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Release To Work Form 1C1 Maryland Transit Administration OVER-THE-COUNTER AND PRESCRIPTION DRUG POLICY Rev No. Issue Date: Supercedes Procedure/Bulletin No. Page 6 of 7 MARYLAND TRANSIT ADMINISTRATION -- SAFETY-SENSITIVE EMPLOYEE RELEASE TO WORK FORM FOR PRESCRIPTION MEDICATIONS ***************************************************************************************** 1. EMPLOYEE: Complete the “Employee’s Section” on the reverse of this form and provide the form to your prescribing physician for completion of the “Physician’s Section.” 2. PHYSICIAN: Please consider the following information and complete the “Physician’s Section” on the reverse of this form. Thank you for your assistance. ***************************************************************************************** CONSIDERATIONS A. The following list of medications of concern if used while performing safety-sensitive work is not definitive or all-inclusive, but is provided as a starting point for your consideration. Analgesics Aspirin w/codeine, Codeine, Darvocet, Darvon, Demerol, Dilaudid, Empirin Compound w/codeine, Levo-Dromoran, Methadone, Morphine, Percocet, Percodan, Soma Compound w/codeine, Talacet, Talwin, Tylenol w/codeine, and Vicodin. Anti-Motion Sickness Antivert, Dramamine, Marezine, Phenergan, Transderm-Scop. Tranquilizers & Sedatives Ativan, Denadryl, Centrax, Compazine, Dalmane, Diazepam, Equani, Halcion, Haldol, Libritabs, Librium, Limbitrol, Paxipam, Phenergan, Prolixin, Serax, Stelazine, Thorazine, Tranxene, Valium, Vlarelease, Xanax. Antidepressants Adapin, Amitriptyline, Asendin, Deprol, Desyrel, Elavil, Endep, Etrafon, Limbitrol, Lithium, Ludiomil, Marplan, Nardil, Norpramin, Pamelor, Parnate, Petrofrane, Sinequan, Surmontil, Tofranil, Triavil, Vivactil. Barbiturates Alurate, Butisol, Dilantin, Mebaral, Nembutal, Pentobarbital, Secobarbital, Seconal, Sedapap, Tuinal. Skeletal Muscle Relaxants Flexeril, Parafon, Soma. Non-Prescription Cough & Cold Remedies, Antihistamines Bendadryl, Bromfed, Chlrotrimetron, Comtrex, Contac, Deconamine, Dimetapp, Dristan, Drixoral, Externdryl, Fedahist, Kronofed, Naldecon, Nolamin, Novafed, Ornade, Phenergan, Rondec, Rynatan, Sinubid, Sinulin, Tavist-D. B. The employee should not be released to work unless you are comfortable that, given the safety-sensitive nature of this patient’s job duties, his/her medical history, current condition and possible side effects of the prescribed medication(s), it is your professional opinion that the medication(s) will have no adverse influence on the employee’s performance of his/her safety-sensitive job duties. Form 1C1- 2 sides (02/01/02) (over) Reviewed By: (Signature) (Date) Human Resources Department Management __________________________________________ Bus Operations Management __________________________________________ Light Rail Operations Management __________________________________________ Metro Rail Operations Management __________________________________________ Safety and Risk Management __________________________________________ _______________________________ __________________________________________ Approved By: Virginia White (Print Name) (Signature) January 25, 2002 (Date) Acting Administrator (Title)
Release To Work Form 1C1 Maryland Transit Administration OVER-THE-COUNTER AND PRESCRIPTION DRUG POLICY Rev No. Issue Date: Supercedes Procedure/Bulletin No. Page 7 of 7 RELEASE TO WORK FORM FOR PRESCRIPTION MEDICATIONS Form 1C1- 2 sides (02/01/02) ************************************************************************************************ Employee’s Section: Printed Name ________________________________________ SS# ____________________ Employee’s MTA Safety-Sensitive Job Function – check those that apply. Υ Operate a transit bus or train. Υ Operate a non-revenue service vehicle requiring a commercial driver’s license (e.g., trucks over 25,000 lbs.). Υ Control the dispatch or movement of transit buses or trains. Υ Maintain/repair transit buses or trains or the electro-mechanical systems controlling train movement. Υ Carry a firearm for security purposes. Υ Supervisor whose duties require the performance of any of the above functions. (Check those that apply.) Medication(s) currently being taken ___________________________________________________________________ I attest that the foregoing information is complete and correct. Employee Signature ____________________________________ Date ____________________ ************************************************************************************************ Physician’s Section: As the attending physician, I have prescribed the following medication(s) to be taken from ______ to ________. _________________________________________ ___________________ Name of Medication Dosage _________________________________________ ___________________ Name of Medication Dosage (PLEASE CHECK ONE OF THE FOLLOWING.) ! Employee may not perform safety-sensitive duties while taking this medication. (Employee – give form to your supervisor.) ! Employee released to perform safety-sensitive duties while taking this medication. (Employee – keep form on your person while at work.) ______________________________________________ ______________________ Physician’s Printed Name Telephone No. ______________________________________________ ______________________ Signature Date Reviewed By: (Signature) (Date) Human Resources Department Management __________________________________________ Bus Operations Management __________________________________________ Light Rail Operations Management __________________________________________ Metro Rail Operations Management __________________________________________ Safety and Risk Management __________________________________________ _______________________________ __________________________________________ Approved By: Virginia White (Print Name) (Signature) January 25, 2002 (Date) Acting Administrator (Title)
