CG-719P DOT/USCG Periodic Drug Testing Form

DEPARTMENT OF
HOMELAND SECURITY
U.S. COAST GUARD

DOT/USCG Periodic Drug Testing Form

OMB 1625-0040
Expires 07/31/2009

CG-719P (Rev 03/04)

Page 1

INSTRUCTIONS: This form MAY be used to satisfy the requirements for “Periodic Drug Testing” in accordance with Title 46
CFR 16.220. If you participate in a USCG “random or pre-employment drug test program,” this form may not be necessary. (See
page 2 for details).
NOTE: The cost of the drug test is the sole responsibility of the applicant, not the Coast Guard.

Section I – Applicant Consent
I certify that I am the described applicant and that I have provided the specimen(s) described below in accordance with Department
of Transportation procedures given in 49 CFR 40. I also understand that making in any way, a false or fraudulent statement, entry,
or evidence is a violation of the U.S Criminal Code at Title 18 U.S.C. 1001 which subjects the violator to federal prosecution and
possible incarceration, fine, or both.
Name: (Last, First, Middle) of Applicant (Print or Type)

Social Security Number

X Signature of Applicant

Date

Section II – Name of SAMHSA Accredited Laboratory (Type or Print)
Name

Address

Section III – Medical Review Officer
DATE SPECIMEN COLLECTED:
_______________________________________

Specimen Analyzed For (DOT 5 Panel):
• Marijuana metabolite
• Cocaine metabolites
• Opiates metabolites
• Phencyclidine
• Amphetamines

The laboratory report has been reviewed in accordance with
procedures given in 49 CFR Part 40, Subpart G, and the
verified test results are: (CIR CLE ONE)

NEGATIVE
POSITIVE/SUBSTITUTED/ADULTERATED or
INVALID TEST (Test Cancelled)
(Please complete the next block for all non-negative results)

FOR POSITIVE/ADULTERATED/CANCELLED DRUG TESTS ONLY: (To be reported to the nearest USCG
Marine Safety Office).
This specimen is verified POSITIVE for _________________________________________________.
The specimen was identified as being SUBSTITUTED or containing the ADULTERANT:
______________________________________________________________.
The test was CANCELLED because (insert reason):
_______________________________________________________________________________________________
I certify that I meet the qualifications for a Medical Review Officer as outlined in Title 49 CFR 40.121. I have reviewed
the results and determined that the applicant’s verified test result is in accordance with Title 49 CFR 40 Subpart G.
MEDICAL REVIEW OFFICER CONTACT
INFORMATION:

MEDICAL REVIEW OFFICER AUTHORITY:

Name:

Signature: _______________________________________

__________________________________________

Address: __________________________________________
__________________________________________
__________________________________________
Phone:

Name: (Printed) ___________________________________

(MRO signature stamp is authorized for negative results only)

Name of MRO Qualifying Organization:
_______________________________________________
Registration Number Issued by Qualifying Organization:

__________________________________________

_____________________________________________
“An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a
valid OMB control number.” “The Coast Guard estimates that the average burden for this report is 5 minutes. You may submit any
comments concerning the accuracy of this burden estimate or any suggestions for reducing the burden to:
Commanding Officer, U. S. Coast Guard National Maritime Center, 4200 Wilson Boulevard, Suite 630, Arlington, VA 22203-1804 or
Office of Management and Budget, Paperwork Reduction Project (1625-0040), Washington, DC 20503.”

DEPARTMENT OF
HOMELAND SECURITY
U.S. COAST GUARD

DOT/USCG Periodic Drug Testing Form

CG-719P (Rev 03/04)

REQUIREMENTS

Page 2

•
•
•
•

OPTION I
PERIODIC TESTING
PROGRAM

OMB 1625-0040
Expires 07/31/2009

•

A drug test is required for all transactions EXCEPT endorsements, duplicates and STCW certificates.
ONLY a DOT 5 Panel (SAMHSA 5 Panel, formerly NIDA 5), testing for Marijuana, Cocaine,
Opiates, Phencyclidine, and Amphetamines will be accepted.
A USCG drug test conducted within the past 185 days by a laboratory accredited by Substance Abuse
and Mental Health Services Administration (SAMHSA), Department of Health and Human Services.
COLLECTION of a urine sample may be conducted by an independent medical facility, private
physician or at an employer-designated site as long as the collection agent meets the qualification
requirements to be a collection agent given Title 49 CFR Part 40.31. It is CRITICAL that the sample is
sent to an accredited SAMHSA laboratory for ANALYSIS or the drug test is invalid.
A list of service agents that can assist in meeting these requirements is included or a list of service
agents can be obtained at www.uscg.mil/hq/g-m/moa/dapip.htm.
The ORIGINAL results are required. A FACSIMILE is acceptable, if it is originated from the
Medical Review Officer (MRO) or the Service Agent assisting the mariner, and sent directly to our
office. The drug test result must be signed and dated by the MRO or by a representative of the service
agent who assisted you in meeting this requirement.

