Implementation Guidelines - Federal Transit Administration - U.S. ...

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U.S. DEPARTMENT OF TRANSPORTATION DRUG AND ALCOHOL TESTING MIS DATA COLLECTION FORM Calendar Year Covered by this Report: ________________ OMB No. 2105-0529 I. Employer: Company Name: Doing Business As (DBA) Name (if applicable): Address:_______________________________________________________________________________ E-mail: ________________________ Name of Certifying Official: Signature: _________________________________________________ Telephone: (_____)______________________________________ Date Certified: ___________________________________________________ Prepared by (if different): ________________________________________________________ Telephone: (_____)________________________ C/TPA Name and Telephone (if applicable): __________________________________________________ (_____)________________________ Check the DOT agency for which you are reporting MIS data; and complete the information on that same line as appropriate: ___ FMCSA – Motor Carrier: DOT #: ______________________ Owner-operator: (circle one) YES or NO Exempt (Circle One) YES or NO ___ FAA – Aviation: Certificate # (if applicable): _______________________ Plan / Registration # (if applicable):___________________________ ___ RSPA – Pipeline: (Check) Gas Gathering__ Gas Transmission__ Gas Distribution__ Transport Hazardous Liquids__ Transport Carbon Dioxide__ ___ FRA – Railroad: Total Number of observed/documented Part 219 “Rule G” Observations for covered employees: __________________________ ___ USCG – Maritime: Vessel ID # (USCG- or State-Issued): ______________________________________ (If more than one vessel, list separately.) ___ FTA – <strong>Transit</strong> II. Covered Employees: (A) Enter Total Number Safety-Sensitive Employees In All Employee Categories: (B) Enter Total Number of Employee Categories: (C) Employee Category Total Number of Employees in this Category If you have multiple employee categories, complete Sections I and II (A) & (B). Take that filled-in form and make one copy for each employee category and complete Sections II (C), III, and IV for each separate employee category. Test Of Number Total III. Drug Testing Data: 1 2 3 4 5 6 7 8 9 10 11 12 Type of Test Refusal Results Pre-Employment Random Post-Accident Reasonable Susp./Cause Return-to-Duty Follow-Up TOTAL IV. Alcohol Testing Data: Results [Should equal the sum of Columns 2, 3, 9, 10, 11, and 12] Type of Test Total Number Of Pre-Employment Random Post-Accident Reasonable Susp./Cause Return-to-Duty Follow-Up TOTAL Verified Negative Results Verified Positive Results ~ For One Or More Drugs Positive For Marijuana Positive For Cocaine Positive For PCP Positive For Opiates Positive For Amphetamines Adulterated Substituted “Shy Bladder” ~ With No Medical Explanation Other Refusals To Submit To Testing 1 2 3 4 5 6 7 8 9 Screening Test Results [Should equal the sum of Columns 2, 3, 7, and 8] Screening Tests With Results Below 0.02 Screening Tests With Results 0.02 Or Greater Number Of Confirmation Tests Results Confirmation Tests With Results 0.02 Through 0.039 Confirmation Tests With Results 0.04 Or Greater Refusal Results “Shy Lung” ~ With No Medical Explanation Other Refusals To Submit To Testing Cancelled Results Cancelled Results 13
PAPERWORK REDUCTION ACT NOTICE (as required by 5 CFR 1320.21) According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 2105-0529. The Department of Transportation estimates that the average burden for this report form is 1.5 hours. You may send comments regarding this burden estimate or any suggestions for reducing the burden to: U.S. Department of Transportation, Office of Drug and Alcohol Policy and Compliance, Room 10403, 400 Seventh Street, SW, Washington, D.C. 20590; OR Office of Management and Budget, Paperwork Reduction Project, 725 Seventeenth Street, NW, Washington, D.C. 20503. Title 18, USC Section 1001, makes it a criminal offense subject to a maximum fine of $10,000, or imprisonment for not more than 5 years, or both, to knowingly and willfully make or cause to be made any false or fraudulent statements of representations in any matter within the jurisdiction of any agency of the United States.
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October 2009 Implementation Guideli
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Notice This document is disseminate
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METRIC/ENGLISH CONVERSION FACTORS E
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Table of Contents Chapter 1. INTROD
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Table of Contents (continued) Secti
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Chapter 1. INTRODUCTION Section 1.
