Ñ DRIVER
ACKNOWLEDGMENT Ñ
DRUG AND ALCOHOL
TESTING POLICY AND MATERIALS
I have received a copy
of the Drug and Alcohol Testing Policy of Independent School District No. ____,
_______________, Minnesota and have read it in its entirety. I understand that I am subject to
the provisions of Article III of the policy, entitled Drug and Alcohol Testing
for Bus Drivers, because the position involves operating a commercial motor
vehicle and requires a commercial driverÕs license.
The
DistrictÕs policy was provided to me:
G Upon
adoption of the policy.
(employee).
G Upon my
hire. (job applicant/new
employee).
G After
receipt of my conditional job offer, before any testing if my job offer is
contingent upon my passing of drug and alcohol testing. (job applicant).
I
also received materials concerning the effects of alcohol and controlled
substances use on an individualÕs health, work, and personal life; signs
and symptoms of an alcohol or drug problem; and available methods of
intervening when an alcohol or drug problem is suspected.
I have been advised that
the Alcohol and Controlled Substances Testing Program Manager is
_____________________________ and that any questions I may have concerning the
Policy should be directed to the Program Manager.
Dated:
|
Signature
of Employee/Applicant
Typed
or Printed Name |
Ñ BUS
DRIVER OR DRIVER APPLICANT Ñ
AUTHORIZATION TO
RELEASE INFORMATION
Section
I. To be completed by the school district, signed by the bus driver, or
driver applicant, and transmitted to the previous employer:
Employee
Printed or Typed Name:
________________________________________________________________
Employee
SS or ID Number:
_____________________________________________________________________
I
hereby authorize release of information from my Department of Transportation
regulated drug and alcohol testing records by my 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.
I understand that information to be released in Section II-A by my previous employer,
is limited to the following DOT-regulated testing items:
1. Alcohol tests with a result of 0.04 or
higher;
2. Verified positive drug tests;
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.
Employee Signature:
__________________________________________________ Date: ____________________
I-A.
School
District Name:
__________________________________________________________________________
Address:
_____________________________________________________________________________________
_____________________________________________________________________________________
Phone
#: _______________________________________ Fax #: _______________________________________
Designated
Employer Representative: ______________________________________________________________
I-B.
Previous
Employer Name:
_______________________________________________________________________
Address:
_____________________________________________________________________________________
_____________________________________________________________________________________
Phone
#: _______________________________________
Designated
Employer Representative (if known):
_____________________________________________________
Section
II. To be completed by the previous employer and transmitted by mail or fax
to the new employer:
II-A. In the two years prior to the date of
the employeeÕs signature (in Section I), for DOT-regulated testing:
1.
Did the employee have alcohol tests with a result of 0.04 or higher? YES
____ NO ____
2.
Did the employee have verified positive drug tests?
YES
____ NO ____
3.
Did the employee refuse to be tested?
YES ____ NO ____
4.
Did the employee have other violations of DOT agency drug and
alcohol
testing regulations?
YES
____ NO ____
5.
Did a previous employer report a drug and alcohol rule
violation
to you?
YES
____ NO ____
6.
If you answered ÒyesÓ to any of the above items, did the
employee
complete the return-to-duty process? N/A_____ YES ____ NO ____
NOTE: If you answered ÒyesÓ to item 5, you
must provide the previous employerÕs report. If you answered ÒyesÓ to item 6, you must also transmit the appropriate return-to-duty
documentation (e.g., SAP report(s), follow-up testing record).
II-B. Name of person providing information in Section II-A:
_______________________________________________ |
Title:
___________________________________________
Phone
#: ________________________________________
Date:
___________________________________________
Ñ BUS
DRIVER OR DRIVER APPLICANT Ñ
REFUSAL TO
SUBMIT TO TESTING
I hereby refuse to
submit to drug/alcohol testing by doing the following:
G Failing to
appear for any test within a reasonable time, as determined by the school
district, consistent with applicable DOT regulations, after being directed to
do so;
G Failing to
remain at the testing site until the testing process is complete;
G Failing to
provide a urine specimen or an adequate amount of saliva or breath for any DOT
drug or alcohol test;
G Failing to
permit the observation or monitoring of any provision of a specimen in the case
of a directly observed or monitored collection in a drug test;
G Failing to
provide a sufficient breath specimen or sufficient amount of urine when
directed and it has been determined that there was no adequate medical
explanation for the failure;
G Failing or
declining to take a second test as directed;
G Failing to
undergo a medical examination or evaluation, as directed by the Medical Review
Officer (MRO) or the Designated Employer Representative (DER);
G Failing to
cooperate with any part of the testing process (e.g., refusing to empty pockets
when so directed by the collector, behaving in a confrontational way that
disrupts the collection process, failing to sign the certification on the form;
or
G Having a
verified adulterated or substituted test as reported by the MRO.