•
OPTION II
RANDOM TESTING

OPTION III
PRE-EMPLOYMENT
TESTING

An ORIGINAL DATED letter on marine employer stationary or, for ACTIVE DUTY MILITARY
MEMBERS, an ORIGINAL DATED letter from your command on command letterhead attesting to
participation in random drug testing programs.
EXAMPLE (From Marine Employers): APPLICANT’S NAME / SSN has been subject to a random
testing program meeting the criteria of Title 46 CFR 16.230 for at least 60 days during the previous 185
days and has not failed nor refused to participate in a chemical test for dangerous drugs.
EXAMPLE (Active Duty Military/Military Sealift Command/N.O.A.A./ Army Corps of Engineers):
APPLICANT’S NAME / SSN has been subject to a random testing program and has never refused to
participate in or failed a chemical drug test for dangerous drugs.

•

An ORIGINAL DATED letter on marine employer stationary signed by a company official, stating
that you have passed a pre-employment chemical test for dangerous drugs within the past 185 days.
EXAMPLE: APPLICANT’S NAME / SSN passed a chemical test for dangerous drugs, required under Title
46 CFR 16.210 within the previous six months of the date of this letter with no subsequent positive drug
test results during the remainder of the six month period.

PRIVACY ACT STATEMENT
IN ACCORDANCE WITH 5 U. S. C. 552a(e)(3), THE FOLLOWING INFORMATION IS PROVIDED TO YOU WHEN SUPPLYING PERSONAL
INFORMATION TO THE U.S. COAST GUARD.
1. AUTHORITY WHICH AUTHORIZED THE SOLICITATION OF INFORMATION 46 U. S. C. 7302, 7305, 7314, 7316, 7319, AND 7502 (SEE 46 CFR
PARTS 10, 12, 13, AND 16).
2. PRINCIPLE PURPOSES FOR WHICH INFORMATION IS INTENDED TO BE USED:
A. TO ESTABLISH ELIGIBILITY FOR A MERCHANT MARINER’S LICENSE AND DOCUMENT ISSUED BY THE COAST GUARD.
B. TO ESTABLISH AND MAINTAIN A CONTINUOUS RECORD OF THE PERSON’S DOCUMENTATION TRANSACTIONS.
C. PART OF THE INFORMATION IS TRANSFERRED TO A FILE MANAGEMENT COMPUTER SYSTEM FOR A PERMANENT
RECORD.
3. THE ROUTINE USES WHICH MAY BE MADE OF THE INFORMATION:
A. TO MAINTAIN RECORDS REQUIRED BY 46 U. S. C. 7319 AND 7502.
B. TO ENABLE ELIGIBLE PARTIES (i.e. the mariner’s heirs or properly designated representative) TO OBTAIN INFORMATION.
C. TO PROVIDE INFORMATION TO THE U.S. MARITIME ADMINISTRATION FOR USE IN DEVELOPING MANPOWER STUDIES
AND TRAINING BUDGET NEEDS.
D. TO DEVELOP INFORMATION AT THE REQUEST OF COMMITTEES OF CONGRESS.
E. TO PROJECT BILLET ASSIGNMENTS AT COAST GUARD MARINE INSPECTION/SAFETY OFFICES.
F. TO PROVIDE INFORMATION TO LAW ENFORCEMENT AGENCIES FOR CRIMINAL OR CIVIL LAW ENFORCEMENT PURPOSES.
G. TO ASSIST U.S. COAST GUARD INVESTIGATING OFFICERS AND ADMINISTRATIVE LAW JUDGES IN DETERMINING
MISCONDUCT, CAUSES OF CASUALTIES, AND APPROPRIATE SUSPENSION AND REVOCATION ACTIONS.
4. WHETHER OR NOT DISCLOSURE OF SUCH INFORMATION IS MANDATORY OR VOLUNTARY (Required by law or optional) AND THE
EFFECTS ON THE INDIVIDUAL, IF ANY, OF NOT PROVIDING ALL OR PART OF THE REQUESTED INFORMATION IS VOLUNTARY,
DISCLOSURE OF THIS INFORMATION IS VOLUNTARY, BUT FAILURE TO PROVIDE MAY RESULT IN NON-ISSUANCE OF THE
REQUESTED DOCUMENT(S).