Appendix D

Appendix H to Part 40 – DOT Drug and Alcohol Testing Management Information System
(MIS) Data Collection Form
The following form is the MIS Data Collection form required for use to report calendar
year MIS data. The instructions for this form are found at https://www.transportation.gov/odapc.
[68 FR 43952, July 25, 2003, as amended 75 FR 8528, February 25, 2010; 82 FR 52247, November 13,
2017; 84 FR 16773, April 23, 2019]

U.S. DEPARTMENT OF TRANSPORTATION DRUG AND ALCOHOL TESTING MIS DATA COLLECTION FORM

Calendar Year Covered by this Report: ________________

I. Employer:
Company Name:

OMB No. 2105-0529

Form DOT F 1385 (Rev. 4/2019)

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
II. Covered Employees: (A) Enter Total Number Safety-Sensitive Employees In All Employee Categories:
(B) Enter Total Number of Employee Categories:
Employee Category

2

3

4

5

6

7

8

9

10

11

12

13

Pre-Employment
Random
Post-Accident
Reasonable Susp./Cause
Return-to-Duty
Follow-Up
TOTAL

Random
Post-Accident
Reasonable Susp./Cause
Return-to-Duty
Follow-Up
TOTAL

7

8

9

Cancelled Results

Other Refusals
To Submit To
Testing

Refusal Results
“Shy Lung” ~
With No Medical
Explanation

6
Confirmation Tests
With Results 0.04 Or
Greater

5

Confirmation Tests
With Results 0.02
Through 0.039

4

Number Of
Confirmation Tests
Results

3
Screening Tests With
Results 0.02 Or
Greater

2
Screening Tests With
Results Below 0.02

Type of Test
Pre-Employment

1
Total Number Of
Screening Test
Results [Should equal
the sum of Columns
2, 3, 7, and 8]

IV. Alcohol Testing Data:

Cancelled Results

Other Refusals To
Submit To
Testing

“Shy Bladder” ~
With No Medical
Explanation

Substituted

Adulterated

Positive For
Amphetamines

Positive For
Opioids

Positive For
PCP

Positive For
Cocaine

Refusal Results
Verified Negative
Results

Total Number Of Test
Results [Should equal
the sum of Columns 2,
3, 9, 10, 11, and 12]

Type of Test

1

Verified Positive
Results ~ For One Or
More Drugs

III. Drug Testing Data:

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.

Total Number of Employees
in this Category

Positive For
Marijuana

(C)

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.