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U.S. DEPARTMENT OF TRANSPORTATION
DRUG AND ALCOHOL TESTING MIS DATA COLLECTION FORM
INSTRUCTION SHEET
This Management Information System (MIS) form is made-up of four sections:
employer information; covered employees (i.e., employees performing DOT
regulated safety-sensitive duties) information; drug testing data; and
alcohol testing data. The employer information needs only to be provided
once per submission. However, you must submit a separate page of data
for each employee category for which you report testing data. If you are
preparing reports for more than one DOT agency then you must submit DOT
agency-specific forms.
Please type or print entries legibly in black ink.
TIP ~ Read the entire instructions before
starting. Please note that USCG-regulated employers do not report alcohol
test results on the MIS form.
Calendar Year Covered by this Report: Enter the appropriate
year.
Section I. Employer
1. Enter your company’s name, to include when applicable, your
“doing business as” name; current address, city, state, and
zip code; and an e-mail address, if available.
2. Enter the printed name, signature, and complete telephone number of
the company official certifying the accuracy of the report and the date
that person certified the report as complete.
3. If someone other than the certifying official completed the MIS form,
enter that person’s name and phone number on the appropriate lines
provided.
4. If a Consortium/Third Party Administrator (C/TPA) performs administrative
services for your drug and alcohol program operation, enter its name and
phone number on the appropriate lines provided.
5. DOT Agency Information: Check the box next to the DOT agency for which
you are completing this MIS form. Again, if you are submitting to multiple
DOT agencies, you must use separate forms for each DOT agency.
a. If you are completing the form for FMCSA, enter your FMCSA DOT Number,
as appropriate. In addition, you must indicate whether you are an owner-operator
(i.e., an employer who employs only himself or herself as a driver) and
whether you are exempt from providing MIS data. Exemptions are noted in
the FMCSA regulation at 382.103(d).
b. If you are completing the form for FAA, enter your FAA Certificate
Number and FAA Antidrug Plan / Registration Number, when applicable.
c. If you are completing the form for RSPA, check the additional box(s)
indicating your type of operation.
d. If you are completing the form for FRA, enter the number of observed/documented
Part 219 “Rule G” Observations for covered employees.
e. If you are submitting the form for USCG, enter the vessel ID number.
If there is more than one number, enter the numbers separately.
Section II. Covered Employees
1. In Box II-A, enter the total number of covered employees (i.e., employees
performing DOT regulated safety-sensitive duties) who work for your company.
Then enter, in Box II-B, the total number of employee categories that
number represents. If you have employees, some of whom perform duties
under one DOT agency and others of whom perform duties under another DOT
agency, enter only the number of those employees performing duties under
the DOT agency for whom you are submitting the form. If you have covered
employees who perform multi-DOT agency functions (e.g., an employee drives
a commercial motor vehicle and performs pipeline maintenance duties for
you), count the employee only on the MIS report for the DOT agency regulating
more than 50 percent of the employee’s safety sensitive function.
[Example: If you are submitting the information for the FRA and you have
2000 covered employees performing duties in all FRA-covered service categories
– you would enter “2000” in the first box (II-A) and
“5” in the second box (II-B), because FRA has five safety-sensitive
employee categories and you have employees in all of these groups. If
you have 1000 employees performing safety-sensitive duties in three FRA-covered
service categories (e.g., engine service, train service, and dispatcher/operation),
you would enter “1000” in the first box (II-A) and “3”
in the second box (II-B).]
TIP ~ To calculate the total number of
covered employees, add the total number of covered employees eligible
for testing during each random testing selection period for the year and
divide that total by the number of random testing periods. (However, no
company will need to factor the average number of employees more often
than once per month). For instance, a company conducting random testing
quarterly needs to add the total of covered employees they had in the
random pool when each selection was made; then divide this number by 4
to obtain the yearly average number of covered employees. It is extremely
important that you place all eligible employees into these random pools.
