Form DOT F 1385 DOT F 1385 MIS Data Collection Form

Procedures for Transportation Drug and Alcohol Testing Program

Rev_MIS_Form

Procedures for Transportation Drug and Alcohol Testing Program

OMB: 2105-0529

Document [doc]
Download: doc | pdf

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: Form DOT F 1385 (Rev. 5/2008)

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):___________________________

___ PHMSA – 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

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

(B) Enter Total Number of Employee Categories:

(

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.

C)




I

1 2 3 4 5 6 7 8 9 10 11 12 13

II. Drug Testing Data
:






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














I

1 2 3 4 5 6 7 8 9

V. Alcohol Testing Data:





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)

A federal agency may not conduct or sponsor, and a person is not required to respond to,

nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2105-0529. Public reporting for this collection of information is estimated to be approximately 90 minutes per response, including the time for reviewing instructions, completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, U.S. Department of Transportation, Office of Drug and Alcohol Policy and Compliance, 1200 New Jersey Avenue, SE, Suite W62-300, Washington, D.C. 20590.




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.



File Typeapplication/msword
Authorjim.swart
Last Modified Bybohdan.baczara
File Modified2008-05-08
File Created2008-05-08

© 2024 OMB.report | Privacy Policy