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

INSTRUCTIONS FOR COMPLETING THE U.S. DEPARTMENT OF ENERGY HRP ALCOHOL TESTING FORM (ATF)

NOTE: Make two copies B forward original to employer; employee retains copy; and Alcohol Technician retains copy

STEP 1

The Breath Alcohol Technician (BAT) completes the information required in this step. Be sure to print the employee’s name and circle the reason for the

test. Print the HRP supervisor's name and phone number. The HRP supervisor is the person who initially or annually nominates the person for HRP

certification. In Step 1-D. Apost-accident@ should be circled for either occurrence or post-accident tests.

NOTE:

If the employee refuses to provide an I.D. number, be sure to indicate this in the remarks section in STEP 3. Proceed with STEP 2.

STEP 2

Instruct the employee to read, sign, and date the employee certification statement in STEP 2.

NOTE:

If the employee refuses to sign the certification statement do not proceed with the alcohol test. Contact the HRP Supervisor.

STEP 3

The BAT completes the information required in this step and checks the type of device (saliva or breath) being used. After conducting the alcohol screening

test, do the following (as appropriate):

Enter the information for the screening test (test number, testing device name, testing device serial number or lot number and expiration date, time of test with

any device-dependent activation times, and the results) on the front of the ATF. For a breath testing device capable of printing, the information may be part

of the printed record.

NOTE: Be sure to enter the result of the test exactly as it is indicated on the breath testing device, e.g., 0.00, 0.02, 0.04, etc.

Affix the printed information to the front of the form in the space provided, or to the back of the form, in a tamper-evident manner (e.g., tape), or the device

may print the results directly on the ATF. If the results of the screening test are less than 0.02, print, sign your name, and enter today’s date in the space

provided. The test process is complete.

If the results of the screening test are 0.02 or greater, a confirmation test must be administered in accordance with DOT regulations. An EVIDENTIAL

BREATH TESTING device that is capable of printing confirmation test information must be used in conducting this test.

Ensure that a waiting period of at least 15 minutes occurs before the confirmation test begins. Circle AYES@ or ANO@ to indicate whether the waiting period

lasted at least 15 minutes.

After conducting the alcohol confirmation test, affix the printed information to the front of the form in the space provided, or to the back of the form, in a

tamper-evident manner (e.g.,tape), or the device may print the results directly on the ATF. Print, sign your name, and enter the date in the space provided. Go

to STEP 4.

STEP 4

If the employee has a breath alcohol confirmation test result of 0.02 or higher, instruct the employee to read, sign, and date the employee certification

statement in STEP 4.

NOTE:

If the employee refuses to sign the certification statement in STEP 4, be sure to indicate this in the remarks line in STEP 3.

Immediately notify the HRP Supervisor if the employee has a breath alcohol confirmation test result of 0.02 or higher.

Make a copy for the employee, make a copy for the BAT records, and forward the original to the employer.

OMB Disclosure Statement

Public reporting burden for this collection of information is estimated to average six minutes per response, including the time for reviewing

instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden,

to Office of Business and Information Management, IM-10, GTN, Paperwork Reduction Project (1910-5122), U.S. Department of Energy, 1000

Independence Ave., SW, Washington, DC 20585-1290; and to the Office of Management and Budget (OMB), Paperwork Reduction Project (1910-

5122), Washington, DC 20503.

Privacy Act Statement

Sections 2165 and 2201(I) of title 42 of the United States Code authorize the collection of information by the U.S. Department of Energy (DOE) to

regulate the possession and use of special nuclear material and access to restricted data. DOE will use the information collected on this form to aid

in the determination of an individual=s eligibility for an HRP certification. The information may also be provided to other agencies of the United

States government for investigations that involve protection of the national security, public health and safety, or the environment. Submission of the

information requested on this form is voluntary, but failure to provide the information may result in denial of an HRP certification. If DOE uses the

information for purposes other than those indicated in this statement, it will provide notice of those additional purposes to persons who have

submitted information on this form.