Form Doe F 470.7 - Human Reliability Program (Hrp) Alcohol Testing Form - 2003

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DOE F 470.7 (07/03)
OMB Control No. 1910-5122
U.S. Department of Energy (DOE)
Human Reliability Program (HRP) Alcohol Testing Form
(Instructions for completing this form are attached.)
STEP 1: TO BE COMPLETED BY ALCOHOL TECHNICIAN
Affix
A. Employee Name __________________________________________________________________
or
(Print)
First
M.I.
Last
print
B. Employee ID No.
__________________________________________________________
screening results
here.
C. Employer Name
__________________________________________________________
_____________________________________(____)________________
HRP Supervisor
Phone Number
D. Reason for Test:
Random Reasonable Susp. Post-Accident Return to Duty Follow-up
Pre-employment
STEP 2: TO BE COMPLETED BY EMPLOYEE
I certify that I am about to submit to alcohol testing required or permitted by U.S. Department of Energy regulations and that the
identifying information provided on the form is true and correct.
____________________________________________________________ ______________/_____/_______
Signature of Employee
Date
Month Day Year
STEP 3: TO BE COMPLETED BY ALCOHOL TECHNICIAN
Affix
(If the technician conducting the screening test is not the same technician who will be conducting the confirmation test, each
or
technician must complete their own form.) I certify that I have conducted alcohol testing on the above named individual in
print
accordance with the procedures established in the U.S. Department of Transportation regulation 49 CFR Part 40, that I am qualified
to operate the testing device(s) identified, and that the results are as recorded.
confirmation
results
Technician: BAT
Device: SALIVA BREATH*
15-Minute Wait: YES NO
here.
Screening Test: (For BREATH DEVICE* write in the space below only if the testing device is not designed to print.)
______ ___________________ _______________________________
_____________ ____________
____________
Affix
Test #
Testing Device Name
Device Serial # or Lot # & Exp. Date
Activation Time
Reading Time
Result
with
CONFIRMATION TEST: Results MUST be affixed to each copy of this form or printed directly onto the form.
tamper evident
tape.
REMARKS:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Affix
_______________________________________
___________________________________
or
Alcohol Technician=s Company
Company Street Address
print
_______________________________________
_______________________________(___)_________
additional
(PRINT) Alcohol Technician=s Name (First, M.I., Last)
Company City, State, Zip
Phone Number
results
______________________________________
____________/_____/_____
here.
Signature of Alcohol Technician
Date
Month Day Year
STEP 4: TO BE COMPLETED BY EMPLOYEE IF TEST RESULT IS 0.02 or HIGHER
Affix
I certify that I have submitted to the alcohol test, the results of which are accurately recorded on this form. I understand that I will
with
be sent home and will not be allowed to perform HRP duties for 24 hours because the results are 0.02 or greater.
tamper evident
tape.
_______________________________________________
______________/______/______
Signature of Employee
Date
Month
Day
Year
Make 2 Copies and Distribute: Original to employer; one copy for employee and one copy for Alcohol Technician.

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