Release Of Information Form printable pdf download

Release of Information Form

Section I. To be completed by the new employer, signed by the employee, and transmitted to the previous employer:

Employee Printed Name: ________________________________________________________________________

Employee SS or ID Number: _____________________________________________________________________

I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer listed in Section I-

A. to the employer listed in Section I- B. This release is in accordance with DOT Regulation 49 CFR Part 40, Section 40.25. I understand that information to be

released in Section II-A by my previous employer, is limited to the following items for the past two years:

1. Alcohol tests with a result of 0.04 or higher;

2. Verified positive drug tests;

3. Refusals to be tested;

4. Other violations of DOT agency drug and alcohol testing regulations;

5. Documentation, if any, of completion of the return-to-duty process following a rule violation;

6. Information obtained from previous employers of a drug and alcohol rule violation.

Employee Signature: ______________________________________________________ Date: ________________

A. Previous Employer Name: _______________________________________________________________________

Address:

_____________________________________________________________________________________

Phone #: _______________________________________ Fax #: _______________________________________

B. New Employer Name: __________________________________________________________________________

Address: _____________________________________________________________________________________

_____________________________________________________________________________________

Phone #: _______________________________________ Fax #: _______________________________________

Designated Employer Representative: ______________________________________________________________

Section II. To be completed by the previous employer and transmitted to the new employer:

In the previous two years, for DOT-regulated testing:

1. Did the employee have alcohol tests with a result of 0.04 or higher?

YES ____ NO ____

2. Did the employee have verified positive drug tests?

YES ____ NO ____

3. Did the employee refuse to be tested?

YES ____ NO ____

4. Did the employee have other violations of DOT agency drug and

alcohol testing regulations?

YES ____ NO ____

5. If you answered “yes” to any of the above items, did the

employee complete the return-to-duty process?

N/A ____ YES ____ NO ____

6. Did a previous employer report a drug and alcohol rule

violation to you?

YES ____ NO ____

[NOTE: Previous employer, if you answered “yes” to any item in Section II-A, you must also transmit a copy / copies of the

appropriate documentation (e.g., CCFs, MRO results reports, BATFs, SAP reports, follow-up testing record) to the new employer.]

Name of person providing information in Section II-A: _______________________________________________

Title: ___________________________________________

Phone #: ________________________________________

Date: ___________________________________________

Kansas Department of Education / School Bus Safety

December 2013

Release Of Information Form

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