Federal ATF Form

U.S. Department of Transportation (DOT)
Alcohol Testing Form

Print Screening Results
Here or Affix with
Tamper Evident Tape

(The instructions for completing this form are on the back of Copy 3)
Step 1: TO BE COMPLETED BY ALCOHOL TECHNICIAN
A: Employee Name ______________________________________________________________________________________
(Print)
(First, M.I., Last)
B: SSN or Employee ID No. _____________________________________________________________________________
C: Employer Name
Street
City, Sate, Zip

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

DER Name and
Telephone No.

D: Reason for Test:

___________________________________________________(_____)____________________
DER Name
DER Phone Number
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 by US Department of Transportation regulations and that the
identifying information provided on the form is true and correct.
___________________________________________________________________
Signature of Employee

_____________/____/_____
Date Month Day Year

Print Confirmation
Results Here or Affix
with Tamper Evident
Tape

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 US 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

STT

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:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
______________________________________________
Alcohol Technician’s Company
_______________________________________________
(PRINT) Alcohol Technician’s Name (First, M.I., Last)
_______________________________________________
Signature of Alcohol Technician

______________________________________________________
Company Street Address
_______________________________(_____)_________________
Company City, State, Zip
Phone Number
__________/____/________
Date

Month Day

Year

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 must not drive, perform safety-sensitive duties, or operate heavy equipment because the results are 0.02 or greater.
______________________________________________________________________
Signature of Employee
Form DOT F 1380 (Rev. 5/2008)

COPY 1 – ORIGINAL – FORWARD TO THE EMPLOYER

_____________/_____/____
Date Month Day Year
OMB No. 2105-0529

Print Additional
Results Here or Affix
With Tamper Evident
Tape

U.S. Department of Transportation (DOT)
Alcohol Testing Form

Print Screening Results
Affix
Here or Affix with
Or
Tamper
Print Evident Tape

(The instructions for completing this form are on the back of Copy 3)

Screening Results
Here

Step 1: TO BE COMPLETED BY ALCOHOL TECHNICIAN
A: Employee Name ______________________________________________________________________________________
(Print)
(First, M.I., Last)
B: SSN or Employee ID No. _____________________________________________________________________________
C: Employer Name
Street
City, State, Zip

_____________________________________________________________________________
_____________________________________________________________________________

Affix
With
Tamper Evident Tape

_____________________________________________________________________________
DER Name and
Telephone No.

___________________________________________________(_____)____________________
DER Name
DER 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 by US Department of Transportation regulations and that the
identifying information provided on the form is true and correct.
___________________________________________________________________
Signature of Employee

_____________/____/_____
Date Month Day Year

Print Confirmation
Results Here or Affix
with Tamper Evident
Tape

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 US 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 ⃞ STT

DEVICE:

⃞ SAL I VA ⃞ 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:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
______________________________________________
Alcohol Technician’s Company
_______________________________________________
(PRINT) Alcohol Technician’s Name (First, M.I., Last)
_______________________________________________
Signature of Alcohol Technician

______________________________________________________
Company Street Address
_______________________________(_____)_________________
Company City, State, Zip
Phone Number
__________/____/________
Date

Month Day

Year

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 must not drive, perform safety-sensitive duties, or operate heavy equipment because the results are 0.02 or greater.
______________________________________________________________________
Signature of Employee
Form DOT F 1380 (Rev. 5/2008)

COPY 2 – EMPLOYEE RETAINS

_____________/_____/____
Date Month Day Year
OMB No. 2105-0529

Print Additional
Results Here or Affix
With Tamper Evident
Tape

U.S. Department of Transportation (DOT)
Alcohol Testing Form

Print Screening Results
Affix
Here or Affix with
Or
Tamper
Print Evident Tape

(The instructions for completing this form are on the back of Copy 3)

Screening Results
Here

Step 1: TO BE COMPLETED BY ALCOHOL TECHNICIAN
A: Employee Name ______________________________________________________________________________________
(Print)
(First, M.I., Last)
B: SSN or Employee ID No. _____________________________________________________________________________
C: Employer Name
Street
City, State, Zip

_____________________________________________________________________________
_____________________________________________________________________________

Affix
With
Tamper Evident Tape

_____________________________________________________________________________
DER Name and
Telephone No.

___________________________________________________(_____)____________________
DER Name
DER Phone Number

D: Reason for Test: Random Reasonable Susp Post-Accident Return to Duty  Follow-up  Pr e-employment
STEP 2: TO BE COMPLETED BY EMPLOYEE
I certify that I am about to submit to alcohol testing required by US Department of Transportation regulations and that the
identifying information provided on the form is true and correct.
___________________________________________________________________
Signature of Employee

_____________/____/_____
Date Month Day Year

Print Confirmation
Results Here or Affix
with Tamper Evident
Tape

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 US 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 ⃞ STT

DEVICE:

⃞ SAL I VA

⃞ 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:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
______________________________________________
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

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 must not drive, perform safety-sensitive duties, or operate heavy equipment because the results are 0.02 or greater.
______________________________________________________________________
Signature of Employee
Form DOT F 1380 (Rev. 5/2008)

COPY 3 – ALCOHOL TECHNICIAN RETAINS

_____________/_____/____
Date Month Day Year
OMB No. 2105-0529

Print Additional
Results Here or Affix
With Tamper Evident
Tape

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 8 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.
BACK OF PAGES 1 and 2

INSTRUCTIONS FOR COMPLETING THE U.S. DEPARTMENT OF TRANSPORTATION ALCOHOL TESTING FORM
NOTE: Use a ballpoint pen, press hard, and check all copies for legibility.
STEP 1

The Breath Alcohol Technician (BAT) or Screening Test Technician (STT) completes the information required in this
step. Be sure to print the employee's name and check the box identifying the reason for the test.
NOTE: If the employee refuses to provide SSN or 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 designated employer representative.

STEP 3

The BAT or STT 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 AFT. 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) such that it does not obscure the original printed information, 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. Check the box indicating
that 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) such that it does not obscure
the original information, 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 DER if the employee has a breath alcohol confirmation test result of 0.02 or higher.
Forward Copy 1 to the employer. Give Copy 2 to the employee. Retain Copy 3 for BAT/STT records.

BACK OF PAGE 3