Form PTN-102
(Rev. 6/2003)
Page 10 of 10
DRUG AND ALCOHOL MANAGEMENT PROGRAM MONITORING FORM / Form PTN-102(Rev. 6/2003)
(GSD-EPC)
Page 1 of 10
Name of Transit Agency:
Address:
City, State, Zip:
Phone:
Contact Person:
Name of Senior Agency (COG, CAA, RPC, or County, if applicable):
Monitored By:
Date Monitored:
TxDOT District:
In Compliance / Not In Compliance
Corrective Action Plan Due Date:
Describe Areas of Non-Compliance:
POLICY STATEMENT ELEMENTS (§655.15) / YES / NO
1. Has the policy statement been approved by the governing board or senior official of the transit agency?
2. Are the approval date and any updates clearly identified?
3. Has the policy statement been made available to every safety sensitive employee?
4. Are there records of an employee signed Acknowledgment form or other documents to show the employee has received a copy or is aware of the policy availability?
5. Does the policy statement include the name and telephone number of the contact person to whom employees may ask questions about the company drug and alcohol testing program?
6. Does the policy statement identify the specific categories of Safety Sensitive Employees who are subject to drug and alcohol testing? (655.4)
· Does it include operating a revenue service vehicle?
· Does it include maintaining a revenue service vehicle?
· Does it include dispatching or controlling movement of a vehicle?
· Does it include operating a non-revenue vehicle that requires a CDL?
· Does it include carrying a firearm for security purposes? (May not apply)
· Does it include Volunteer Employees? (May not apply)
7. Does the policy statement include an analysis of safety sensitive job functions to determine which employees were designated to be safety sensitive?
8. Does the policy state that participation in the drug and alcohol testing program is a condition of employment for all safety sensitive employees? (655.49)
9. Does the policy state that an alcohol test may be conducted just before, during and just after performing a safety sensitive function? (655.45)
10. Does the policy state that the use of illegal drugs is prohibited at all times and employees may be tested for drugs anytime while on duty? (655.45)
11. Does the policy state that consumption of alcohol is prohibited when performing a safety sensitive function? (655.32)
12. Does the policy state that employees are prohibited from consuming alcohol 4 hours prior to performing safety sensitive functions? (655.33)
13. Does the policy state that employees must not consume alcohol for 8 hours following an accident or until a post accident test is conducted? (655.34)
14. Does the policy state that employees are prohibited from consuming alcohol while on call? (655.33)
15. Does the policy state that on-call employees will be given the opportunity to acknowledge the use of alcohol and the inability to perform safety sensitive functions? (655.33)
16. Does the policy state that employees will be removed from safety sensitive duties if their breath alcohol test is 0.04 or above?
17. Does the policy state which prohibited substances the employees will be tested for?
POLICY STATEMENT ELEMENTS (§655.15) (cont.) / YES / NO
18. Does the policy statement identify specific circumstances for Pre-Employment Testing?
· A negative drug test required prior to performing safety sensitive duties? (655.41)
· Evidence of a successful rehab program for an employee/applicant who previously failed a DOT drug test? (655.41)
· A negative drug test for a transferring employee? (655.41)
· A pre-employment test for an employee who has been removed from safety sensitive duties and removed from the random testing pool for more than 90 days? (655.41)
· Circumstances for pre-employment alcohol testing if conducted? (655.42)
Note: Pre-Employment alcohol testing is optional.
19. Does the policy statement identify specific circumstances for Random Testing? (655.45)
· Random selections are made using a scientifically valid method?
· Testing will be spread reasonably throughout all periods of the calendar year?
· Testing is conducted on all hours and days when safety sensitive duties are performed?
· Testing is unannounced and immediate?
· Allows no discretion by management personnel as to who is selected or notified?
20. Does the policy statement identify specific circumstances for Post Accident Testing?
· FTA post accident testing thresholds for fatalities? (655.4)
· FTA post accident testing thresholds for bodily injury? (655.4)
· FTA post accident testing thresholds for vehicle disabling damage? (655.4)
· Testing safety sensitive employees whose performance could have contributed to the accident? (655.44)
· Not testing employees whose performance can be completely discounted as a contributing factor? (655.44)
· Conduct drug testing within 32 hours? (655.44)
· Conduct alcohol testing within the 2-hour and 8-hour rules? (655.44)
· Require an employee to remain readily available? (655.44)
21. Does the policy state employees involved in an accident are prohibited from consuming alcohol for at least 8 hours following an accident, or until post-accident testing has taken place, which ever comes first? (655.34)
22. Does the policy statement identify specific circumstances for Reasonable Suspicion Testing? (655.43)
· Determinations are made based on specific, contemporaneous, articulable observations concerning the appearance, behavior, speech and body odor?
· Determinations are made by one or more trained supervisors or company official?
23. Does the policy statement identify specific circumstances for Return To Duty and Follow Up Testing?
· Is it clearly stated if the transit agency has a Zero Tolerance or Second Chance Policy?
