Form DOE F 470.7 DOE F 470.7 Human Reliability Program (HRP) Alcohol Testing Form

DOE F 470.7 (07/03)

OMB Control No. 1910-5122

U.S. Department of Energy (DOE)
Human Reliability Program (HRP) Alcohol Testing Form
(Instructions for completing this form are attached.)

STEP 1: TO BE COMPLETED BY ALCOHOL TECHNICIAN
A. Employee Name __________________________________________________________________
(Print)
First
M.I.
Last
B. Employee ID No.

__________________________________________________________

C. Employer Name

__________________________________________________________

Affix
or
print
screening results
here.

_____________________________________(____)________________
HRP Supervisor
Phone Number
D. Reason for Test:

Random Reasonable Susp. Post-Accident Return to Duty Follow-up

Pre-employment

STEP 2: TO BE COMPLETED BY EMPLOYEE
I certify that I am about to submit to alcohol testing required or permitted by U.S. Department of Energy regulations and that the
identifying information provided on the form is true and correct.
____________________________________________________________ ______________/_____/_______
Signature of Employee
Date Month Day Year
STEP 3: TO BE COMPLETED BY ALCOHOL TECHNICIAN
(If the technician conducting the screening test is not the same technician who will be conducting the confirmation test, each
technician must complete their own form.) I certify that I have conducted alcohol testing on the above named individual in
accordance with the procedures established in the U.S. Department of Transportation regulation 49 CFR Part 40, that I am qualified
to operate the testing device(s) identified, and that the results are as recorded.
Technician: BAT

Device: SALIVA BREATH*

15-Minute Wait: YES NO

Screening Test: (For BREATH DEVICE* write in the space below only if the testing device is not designed to print.)
______ ___________________ _______________________________
Test # Testing Device Name
Device Serial # or Lot # & Exp. Date

_____________ ____________ ____________
Activation Time Reading Time Result

CONFIRMATION TEST: Results MUST be affixed to each copy of this form or printed directly onto the form.
REMARKS:

Affix
or
print
confirmation
results
here.
Affix
with
tamper evident
tape.

___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
_______________________________________
Alcohol Technician=s Company
_______________________________________
(PRINT) Alcohol Technician=s Name (First, M.I., Last)

___________________________________
Company Street Address
_______________________________(___)_________
Company City, State, Zip
Phone Number

______________________________________
Signature of Alcohol Technician

____________/_____/_____
Date Month Day Year

Affix
or
print
additional
results
here.

STEP 4: TO BE COMPLETED BY EMPLOYEE IF TEST RESULT IS 0.02 or HIGHER
I certify that I have submitted to the alcohol test, the results of which are accurately recorded on this form. I understand that I will
be sent home and will not be allowed to perform HRP duties for 24 hours because the results are 0.02 or greater.
_______________________________________________
Signature of Employee

______________/______/______
Date Month Day Year

Make 2 Copies and Distribute: Original to employer; one copy for employee and one copy for Alcohol Technician.

Affix
with
tamper evident
tape.

INSTRUCTIONS FOR COMPLETING THE U.S. DEPARTMENT OF ENERGY HRP ALCOHOL TESTING FORM (ATF)
NOTE: Make two copies B forward original to employer; employee retains copy; and Alcohol Technician retains copy

STEP 1

The Breath Alcohol Technician (BAT) completes the information required in this step. Be sure to print the employee’s name and circle the reason for the
test. Print the HRP supervisor's name and phone number. The HRP supervisor is the person who initially or annually nominates the person for HRP
certification. In Step 1-D. Apost-accident@ should be circled for either occurrence or post-accident tests.
NOTE: If the employee refuses to provide an I.D. number, be sure to indicate this in the remarks section in STEP 3. Proceed with STEP 2.

STEP 2

Instruct the employee to read, sign, and date the employee certification statement in STEP 2.
NOTE: If the employee refuses to sign the certification statement do not proceed with the alcohol test. Contact the HRP Supervisor.

STEP 3

The BAT completes the information required in this step and checks the type of device (saliva or breath) being used. After conducting the alcohol screening
test, do the following (as appropriate):
Enter the information for the screening test (test number, testing device name, testing device serial number or lot number and expiration date, time of test with
any device-dependent activation times, and the results) on the front of the ATF. For a breath testing device capable of printing, the information may be part
of the printed record.
NOTE: Be sure to enter the result of the test exactly as it is indicated on the breath testing device, e.g., 0.00, 0.02, 0.04, etc.
Affix the printed information to the front of the form in the space provided, or to the back of the form, in a tamper-evident manner (e.g., tape), or the device
may print the results directly on the ATF. If the results of the screening test are less than 0.02, print, sign your name, and enter today’s date in the space
provided. The test process is complete.
If the results of the screening test are 0.02 or greater, a confirmation test must be administered in accordance with DOT regulations. An EVIDENTIAL
BREATH TESTING device that is capable of printing confirmation test information must be used in conducting this test.
Ensure that a waiting period of at least 15 minutes occurs before the confirmation test begins. Circle AYES@ or ANO@ to indicate whether the waiting period
lasted at least 15 minutes.
After conducting the alcohol confirmation test, affix the printed information to the front of the form in the space provided, or to the back of the form, in a
tamper-evident manner (e.g.,tape), or the device may print the results directly on the ATF. Print, sign your name, and enter the date in the space provided. Go
to STEP 4.

STEP 4

If the employee has a breath alcohol confirmation test result of 0.02 or higher, instruct the employee to read, sign, and date the employee certification
statement in STEP 4.
NOTE: If the employee refuses to sign the certification statement in STEP 4, be sure to indicate this in the remarks line in STEP 3.
Immediately notify the HRP Supervisor if the employee has a breath alcohol confirmation test result of 0.02 or higher.
Make a copy for the employee, make a copy for the BAT records, and forward the original to the employer.

OMB Disclosure Statement
Public reporting burden for this collection of information is estimated to average six minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden,
to Office of Business and Information Management, IM-10, GTN, Paperwork Reduction Project (1910-5122), U.S. Department of Energy, 1000
Independence Ave., SW, Washington, DC 20585-1290; and to the Office of Management and Budget (OMB), Paperwork Reduction Project (19105122), Washington, DC 20503.

Privacy Act Statement
Sections 2165 and 2201(I) of title 42 of the United States Code authorize the collection of information by the U.S. Department of Energy (DOE) to
regulate the possession and use of special nuclear material and access to restricted data. DOE will use the information collected on this form to aid
in the determination of an individual=s eligibility for an HRP certification. The information may also be provided to other agencies of the United
States government for investigations that involve protection of the national security, public health and safety, or the environment. Submission of the
information requested on this form is voluntary, but failure to provide the information may result in denial of an HRP certification. If DOE uses the
information for purposes other than those indicated in this statement, it will provide notice of those additional purposes to persons who have
submitted information on this form.