Form Cg-719p - Dot/uscg Periodic Drug Testing Form Page 2
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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 2
•
A drug test is required for all transactions EXCEPT endorsements, duplicates and STCW certificates.
REQUIREMENTS
•
ONLY a DOT 5 Panel (SAMHSA 5 Panel, formerly NIDA 5), testing for Marijuana, Cocaine,
Opiates, Phencyclidine, and Amphetamines will be accepted.
•
A USCG drug test conducted within the past 185 days by a laboratory accredited by Substance Abuse
and Mental Health Services Administration (SAMHSA), Department of Health and Human Services.
•
COLLECTION of a urine sample may be conducted by an independent medical facility, private
physician or at an employer-designated site as long as the collection agent meets the qualification
OPTION I
requirements to be a collection agent given Title 49 CFR Part 40.31. It is CRITICAL that the sample is
sent to an accredited SAMHSA laboratory for ANALYSIS or the drug test is invalid. The SAMHSA
approved laboratory list can be obtained at
PERIODIC TESTING
A list of service agents that can assist in meeting these requirements is included or a list of service
PROGRAM
agents can be obtained at
•
The ORIGINAL results are required. A FACSIMILE is acceptable, if it is originated from the
Medical Review Officer (MRO) or the Service Agent assisting the mariner, and sent directly to our
office. The drug test result must be signed and dated by the MRO or by a representative of the service
agent who assisted you in meeting this requirement.
•
An ORIGINAL DATED letter on marine employer stationary or, for ACTIVE DUTY MILITARY
MEMBERS, an ORIGINAL DATED letter from your command on command letterhead attesting to
participation in random drug testing programs.
OPTION II
EXAMPLE (From Marine Employers): APPLICANT’S NAME / SSN has been subject to a random
testing program meeting the criteria of Title 46 CFR 16.230 for at least 60 days during the previous 185
RANDOM TESTING
days and has not failed nor refused to participate in a chemical test for dangerous drugs.
EXAMPLE (Active Duty Military/Military Sealift Command/N.O.A.A./ Army Corps of Engineers):
APPLICANT’S NAME / SSN has been subject to a random testing program and has never refused to
participate in or failed a chemical drug test for dangerous drugs.
•
OPTION III
An ORIGINAL DATED letter on marine employer stationary signed by a company official, stating
that you have passed a pre-employment chemical test for dangerous drugs within the past 185 days.
PRE-EMPLOYMENT
EXAMPLE: APPLICANT’S NAME / SSN passed a chemical test for dangerous drugs, required under Title
46 CFR 16.210 within the previous six months of the date of this letter with no subsequent positive drug
TESTING
test results during the remainder of the six month period.
PRIVACY ACT STATEMENT
IN ACCORDANCE WITH 5 U. S. C. 552a(e)(3), THE FOLLOWING INFORMATION IS PROVIDED TO YOU WHEN SUPPLYING PERSONAL
INFORMATION TO THE U.S. COAST GUARD.
1.
AUTHORITY WHICH AUTHORIZED THE SOLICITATION OF INFORMATION 46 U. S. C. 7302, 7305, 7314, 7316, 7319, AND 7502 (SEE 46 CFR
PARTS 10, 12, 13, AND 16).
2.
PRINCIPLE PURPOSES FOR WHICH INFORMATION IS INTENDED TO BE USED:
A.
TO ESTABLISH ELIGIBILITY FOR A MERCHANT MARINER’S LICENSE AND DOCUMENT ISSUED BY THE COAST GUARD.
B.
TO ESTABLISH AND MAINTAIN A CONTINUOUS RECORD OF THE PERSON’S DOCUMENTATION TRANSACTIONS.
C.
PART OF THE INFORMATION IS TRANSFERRED TO A FILE MANAGEMENT COMPUTER SYSTEM FOR A PERMANENT
RECORD.
3.
THE ROUTINE USES WHICH MAY BE MADE OF THE INFORMATION:
A.
TO MAINTAIN RECORDS REQUIRED BY 46 U. S. C. 7319 AND 7502.
B.
TO ENABLE ELIGIBLE PARTIES (i.e. the mariner’s heirs or properly designated representative) TO OBTAIN INFORMATION.
C.
TO PROVIDE INFORMATION TO THE U.S. MARITIME ADMINISTRATION FOR USE IN DEVELOPING MANPOWER STUDIES
AND TRAINING BUDGET NEEDS.
D.
TO DEVELOP INFORMATION AT THE REQUEST OF COMMITTEES OF CONGRESS.
E.
TO PROJECT BILLET ASSIGNMENTS AT COAST GUARD MARINE INSPECTION/SAFETY OFFICES.
F.
TO PROVIDE INFORMATION TO LAW ENFORCEMENT AGENCIES FOR CRIMINAL OR CIVIL LAW ENFORCEMENT PURPOSES.
G.
TO ASSIST U.S. COAST GUARD INVESTIGATING OFFICERS AND ADMINISTRATIVE LAW JUDGES IN DETERMINING
MISCONDUCT, CAUSES OF CASUALTIES, AND APPROPRIATE SUSPENSION AND REVOCATION ACTIONS.
4.
WHETHER OR NOT DISCLOSURE OF SUCH INFORMATION IS MANDATORY OR VOLUNTARY (Required by law or optional ) AND THE
EFFECTS ON THE INDIVIDUAL, IF ANY, OF NOT PROVIDING ALL OR PART OF THE REQUESTED INFORMATION IS VOLUNTARY,
DISCLOSURE OF THIS INFORMATION IS VOLUNTARY, BUT FAILURE TO PROVIDE MAY RESULT IN NON-ISSUANCE OF THE
REQUESTED DOCUMENT(S).
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