Post-Accident Alcohol And Drug Test Documentation Form printable pdf download

POST ACCIDENT ALCOHOL AND DRUG TEST DOCUMENTATION FORM

Driver/Employee: _______________________ was involved in a commercial motor vehicle

accident on ________________, at _______am/pm, requiring the administration of post-accident

alcohol and drug tests pursuant to 49 CFR § 382.303. The company was first notified of the

accident at ______ am/pm on______________, by ________________________ . The accident

occurred at or near______________________________________________. The following

efforts were undertaken to have the employee tested as required by the regulations:

_____________________________________________________________________________

_____________________________________________________________________________.

ALCOHOL TESTING

Time of completed alcohol test ____________am/pm. An alcohol test was administered within two

hours of the accident that demonstrated a blood alcohol concentration of _______________. An

alcohol test could not be administered to the employee within two hours of the accident because:

_____________________________________________________________________________

_____________________________________________________________________________.

An alcohol test was administered after _____________ hours (but not more than eight), which

demonstrated a blood alcohol concentration of ____________. An alcohol test was not

administered within eight hours of the accident because:

____________________________________________________________________________

_____________________________________________________________________________

If an alcohol test was not administered within eight hours, list any facility (name, address, phone

#) that could have performed a blood alcohol test:

_____________________________________________________________________________

DRUG TESTING

Time of completed urine collection __________________ am/pm.

A drug test (check one)

was

was not

administered within 32 hours of the accident.

A drug test was not administered within 32 hours because:

_____________________________________________________________________________

____________________

_______________________

Designated Employee Representative (DER)

Date

TABLE FOR §382.303(A) and (B)

Type of accident involved

Citation issued to the CMV

Test must be performed by

driver

employer

i. Human fatality

YES

ii. Bodily injury with immediate medical

YES

treatment away from the scene

iii. Disabling damage to any motor vehicle

YES

requiring tow away

Post-Accident Alcohol And Drug Test Documentation Form

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