Step 1: TO BE COMPLETED BY ALCOHOL TECHNICIAN

A: Employee Name:_______________________________________
                                    (Print) (Frst, M.I., Last)

B: SSN or Employee ID No._________________________________

C: Employer Name ________________________________________

Street                   _____________________________________

City, ST ZIP          ________________________________________

DER Name and Telephone No. ___________ (___)_______________

                                             DER Name       DER Phone Number

D: Reason for Test: Random, Reasonable Susp., Post-Accident, Return to Duty, Follow Up, Pre-Employment

Affix or print screening results here

Affix with tamper evident tap

STEP 2: TO BE COMPLETED BY EMPLOYEE

I certify that I am about to submit to alcohol testing required by US Department of Transportation regulations and that the identifying information provided on the form is true and correct.

Signature of Employee__________________________________________

Date Month Day Year __________________________________________

STEP 3: TO BE COMPLETED BY ALCOHOL TECHNICIAN

(If the technician conducting the screening test is not the same technician who will be conducting the confirmation test, each technician must complete their own form.) I certify that I have conducted alcohol testing on the above named individual in accordance with the procedures established in the US Department of Transportation regulation, 49 CFR Part 40, that I am qualified to operate the testing device(s) identified, and that the results are as recorded.

TECHNICIAN: BAT STT
DEVICE: SALIVA BREATH*

15-Minute Wait: Yes No

SCREENING TEST: (For BREATH DEVICE* write in the space below only if the testing device is not designed to print.)

_____      _________________      _______________________    
Test #      Testing Device Name     Device Serial # OR Lot # & Exp Date
_____________     ___________      ______
Activation Time      Reading Time      Result

CONFIRMATION TEST: Results MUST be affixed to each copy of this form or printed directly onto the form.

REMARKS:___________________________________________

_________________________      _____________________
Alcohol Technician’s Company      Company Street Address
___________________________________________

(PRINT) Alcohol Technician’s Name (First, M.I., Last)
_____________________     _____________

Company City, State, Zip      Phone Number
__________________________     __________/____/____

Signature of Alcohol Technician      Date Month Day Year

Affix Or Print Comfirmation Result Here

Affix With Tamper Evident Tape

STEP 4: TO BE COMPLETE BY EMPLOYEE IF TEST RESULT IS 0.02 OR HIGHER

I certify that I have submitted to the alcohol test, the results of which are accurately recorded on this form. I understand that I must not drive, perform safety-sensitive duties, or operate heavy equipment because the results are 0.02 or greater.

__________________           __________________

Signature of Employee          Date Month Day Year

Affix Or Print Additional Results Here

Affix With Tamper Evident Tape