Page 1 and 2: U.S. Department of Transportation F
Page 3 and 4: REPORT DOCUMENTATION PAGE Form Appr
Page 5 and 6: Introduction The National Transport
Page 7 and 8: Policy The “Dear Colleague” let
Page 9 and 10: Policy System Name: Utah Transit Au
Page 11 and 12: UTA Management Drug & Alcohol Polic
Page 13 and 14: POLICY Number 1C1 Effective Date: 3
Page 15 and 16: POLICY Number 1C1 Effective Date: 3
Page 17: POLICY Number 1C1 Effective Date: 3
Page 21 and 22: ALCOHOL AND DRUG POLICY 2001 Revisi
Page 23 and 24: ALCOHOL AND DRUG POLICY Alcohol Pos
Page 25 and 26: OVER-THE-COUNTER MEDICATION To be C
Page 27 and 28: Subject: Substance Abuse- Drug Free
Page 29 and 30: SECTION XXX MEDICATION Applicants -
Page 31 and 32: Policy System Name: ATC/Vancom of N
Page 33 and 34: PROCEDURES
Page 35 and 36: In the third approach, the employer
Page 37 and 38: MEDICATION APPROVAL FORM (For Safet
Page 39 and 40: Procedures System Name: Maryland Tr
Page 41 and 42: Maryland Transit Administration SAF
Page 43 and 44: Procedures System Name: Orange Coun
Page 45 and 46: OVER-THE-COUNTER MEDICATION To be C
Page 47 and 48: Subject: Substance Abuse- Drug Free
Page 49 and 50: Disadvantages: Neither employees no
Page 51 and 52: Los Angeles County Metropolitan Tra
Page 53 and 54: Asendin Tablets X Aspirin X Astemiz
Page 55 and 56: Training The “Dear Colleague” l
Page 57 and 58: OVER-THE-COUNTER MEDICINES What’s
Page 59 and 60: ADVICE FOR AMERICANS ABOUT SELF-CAR
Page 61 and 62: Fact is, today’s OTC med icines
Page 63 and 64: You can help yourself read the labe
Page 65 and 66: ■ Do not use laxatives when you h
Page 67 and 68: PREGNANCY AND BREAST-FEEDING Drugs
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■ Never call medicine candy to ge
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For free bulk quantities, write: CO
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Training Aid Name: How to Read a Dr
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InteliHealth: Page 2 of 3 © 2002,
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Training Aid Name: Prescription Med
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Health Care: Prescription Medicines
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Training Aid Name: Quick Tips -When
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When you pick up your medicine at t
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Training Aid Name: A Guide to Manag
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Speak up The more information your
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Rx & OTC Medications Safety-sensiti
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Legal drugs can be a problem Legal
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Employee Substance Abuse Training
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Transit Employees Responsibility Pr
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PRESCRIPTION AND OVER-THE-COUNTER D
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Summary of Do's and Don'ts Medicati
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Training Aid Name: Public Transport
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MODULE 8: PRESCRIPTION DRUGS Notes
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View Graph 8-3 Since each of these
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Notes to the Instructor MODULE 9: O
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Other Substances View Graph 9-4 Bes
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Notes to the Instructor MODULE 10:
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Many times a marijuana joint is use
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Module 8: Prescription Drugs Exerci
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Module 9: Over-the-Counter Drugs Ex
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Prescription Drugs 8-1 MODULE 8: PR
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Prescription Drugs 8-3 TRANSIT EMPL
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Prescription Drugs 8-5 DRIVING SKIL
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Over-the-Counter Drugs 9-2 OVER-THE
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Over-the-Counter Drugs 9-4 COMMONLY
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Over-the-Counter Drugs 9-6 MODULE 9
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Combining Drugs 10-2 EFFECTS OF COM
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Combining Drugs 10-4 MODULE 10 DISC
