MIS Data Collection Form

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

Calendar Year Covered by this Report: ________________

OMB No. 2105-0529

I. Employer:
Company Name:
Doing Business As (DBA) Name (if applicable):
Address:_______________________________________________________________________________ E-mail: ________________________
Signature: _________________________________________________

Name of Certifying Official:

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

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.

Total Number of Employees
in this Category

III. Drug Testing Data:
3

4

5

6

7

8

9

10

11

12

13

Pre-Employment
Random
Post-Accident
Reasonable Susp./Cause
Return-to-Duty
Follow-Up
TOTAL

Pre-Employment
Random
Post-Accident
Reasonable Susp./Cause
Return-to-Duty
Follow-Up
TOTAL

4

5

6

7

8

9

Cancelled Results

Other Refusals
To Submit To
Testing

“Shy Lung” ~
With No Medical
Explanation

Confirmation Tests
With Results 0.04 Or
Greater

Confirmation Tests
With Results 0.02
Through 0.039

Refusal Results
Number Of
Confirmation Tests
Results

3
Screening Tests With
Results 0.02 Or
Greater

2
Screening Tests With
Results Below 0.02

Type of Test

1
Total Number Of
Screening Test
Results [Should equal
the sum of Columns
2, 3, 7, and 8]

IV. Alcohol Testing Data:

Cancelled Results

Other Refusals To
Submit To
Testing

“Shy Bladder” ~
With No Medical
Explanation

Substituted

Adulterated

Positive For
Amphetamines

Positive For
Opiates

Positive For
PCP

Positive For
Cocaine

Positive For
Marijuana

Verified Positive
Results ~ For One Or
More Drugs

Refusal Results
Verified Negative
Results

Type of Test

2

Total Number Of Test
Results [Should equal
the sum of Columns 2,
3, 9, 10, 11, and 12]

1

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.