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Transit employers may go beyond the
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Recommendation: Know the Regulation
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Sample Documentation Chapter 1. Int
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DHHS-Certified Laboratories, Center
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FTA Drug and Alcohol Management Inf
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Research And Special Programs Admin
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employment in safety-sensitive posi
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What happens in these cases? The pu
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Section 3. SAFETY-SENSITIVE • Ope
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performing the volunteer service ar
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Safety-sensitive Examples of Nation
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• A description of the consequenc
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projects, the employer should notif
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Sample Documentation Chapter 2. Reg
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Certification of Compliance for FTA
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4. Atlanta Federal Center Suite 17T
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1. Liability of Service Agents Yasu
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plaintiffs agreed that their positi
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FTA and FMCSA Regulatory Comparison
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FTA and FMCSA Regulatory Comparison
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process ensures that all critical c
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Chapter 3. Program Formulation 3-4
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Chapter 4. POLICY DEVELOPMENT AND C
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concentration of 0.04 or greater th
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has a confirmed alcohol concentrati
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MRO before the employer is notified
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policy with the requirement to form
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Do not assume that your contractors
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PRE-EMPLOYMENT DRUG TESTING NOTIFIC
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Sample Program Notification Letter
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authorized by the employer to make
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The 60 minutes of awareness trainin
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medications which could result in p
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employees who have problems with pr
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particular alcohol testing device t
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emain current with the regulations
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− Changes in Rules, Guidance and
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Exhibit 5-1 Summary of Education an
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Exhibit 5-3 Typical Agenda for Supe
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Exhibit 5-4 REASONABLE SUSPICION TR
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Chapter 6. TYPES OF TESTING Six typ
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Previous DOT Employer Record Check
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the “insufficient volume” proce
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for employees what is meant by on-d
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Nonfatal accidents involving a bus,
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Testing for drugs and alcohol follo
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iases in the process. To be conside
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1. Determine how frequently random
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In many small transit systems, ever
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Before making the return-to-duty re
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up testing program. The SAP must do
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Employee Discharged BAC >= 0.04 Con
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Employee Discharged Split Specimen
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Sample Documentation Chapter 6. Typ
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1) Accident Report Number: 2) Locat
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Chapter 7. DRUG TESTING PROCEDURES
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Recommendation Multiple Collection
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spouse, relative) or a close person
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The DOT requires the new version of
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9. The collector must direct the em
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evening contact telephone numbers i
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temperature range (90.0 to 100.0 F)
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publishes its final rule establishi
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for the preceding 6 months ending o
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Chapter 7. Drug Testing Procedures
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• The MRO will verify the test re
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The MRO may change a verified test
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direct the DER to have the employee
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employee for a retest under direct
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Sample Documentation Chapter 7. Dru
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Collection Site Checklist (cont.) (
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12. You may now wash your hands and
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Privacy Act Statement: (For Federal
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than an EBT, that is approved by th
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Breath Alcohol Technician (§40.213
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availability and the need for backu
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At the conclusion of the screen tes
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sufficient amount of breath. A medi
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In addition to stipulating the cons
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Sample Documentation Chapter 8. Alc
Page 178 and 179: [Federal Register: May 4, 2001 (Vol
Page 180 and 181: The Conforming Products List is the
Page 182 and 183: Highway Safety Programs; Model Spec
Page 184 and 185: 45420 Federal Register / Vol. 65, N
Page 186 and 187: 45422 Federal Register / Vol. 65, N
Page 188: U.S. Department of Transportation (
Page 194 and 195: Section 1. SAP QUALIFICATIONS A sub
Page 196 and 197: Education/Treatment Program Referra
Page 198 and 199: Employers are not required to follo
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Page 202 and 203: 10 weeks, with most sessions schedu
Page 204 and 205: _____________________________ _____
Page 206 and 207: FOLLOW-UP TESTING PROCESS SAP Input
Page 208 and 209: Alcohol Test Results
Page 210 and 211: when the applicant was assigned saf
Page 212 and 213: may arrange to have the consortium
Page 214 and 215: • Employers and service agents sh
Page 216 and 217: The list of randomly selected trans
Page 218 and 219: A. At a Nonprofit Agency or Indepen
Page 220 and 221: Reporting Period: Laboratory Name a
Page 222 and 223: Record Retention Checklists (page 2
