Drug & Alcohol Background Check Form Mobile App

Included Fields

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

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

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  Employee Name:

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  Employee SS or ID Number:

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

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  Employee Signature:

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  New Date

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  I-A

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  New Employer Name:

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  Address:

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  City:

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  Zipcode:

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  State:

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  Phone #:

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  Fax #:

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  Designated Employer Representative (if known):

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

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  II-A.

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

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

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  Did the employee have verified positive drug tests?

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  Did the employee refuse to be tested?

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

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

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

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

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  II-B.

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  Name of person providing information in Section II-A:

• ...and More!