance abuse. Tests performed under the employers authority will not be collected using dot forms. Dot drug and alcohol testing guide for dot employees. Download free printable drug test consent form samples in pdf, word and excel formats. Drug and alcohol screening assessment drug and alcohol assessment helps inform a comprehensive care and management plan that meets all of the needs of the individual. You are notified to appear to the facility above for a drug test as required by the wgmaila policy on drugs. Pursuant to the student random drug and alcohol policy, i authorize the following. Step 3 before you print off the document and hand it back to your employer, hr officer, or whoever is performing the drug test. Drugs that tend to slow the central nervous system. Fta postaccident drug and alcohol testing decision form. Please m ake copi es as needed and pleas e type or print l egibly. Page 90 drug and alcohol screening assessment u there is potential for largescale human and financial savings in increasing our recognition of and developing our response to cooccurring disorders u there is a need to improve the effectiveness of responses to highprevalence disorders anxiety, depression, and hazardous rather than dependent substance abuse.
A drug testing consent form is used by companies and organizations to conduct mandatory drug and alcohol tests for all of their employees. For first time offenders they will be allowed to return to work after a positive test if they. The dissemination of a tip is the last step in a process that begins with the recommendation of an. Drug and alcohol test consent form adobe pdf ms word. Create your own drug and alcohol testing policy sample. You are to proceed immediately to the collection site. Assessment of alcohol and other drug use behaviors among. I understand the results of the test may not be used in any criminal proceeding.
Drug test consent form 2 free templates in pdf, word. The screening test is performed first, and if it provides a positive result an alcohol concentration of. The procedures that will be used to test for alcohol or controlled substance. The drug and alcohol testing consent form is used by employers to screen applicants and employees for drug andor alcohol use. Driver preemployment controlled substances statement page 18. For group tests, record results on the drug and alcohol testing form. The federal transit administration fta drug and alcohol. Reason for t he clients referral in clude deta ils tha t lead to a form al eap referral by the em ployer if ap plicable. Step 1 the breath alcohol technician bat or screening test technician stt completes the information required in this step. Drug and alcohol testing program registration sample form.
Use this form when testing employees not regulated by dot. Most companies will demand this test or screening before they hire a job candidate for the position that he is applying for. Screening and assessment for alcohol and other drug abuse. When you have completed this form either fax to 0845 519 6471 or. An explanation of what constitutes a refusal to submit to a test. Alcohol use history use one or both of the following ways to take an alcohol use history.
To determine whether you have a federal, nonfederal or forensic form, look continue reading drug and alcohol testing forms faqs. Drugs that alter moods thoughts and sense perceptions. Fta suggested collection site drug test correction. Positiverefused drugalcohol test report by employer. Ensure you read through the entirety of the form before providing any information however. These kits can test for a wide range of drugs of abuse and are designed for urinebased drug testing. Free drug alcohol testing consent form word pdf eforms. Dot is committed to ensuring that information is available in appropriate alternative formats to meet the requirements of persons who have a disability. Drug and alcohol test referral form to ask for advice before or during the completion of this form or to request dna testing phone the fts admin team on 01924 480272. The test will usually require the patient to supply a hair or urine sample. Anyone who fails an initial breath alcohol test shall be retested 15 minutes after the first test. If alcohol testing is not conducted within 2 hours after the accident, document the reason for the delay on this form. Release of previous employers dot drugalcohol testing.
Assessment of alcohol and other drug use behaviors among adolescents ken c. Hillsborough high school to release specimens to the testing laboratoryies. I further understand that a positive test for alcohol and or drugs, or my refusal to authorize the tests by signing this form. Helps you comply with alcohol and drug testing procedure requirements. Use a ballpoint pen, press hard, and check all copies for legibility. Referal for random breath alcohol and drug testing form 3. Learn vocabulary, terms, and more with flashcards, games, and other study tools. Hillsborough high school student random drug and alcohol. Drug and alcohol testing consent form quick draws llc. Scientific consultant to the national institute on alcohol abuse and alcoholism, bethesda, md the corpus of formal psychometric instruments, research on these measures, and conceptual frameworks on psychological assessment is exten sive. A custody and control form, often called a ccf, is a fivepart carbon copy form used to document the information pertaining to a drug test.
