Notice to Driver and Safety Sensitive Applicants

REQUEST/CONSENT FOR INFORMAnON FROM PREVIOUS EMPLOYER ON ALCOHOL & CONTROLLED SUBSTANCES TESTINGSECTION 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEEI, (Print Name)First, M.I., Last Social Security Numberhereby authorize that:Previous Employer:Street:City, State, Zip:Telephone:Fax No.may release and forward information requested by Section 2 (below) ofthis document concerning my Alcohol and Controlled Substances Testingrecords to:Prospective Employer:Attention:Marin Senior Coordinating Council Inc. (Whistlestop Wheels)Jon GaffueyStreet: 930 Tamalpais Avenue Telephone:City, State, Zip: San Rafael, CA 94901 Fax No. 415-456-1581Applicant SignatureDateThis is in compliance with §382.405(f) and (h), which state:two years, which are maintained by the driver's previous employers under(f) Records shall be made available to a subsequent employer upon receipt ofa §382.401(b)(l(i) through (iii). As well as other violations ofDOT agency drugwritten request from a driver. Disclosure by that subsequent employer isand alcohol testing regulations and, with respect to any employee who violatedpermitted only as expressly authorized by the terms ofthe driver's request. DOT drug and alcohol regulation, documentation ofthe employee's successful(h) An employer shall release information regarding driver's records as directed completion ofDOT return-to-duty requirements (including follow up drug tests.by the specific, written consent ofthe driver authorizing release ofthe (c) The information in paragraph (b) ofthis section must be obtained andinformation to an identified person. Release ofsuch information by the person reviewed by the employer no later than 14 calendar days after the first time areceiving the information is permitted only in accordance with the terms ofthe driver performs safety-sensitive functions for an employer.employee's consent. (d) The prospective employer must provide to each ofthe driver's employers§382.413(a)(b)(c)(0)(f) further state:within the two preceding years the driver's specific written authorization ft)r(a) An employer may obtain, pursuant to a driver's written consent, any ofthe release ofthe information in paragraph (b)information concerning the driver which is maintained under this part by fhe (e) The release ofany information under this part may take the form ofdriver's previous employers.personal interviews, telephone interviews, letters, or any other method of(b)IAn employer shall obtain, pursuant to a driver's consent, information on obtaining information that ensures confidentiality. Each employer must maintainthe driver's alcohol tests with a concentration result of0.04 or greater positive a written, confidential record with respect to each past employer contacted.controlled substances test results, and refusals to be tested, within the preceding ISECTION 2: . TO BE COMPLETED BY PREVIOUS EMPLOYERCOMPLETE THIS SECTION AS IT PERTAINS TO PART 382. SEE SEC. 382.413(b), ABOVE. YES NOI. Has this person ever tested positive for a controlled substance in the last two years? D D2. Has this person ever had an alcohol test with a Breath Alcohol Concentration 0.04 or greater in the last two years? D D3. Has this person ever refused a required test for drugs or alcohol in the last two years? D DIfYES to any ofthe above questions, please give the SAP's (Substance Abuse Professional) name, address and phone number tor further reference.Name:Street:City, State, Zip:Section 2 Completed by (Signature):Date:SECTION 3: TO BE COMPLETED BY PROSPECTIVE EMPLOYERThis form was (check one) D Faxed to previous employer. DComplete below when information is obtained.Information received from:Mailed. Date:Recorded by: Method: D Fax D MailD P!lOneDate: D Personal Interview