Request For Dot Drug And Alcohol Testing Information From Previous Employer Template
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2REQUEST FOR DOT DRUG AND ALCOHOL TESTING INFORMATION
FROM PREVIOUS EMPLOYER
PLEASE RETURN TO:
COMPANY:_______________________________________________________________________________________
ADDRESS: _______________________________________________________________________________________
CITY, ST. ZIP:_____________________________________________________________________________________
ATTENTION:_________________________________________________________PHONE:______________________
(Name of individual requesting information)
APPLICANT NAME:________________________________________________SSN:____________________________
Pursuant to Federal Regulation 49 CFR part 40.25, please furnish the requested information.
I hereby authorize_________________________________________________________________________________
(Previous employer’s name)
to release the alcohol and controlled substances testing information listed below to the above named company.
SIGNED:____________________________________________________________________DATE:_______________
(Signature of employee)
WITNESS: ________________________________________________________________DATE:_________________
Previous employer must supply the following information regarding the above named individual during the past two years
while employed to perform DOT covered safety sensitive functions:
YES
NO
1. Alcohol tests with a result of 0.04 or higher alcohol concentration?
(
)
(
)
2. Verified positive drug tests?
(
)
(
)
3. Refusals to be tested (including verified adulterated or substituted drug test results)? (
)
(
)
4. Other violations of DOT agency drug and alcohol testing regulations?
(
)
(
)
5. Did a previous employer report a drug or alcohol rule violation to you?
(
)
(
)
6. If the answer is “yes” to any of the above items, did the employee complete the
return-to-duty process?
(
)
(
)
SIGNED:____________________________________________________________________DATE:_______________
(Signature of individual supplying information)
If the answer to item #5 is “yes”, then you must provide the previous employer’s report even though it may be outside the
two year time period. 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 records, etc.). If you referred the individual to a Substance Abuse
Professional please supply the following information.
NAME: __________________________________________________________________________________________
ADDRESS:_______________________________________________________________________________________
CITY, ST. ZIP:__________________________________________________________ PHONE:___________________
DISA, INC.
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