· Is it clearly stated that if there is a Second Chance Policy that all return to duty and follow up testing will be conducted as specified in 49 CFR Part 40? (655.46)
POLICY STATEMENT ELEMENTS (§655.15) (cont.) / YES / NO
24. Does the policy state that all drug and alcohol testing will be conducted in accordance with 49 CFR Part 40? (655.15e and 655.51)
25. Does the policy state that Part 40 will be made available to employees upon request? (655 Subpart B Section A)
26. Does the policy statement identify specific circumstances for Dilute Negative test results?
· Policy states whether or not the employee will be required to immediately take another unobserved drug test? (40.197)
· Specifies if different types of tests follow different policies? (40.197)
27. Does the policy state behavior that constitutes a Test Refusal? (655.15)
· Failure to appear at the collection site in a reasonable time. (Does not apply to pre-employment) (40.191/.261)
· Refusal to provide a specimen. (Verbal or physical absence) (40.191/.261)
· Failure to provide a sufficient specimen with no medical explanation. (40.191/.261)
· Failure to remain at the testing site until the testing process is completed. (Does not apply to pre-employment) (40.191/.261)
· Failure to have a medical evaluation if required by an MRO. (40.191/.261)
· Failure to cooperate with any part of the testing process. (40.191/.261)
· Failure to allow monitoring or direct observation for drug testing. (40.191)
· Failure to take a second test if directed to do so. (40.191)
· MRO verification of a test as adulterated or substituted. (40.191)
· Failure to sign Step 2 of the Alcohol Testing Form. (40.261)
· Failure to remain available for testing following an accident. (655.44)
· Policy states that refusing a non-DOT is not a refusal to take a DOT test.
28. Does the policy statement specify the consequences for positive drug test results or positive alcohol test results, or refusing to submit to a test? (655.61)
· The employee will be immediately removed from safety sensitive duties. (655.61)
· The employee will be referred to a Substance Abuse Professional. (655.62)
29. Does the policy state the consequences for a safety sensitive employee who has an alcohol concentration of 0.02 or above, but less than 0.04? (655.35)
· Temporary removal from safety sensitive duties until the next shift, but not less than 8 hours, or
· Temporary removal from safety sensitive duties until verified alcohol concentration is less than 0.02.
· Other company policies separate from DOT regulations.
30. Does the policy state when employees are subject to drug or alcohol testing such as days of the week, hours, holidays, etc?
31. Does the policy statement describe the employee’s right to access his or her own drug and alcohol records?
32. Is the non-DOT, transit agency internal policy requirements not required by DOT, (i.e., Second Chance Policy, or non-DOT post accident testing), clearly stated in the policy statement?
DRUG FREE WORKPLACE ACT / YES / NO
Note: The DFW Act applies to all employees in the transit agency. The FTA regulations apply only to the safety sensitive employees. The regulations are separate, but similar in several ways.
1. Is there a written policy notifying all employees of the prohibited behavior as specified in the Drug Free Workplace Act?
2. Does the policy specify unlawful manufacture, distribution; dispensing, possession and use of controlled substances are prohibited in the workplace?
3. Is there a drug free awareness program to inform employees about the dangers of drug abuse in the workplace? Examples are posters, brochures and training classes.
4. Is there a drug free awareness program to inform employees about the company policy of maintaining a drug free workplace?
5. Is there a drug free awareness program to inform employees about available drug counseling, rehabilitation programs and employee assistance programs?
6. Does the policy specify the actions to be taken against the employee for violations of the Drug Free Workplace policy?
7. Is each employee given a copy of the policy statement?
8. Does the policy state that compliance with the Drug Free Workplace is a condition of employment?
9. Does the policy state that the employee must notify the employer within 5 days of any drug related convictions for violations in the workplace?
10. Does the policy state the employer must notify TxDOT within 10 days of any drug related convictions for violations in the workplace?
11. Does the policy state the type of personnel actions that will be taken against employees who violate the Drug Free Workplace Act? This must include either employee termination or referral to a substance abuse rehabilitation program.
12. Does the employer make a good faith effort to maintain a drug free workplace through implementation of the above requirements?
EDUCATION AND TRAINING PROGRAMS (§655.14) / YES / NO /
1. Are drug and alcohol program information materials and employee assistance program (EAP) information displayed in the workplace?
2. Are drug and alcohol program information materials and employee assistance program (EAP) information distributed to every covered employee?
3. Do all covered employees receive at least 60 minutes of training on the effects and consequences of drug use?
4. Does training include effects on personal health, safety, and the work environment and on the signs and symptoms that indicate prohibited drug use?
5. Do all supervisors receive at least 60 minutes of training on the physical, behavioral, speech and performance indicators of probable drug use?
6. Do all supervisors receive at least 60 minutes of training on the physical, behavioral, speech and performance indicators of alcohol misuse?