[As an example, if Company A had 1500 employees in the first quarter random
pool, 2250 in the second quarter, 2750 in the third quarter; and 1500
in the fourth quarter; 1500 + 2250 + 2750 + 1500 = 8000; 8000 / 4 = 2000;
the total number of covered employees for the year would be reported as,“2000”.
If you conduct random selections more often than once per month (e.g.,
you select daily, weekly, bi-weekly), you do not need to compute this
total number of covered employees rate more than on a once per month basis.
Therefore, employers need not compute the covered employees rate more
than 12 times per year.]
2. If you are reporting multiple employee categories, enter the specific
employee category in box II-C; and provide the number of employees performing
safety-sensitive duties in that specific category.
[Example: You are submitting data to the FTA and you have 2000 covered
employees. You have 1750 personnel performing revenue vehicle operation
and the remaining 250 are performing revenue vehicle and equipment maintenance.
When you provide vehicle operation information, you would enter “Revenue
Vehicle Operation” in the first II-C box and “1750”
in the second II-C box. When you provide data on the maintenance personnel,
you would enter “Revenue Vehicle and Equipment Maintenance”
in the first II-C box and “250” in the second II-C box.]
TIP ~ A separate form for each employee
category must be submitted. You may do this by filling out a single MIS
form through Section II-B and then make one copy for each additional employee
category you are reporting. [For instance, if you are submitting the MIS
form for the FMCSA, you need only submit one form for all FMCSA covered
employees working for you – your only category of employees is “driver.”
If you are reporting testing data to the FAA and you employ only flight
crewmembers, flight attendants, and aircraft maintenance workers, you
need to complete one form each for category – three forms in all.
If you are reporting to FAA and have all FAA categories of covered employees,
you must submit eight forms.]
Here is a full listing of covered-employee categories:
FMCSA (one category): Driver
FAA (eight categories): Flight Crewmember; Flight Attendant;
Flight Instructor; Aircraft Dispatcher; Aircraft Maintenance; Ground Security
Coordinator; Aviation Screener; Air Traffic Controller
RSPA (one category): Operation/Maintenance/Emergency
Response
FRA (five categories): Engine Service; Train Service;
Dispatcher/Operation; Signal Service; Other [Includes yardmasters, hostlers
(non-engineer craft), bridge tenders; switch tenders, and other miscellaneous
employees performing 49 CFR 228.5 (c) defined covered service.]
USCG (one category): Crewmember
FTA (five categories): Revenue Vehicle Operation; Revenue
Vehicle and Equipment Maintenance; Revenue Vehicle Control/Dispatch; CDL/Non-Revenue
Vehicle; Armed Security Personnel
Section III. Drug Testing Data
This section summarizes the drug testing results for all covered employees
(to include applicants). The table in this section requires drug test
data by test type and by result. The categories of test types are: Pre-Employment;
Random; Post-Accident; Reasonable Suspicion / Reasonable Cause; Return-to-Duty,
and Follow-Up.
The categories of type of results are: Total Number of Test Results [excluding
cancelled tests and blind specimens]; Verified Negative; Verified Positive;
Positive for Marijuana; Positive for Cocaine; Positive for PCP; Positive
for Opiates; Positive for Amphetamines; Refusals due to Adulterated, Substituted,
“Shy Bladder” with No Medical Explanation, and Other Refusals
to Submit to Testing; and Cancelled Results.
TIP ~ Do not enter data on blind specimens submitted
to laboratories. Be sure to enter all pre-employment testing data regardless
of whether an applicant was hired or not. You do not need to separate
reasonable suspicion and reasonable cause drug testing data on the MIS
form. [Therefore, if you conducted only reasonable suspicion drug testing
(i.e., FMCSA and FTA), enter that data; if you conducted only reasonable
cause drug testing (i.e., FAA, RSPA, and USCG); or if you conducted both
under FRA drug testing rules, simply enter the data with no differentiation.]
