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 06/30/2012

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

Social Security Number

_

Signature of Applicant

_

Date: (Month/Day/Year e.g. 11/09/2012)

X

/

/

SECTION II – NAME OF SAMHSA ACCREDITED LABORATORY
Name

Address

City

State

Zip Code

SECTION III – MEDICAL REVIEW OFFICER
Date Specimen Collected: (Month/Day/Year e.g. 11/09/2012)

/

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

/

NEGATIVE

Specimen Analyzed For (DOT 5 Panel):

POSITIVE/SUBSTITUTED/ADULTERATED or

Marijuana metabolite
Cocaine metabolites
Opiates metabolites
Phencyclidine
Amphetamines

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:

This specimen was identified as being SUBSTITUTED or containing the ADULTERANT:

The test was CANCELLED because (insert reason):

I certify that I meet 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.

Name

MEDICAL REVIEW OFFICER CONTACT INFORMATION
Last
First
Middle

Name
(Printed)

Last

MEDICAL REVIEW OFFICER AUTHORITY
First
Middle

Signature (MRO signature stamp is authorized for negative results only)
Address

City

Phone
CG-719P (9/12)

(

State

)

-

Zip Code

Name of MRO Qualifying Organization
Registration Number Issued by Qualifying Organization
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DOT/USCG PERIODIC DRUG TESTING FORM
A drug test is required for all transactions EXCEPT endorsements, documents of continuity,
duplicates, and STCW certificates.

REQUIREMENTS
Only a DOT 5 Panel (SAMHSA 5 Panel, formerly NIDA 5), testing for Marijuana, Cocaine, Opiates,
Phenycyclidine, 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.

OPTION I
PERIODIC TESTING
PROGRAM

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 in Title 49 CFR Part 40.30. It is CRITICAL that the
sample is sent to an accredited SAMHSA laboratory for ANALYSIS or the drug test is invalid.
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 from the 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

EXAMPLE (From Mariner 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 with no subsequent positive
drug test results during the remainder of the six month period.
An ORIGINAL DATED letter on mariner 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, 11, 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 42 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).
"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, 100 Forbes Drive,
Martinsburg, WV 25404 or Office of Management and Budget, Paperwork Reduction Project (1625-0040), Washington, DC 20503."
CG-719P (9/12)

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