7. Are there written records to verify employee training conducted? (655.71)
PRE-EMPLOYMENT DRUG TESTING (§655.41) / YES / NO
1. Are new employees tested and verified negative for drug use prior to being allowed to perform safety sensitive functions?
2. Is there a spread sheet or similar document used to provide written verification that negative test results are obtained before the employee begins safety sensitive duties?
3. Is the employee notified that Pre-Employment testing is required by Part 655? (655.17)
4. Are previous non safety sensitive employees transferring into a safety sensitive position, tested and verified negative for drugs prior to being allowed to perform safety sensitive functions?
5. Are employees who have not been in a safety sensitive function for 90 days, and have not been in the random selection pool, administered a Pre-Employment test with a verified negative result before being allowed to perform safety sensitive functions?
6. If a transfer employee was working in a safety sensitive position within the past 2 years, was drug and alcohol information requested from the previous employer? (40.25)
7. Does the new employee provide written permission to contact the previous employer about drug and alcohol information? (40.25)
8. Does the request to the previous employer include requests for information on: alcohol tests greater than 0.04, positive drug test results, test refusals, other violations of DOT drug and alcohol testing regulations, documentation of any return to duty process? (40.25b)
9. Is there documentation showing good faith effort in attempting to obtain drug and alcohol information from any previous employers? (40.25)
10. If for some reason a Pre-Employment test is canceled, is the employee required to take another Pre-Employment test before beginning safety sensitive duties?
11. If Pre-Employment alcohol testing is conducted, is testing conducted prior to allowing the employee to perform safety sensitive functions, and is testing conducted using procedures set forth in Part 40? Note: Pre-Employment Alcohol Testing is not required. (655.42)
REASONABLE SUSPICION TESTING (§655.43) / YES / NO
1. Are employees tested for drug and/or alcohol when the employer believes the employee has used drugs and/or alcohol?
2. Does a trained supervisor or company official make the required observations? A supervisor or company official must be trained in detecting signs and symptoms of drug and alcohol misuse. (655.14b)
3. Is there a supervisor checklist that states that reasonable suspicion testing must be based on specific, contemporaneous (current), articulable (describable) observations that check for appearance, behavior, speech or body odors?
4. Is alcohol testing permitted only if the observations are conducted just proceeding, during or just after the workday of the safety sensitive employee?
5. Is the alcohol testing conducted within 2 hours of being observed and determined to be using alcohol?
6. Are attempts to conduct the alcohol testing ceased after the 8-hour time limit has expired?
REASONABLE SUSPICION TESTING (§655.43) (cont.) / YES / NO
7. Are there written records explaining the delays and actions taken if the testing can not be conducted after the 2-hour and 8-hour time limits? Note: Alcohol testing may be conducted between 2 hours and 8 hours if the delay can be justified in writing.
8. Are Reasonable Suspicion referral documents maintained on file? (655.71)
POST-ACCIDENT TESTING (§655.44) / YES / NO /
1. Is drug and alcohol testing conducted as soon as practicable following a Fatal accident? Note: Testing is mandatory.
2. Are DOT forms used for the non-fatal accidents that meet the FTA testing criteria, and non-DOT forms used for post accident testing that is required by the transit agency? (40.47a) (40.227a) (40.13f)
3. If post-accident testing is conducted under non-DOT criteria, (transit agency policy) is the employee informed that it is a non-DOT test?
4. If the incorrect CCF or ATF is used, does the transit agency know how to make the necessary corrections? (40.205b) (40.271b)
5. If the transit agency determines drug and alcohol testing is not required, are written details filed to include how such a decision was made, and is there a designated person to make such a decision? (655.44d) (655.71c) (40.3)
6. Are other employees who may have contributed to a fatal or non-fatal accident tested for drugs and alcohol? (655.44a)
7. Does the transit agency comply with the 32 hour rule for drug testing and the 2 and 8-hour rules for alcohol testing?
RANDOM TESTING (§655.45) / YES / NO
1. Are random test selections or draws conducted at least once a quarter? (655.45e) (Preamble to 655)
2. Is the employee roster updated prior to the draw or selection being conducted?
3. Does the transit agency (or C/TPA) use a computer based random number generator or similar scientific method to select employees who must test? (655.45e)
4. Are non-DOT employees placed in a separate random testing pool from the pool of safety sensitive employees? (655.45) (40.347)
5. Are random drug and alcohol test dates unannounced, unpredictable, and spread reasonably throughout the year? (655.45g)
6. Is random drug testing conducted at all times of the day when safety sensitive functions are being performed to include nights, weekends, and holidays? (655.45g)
7. Is there an Order for Testing form, and/or a spreadsheet or similar documentation used to track critical dates and times in the random testing process? Documentation must clearly demonstrate the employee arrived at the collection site in a timely manner. (655.45h) (40.191) (40.61a)
8. Are complete random testing documents available that clearly show all steps in the process from employee selection to verified test results? (655.71c)
9. Do employees selected and notified for random testing immediately cease safety sensitive duties and proceed immediately to the test site? (655.45h)