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MODULE 8: PRESCRIPTION DRUGS Prescr
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Notes Prescription Drugs 41
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MODULE 9: OVER-THE-COUNTER DRUGS Ma
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Notes Over-the-Counter Drugs 45
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MODULE 10: COMBINING DRUGS Each of
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Notes Combining Drugs 49
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Module 8: Prescription Drugs Exerci
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Prescription & Over-the-Counter (OT
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Anti-Motion Sickness: Can cause; dr
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Antidepressants: Can cause; seizure
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Muscle Relaxers: Can cause; drowsin
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Points to Remember Every one is an
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RETENTION TIMES OF DRUGS IN URINE G
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MARYLAND TRANSIT ADMINISTRATION OVE
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Maryland Transit Administration Pre
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PRESCRIPTION AND OVER-THE- COUNTER
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NTSB Directive The National Transpo
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Definitions (Rx) • Prescription d
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Definitions (OTC) • Over-The-Coun
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FTA Recommended Policy Elements FTA
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Suggested Elements of an Rx/OTC Pol
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Suggested Management/ Supervisor Re
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Suggested Employee Roles and Respon
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Employee Warnings • Do not take l
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Employee Warnings (Cont.) • Chang
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Suggested Employer Physician/MRO Re
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Medical Review Procedural Model 2 (
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Suggested Employee Awareness Traini
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Summary • The primary objective o
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Common Anti-inflammatory and Pain M
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Common Antihistamines* (List not al
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Common Muscle Relaxants* (List not
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Common Stimulants* (List not all-in
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Possible Side Effects of Common OTC
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Possible Side Effects of OTC Cold a
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Common OTC Stimulants (List not all
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Post-Accident Documentation for Det
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17) If no alcohol test occurred bec
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1a) Name of medication: 1b) How muc
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APPENDICES
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BY ORDER OF THE SECRETARY OF THE AI
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AFI48-123 22 MAY 2001 163 A7.32.4.
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Rx and OTC Medication Lists Name: A
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MEDICATION WAIVERS - 134 -
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DISCUSSION: Medication side effects
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CLASS 2A: NO WAIVER ACTION REQUIRED
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CLASS 2B: INFORMATION ONLY , CHRONI
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CLASS 3: CHRONIC USE REQUIRING WAIV
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- 144 -
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Rx and OTC Medication Lists Name: V
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a result, Glaxo-Wellcome has volunt
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ACIP Influenza Recommendations - AF
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stopped. Note that the nasal spray
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in completing the FAA required docu
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Heart/cardiac medications: The FAA
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containing cocaine ("TAC"). There i
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Rx and OTC Medication List Name: Me
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NOTE: 1. Mouthwashes - Scope, Liste
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HOW DO THESE MEDICATIONS AFFECT YOU
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Internet Resources/Reference Materi
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