Revised _ MIS_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: 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

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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.