For USCG, enter any “Serious Marine Incident” testing in the
Post-Accident row. For FRA, do not enter post accident data (the FRA does
not collect this data on the MIS form). Finally, you may leave blank any
row or column in which there were no results, or you may enter “0”
(zero) instead. Please note that cancelled tests are not included in the
“total number of test results” column.
Section III, Column 1. Total Number of Test Results
~ This column requires a count of the total number of test results in
each testing category during the entire reporting year. Count the number
of test results as the number of testing events resulting in negative,
positive, and refusal results. Do not count cancelled tests and blind
specimens in this total.
[Example: A company that conducted fifty pre-employment tests would enter
“50” on the Pre-Employment row. If it conducted one hundred
random tests, “100’ would be entered on the Random row. If
that company did no post-accident, reasonable suspicion, reasonable cause,
return-to-duty, or follow-up tests, those categories will be left blank
or zeros entered.]
Section III, Column 2. Verified Negative Results ~ This
column requires a count of the number of tests in each testing category
that the Medical Review Officer (MRO) reported as negative. Do not count
a negative-dilute result if, subsequently, the employee underwent a second
collection; the second test is the test of record.
[Example: If forty-seven of the company’s fifty pre-employment
tests were reported negative, “47” would be entered in Column
2 on the Pre-Employment row. If ninety of the company’s one hundred
random test results were reported negative, “90” would be
entered in Column 2 on the Random row. Because the company did no other
testing, those other categories would be left blank or zeros entered.]
Section III, Column 3. Verified Positive Results ~ For
One Or More Drugs ~ This column requires a count of the number of tests
in each testing category that the MRO reported as positive for one or
more drugs. When the MRO reports a test positive for two drugs, it would
count as one positive test.
[Example: If one of the fifty pre-employment tests was positive for two
drugs, “1” would be entered in Column 3 on the Pre-Employment
row. If four of the company’s one hundred random test results were
reported positive (three for one drug and one for two drugs), “4”
would be entered in Column 3 on the Random row.]
- Section III, Columns 4 through 8. Positive
(for specific drugs) ~ These columns require entry of the by-drug data
for which specimens were reported positive by the MRO.
[Example: The pre-employment positive test reported by the MRO was
positive for marijuana, “1” would be entered in Column
4 on the Pre-Employment row. If three of the four positive results
for random testing were reported by the MRO to be positive for marijuana,
“3” would be entered in Column 4 on the Random row. If
one of the four positive results for random testing was reported positive
for both PCP and opiates, “1” would be entered in Column
6 on the Random row and “1” would be entered in Column
7 of the Random row.]
TIP ~ Column 1 should equal the sum of
Columns 2, 3, 9, 10, 11, and 12. Remember you have not counted specimen
results that were ultimately cancelled or were from blind specimens. So,
Column 1 = Column 2 + Column 3 + Column 9 + Column 10 + Column 11 + Column
12. Certainly, double check your records to determine if your actual results
count is reflective of all negative, positive, and refusal counts.
An MRO may report that a specimen is positive for more than one drug.
When that happens, to use the company example above (i.e., one random
test was positive for both PCP and opiates), the positive results should
be recorded in the appropriate columns – PCP and opiates in this
case. There is no expectation for Columns 4 through 8 numbers to add up
to the numbers in Column 3 when you report multiple positives.
Section III, Columns 9 through 12. Refusal Results ~
The refusal section is divided into four refusal groups – they are:
Adulterated; Substituted; “Shy Bladder” ~ With No Medical
Explanation; and Other Refusals To Submit to Testing. The MRO reports
two of these refusal types – adulterated and substituted specimen
results – because of laboratory test findings.
