Pace Pace Drug & Alcohol Testing And Dot Physical Compliance Form printable pdf download

Pace Pace Drug & Alcohol Testing And Dot Physical Compliance Form

VANPOOL OFFICE USE ONLY

Cust #: _______________

Pace Drug & Alcohol Testing and DOT Physical Compliance Form

Agency/Municipality: ______________________________

Date: ______________________

Each time a driver is tested for drugs and alcohol, complete this form and send it to:

Pace Suburban Bus Service

Attn: Vanpool Services

550 West Algonquin Road

Arlington Heights, IL 60005

Please mark the envelope “Confidential”

EMPLOYEE INFORMATION

Name: ___________________________________________

Social Security #: __________________________________

TESTING INFORMATION RESULT:

Pre-Employment (NIDA-5 & Breath Alcohol): _________________________________

Post Accident (NIDA-5 & Breath Alcohol): ____________ Date of Accident: _________

Reasonable Suspicion (NIDA-5 & Breath Alcohol): ______________________________

Return to Duty/Follow-up (NIDA-5 & Breath Alcohol): __________________________

Biennial Recertification (10-Panel only/no Breath Alcohol): _______________________

DOT Medical Examiner Certificate: __________________________________________

(Please include a legible copy of the DOT card)

Random: ________________________________________________________________

Testing Facility: ________________________________________ Testing Date: ____________

This is to confirm that the employee named above was tested for drugs and alcohol in accordance with Pace

guidelines and FTA regulations, and is in compliance with Pace’s Drug and Alcohol Testing Policy. Evidence

of the testing is on file at the agency/municipality.

________________________________________________

__________________

Transportation Coordinator’s Signature

Date

11/9/2007

Pace Pace Drug & Alcohol Testing And Dot Physical Compliance Form