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U.S. DEPARTMENT OF TRANSPORTATION DRUG AND ALCOHOL TESTING MIS DATA COLLECTION FORM

Calendar Year Covered by this Report: _________________


I. Employer:
Company Name: _________________________________________________________________________________________
Doing Business As (DBA) Name (if applicable): _________________________________________________________________
Address:_________________________________________________________________ E-mail: ________________________
Name of Certifying Official: Signature: _________________________________________________
Telephone: (_____)______________________________________ Date Certified: ______________________________________
Prepared by (if different): ___________________________________________________ Telephone: (_____)_________________
C/TPA Name and Telephone (if applicable): ______________________________________ (_____)_________________________

Check the DOT agency for which you are reporting MIS data; and complete the information on that same line as appropriate:

___ FMCSA – Motor Carrier: DOT #: ______________________ Owner-operator: (circle one) YES or NO      Exempt (Circle One) YES or NO
___ FAA – Aviation: Certificate # (if applicable): _______________________ Plan / Registration # (if applicable):_________________
___ RSPA – Pipeline: (Check) Gas Gathering__ Gas Transmission__ Gas Distribution__ Transport Hazardous Liquids__ Transport Carbon Dioxide__
___ FRA – Railroad: Total Number of observed/documented Part 219 “Rule G” Observations for covered employees: ______________
___ USCG – Maritime: Vessel ID # (USCG- or State-Issued): ______________________________________  (If more than one vessel, list separately.)
___ FTA – Transit

II. Covered Employees: (A) Enter Total Number Safety-Sensitive Employees In All Employee Categories: ______________________

(B) Enter Total Number of Employee Categories: ____________________

(C)
Employee Category
Total Number of Employees in this Category
   

If you have multiple employee categories, complete Sections I and II (A) & (B). Take that filled-in form and make one copy for each employee category and complete Sections II (C), III, and IV for each separate employee category.

III. Drug Testing Data:
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13
Type of Test Total Number Of Test Results [Should equal the sum of Columns 2, 3, 9, 10, 11, and 12] Verified Negative Results Verified Positive Results ~ For One Or More Drugs Positive For
Marijuana
 Positive For
Cocaine
 Positive For
PCP
 Positive For
Opiates
 Positive For
Amphetamines
 Refusal Results Cancelled Results
Adulterated Substituted “Shy Bladder” ~ With No Medical Explanation Other Refusals To Submit To Testing
Pre-Employment                          
Random                          
Post-Accident                          
Reasonable Susp./Cause                          
Return-to-Duty                          
Follow-Up                          
TOTAL                          

lV. Alcohol Testing Data

 
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2
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9
Type of Test Total Number Of Screening Test Results [Should equal the sum of Columns 2, 3, 7, and 8] Screening Tests With Results Below 0.02 Screening Tests With Results 0.02 Or Greater Number Of Confirmation Tests Results Confirmation Tests With Results 0.02 Through 0.039 Confirmation Tests With Results 0.04 Or Greater Refusal Results Cancelled Results
“Shy Lung” ~ With No Medical Explanation Other Refusals To Submit To Testing
Pre-Employment                  
Random                  
Post-Accident                  
Reasonable Susp./Cause                  
Return-to-Duty                  
Follow-Up                  
TOTAL                  


PAPERWORK REDUCTION ACT NOTICE (as required by 5 CFR 1320.21)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 2105-0529. The Department of Transportation estimates that the average burden for this report form is 1.5 hours. You may send comments regarding this burden estimate or any suggestions for reducing the burden to: U.S. Department of Transportation, Office of Drug and Alcohol Policy and Compliance, Room 10403, 400 Seventh Street, SW, Washington, D.C. 20590; OR Office of Management and Budget, Paperwork Reduction Project, 725 Seventeenth Street, NW, Washington, D.C. 20503.

Title 18, USC Section 1001, makes it a criminal offense subject to a maximum fine of $10,000, or imprisonment for not more than 5 years, or both, to knowingly and willfully make or cause to be made any false or fraudulent statements of representations in any matter within the jurisdiction of any agency of the United States.