______School District
Drug and Alcohol Testing Program
TITLE OF FORM:
CONSENT FOR PRE-EMPLOYMENT TESTING
RELEASE OF INFORMATION
This form is for you to use when you first begin to train a driver or upon hire of a driver who has already been trained.
It gives the district the driver's permission to get information from their previous employer(s) and to perform a pre-employment drug test.
Have the driver fill out the form. Make sure they list all previous employers over the last two years for whom they have performed a safety sensitive function. (e.g. driving a bus). Use additional sheets if necessary.
You will use this information to contact the previous employer. Attach this form to the DOCUMENTATION OF TELEPHONE CONFIRMATION FROM A PREVIOUS EMPLOYER form or the DOCUMENTATION OF TESTING INFORMATION BY A PREVIOUS EMPLOYER form.
Copy this form as needed.
Keep a copy of this form in the employee's DOT file. These files should be kept in a secured file separate from personnel files
______School District's offer of employment is conditional upon successful result of a drug test prior to the first time you perform a safety sensitive function for ______School District.
CONSENT FOR PRE-EMPLOYEMENT TESTING
If you wish to complete the employment process, you must consent to testing by signing this form and being tested. Your signature indicates consent of testing on a urine specimen provided by you in order to determine the presence of controlled substance(s). The result of the test will be used to determine eligibility for employment with ______School District. If you fail to report for testing within 24 hours of being directed to do so by ______School District, the offer of employment will be rescinded.
RELEASE OF INFORMATION
Pursuant to 49CFR 392.413, I authorize any and all of my previous employers to release the following information to ______School District:
a. Alcohol tests with a concentration result of 0.04 or greater.
b. Positive test results for controlled substances.
c. Refusals to be tested.
I understand that if ______School District is unable to obtain this information from my employers for the preceding two years no later than 14 calendar days after the first time I perform a safety sensitive function for ______School District, I will be removed from duty until the information is obtained. If ______School District is unable to obtain the information, I will be terminated from employment with ______School District.
I understand that ______School District will terminate my employment if my employer(s) during the preceding two years provide information on alcohol tests with a concentration of 0.04 or greater, verified positive controlled substances test results, or refusal to be tested and I am unable to provide information on a subsequent Substance Abuse Professional evaluation and/or determination under 40 CFR 382-401(c)(4) and compliance with 49 CFR 382.309 (Return to Duty Testing).
I understand that ______School District has the responsibility for protecting the confidentiality of this information. During the preceding two years, I have performed safety-sensitive functions requiring a commercial Driver's License (CDL) for the following companies.
1. ______
CompanyAddress
______
Dates EmployedContact PersonTelephone
2. ______
CompanyAddress
______
Dates EmployedContact PersonTelephone
The information provided on this form is true, correct and complete.
______
applicant signature applicant name (printed)
______
Social Security NumberDate