Page 224 and 225: Retains CCF1 Split Lab - CCF1 Labor
Page 226 and 227: CCF1 Split Lab Retains - CCF1 Labor
Page 230 and 231: Chapter 11. CONSORTIA AND THIRD PAR
Page 232 and 233: Greater Expertise. The FTA and DOT
Page 234 and 235: Section 2. CONSIDERATIONS IN ESTABL
Page 236 and 237: esults (≥0.02) between the BAT an
Page 238 and 239: consideration. Thus, the more diver
Page 240 and 241: Section 5. IS A CONSORTIUM RIGHT FO
Page 242 and 243: • Procurement of testing services
Page 244 and 245: • Consider which consortium model
Page 246 and 247: Exhibit 11-1 Role of State DOTs in
Page 248 and 249: Exhibit 11-3 CONSORTIA RESPONSIBILI
Page 250 and 251: Chapter 12. PROGRAM MONITORING As a
Page 252 and 253: • Conduct periodic review of serv
Page 254 and 255: compliance. You are encouraged to c
Page 256 and 257: Chapter 13. THE DRUG-FREE WORKPLACE
Page 258 and 259: Violations of the act may result in
Page 260 and 261: Exhibit 13-1 DRUG-FREE WORKPLACE AC
Page 262 and 263: Chapter 14. SUBSTANCE ABUSE MANAGEM
Page 264 and 265: Notification of audit Requested mat
Page 266 and 267: them to move throughout the facilit
Page 268 and 269: above materials. ⎯⎯Procedures t
Page 270 and 271: DAY 3 Time Activity Team Address of
Page 272 and 273: Date of Collection Jan-01 Nov-00 Se
Page 274 and 275: Time of the Test Time of the Test 8
Page 276 and 277: Each auditor will discuss the porti
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Sample Re-audit Agenda DAY 1 Time A
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Index of Appendices Appendix A. Acr
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AA Alcoholics Anonymous Appendix A.
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RFP Request for Proposal RIA Radio
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Newsletters Appendix B. Additional
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U.S. Department of Labor. What Work
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Other Government Web sites Drug and
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Appendix C Americans with Disabilit
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sensitive duties for the illegal us
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If the individual is qualified and
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allegation of discrimination under
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Appendix D. Certified Laboratories
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DrugProof, Divison of Dynacare 543
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One Source Toxicology Laboratory, I
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The following laboratories are volu
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Federal Register / Vol. 65, No. 141
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Appendix F. Fact Sheets Drug Detect
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Social Issues • Two-thirds of all
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• The euphoric stimulation increa
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• Paranoia • Profuse sweating a
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connection between marijuana smokin
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Opiates (Narcotics) Fact Sheet Opia
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Phencyclidine (PCP) Fact Sheet Phen
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Appendix G Questions and Answers
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ecipient, and someone other than th
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Q. Can transit operators receive wa
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Q. If an employee changed jobs prio
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Q. How much training are employers
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acceptable for the company-required
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Q. In a post-accident situation req
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employees and 50 non-DOT employees,
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Q: What actual address is required
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Q: Can a split specimen be sent to
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actual employee of the employer may
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Q: Must collectors, BATs, STTs, MRO
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an observer, or a monitor for co-wo
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Q: If a collector makes an error on
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Appendix H Terms and Definitions
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indirectly, one controls or has the
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Confirmation validity test Confirme
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These terms include any designee of
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Medical Review Officer (MRO) A pers
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Random test Reason to believe Reaso
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Safety-sensitive function Any of th
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trolley bus, or vessel. A “mass t
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49 CFR Part 40 Updated August 31, 2
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§ 40.89 What is validity testing,
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Page 4 of 100 § 40.287 What inform
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Page 6 of 100 Subpart A - Administr
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Page 8 of 100 Medical Review Office
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Page 10 of 100 § 40.17 Is an emplo
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Page 12 of 100 (b) You must request
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Page 14 of 100 (4) The collector's
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Page 16 of 100 (1) To avoid distrac
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Page 18 of 100 (f) Direct the emplo
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Page 20 of 100 (g) As the collector
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Page 22 of 100 participate in the D
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Page 24 of 100 (b) You must determi
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Page 26 of 100 (d) If you have not
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Page 28 of 100 December 31 of the p
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Page 30 of 100 (a) Review Copy 2 of
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Page 32 of 100 (1) As the DER, you
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Page 34 of 100 (i) Recent needle tr
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Page 36 of 100 (2) If you receive i
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Page 38 of 100 (iii) If a negative
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Page 40 of 100 (6) Result of the te
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Page 42 of 100 (d) When you receive
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Page 44 of 100 (1) Report that the
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Page 46 of 100 (2) There is not an
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Page 48 of 100 (c) The laboratory r
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Page 50 of 100 (6) The failure to d
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Page 52 of 100 partially meets thes
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Page 54 of 100 (c) As the user of t
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Page 56 of 100 (vi) You must then d
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Page 58 of 100 (i) You may transmit
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Page 60 of 100 (b) In the case of a
