Drug And Alcohol Testing Questionnaire Template - Connecticut Department Of Labor
Download a blank fillable Drug And Alcohol Testing Questionnaire Template - Connecticut Department Of Labor in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Drug And Alcohol Testing Questionnaire Template - Connecticut Department Of Labor with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1UC-843(Rev 7/17/15)
CONNECTICUT DEPARTMENT OF LABOR
Drug and Alcohol Testing Questionnaire
Case #:
CLAIMANT NAME:
SSN #:
Dear Employer:
The above named individual has indicated that his/her unemployment resulted from the failure of a drug/alcohol test.
Certain information regarding the test is required in order to determine the individual’s eligibility for unemployment
benefits and the extent of your account’s liability for any benefits which may be paid. The following release authorizes
you to disclose the information requested below for the purpose of determining the claimant’s eligibility for
unemployment benefits.
EMPLOYER NAME:
EMPLOYER REG #:
I hereby authorize the above named employer to release to the Department of Labor the information requested below
and any clarifying information that may be required for the purpose of determining my eligibility for unemployment
benefits.
CLAIMANT’S SIGNATURE:______________________________________ DATE:___________________
1. When was the drug/alcohol test administered?
2. What type of test was administered? (e.g., urinalysis test; breath alcohol test)
3. What was the nature of the test? (e.g., reasonable suspicion; pre-employment; random)
4. Explain in detail why the individual was referred for the test (e.g., in the case of “reasonable suspicion” testing,
what kind of behavior was observed and by whom?
5. Was the test mandated by federal law? Yes
No
Please explain:
6. Was the claimant legally disqualified under state or federal law from performing the job for which s/he was
hired as a result of the failure of the test? Yes
No
Please explain:
7. Please attach:
a copy of the Federal Drug Testing Custody and Control Form, if applicable
a copy of the Medical Review Officer’s certification of the test result, if applicable
a copy of the Breath Alcohol Testing Form with test results affixed, if applicable
in all cases, a copy of the applicable portion of the employer’s drug/alcohol testing policy
8. Rebuttal to information provided by the claimant is requested. Yes, copy attached
N/A
Please be advised that if your response to this questionnaire is not received
By
on
a decision will be issued based on the information available.
_________________________________ ________________
__________________
__________
EMPLOYER REPRESENTATIVE
TITLE
PHONE
DATE
R
:
ETURN THIS COMPLETED QUESTIONNAIRE AND ANY ADDITIONAL INFORMATION TO
A
S
:
:
F
:
DJUDICATIONS
PECIALIST
PHONE #
AX #
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Life