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Drug & Alcohol Background Check Form Mobile App

 Drug & Alcohol Background Check Form  In the Drug & Alcohol Background Check Form application the employee gives the employer the authorization to perform a drug & alcohol background check. It is a simple and efficient way to collect and store the authorizations by employer and organizations. A new employee or job applicant authorize a release of information from my Department of Transportation regulated drug and alcohol testing records by his previous employer, listed in Section I-B, to the employer listed in Section I-A. This release is in accordance with DOT Regulation 49 CFR Part 40, Section 40.25 and 391.23. Employees understand that information to be released in Section II-A by his previous employer, is limited to the following DOT-regulated testing items: 1. Alcohol test with a result of 0.04 or higher; 2. Verified positive drug test; 3. Refusals to be tested; 4. Other violations of DOT agency drug and alcohol testing regulations; 5. Information obtained from previous employers of a drug and alcohol rule violation; 6. Documentation, if any, of completion of the return-to-duty process following a rule violation. As an employer, you must, after obtaining an employee’s written consent, request the information about the employee listed in paragraph (b) of this section. This requirement applies only to employees seeking to begin performing safety-sensitive duties for you for the first time (i.e., a new hire, an employee transfer into a safety-sensitive position). If the employee refuses to provide this written consent, you must not permit the employee to perform safety-sensitive functions. 

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Drug & Alcohol Background Check Form Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    To be completed by the new employer, signed by the employee, and transmitted to the previous empl...

  • Ico textbox

    Employee Name:

  • Ico textbox

    Employee SS or ID Number:

  • Ico statictext

    I hereby authorize release of information from my Department of Transportation regulated drug and...

  • Ico signature

    Employee Signature:

  • Ico date

    New Date

  • Ico statictext

  • Ico statictext

    I-A

  • Ico textbox

    New Employer Name:

  • Ico textbox

    Address:

  • Ico textbox

    City:

  • Ico integer

    Zipcode:

  • Ico dropdown

    State:

  • Ico integer

    Phone #:

  • Ico integer

    Fax #:

  • Ico textbox

    Designated Employer Representative (if known):

  • Ico statictext

    To be completed by the previous employer and transmitted by mail or fax to the new employer:

  • Ico statictext

    II-A.

  • Ico statictext

    In the three years prior to the date of the employee’s signature (in Section I), for DOT-regulate...

  • Ico dropdown

    Did the employee have alcohol tests with a result of 0.

  • Ico dropdown

    Did the employee have verified positive drug tests?

  • Ico dropdown

    Did the employee refuse to be tested?

  • Ico dropdown

    Did the employee have other violations of DOT agency drug alcohol testing regulations?

  • Ico dropdown

    Did a previous employer report a drug and alcohol rule violation to you?

  • Ico dropdown

    If you answered “yes” to any of the above items, did the employee complete the return-to-duty pr...

  • Ico statictext

    NOTE: If you answered “yes” to item 5, you must provide the previous employer’s report.

  • Ico statictext

    II-B.

  • Ico textbox

    Name of person providing information in Section II-A:

  • ...and More!

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