When an individual does not provide enough urine at the collection site,
the MRO conducts or causes to have conducted a medical evaluation to determine
if there exists a medical reason for the person’s inability to provide
the appropriate amount of urine. If there is no medical reason to support
the inability, the MRO reports the result to the employer as a refusal
to test: Refusals of this type are reported in the “Shy Bladder”
~ With No Medical Explanation category.
Finally, additional reasons exist for a test to be considered a refusal.
Some examples are: the employee fails to report to the collection site
as directed by the employer; the employee leaves the collection site without
permission; the employee fails to empty his or her pockets at the collection
site; the employee refuses to have a required shy bladder evaluation.
Again, these are only four examples: there are more.
- Section III, Column 9. Adulterated ~ This column
requires the count of the number of tests reported by the MRO as refusals
because the specimens were adulterated.
[Example: If one of the fifty pre-employment tests was adulterated,
“1” would be entered in Column 9 of the Pre-Employment row.]
- Section III, Column 10. Substituted ~ This column
requires the count of the number of tests reported by the MRO as refusals
because the specimens were substituted.
[Example: If one of the 100 random tests was substituted, “1”
would be entered in Column 10 of the Random row.]
- Section III, Column 11. “Shy Bladder”
~ With No Medical Explanation ~ This column requires the count
of the number of tests reported by the MRO as being a refusal because
there was no legitimate medical reason for an insufficient amount of
urine.
[Example: If one of the 100 random tests was a refusal because of
shy bladder, “1” would be entered in Column 11 of the
Random row.]
- Section III, Column 12. Other Refusals To Submit
To Testing ~ This column requires the count of refusals other
than those already entered in Columns 9 through 11.
[Example: If the company entered “100” as the number
of random specimens collected, however it had five employees who refused
to be tested without submitting specimens: two did not show up at
the collection site as directed; one refused to empty his pockets
at the collection site; and two left the collection site rather than
submit to a required directly observed collection. Because of these
five refusal events, “5” would be entered in Column 11
of the Random row.]
TIP ~ Even though some testing events result
in a refusal in which no urine was collected and sent to the laboratory,
a “refusal” is still a final test result. Therefore, your
overall numbers for test results (in Column 1) will equal the total number
of negative tests (Column 2); positives (Column 3); and refusals (Columns
9, 10, 11, and 12). Do not worry that no urine was processed at the laboratory
for some refusals; all refusals are counted as a testing event for MIS
purposes and for establishing random rates.
Section III, Column 13. Cancelled Tests ~ This column
requires a count of the number of tests in each testing category that
the MRO reported as cancelled. You must not count any cancelled tests
in Column 1 or in any other column. For instance, you must not count a
positive result (in Column 3) if it had ultimately been cancelled for
any reason (e.g., specimen was initially reported positive, but the split
failed to reconfirm).
[Example: If a pre-employment test was reported cancelled, “1”
would be entered in Column 13 on the Pre-Employment row. If three of the
company’s random test results were reported cancelled, “3”
would be entered in Column 13 on the Random row.]
TOTAL Line. Columns 1 through 13 ~ This line requires
you to add the numbers in each column and provide the totals.
Section IV. Alcohol Testing Data
This section summarizes the alcohol testing conducted for all covered
employees (to include applicants). The table in this section requires
alcohol test data by test type and by result. The categories of test types
are: Pre-Employment; Random; Post-Accident; Reasonable Suspicion / Reasonable
Cause; Return-to-Duty, and Follow-Up.
The categories of results are: Number of Screening Test Results; Screening
Tests with Results Below 0.02; Screening Tests with Results 0.02 Or Greater;
Number of Confirmation Test Results; Confirmation Tests with Results 0.02
through 0.039; Confirmation Tests with Results 0.04 Or Greater; Refusals
due to “Shy Lung” with No Medical Explanation, and Other Refusals
to Submit to Testing; and Cancelled Results.
