Title of Form: POSITIVE CONTROLLED SUBSTANCE TEST RESULT REPORT

California Vehicle Code Sections 13376(b)(1)- 13376(b)(4) require employers who provide pupil transportation to report to the Department of Motor Vehicles (DMV), any driver or applicant who has tested positive for a controlled substance; when a rehabilitation or return to duty program is imposed; any subsequent positive controlled substance test results; and if a participant is dropped from a rehabilitation/return to duty program. The employer must report within five days of receiving notification of a positive test result.

Please use this form to report such drivers or applicants to the DMV. If an employee was dismissed for cause due to a positive controlled substance test, you must use this form. DO NOT use a Dismissal for Reason Involving Pupil Transportation Safety form (DL 128).

Mail completed forms to the:

Driver Safety Actions Unit

P.O. Box 187010-7010

Sacramento, CA 95818-7010

Attn: MS-J256 Special Certificate.

You will be notified of the action taken by the department.

Submit a copy of this form to your local CHP Office:

Atwater Office:

California Highway Patrol Office

Attn: School Bus Office/Coordinator

1500 Bell Drive

Atwater, CA 95301

Los Banos Office

California Highway Patrol Office

Attn: School Bus Office/Coordinator

706 W. Pacheco Blvd.

Los Banos, CA 93635

POSITIVE CONTROLLED SUBSTANCE TEST RESULT REPORT

California Vehicle Code Sections 13376(b)(1)- 13376(b)(4) require employers who provide pupil transportation to report to the Department of Motor Vehicles (DMV), any driver or applicant who has tested positive for a controlled substance; when a rehabilitation or return to duty program is imposed; any subsequent positive controlled substance test results; and if a participant is dropped from a rehabilitation/return to duty program. The employer must

report within five days of receiving notification of a positive test result.

Please use this form to report such drivers or applicants to the DMV. If an employee was dismissed for cause due to a positive controlled substance test,

you must use this form. DO NOT use a Dismissal for Reason Involving Pupil Transportation Safety form (DL 128).

Mail completed forms to the Driver Safety Actions Unit, P.O. Box 187010-7010, Sacramento, CA 95818-7010, Attn: MS-J256 Special Certificate. You will be notified of the action taken by the department.

Submit a copy of this form to your local California Highway Patrol Office, Attn: School Bus Office/Coordinator

Programs and testing must comply with the requirements specified in Section 382 of Title 49 of the Code of Federal Regulations.

PLEASE TYPE OR PRINT LEGIBLEY THEFOLLOWING INFORMATION:

DRIVER’S FULL NAME (FIRST) (MIDDLE) (LAST) / BIRTHDATE / DRIVER LICENSE NUMBER
ADDRESS(STREET)(CITY)(STATE)ZIP CODE / TELEPHONE NUMBER
()
CURRENT CERTIFICATE EXPIRATION DATE (RENEWAL) / CERTIFICATE APPLICATION DATE (ORIGINAL) / CERTIFICATE TYPE
AGENCYNAME/ADDRESSADMINISTERING TEST (STREET)(CITY)(STATE)(ZIP CODE)
REASON FOR TEST (PRE-EMPLOYMENT, POST ACCIDENT, REASONABLE SUSPICIAN, RANDOM, RETURN TO DUTY, FOLLOW UP) / TEST DATE / TEST RESULTS/TEST REFUSED
()
EMPLOYER NAME/ADDRESS (PLEASED PRINT) (STREET)(CITY) (STATE) (ZIP CODE) / EMPLOYER’S TELEPHONE NUMBER
()

REHABILITATION/RETURN TO DUTY PROGRAM INFORMATION

(FOR EXISTING CERTIFICATE HOLDERS ONLY)
REHABILITATION/RETURNTO DUTY PROGRAM NAME/ADDRESS(STREET)(CITY)(STATE)(ZIP CODE)
PROGRAM LENGTH / DATE PROGRAM BEGINS
EMPLOYER IMPOSTING PROGRAM PARTICIPATION (PLEASE PRINT) / CURRENT DATE / EMPLOYER’S TELEPHONE NUMBER
()

POST PROGRAM DROPS

POSITIVE RESULTS SHOWN / DATE OF POSITIVE TEST RESULTS
REASON DRIVER WAS DROPPED / DATE DRIVER DROPPED
NAME/AGENCYOF INDIVIDUAL REPORTING DROP INFORMATIONCURRENT DATE / TELEPHONE NUMBER
()
I am reporting this driver as required Section 13376(b)(1) of the California Vehicle Code.
PERSON REPORTING APPLICANT/DRIVER (PLEASE PRINT) / SIGNATURE / DATE

DS 334 (NEW 5/98)