Release Of Information Form - Texas Department Of Transportation

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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 IA, to the employer listed in
Section IB. This release is in accordance with DOT regulation 49 CFR Part 40, Section25. I
understand that information to be released in Section II-A by my previous employer, is limited to
the following items in 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
6. Information obtained from previous employers of a drug and alcohol rule violation.
A. Employee Signature:
Previous Employer Name:
Phone #:
Fax #:
B. New Employer Name:
Phone #:
Fax #:
Designated Employer Representative:
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