TIP ~ Be sure to enter all pre-employment
testing data regardless of whether an applicant was hired or not. Of course,
for most employers pre-employment alcohol testing is optional, so you
may not have conducted this type of testing. You do not need to separate
“reasonable suspicion” and “reasonable cause”
alcohol testing data on the MIS form. [Therefore, if you conducted only
reasonable suspicion alcohol testing (i.e., FMCSA, FAA, FTA, and RSPA),
enter that data; if you conducted both reasonable suspicion and reasonable
cause alcohol testing (i.e.., FRA), simply enter the data with no differentiation.]
RSPA does not authorize “random” testing for alcohol. Finally,
you may leave blank any row or column in which there were no results,
or you may enter “0” (zero) instead. Please note that USCG-regulated
employers do not report alcohol test results on the MIS form: Do not fill-out
Section IV if you are a USCG-regulated employer.
Section IV, Column 1. Total Number of Screening Test Results
~ This column requires a count of the total number of screening test results
in each testing category during the entire reporting year. Count the number
of screening tests as the number of screening test events with final screening
results of below 0.02, of 0.02 through 0.039, of 0.04 or greater, and
all refusals. Do not count cancelled tests in this total.
[Example: A company that conducted twenty pre-employment tests would enter
“20” on the Pre-Employment row. If it conducted fifty random
tests, “50’ would be entered. If that company did no post-accident,
reasonable suspicion, reasonable cause, return-to-duty, or follow-up tests,
those categories will be left blank or zeros entered.]
Section IV, Column 2. Screening Tests With Results Below 0.02
~ This column requires a count of the number of tests in each testing
category that the BAT or STT reported as being below 0.02 on the screening
test.
[Example: If seventeen of the company’s twenty pre-employment screening
tests were reported as being below 0.02, “17” would be entered
in Column 2 on the Pre-Employment row. If forty-four of the company’s
fifty random screening test results were reported as being below 0.02,
“44” would be entered in Column 2 on the Random row. Because
the company did no other testing, those other categories would be left
blank or zeros entered.]
Section IV, Column 3. Screening Tests With Results 0.02 Or Greater
~ This column requires a count of the number of screening tests in each
testing category that BAT or STT reported as being 0.02 or greater on
the screening test.
[Example: If one of the twenty pre-employment tests was reported as being
0.02 or greater, “1” would be entered in Column 3 on the Pre-Employment
row. If four of the company’s fifty random test results were reported
as being 0.02 or greater, “4” would be entered in Column 3
on the Random row.]
Section IV, Column 4. Number of Confirmation Test Results
~ This column requires entry of the number of confirmation tests that
were conducted by a BAT as a result of the screening tests that were found
to be 0.02 or greater. In effect, all screening tests of 0.02 or greater
should have resulted in confirmation tests. Ideally the number of tests
in Column 3 and Column 4 should be the same. However, we know that this
required confirmation test sometimes does not occur. In any case, the
number of confirmation tests that were actually performed should be entered
in Column 4.
[Example: If the one pre-employment screening test reported as 0.02 or
greater had a subsequent confirmation test performed by a BAT, “1”
would be entered in Column 4 on the Pre-Employment row. If three of the
four random screening tests that were found to be 0.02 or greater had
a subsequent confirmation test performed by a BAT, “3” would
be entered in Column 4 on the Random row.]
Section IV, Column 5. Confirmation Tests With Results 0.02 Through
0.039 ~ This column requires entry of the number of confirmation
tests that were conducted by a BAT that led to results that were 0.02
through 0.039.
[Example: If the one pre-employment confirmation test yielded a result
of 0.042, Column 5 of the Pre-Employment row would be left blank or zeros
entered. If two of the random confirmation tests yielded results of 0.03
and 0.032, “2” would be entered in Column 5 of the Random
row.]
Section IV, Column 6. Confirmation Tests With Results 0.04 Or
Greater ~ This column requires entry of the number of confirmation
tests that were conducted by a BAT that led to results that were 0.04
or greater.
