Form Cg-719p - Dot/uscg Periodic Drug Testing Form - Us Coast Guard printable pdf download

DEPARTMENT OF

HOMELAND SECURITY U.S.

Expires 06/30/2012

DOT/USCG Periodic Drug Testing Form

OMB 1625-0040

COAST GUARD

Page 1

CG-719P (Rev 03/04)

INSTRUCTIONS: This form MAY be used to satisfy the requirements for “Periodic Drug Testing” in accordance with Title 46 CFR 16.220. If

you participate in a USCG “random or pre-employment drug test program,” this form may not be necessary. (See page 2 for details.)

NOTE: The cost of the drug test is the sole responsibility of the applicant, not the Coast Guard.

Section I - Applicant Consent

I certify that I am the described applicant and that I have provided the specimen(s) described below in accordance with Department of

Transportation procedures given in 49 CFR 40. I also understand that making in any way, a false or fraudulent statement, entry, or evidence

is a violation of the U.S. Criminal Code at Title 18 U. S. C. 1001 which subjects the violator to federal prosecution and possible

incarceration, fine, or both.

Name: (Last, First, Middle) of Applicant (Print or Type)

Social Security Number

Signature of Applicant

Date

Section II - Name of SAMHSA Accredited Laboratory (Type or Print)

Name

Address

Section III - Medical Review Officer

DATE SPECIMEN COLLECTED:

The laboratory report has been reviewed in accordance with

_______________________________________

procedures given in 49 CFR Part 40, Subpart G, and the

Specimen Analyzed For (DOT 5 Panel):

verified test results are: (CIRCLE ONE)

• Marijuana metabolite

NEGATIVE

• Cocaine metabolites

POSITIVE/SUBSTITUTED/ADULTERATED or

• Opiates metabolites

INVALID TEST (Test Cancelled)

• Phencyclidine

• Amphetamines

(Please complete the next block for all non-negative results)

FOR POSITIVE/ADULTERATED/CANCELLED DRUG TESTS ONLY: (To be reported to the nearest USCG

Marine Safety Office).

This specimen is verified POSITIVE for _______________________________________________________.

This specimen was identified as being SUBSTITUTED or containing the ADULTERANT:

_____________________________________________________________________________________________.

The test was CANCELLED because (insert reason):

I certify that I meet qualifications for a Medical Review Officer as outlined in Title 49 CFR 40.121. I have reviewed the

results and determined that the applicant's verified test result is in accordance with Title 49 CFR 40 Subpart G.

MEDICAL REVIEW OFFICER AUTHORITY:

MEDICAL REVIEW OFFICER CONTACT INFORMATION:

Name:

_______________________________________

(Printed)

Name:

_________________________________________

Signature:___________________________________________

_____________________________________

Address:

(MRO signature stamp is authorized for negative results only)

_____________________________________

Name of MRO Qualifying Organization:

___________________________________________________

_____________________________________

Registration Number Issed by Qualifying Organization:

Phone:

_________________________________________

"An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB

control number." "The Coast Guard estimates that the average burden for this report is 5 minutes. You may submit any comments concerning the

accuracy of this burden estimate or any suggestions for reducing the burden to: Commanding Officer, U. S. Coast Guard National Maritime Center,

100 Forbes Drive, Martinsburg, WV 25404 or Office of Management and Budget, Paperwork Reduction Project (1625-0040), Washington, DC

20503."

Form Cg-719p - Dot/uscg Periodic Drug Testing Form - Us Coast Guard

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