Form 8060-12 Authorization for Release of DOT Drug and Alcohol Testin

INSTRUCTIONS
FAA FORM 8060-12, AUTHORIZATION FOR RELEASE OF DOT DRUG AND ALCOHOL TESTING
RECORDS UNDER PRIA AND MAINTAINED UNDER TITLE 49 CODE OF FEDERAL REGULATIONS
(49 CFR) PART 40

Pilot Records Improvement Act Of 1996 (PRIA)
Title 49 U.S.C. § 44703(h), RECORDS OF EMPLOYMENT OF PILOT APPLICANTS, as amended

Air Carriers should use this form to request the appropriate records from current and/or past employers as
contemplated under 49 U.S.C. § 44703(h), Records of Employment of Pilot Applicants, As Amended.
NOTICE: This request is for the 5-year period preceding the date of the employee’s signature in Part I
of this form. This request will not be deemed valid unless Parts I and II are completed as specified.
Pursuant to 49 U.S.C. § 44703(h)(5), a person who receives a request for records under 49 U.S.C. §
44703(h)(1) shall furnish a copy of all such requested records maintained by the person not later than 30 days
after receiving the request. An additional copy must be furnished to the subject of this request only if that
person has so indicated on the attached FAA Form 8060-11A, by checking the ‘YES’ block. See the note to
the previous employer at the bottom of FAA Form 8060-12. This form may be photocopied for use, or is
available on the Internet at http://www.faa.gov/pilots/lic_cert/pria/ or http://forms.faa.gov/
This form is to be used as an attachment to FAA Forms 8060-11 and 8060-11A. A separate form must be
used for each airman whose records are requested. Do not use with FAA Forms 8060-10 or 8060-10A.
Part I: To be completed by the new employer and signed by the applicant/employee.
All entries must be completed legibly with black or dark blue ink.
1. TO – enter the name and address of the applicant/employee’s previous employer.
2. Enter the name and SSN of the applicant/employee. (SSN is optional – see Privacy Act statement below)
3. Enter the name and air carrier certificate number of the requesting employer.
4. Enter the name of the Designated Employer Representative authorized to receive the released records.
5. Signature – signature of the applicant/employee.
6. Date – enter the date of the request
Part II: To be completed by the previous employer (DER). DER is assigned IAW 49 CFR Part 40.
All entries must be completed legibly with black or dark blue ink.
1. DER answers questions 1 through 6, and prepares copies of the required supporting documents.
2. Enter the name of the Designated Employer Representative authorized to release the requested records.
3. Enter the phone / Email address / FAX numbers of the person (DER) providing the requested records.
4. Enter the date that the requested records have been prepared and forwarded to the new employer.
PAPERWORK REDUCTION ACT STATEMENT
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 currently valid OMB Control Number. The OMB Control Number for this information collection is 2120-0607. Public reporting for this
collection of information is estimated to be approximately 10 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of information. All responses to this
collection of information are mandatory (Title 49 United States Code (49 U.S.C.) § 44703(h). 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,
Federal Aviation Administration, 10101 Hillwood Parkway, Fort Worth, TX 76177-1524

SEE PRIVACY ACT STATEMENT BELOW

FAA Form 8060-12 (10-05)