[Example: Because the one pre-employment confirmation test yielded a
result of 0.042, “1” would be entered in Column 6 of the Pre-Employment
row. If one of the random confirmation tests yielded a result of 0.04,
“1” would be entered in Column 6 of the Random row.]
TIP ~ Column 1 should equal the sum of Columns 2,
3, 7, and 8. The number of screening tests results should reflect the
number of screening tests you have no matter the result (below 0.02 or
at or above 0.02, plus refusals to test), unless of course, the tests
were ultimately cancelled. So, Column 1 = Column 2 + Column 3 + Column
7 + Column 8. Certainly, double check your records to determine if your
actual screening results count is reflective of all these counts.
There is no need to record MIS confirmation tests results below 0.02:
That is why we have no column for it on the form. [If the random test
that screened 0.02 went to a confirmation test, and that confirmation
test yielded a result below 0.02, there is no place for that confirmed
result to be entered.] We assume that if a confirmation test was completed
but not listed in either Column 5 or Column 6, the result was below 0.02.
In addition, if the confirmation test ended up being cancelled, it should
not have been included in Columns 1, 3, or 4 in the first place.
Section IV, Columns 7 and 8. Refusal Results ~ The refusal
section is divided into two refusal groups – they are: Shy Lung
~ With No Medical Explanation; and Other Refusals To Submit to Testing.
When an individual does not provide enough breath at the test site, the
company requires the employee to have a medical evaluation to determine
if there exists a medical reason for the person’s inability to provide
the appropriate amount of breath. If there is no medical reason to support
the inability as reported by the examining physician, the employer calls
the result a refusal to test: Refusals of this type are reported in the
“Shy Lung ~ With No Medical Explanation” category.
Finally, additional reasons exist for a test to be considered a refusal.
Some examples are: the employee fails to report to the test site as directed
by the employer; the employee leaves the test site without permission;
the employee fails to sign the certification at Step 2 of the ATF; the
employee refuses to have a required shy lung evaluation. Again, these
are only four examples; there are more.
- Section IV, Column 7. “Shy Lung” ~ With
No Medical Explanation ~ This column requires the count of the number
of tests in which there is no medical reason to support the employee’s
inability to provide an adequate breath as reported by the examining
physician; subsequently, the employer called the result a refusal to
test.
[Example: If one of the 50 random tests was a refusal because of
shy lung, “1” would be entered in Column 7 of the Random
row.]
- Section IV, Column 8. Other Refusals To Submit To Testing ~ This column
requires the count of refusals other than those already entered in Columns
7.
[Example: The company entered “50” as the number of random
specimens collected, however it had one employee who did not show
up at the testing site as directed. Because of this one refusal event,
“1” would be entered in Column 8 of the Random row.]
TIP ~ Even though some testing events result
in a refusal in which no breath (or saliva) was tested, there is an expectation
that your overall numbers for screening tests (in Column 1) will equal
the total number of screening tests with results below 0.02 (Column 2);
screening tests with results 0.02 or greater (Column 3); and refusals
(Columns 7 and 8). Do not worry that no breath (or saliva) was tested
for some refusals; all refusals are counted as a screening test event
for MIS purposes and for establishing random rates.
Section IV, Column 9. Cancelled Tests ~ This column
requires a count of the number of tests in each testing category that
the BAT or STT reported as cancelled. Do not count any cancelled tests
in Column 1 or in any other column other than Column 9. For instance,
you must not count a 0.04 screening result or confirmation result in any
column, other than Column 9, if the test was ultimately cancelled for
some reason (e.g., a required air blank was not performed).
[Example: If a pre-employment test was reported cancelled, “1”
would be entered in Column 9 on the Pre-Employment row. If three of the
company’s random test results were reported cancelled, “3”
would be entered in Column 13 on the Random row.]
TOTAL Line. Columns 1 through 9 ~ This line requires
you to add the numbers in each column and provide the totals.
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