Form Cg-719p - Dot/uscg Periodic Drug Testing Form
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1
2DEPARTMENT OF
TRANSPORTATION
OMB-2115-0514
DOT/USCG Periodic Drug Testing Form
U.S. COAST GUARD
CG-719P (Rev 7/02)
Page 1
INSTRUCTIONS: This form MAY be used to satisfy the requirements for “Periodic Drug Testing” in accordance with Title 46
CFR 16.220. If you participate in a USCG “random or pre-employment drug test program,” this form may not be necessary. (See
page 2 for details).
NOTE: The cost of the drug test is the sole responsibility of the applicant, not the Coast Guard.
Section I – Applicant Consent
I certify that I am the described applicant and that I have provided the specimen(s) described below in accordance with Department
of Transportation procedures given in 49 CFR 40. I also understand that making in any way, a false or fraudulent statement, entry,
or evidence is a violation of the U.S Criminal Code at Title 18 U.S.C. 1001 which subjects the violator to federal prosecution and
possible incarceration, fine, or both.
Name: (Last, First, Middle) of Applicant (Print or Type)
Social Security Number
X
Signature of Applicant
Date
Section II – Name of SAMHSA Accredited Laboratory (Type or Print)
Name
Address
Section III – Medical Review Officer
DATE SPECIMEN COLLECTED:
The laboratory report has been reviewed in accordance with
_______________________________________
procedures given in 49 CFR Part 40, Subpart G, and the
Specimen Analyzed For (DOT 5 Panel):
verified test results are: (CIR CLE ONE)
• Marijuana metabolite
• Cocaine metabolites
NEGATIVE
• Opiates metabolites
POSITIVE/SUBSTITUTED/ADULTERATED or
• Phencyclidine
INVALID TEST (Test Cancelled)
• Amphetamines
(Please complete the next block for all non-negative results)
FOR POSITIVE/ADULTERATED/CANCELLED DRUG TESTS ONLY: (To be reported to the nearest USCG
Marine Safety Office).
This specimen is verified POSITIVE for _________________________________________________.
The specimen was identified as being SUBSTITUTED or containing the ADULTERANT:
______________________________________________________________.
The test was CANCELLED because (insert reason):
_______________________________________________________________________________________________
I certify that I meet the qualifications for a Medical Review Officer as outlined in Title 49 CFR 40.121. I have reviewed
the results and determined that the applicant’s verified test result is in accordance with Title 49 CFR 40 Subpart G.
MEDICAL REVIEW OFFICER CONTACT
MEDICAL REVIEW OFFICER AUTHORITY:
INFORMATION:
Name: (Printed) ___________________________________
Name:
__________________________________________
Signature: _______________________________________
(MRO signature stamp is authorized for negative results only)
Address: __________________________________________
Name of MRO Qualifying Organization:
__________________________________________
_______________________________________________
__________________________________________
Registration Number Issued by Qualifying Organization:
Phone:
__________________________________________
_____________________________________________
“An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a
valid OMB control number.” “The Coast Guard estimates that the average burden for this report is 5 minutes. You may submit any
comments concerning the accuracy of this burden estimate or any suggestions for reducing the burden to:
nd
Commandant (G-CIM), U. S. Coast Guard, 2100 2
Street, SW, Washington, DC 20593-0001 or Office of Management and Budget,
Paperwork Reduction Project (2115-0514), Washington, DC 20503.”
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