AUTHORIZATION FOR RELEASE OF DOT DRUG AND ALCOHOL TESTING RECORDS UNDER PRIA AND MAINTAINED UNDER TITLE 49 CODE FEDERAL REGULATIONS (49 CFR) PART 40
PRIVACY ACT STATEMENT: This statement is provided pursuant to the Privacy Act of 1974, 5 USC § 552a:
The authority for collecting this information is contained in 49 U.S.C. §§ 40113, 44702, 44703, 44709. The principal purpose for which the information is intended to be used is to identify and
evaluate your qualifications and eligibility for the issuance of an airman certificate and/or rating. Submission of the data is mandatory, except for the Social Security Number, which is
voluntary. Failure to provide all required information will result in our being unable to issue you a certificate and/or rating. The information collected on this form will be included in a Privacy
Act System of Records known as DOT/FAA 847, titled “Aviation Records on Individuals” and will be subject to the routine uses published in the System of Records Notice (SORN) for DOT/FAA
847 (see www.dot.gov/privacy/privacyactnotices), including:
(a) Providing basic airmen certification and qualification information to the public upon request; examples of basic information include:
• The type of certificates and ratings held, limitations, date of issuance and certificate number;
• The status of the airman’s certificate (i.e., whether it is current or has been amended, modified, suspended or revoked for any reason);
• The airman’s home address, unless requested by the airman to be withheld from public disclosure per 49 U.S.C. 44703(c);
• Information relating to an airman’s physical status or condition used to determine statistically the validity of FAA medical standards; and the date, class, and restrictions of the latest physical
• Information relating to an individual’s eligibility for medical certification, requests for exemption from medical requirements, and requests for review of certificate denials.
(b) Using contact information to inform airmen of meetings and seminars conducted by the FAA regarding aviation safety.
(c) Disclosing information to the National Transportation Safety Board (NTSB) in connection with its investigation responsibilities.
(d) Providing information about airmen to Federal, State, local and tribal law enforcement agencies when engaged in an official investigation in which an airman is involved.
(e) Providing information about enforcement actions, or orders issued thereunder, to Federal agencies, the aviation industry, and the public upon request.
(f) Making records of delinquent civil penalties owed to the FAA available to the U.S. Department of the Treasury and the U.S. Department of Justice (DOJ) for collection pursu-ant to 31 U.S.C.
3711(g).
(g) Making records of effective orders against the certificates of airmen available to their employers if the airmen use the affected certificates to perform job responsibilities for those
employers.
(h) Making airmen records available to users of FAA’s Safety Performance Analysis System (SPAS), including the Department of Defense Commercial Airlift Division’s Air Car-rier Analysis
Support System (ACAS) for its use in identifying safety hazards and risk areas, targeting inspection efforts for certificate holders of greatest risk, and monitoring the effectiveness of targeted
oversight actions.
(i) Making records of an individual’s positive drug test result, alcohol test result of 0.04 or greater breath alcohol concentration, or refusal to submit to testing required under a DOT-required
testing program, available to third parties, including current and prospective employers of such individuals. Such records also contain the names and titles of indi-viduals who, in their
commercial capacity, administer the drug and alcohol testing programs of aviation entities.
(j) Providing information about airmen through the Civil Aviation Registry’s Comprehensive Airmen Information System to the Department of Health and Human Services, Office of Child
Support Enforcement, and the Federal Parent Locator Service that locates noncustodial parents who owe child support. Records in this system are used to identify airmen to the child support
agencies nationwide in enforcing child support obligations, establishing paternity, establishing and modifying support orders and location of obligors. Records listed within the section on
Categories of Records are retrieved using Connect: Direct through the Social Security Administration’s secure environment.
(k) Making personally identifiable information about airmen available to other Federal agencies for the purpose of verifying the accuracy and completeness of medical information provided
to FAA in connection with applications for airmen medical certification.
(l) Making records of past airman medical certification history data available to Aviation Medical Examiners (AMEs) on a routine basis so that AMEs may render the best medical certification
decision.
(m) Making airman, aircraft and operator record elements available to users of FAA’s Skywatch system, including the Department of Defense (DoD), the Department of Homeland Security
(DHS), DOJ and other authorized Federal agencies, for their use in managing, tracking and reporting aviation-related security events.
(n) Other possible routine uses published in the Federal Register (see Prefatory Statement of General Routine Uses for additional uses (65 F.R. 19477-78) For example, a record from this
system of records may be disclosed to the United States Coast Guard (Coast Guard) and to the Transportation Security Administration (TSA) if information from this system was shared with
either agency when that agency was a component of the Department of Transportation (DOT) before its transfer to DHS and such disclosure is necessary to accomplish a DOT, TSA or Coast
Guard function related to this system of records.
FAA Form 8060-12 (10/05)

