U.S. DEPARTMENT OF TRANSPORTATION DRUG AND ALCOHOL TESTING MIS DATA COLLECTION FORM
Calendar Year Covered by this Report: ________________
OMB No. 2105-0529
I. Employer:
Form DOT F 1385 (Rev. 5/2008)
Company Name:
Doing Business As (DBA) Name (if applicable):
Address:_______________________________________________________________________________ E-mail: _______________________
Name of Certifying Official:
Signature: _________________________________________________
Telephone: (_____)______________________________________ Date Certified: ___________________________________________________
Prepared by (if different): ________________________________________________________ Telephone: (_____)________________________
C/TPA Name and Telephone (if applicable): __________________________________________________ (_____)________________________
Check the DOT agency for which you are reporting MIS data; and complete the information on that same line as appropriate:
___ FMCSA – Motor Carrier: DOT #: ______________________ Owner-operator: (circle one) YES or NO
Exempt (Circle One) YES or NO
___ FAA – Aviation: Certificate # (if applicable): _______________________ Plan / Registration # (if applicable):___________________________
___ PHMSA – Pipeline: (Check) Gas Gathering__ Gas Transmission__ Gas Distribution__ Transport Hazardous Liquids__ Transport Carbon Dioxide__
___ FRA – Railroad: Total Number of observed/documented Part 219 “Rule G” Observations for covered employees: __________________________
___ USCG – Maritime: Vessel ID # (USCG- or State-Issued): ______________________________________ (If more than one vessel, list separately.)
___ FTA – Transit
II. Covered Employees: (A) Enter Total Number Safety-Sensitive Employees In All Employee Categories
:
(B) Enter Total Number of Employee Categories:
(C)
If you have multiple employee categories, complete Sections I
Employee Category
Total Number of Employees
and II (A) & (B). Take that filled-in form and make one copy for
in this Category
each employee category and complete Sections II (C), III, and IV
for each separate employee category.
III. Drug Testing
Data:
1
2
3
4
5
6
7
8
9
10
11
12
13
Refusal Results
Type of Test
Pre-Employment
Random
Post-Accident
Reasonable Susp./Cause
Return-to-Duty
Follow-Up
TOTAL
IV. Alcohol Testing Data:
1
2
3
4
5
6
7
8
9
Refusal Results
Type of Test
Pre-Employment
Random
Post-Accident
Reasonable Susp./Cause
Return-to-Duty
Follow-Up
TOTAL