Medium

Available on

Apple Android Windows

Drug and Alcohol Records Request Mobile App

The Drug and Alcohol Records Request form can be utilized by companies that are hiring individuals subject to workplace drug and alcohol testing under 49 CFR Part 40 for the Federally regulated transportation industry. The form collects in-depth information concerning drug and alcohol records to flag substance abuse problems, drug abuse problems, alcohol abuse problems, and the failure of a drug test by an employee that is subject to testing under federal law. Alcohol testing and drug testing are federally mandated procedures to ensure that individuals operating motor vehicles in such a way as being subject to federal oversight (truck drivers, bus drivers, etc.) do not suffer from a substance use disorder. In order to obtain records that may otherwise be protected by privacy laws, this consent form allows a previous employer, or substance abuse professional, to minimize the chance that a driver engaging in alcohol or drug abuse is able to operate a vehicle commercially without being drug-free, avoiding alcohol misuse, and/or having successfully completed substance abuse treatment,

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

Want to learn more about GoCanvas?

Request a Demo

Take a peek inside the Drug and Alcohol Records Request 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.'}}

  • {{data.title}}

Included Fields

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

  • Ico textbox

    Employee First Name

  • Ico textbox

    Employee Last Name

  • Ico textbox

    Social Security/ID Number

  • Ico textbox

    Employer

  • Ico textbox

    Employer Street Address

  • Ico dropdown

    Employer City

  • Ico textbox

    Employer State

  • Ico textbox

    Zip Code

  • Ico textbox

    Employer Phone Number

  • Ico statictext

    This written request is being submitted to obtain Drug & Alcohol Testing information as listed an...

  • Ico signature

    Authorized Signature

  • Ico date

    Date

  • Ico statictext

    Please furnish the required information below pursuant to the Code of Federal Regulations, Title ...

  • Ico statictext

  • Ico statictext

    Drug & Alcohol information for the above named individual during the past three years while emplo...

  • Ico dropdown

    Alcohol tests with a result of .

  • Ico dropdown

    Verified Positive Drug Test?

  • Ico dropdown

    Refusals to be tested (including adulterated or substituted specimen)?

  • Ico dropdown

    Other violations of DOT agency drug and alcohol testing regulations?

  • Ico dropdown

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

  • Ico dropdown

    Did the employee complete The Return-to-Duty process?

  • Ico dropdown

    Provider Type

  • Ico textbox

    Other type:

  • Ico multiline

    Please provide the additional Drug & Alcohol records in your possession, specifically those liste...

  • Ico signature

    Employee Signature

  • Ico date

    Date

  • Ico statictext

    Copies of the drug and alcohol testing records have been supplied as requested to the above compa...

  • Ico dropdown

    I have provided a copy of the previous employer’s report and the Return-to-Duty documentation:

  • ...and More!

Related Other Services Apps... and they're all free for GoCanvas subscribers!

App Name

New Customer Form

This new customer form mobile app provides simple new customer forms for service based companies such as dry cleaning, law...

App Name

School Injury Report - Simple Version

If you're a staff member at a school the School Injury Report Mobile App is perfect for collecting key accident/injury inf...

App Name

OSHA - Notice of Alleged Safety Viola...

"OSHA inspections for occupational safety can reveal health hazards and even imminent danger. This mobile app for the comp...

App Name

Parking Citation

The Parking Citation mobile app for police departments and parking services professionals makes it possible to generate ne...

App Name

Natural Gas - Pipeline Survey

The Natural Gas Pipeline Survey mobile app was designed specifically for the natural gas industry. Instead of using paper ...

App Name

VA Dem House Race - Political Canvass...

This VA Dem House Race Political Canvassing Form was developed to be an electronic form of a survey sent out by the Virgin...

App Name

Road Construction and Equipment Tracking

The Road Construction and Equipment Tracking mobile app for construction managers and road crews tracks employee time shee...

App Name

Apparel Retail Form

This handy apparel retail form mobile app was built for a mobile retail sales associate or sales assistant. Great for depa...

More Information