Form Approved: OMB No. 2120-0607
Exp: 3/31/2020
AUTHORIZATION FOR RELEASE OF DOT DRUG AND ALCOHOL TESTING RECORDS UNDER
PRIA AND MAINTAINED UNDER TITLE 49 CODE OF FEDERAL REGULATIONS (49 CFR) PART 40
Pilot Records Improvement Act Of 1996 (PRIA)
Title 49 U.S.C. § 44703(h), RECORDS OF EMPLOYMENT OF PILOT APPLICANTS, as amended
Part I:
To be completed by the new employer, signed by the applicant/employee, and transmitted to the previous employer.
TO:

___________________________________
(Previous Employer Name – Printed)

________
(Street Address)

,

__________,
(City)

_________,
(State)

__________
(Zip)

I, ______________________________________________ SSN: ________________________ have applied for employment
(Applicant/Employee Name – Printed)

(OPTIONAL – See the attached Privacy Act statement)

with ____________________________________________________, _______________________, and hereby authorize the
(Hiring Air Carrier Name – Printed)

(Air Carrier Certificate Number)

release of records from Department of Transportation-regulated drug and alcohol testing of me by my previous employer,
to ______________________

__________________________________ FAX Number:__________________________

(Printed name of the Designated Employer Representative (DER) authorized to receive the released records)

(Of the hiring Air Carrier)

I understand that this release of 5 years of records by my previous employer satisfies the requirements of DOT Code of Federal
Regulations 49 CFR § 40.25(a)-(i) and 49 CFR § 40.333, and is limited to the following DOT-regulated testing records:
1.
2.
3.
4.
5.
6.
7.
8.

Confirmed alcohol test results indicating an alcohol concentration of 0.04 or greater;
Verified positive drug test results;
Documentation of refusals to take required alcohol and/or drug tests (including substituted or adulterated test results);
Documentation of other violations of DOT agency drug and alcohol testing regulations;
Substance Abuse Professional (SAP) reports;
All follow-up test results and schedules for follow-up tests, including documentation of each return-to-duty test;
Information obtained from previous employers under 49 CFR § 40.25 concerning drug and/or alcohol violations;
Records of negative and cancelled drug test results, and confirmed alcohol test results with an alcohol concentration
of less than 0.039.

Applicant/Employee Signature: _____________________________________________

Date: ________________________

A reproduction of this authorization shall be deemed effective and valid as an original.
Part II:
To be completed by the previous employer (DER) and transmitted by mail or fax to the new employer.
In the five year period, prior to the date of the employee’s signature in Part I, for DOT regulated testing:
1. Did the employee have any confirmed alcohol tests with a concentration of 0.04 or higher?

YES_____ NO_____

2. Did the employee have any verified positive drug tests?

YES_____ NO_____

3. Did the employee refuse to be tested?

YES_____ NO_____

4. Did the employee have other violations of DOT agency drug and/or alcohol testing regulations?

YES_____ NO_____

5. Did a previous employer report a drug and/or alcohol rule violation to you?

YES_____ NO_____

6. If you answered ‘yes’ to any of the above items, did the employee complete the
‘return-to-duty’ process?

N/A_____ YES_____ NO_____

If you answered ‘yes’ to item 6, please provide the appropriate return-to-duty documentation (SAP reports and follow-up testing).
49 U.S.C. § 44703(h)(1)(B) requires ‘records’ to be furnished. This includes records of positive as well as negative results.
Name of the Designated Employer Representative (DER) providing the records:_______________________________________
Phone Number:_______________________Email or FAX Number:_____________________________ Date:_______________
PREVIOUS EMPLOYER: If the individual named in Part I above has requested a copy of their records pursuant to a PRIA
records request on FAA Form 8060-11A, AIRMAN NOTICE AND RIGHT TO RECEIVE COPY -- AIR CARRIER AND OTHER
RECORDS (PRIA), copies of the Drug and Alcohol records must be provided to the individual (Title 49 U.S.C. § 44703(h)(6)).
Forward copies of the Drug and Alcohol records to the address provided by the individual on FAA Form 8060-11A.

FAA Form 8060-12 (10-05)