Revision 11d jun 1, 2015 for more information on the faa drug and alcohol testing program, please visit. Afterwards the results of the test will be made known to the patient and, if positive, the employee or individual whos been tested may face consequences if the company operates a. It initially focuses on the cause of the presenting intoxication and secondarily aims to establish the persons drug and alcohol use frequency, level and risk. New directions provides professional drug and alcohol assessments and evaluations inperson, online or by phone for individuals in 48 states. If that is the case, stop all alcohol and drug use and proceed to. Documents and forms us department of transportation. Department of labors working partners for an alcohol and drugfree workplace program advisory assists users to build tailored drugfree workplace policies and provides guidance on how to develop a comprehensive drugfree workplace program. This appendix provides information about and samples of screening and assessment tools for substance use disorders. I have tested positive, or refused to test, on a dot preemployment drug or alcohol test for an employer who did not hire me in the past two years 3 years for cmv drivers, 5 years for pilots. The drug and alcohol test consent form allows a 3rd party, usually an employer, to conduct a quick medical examination. I understand that, should my testing results be confirmed positive or i refuse to test, i will be subject to the companys disciplinary action, including possible discharge. Drug and alcohol test referral form forensic testing. The breath alcohol test will be performed at the lsuhsc drug testing office by a trained breath alcohol technician bat. Drug and alcohol screening assessment queensland health.
Within the form, the employee gives the employer permission to test their urine. I hereby acknowledge that i have been advised of the citadel s policy on hallucinogenic, narcotic, and other controlled drugs and substances and drug paraphernalia and drug testing policy. Alcohol and drug counselor exam practice test updated 2020. This document provides guidance on the drug and alcohol testing for dot employees. In the description of each tool, the definition follows the tool acronym. Please specify the company for which this occurred below.
The indiana department of child services dcs will consider using drug screening as a component of a comprehensive assessment of the family when there is an allegation of substance abuse or an indication that substance abuse may be a factor in the report of child. Keep all your key alcohol and controlled substance forms in one spot. This form may also be justified by reasonable suspicion of drug or alcohol abuse. Review the drugalcohol procedures manual with new hire cdl drivers and with existing employees taking on cdlcovered functions. Drivers of cmvs can learn about drug and alcohol rules, types of tests required and their rights, responsibilities and requirements here. The alcohol use disorders identification test audit is a 10item screening tool developed by the world health organization who to assess alcohol consumption, drinking behaviors, and alcohol related problems. Attachment f is an explanation of positive test result form which should be used by the school district to request that the employee or job applicant submit.
Federal aviation administration, drug abatement division aam810 800 independence avenue, s. Step 2 enter your name at the top and that of the company. The authorization and instruction form will direct the clinic what type of tests to perform drug, alcohol or both, which ccf to use dot or nondot, what. Both a clinicianadministered version page 1 and a selfreport version of the audit page 2 are provided.
This consent form will remain in effect unless an activity drop form is completed. Be sure to print the employees name and check the box identifying the reason for the test. Agreeing to take a drug test will show an applicants willingness. Record the results and actions on the individual drug and alcohol test form. Test records for an individual test, record the results on the individual drug and alcohol test form.
Two verified drug andor alcohol violation an employee who has verified positive drug test results on two drug tests required by 14 cfrpart 120 and conducted after september 19, 1994 is permanently precluded from performing for an employer the safetysensitive duties the employee performed prior to the second drug test. Dot drug and alcohol testing guide for dot employees us. If no alcohol test is administered within 8 hours, cease all efforts to have the test administered and update the documentation. Types of alcohol tests employee screening services. I further understand that a positive test for alcohol andor drugs, or my refusal to authorize the tests by signing this form. If drug test is not conducted within 32 hours after the accident, cease all efforts to administer. A positive test for alcohol and or drugs, or my refusal to authorize the test s by signing this form, taking the specified test s or producing a specimen, may result in the following action. Drug and alcohol testing mis data collection form fmcsa. Release of information form 49 cfr part 40 drug and alcohol testing suggested format dot agency specific documents. I hereby agree, upon a request made under the drugalcohol testing policy of. Examples of screening and assessment tools for substance use disorders. Attachment a is a driver acknowledgmentdrug and alcohol testing policy materials form which should be used to document receipt of the policy and other materials by drivers and driver applicants. Create your own drug and alcohol workplace testing policy option 1 the u. Resources for employers as an employer, you have a responsibility to implement and conduct drug and alcohol testing programs.
Drug test consent form 2 free templates in pdf, word, excel. Consent form to release alcoholcontrolled substances test. Applicants rejection of my employment application for public safety related positions for one year or until i. Afterwards the results of the test will be made known to the patient and, if positive, the employee or individual whos been tested may face consequences if the company operates a drug free work. Department of psychiatry university of minnesota, minneapolis, mn alcohol and other drug aod involvement by adolescents is still a major public health issue in this country. Shop the forms you need for a compliant drug and alcohol testing program. Drug and alcohol test referral form to ask for advice before or during the completion of this form or to request dna testing phone the fts admin team on 0845 519 6472 01924 480272.
789 1156 99 859 875 1282 547 719 1374 217 486 888 1267 698 617 1552 396 1102 205 723 1213 458 1111 1563 220 89 1250 1348 1048 1060 230 410 242 370 1058 616 164 1033 1151 1489 1206