Order For Testing Form
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1To be completed by collection site personnel upon
arrival at site and returned to employer with
Employer’s copy of Chain of Custody Form.
ORDER FOR TESTING
____________ ____________ ____________
Time
Date
Collection Site
Personnel Initials
The Federal Transit Administration issued regulations (49 CFR Part 655)
_________________________________________
that require all safety-sensitive employees/applicants to submit to drug
Print Collection Site Personnel Name
and alcohol testing as a condition of employment in a safety-sensitive
position. Refusing to submit to testing; providing false information in
connection with said testing; adulterating, substituting, or tampering with the specimen; or failing to
cooperate with any part of the collection process is a violation of the regulations and of company policy.
Testing is to be accomplished on the date, time and location indicated below. You must present this
form at the collection site.
Print Full Name:________________________________________ ID # __________________________
Collection Site Location: ________________________________________________________________
You must report no later than __________________ am/pm, on ____________________________(date)
Failure to complete a drug and/or alcohol test will be considered a test refusal.
* Pre-employment tests = New applicants, transfer from a non-safety-sensitive position, return to active status.
** Return-to-Duty tests = Only performed following a positive/refusal to test and successful completion of SAP
counseling.
Type of Test:
Drug
Alcohol
Both
Test Authority:
DOT-FTA
Non-DOT
DOT- Other ____________________
Test Category:
Pre-employment*
Random
Post-accident
Reasonable Suspicion
Return-to-duty**
Follow-up
Retest, Specify: __________________________________________________
Yes
No
Observed Collection:
Transported:
Yes, By Whom:___________________________________________
No
Picture ID:
Yes
No
Other Special Instructions:_______________________________________________________________
Supervisor Authorizing Test: _________________________ __________________ ________________
Print Name
Date
Time Notified
Designated Employer Representative / DAPM:_________________________ _____________________
Print Name
Phone Number
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Parent category: Business