SECTION 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

 

 

1. (Print name) __________________________________ ______________________________

                                First, MI, Last                                                                                          Social Security Number

 

                                                                                                hereby authorize that

 

Previous Employer________________________________________                Telephone _______________

                                               

Street                ________________________________________  Fax No. _________________

 

 

City, State, Zip    _________________________________________

 

 

Applicant signature                __________________________________________  Date _______________________

 

 

 

This is in compliance with S382.405(f) and (h)which state

                (f) Records shall be made available to a subsequent employer upon receipt of a written request from a driver Disclosure by the subsequent employer is permitted only as expressly authorized by the terms of the driver’s request.  

                (h) An employer shall release information regarding a driver’s records as directed by the specific written consent of the driver authorizing release of the information to an certified person.  Release of such information by the person receiving the information is permitted only in accordance with the terms of the employee’s consent. S382.413 (a)(b)(d)(e)(f)(h) further state S382.413 Inquiries for alcohol and controlled substances information from previous employers.  a)(1) An employer shall pursuant to the driver’s written authorization, inquire about the following information on a driver from the dirver’s previous employers, during the preceding two years from the date of application, which are maintained by the driver’s previous employer under S382.401(b)(1)(i) through (iii) of this subpart     

                (i) Alcohol tests with a result of 0.04 alcohol concentration or greater;

                (ii) Verified positive controlled substances test result; and

                (iii) Refusals to be tested

                (2) The information obtained from a previous employer may contain any alcohol and drug information of the previous employer obtained from other previous employers under paragraph (a)(1) of this section.

                (b) If feasible the information in paragraph (a) of this section must be obtained and reviewed by the employer prior the first time a driver performs safety-sensitive functions for the employer.  If not feasible, the information must be obtained and reviewed as soon as possible, but not later than 14 calendar days after the first time a driver performs safety-sensitive functions for the employer. An employer may not permit a driver to perform safety-sensitive functions after 14 days without having made a good faith effort to obtain the information as soon as possible.  If a driver hired or used by the employer ceases before the employer has obtained the information in paragraph (a) of this section the employer must still make a good faith effort to obtain the information.

                (d) The prospective employer must provide to each of the driver’s previous employers the driver’s specific, written authorization for release of the information in paragraph (a) of this section.

                (e) The release of any information under this section may take the form of personal interviews, telephone interviews, letters, or any other method of transmitting information that ensures confidentiality.

                (f) The information in paragraph (a) of this section may be provided directly to the prospective employer by the driver, provided the employer assures itself that the information is true and accurate.

                (h) Employers need not obtain information under paragraph (a) of this section generated by previous employers prior to the starting dates in S382.115   of this part.

 

 

 

 

 

 

SECTION 2: TO BE COMPLETED BY PREVIOUS EMPLOYER

 

 

If driver was not subject to Part 382 testing requirements while employed by this employer, please check here  ________, sign below and return.

 

       1. Has this person ever tested positive for a controlled substance in the last two years?                                             YES  ______  NO______

 

       2. Has this person ever had an alcohol test with a Breath Alcohol Concentration 0.04 or greater in the last two years?        YES ______   NO ______

 

       3. Has this person ever refused a required test for drugs or alcohol in the last two years?                                                           YES ______  NO ______        

 

                * Please include information received from other previous employers

 

If YES to any of the above questions, please give the Sap’s (Substance Abuse Professional) name, address and phone number for further reference.

 

 

Name ________________________________________Street_______________________________                                       

City, State, Zip____________________________________________________Telephone___________                                                                                                                                                                      

 

Section 2 completed by: (Signature) _________________________________Date____________________

 

                               

 

SECTION 3: TO BE COMPLETED BY PROSPECTIVE EMPLOYER

 

 

 

This form was  ______ FAXED to previous employer _________ mailed   (check one)          Date: ____________________________

 

Complete below when information is obtained:

 

Information received from

 

__________________________________________________________________________________________

 

 

 

Recorded by: ________________________________________________________ 

 

 

 

Method received:  FAX_____ Mail _____ Phone______     Personal interview ________  

 

                                                                                                                                          

                                                                                                                               

Date:____________________________________