UNIVERSITY OF CALIFORNIA, DAVIS

PREVIOUS EMPLOYMENT RECORD RELEASE

SECTION I - COMPLETED BY APPLICANT
NOTE: Any misrepresentation, falsification or omission of facts herein may be grounds for disqualification, release or dismissal.
Have you worked in a safety-sensitive position in the past three years? ___ Yes ___ No
Have you applied for and not received work in a safety-sensitive position in the past three years? ___ Yes ___ No
If you answered “No” to both questions, skip the remaining questions, and sign and date the form in Section I. If you answered “Yes” to either question, answer the remaining questions and complete Section II, including the Release Authorization for each previous employer from the preceding three years.
In regards to any safety-sensitive job(s) for which you applied and were not hired:

Have you tested positive on any DOT pre-employment drug or alcohol test? ___Yes___ No

Have you refused to take a DOT pre-employment drug or alcohol test? ___Yes___ No
______
Printed Name of Applicant Signature of Applicant Date
SECTION II- COMPLETED BY APPLICANT
TO:PLEASE RETURN TO:
______
COMPANY NAMEUC Davis, DOT Program
______ATTN: Tina Winger
NAME/ TITLE1 Shields Ave, Davis, CA 95616
______
ADDRESSPHONE530-752-6077
______FAX530-752-6140
CITY/ STATE/
______
FAX
Applicant: ______SSN#: ______has made application to UC Davis for a safety-sensitive position as defined in 49CFR, Part 382.107. Pursuant to Part 382.413 and the signed release below, we are requesting that you provide answers to the question in Section III below, records of which should be maintained by all previous employers pursuant to 49CFR, Part382.401.
I hereby authorize the previous employer identified in Section II to answer the questions in Section III below as they pertain to when I was in their employment, acting as their agent, under contract with them, or acting as their representative in any capacity during the two years preceding the date listed below.
______
Signature of Applicant Date
______
Signature of Witness Date
SECTION III - COMPLETED BY PREVIOUS EMPLOYER
What were the dates of applicant’s employment? From: ______To: ______
DURING THE PRECEDING THREE YEARS (Circle YourAnswer):
  1. Was s/he employed in a safety-sensitive function? Yes No
  2. Did s/he test positive for Alcohol concentration of .04 or greater? Yes No
  3. Did s/he have a verified Positive for controlled substances covered in 49CFR Part 40? Yes No
  4. If positive (or a refusal), was s/he referred to a substance abuse professional? Yes No Not Applicable
  • If “Yes,” did s/he see a substance abuse professional? Yes No
  • If “Yes,” did this substance abuse professional recommend treatment? Yes No
  • If “Yes,” did s/he complete treatment? Yes No
  • If “Yes,” did s/he undergo a return-to-duty test? Yes No
  • If “Yes,” did the return-to-duty test indicate a verified negative result? Yes No
  • If “Yes,” did s/he complete the SAP’s recommended follow-up testing program? Yes No
  1. At any time has s/he refused an alcohol or controlled substance test required under DOT? Yes No
  • If “Yes,” which test did s/he refuse:
___ Reasonable Suspicion Alcohol___ Reasonable Suspicion Controlled Substance
___ Follow-Up Alcohol___ Follow-Up Controlled Substance
___ Post-Accident Alcohol___ Post-Accident Controlled Substance
Completed by: ______
Please Print NameSignatureDate

Rev 01/13/2017 TMW