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Page 62 of 100 (iii) Key DOT drug t
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Page 64 of 100 § 40.295 May employ
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Page 66 of 100 (e) The requirements
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Page 68 of 100 accident drug test r
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Page 70 of 100 § 40.343 What tasks
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Page 72 of 100 and follow-up testin
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Page 74 of 100 (b) In exercising th
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Page 76 of 100 resubmit the matter
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Page 78 of 100 § 40.397 When does
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Appendix A to Part 40 - DOT Standar
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Appendix C to Part 40-DOT Drug Test
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Page 84 of 100 Appendix E to Part 4
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Appendix G to Part 40—Alcohol Tes
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Page 88 of 100
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Page 90 of 100
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I. Employer: Company Name: Page 92
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Page 94 of 100 The following form a
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Section III. Drug Testing Data Page
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Page 98 of 100 TIP ~ Even though so
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Page 100 of 100 Finally, additional
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43946 Federal Register / Vol. 68, N
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49 CFR Part 655
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2 Electronic access to this rule an
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duty and follow-up testing under sp
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When the drug and alcohol rules ini
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the consequences for prohibited dru
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Labor unions: 3 Trade associations:
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FTA Response. FTA opts not to inclu
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Since each employer uses its own te
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Most of the commenters to this sect
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themselves that employees can succe
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Several commenters responding to th
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service providers and the employer.
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esponsibility of FTA transit funds
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26 Federalism assessment. However,
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Part 655 - Prevention of Alcohol Mi
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655.52 Substance abuse professional
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(b) This part must be read in conju
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(2) The volunteer performs a safety
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Refuse to submit means any circumst
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An employer must have an anti-drug
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part. (c) Specific information conc
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(5) Phencyclidine. (c) Consumption
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concentration less than 0.04. This
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§655.43 Reasonable suspicion testi
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48 the reasons the alcohol test was
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(c) Rates for drug testing. (1) Whe
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annual percentage rate under this p
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(a) Each employer shall require a c
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56 for evaluating and resolving pro
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qualifying the supervisors to make
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60 (12) Number of covered employees
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post-accident alcohol test indicati
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equired to be maintained by this pa
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(b) A certification must be authori
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Drug-Free Workplace Act
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TABLE OF CONTENTS INTRODUCTION ....
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egulations that have been made sinc
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The behaviors that are prohibited b
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⎯ An individual who refuses to su
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Have employees been notified that p
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⎯ Add a bluing agent to the toile
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Are employees who are subject to te
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LABORATORY TESTING Are all drug tes
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⎯ Direct the analysis of the spli
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Is only one test conducted at a tim
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Does the BAT notify the employer’
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Does the SAP evaluate whether a saf
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ADMINISTRATIVE REQUIREMENTS If a pr
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Are procedures in place to have emp
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hours following the accident, the e
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Are random numbers substituted only
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Are employees that are subject to f
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OTHER TRAINING Consistent with the
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♦ Documents presented by a covere
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CERTIFICATION ♦ Each year transit
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A R DMINISTRATIVE EQUIREMENTS Do th
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DRUG AND ALCOHOL POLICY REVIEW QUES
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Meeting FTA thresholds; Meeting dru
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CONSEQUENCES OF A FAILED OR REFUSED
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How much notice is given to the emp
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RECORDS MANAGEMENT QUESTIONNAIRE AP
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If the information requested is not
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Has the employer met the minimum an
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Do the records indicate that any dr
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Does the employer utilize the stand
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If tests are cancelled because of a
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If you conducted the initial test,
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SALIVA TEST TECHNICIAN QUESTIONNAIR
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MEDICAL REVIEW OFFICER (MRO) QUESTI
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What action would you take if the s
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• • • As the SAP, can you sub
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Do you assist your members in any w
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