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

CUI//PRVCY
when filled in

DOE F 470.7 (06/2023)
PREVIOUS EDITIONS ARE OBSOLETE

OMBOMB Control No. 1910-5122
Expiration Date:

U.S. DEPARTMENT OF ENERGY
HUMAN RELIABILITY PROGRAM (HRP)
ALCOHOL TESTING FORM

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. This statement is in reference to
the relevant System of Records Notice (SORN) per Circular A-108, DOE-50, HRP Records SORN 230104
(https://www.federalregister.gov/documents/2009/01/09/E8-31316/privacy-act-of-1974-publication-of-compilation-ofprivacy-act-systems-of-records).
OMB BURDEN DISCLOSURE STATEMENT
This data is being collected to administer an alcohol test. The data you supply will be used for alcohol testing to ensure
that individuals who occupy positions affording access to certain materials, nuclear explosive devices, facilities, and
programs meet the highest standards of reliability and physical and mental suitability. Public reporting burden for this
collection of information is estimated to average 10 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 the Chief Information
Officer, Enterprise Policy Development & Implementation Office, IM-22, Information Collection Management
Program (1910-5122), U.S. Department of Energy, 1000 Independence Ave., SW, Washington, DC 20585; and to
the Office of Management and Budget (OMB), OIRA, Paperwork Reduction Project (1910-5122), Washington, DC
20503. Notwithstanding any other provision of the law, no person is required to respond to, nor shall any 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.
Submission of this data is mandatory.

SECTION I. INSTRUCTIONS
NOTE: Make two copies and 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 check mark 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. A reason for test 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.

DOE F 470.7 (06/2023)

Section 508 Compliant

DOE F 470.7 (06/2023)
PREVIOUS EDITIONS ARE OBSOLETE

CUI//PRVCY
when filled in

OMBOMB Control No. 1910-5122
ation Expiration Date:

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 Bureau of Alcohol, Tobacco, Firearms and
Explosives (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.

STEP 4

•

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 YES or NO 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.

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.

DOE F 470.7 (06/2023)

Page 2 of 3

Section 508 Compliant

CUI//PRVCY
when filled in

DOE F 470.7 (06/2023)
PREVIOUS EDITIONS ARE OBSOLETE

OMB
OM Control No. 1910-5122
Expiration
Date:
atio

SECTION II. FORM COMPLETION STEPS
STEP 1: TO BE COMPLETED BY ALCOHOL TECHNICIAN
1. Employee Name:
2. Employee ID No:
3. Employer Name:
4. HRP Supervisor:

Affix or
print
screening results
here.

5. Phone Number:

6. 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:
7. Signature of Employee:
8. Date:

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.
Device: ☐ SALIVA ☐ BREATH* ☐ 15-Minute Wait: ☐ YES ☐ NO

Technician (BAT):

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

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

Result

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

9. REMARKS:

10. Alcohol Technician’s Company:
12. Company City, State, Zip:
14. Alcohol Technician’s Name:

11. Company Street Address:
13. Phone Number:
15. Signature:

16. Date:

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.
17. Signature of Employee:
18. Date:

DOE F 470.7 (06/2023)

Page 3 of 3

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

Section 508 Compliant