Prescription and Over-the-Counter Medications Tool Kit ... - Home

Maryland Transit Administration
Prescription & Over-the Over the-Counter Counter Drug Policy
Safety Sensitive Employee’s responsibility before
taking a PRESCRIP TION
PRESCRIP TION medication
V obtain form 1C1 from
- your Supervisor
- the MTA’s Benefits Department
at 410-767-3850
(if you forget once you have reached
your Doctor’s office you can request
one be faxed by calling the MTA’s
Benefits Department)
Maryland Transit Administration
Prescription & Over-the Over the-Counter Counter Drug Policy
FORM 1C1
Maryland Transit Administration
Prescription & Over-the Over the-Counter Counter Drug Policy
You complete this section of form 1C1 prior to giving it to your Doctor.
R ELEA SE TO WOR K FORM FOR PR ESC R IPTION MED IC A TION S
Emplo y ees Sect io n:
N a me: ___ __ __ __ ___ _ SS# : _ __ ___ __ __ __ __
Emplo y ee’s FTA Safety Sensitiv e Jo b Functio n - check tho se tha ta pply
Opera te a transit bus o r tra in
Opera te a non-rev enue serv ice v ehicle requir ing a C D L ( e.g . truckso v er 25 ,00 0 lbs.)
Co nt ro l the dispatch or movement oftransit buses or trains
M a int a in/repa ir t ransit buses o r t ra ins o r t he elect ro -mechanica l sy st ems cont ro lling
train movement.
C a rry a firea rm f o r securit y purpo ses.
Superv iso r w ho se dut ies require t he perf o rma nce of a ny of t he abov e f unct ions.
(C heck which a pplies)
Medica t io ns currently being ta ken __ ___ __ __ __ ___ __ __ __ ___ __ _
I a tt est t hat t he fo reg o ing info rma tion is co mplet e a nd co rrect .
Emplo y ee Sig nat ure __ __ __ __ ___ __ __ __ __ D a t e_ __ __ __ _