PAPERWORK REDUCTION ACT NOTICE (as required by 5 CFR 1320.21)
Public
reporting burden for this collection of information is estimated for each
respondent to averadge: 1 minute/employee, 4 minutes/Breath
Alcohol Technician. Individuals may send comments regarding these burden estimates,
or any other aspect of this collection of information, including suggestions
for reducing the burden, to U.S. Department of Transportation, Drug and alcohol
Policy and Compliance, Room 10403,
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INSTRUCTIONS
FOR COMPLETING THE
NOTE: Use a ballpoint pen, press hard, and check all copies for legibility.
STEP 1: The Breath Alcohol Technician (BAT) or Screening Test Technician (STT) completes the information required in this step. Be sure to print the employee’s name and check the box identifying the reason for the test.
NOTE: If the employee refuses to provide SSN or I.D. number, be sure to indicate this in the remarks section in STEP 3. Proceed with STEP 2.
STEP 2: Instruct the employee to read, sign, and date the employee certification in STEP 2.
NOTE: If the employee refuses to sign the certification statement, do not proceed with the alcohol test. Contact the designated employer representative.
STEP 3: The BAT or STT completes the information required in this step and checks the type of device (saliva or breath) being used. After conducting the alcohol screening test, do the following (as appropriate):
Enter the information for the screening test (test number, testing device name, testing device serial number or lot number and expiration date, time of test with any device-dependent activation times, and the results), on the front of the AFT. For a breath testing device capable of printing, the information may be part of the printed record.
NOTE: Be sure to enter the result of the test exactly as it is indicated on the breath testing device, e.g., 0.00, 0.02, 0.04, etc.
Affix the printed information in the space provided, in a tamper-evident manner (e.g., tape), or the device may print the results directly on the ATF. If the results of the screening test are less than 0.02, print, sign your name, and enter today’s date in the space provided. The test process is complete.
If the results of the screening are 0.02 or greater, a confirmation test must be administered in accordance with DOT regulations. An EVIDENTIAL BREATH TESTING device that is capable of printing confirmation test information must be used in conducting this test.
After conducting the alcohol confirmation test, affix the printed information in the space provided, in a tamper-evident manner (e.g., tape), or the device may print the results directly on the ATF. Print, sign your name, and enter the date in the space provided. Go to STEP 4.
STEP 4: If the employee has a breath alcohol confirmation test result of 0.02 or higher, instruct the employee to read, sign, and date the employee certification statement in STEP 4.
NOTE: If the employee refuses to sign the certification statement in STEP 4, be sure to indicate this in the remarks line in STEP 3.
Immediately notify the DER if the employee has a breath alcohol confirmation test result of 0.02 or higher.
Forward Copy1 to the employer. Give Copy 2 to the employee. Retain Copy 3 for BAT/STT records.
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