[An
applicant who fails to appear for a preemployment test, who leaves the testing
site before the preemployment testing process commences, or who does not
provide a urine specimen because he or she left before it commences, is not
deemed to have refused to submit to testing.]
I
recognize that my refusal subjects me to the consequences specified in federal
law and regulations. It also
constitutes a presumption of a positive result. I further recognize that if I am an applicant, I will
be disqualified from consideration for the conditionally-offered position. If I am an employee, I will not be
permitted to perform safety-sensitive functions, and will be considered
insubordinate and subject to disciplinary action, up to and including
dismissal. If the school district
offers me an opportunity to return to a DOT safety-sensitive function, I
understand I will be evaluated by a substance abuse professional, and will be
required to submit to a return-to-duty test prior to being considered for
reassignment to safety-sensitive functions.
Date:
Time:
|
Signature
of Employee/Applicant |
Supervisor: ______________________________ |
SupervisorÕs
Signature |
Comments:
G
Employee
refusal to sign
SupervisorÕs
Initials:
Ñ
PRETEST NOTICE Ñ
I the undersigned
employee/job applicant of Independent School District No. ____,
_______________, Minnesota (ÒSchool DistrictÓ) do hereby acknowledge that I
have been provided a copy of the School DistrictÕs Drug and Alcohol Testing
Policy.
Date:
____________________________ |
_______________________________________________ Signature
of Employee/Job Applicant _______________________________________________ Typed
or Printed Name |
[Employee Name]
[Employee Address]
RE: Drug
and/or Alcohol Test
[Date
of Testing]
NOTICE OF TEST
RESULTS AND VARIOUS RIGHTS
Test
Results:
Independent
School District No. ___, ____________________, Minnesota has received the test
result report from the testing laboratory:
G Your
initial screening test result was negative.
G Your confirmatory test
result was negative.
G Your
confirmatory test result was positive.
Test
Result Report:
You
have the right to request and receive from the school district a copy of the
test result on any drug or alcohol test.
Right
to Explain Positive Test Result:
In
the case of a positive test result on a confirmatory test, you have the right
to explain the results. You may,
within three (3) working days after notice of a positive test result on a
confirmatory test, submit information to the school district, in addition to
any information already submitted, to explain that result. Attached to this Notice is a document
entitled ÒExplanation of Positive Test ResultÓ for this purpose.
Right
to Request Confirmatory Retests: |
In
the case of a positive test result on a confirmatory test, you have the right
to request a confirmatory retest of the original sample at your own expense.
Within
five (5) working days after notice of the confirmatory test result, you must
notify the school district in writing of your intention to obtain a
confirmatory retest.
Within
three (3) working days after receipt of the notice, the school district shall
notify the original testing laboratory that you have requested the
laboratory to conduct the confirmatory retest or to transfer the sample to
another laboratory licensed under Minn. Stat. ¤ 181.953, Subd. 1 to
conduct the confirmatory retest.
The original testing laboratory shall ensure that appropriate
chain-of-custody procedures are followed during transfer of the sample to the
other laboratory. The confirmatory
retest must use the same drug or alcohol threshold detection levels as used in
the original confirmatory test. If
the confirmatory retest does not confirm the original positive test result, no
adverse personnel action based on the original confirmatory test may be taken
against you.
Other
Rights:
In
the case of a positive test result on a confirmatory test, you may have other
rights provided under the sections detailed below.
A. Employee
Discharge and Discipline
1. The
school district may not discharge, discipline, discriminate against, request or
require rehabilitation of an employee whose position does not require a
commercial driverÕs license on the basis of a positive test result from an
initial screening test that has not been verified by a confirmatory test.
In
the case of a positive test result on a confirmatory test, the employee shall
be subject to discipline which includes, but is not limited to, immediate
suspension without pay and immediate discharge, pursuant to the provisions of
this policy.
2. The
school district may not discharge an employee whose position does not require a
commercial driverÕs license for whom a positive test result on a confirmatory
test was the first such result for the employee on a drug or alcohol test
requested by the school district, unless the following conditions have been
met:
a. The
school district has first given the employee an opportunity to participate in,
at the employeeÕs own expense or pursuant to coverage under an employee benefit
plan, either a drug or alcohol counseling or rehabilitation program, whichever
is more appropriate, as determined by the school district after consultation
with a certified chemical use counselor or a physician trained in the diagnosis
and treatment of chemical dependency; and
b. The
employee has either refused to participate in the counseling or rehabilitation
program or has failed to successfully complete the program, as evidenced by
withdrawal from the program before its completion or by a positive test result
on a confirmatory test after completion of the program.
3. Notwithstanding
Paragraph 1., the school district may temporarily suspend the tested employee
or transfer that employee to another position at the same rate of pay pending
the outcome of the confirmatory test and, if requested, the confirmatory
retest, provided the school district believes that it is reasonably necessary
to protect the health or safety of the employee, co-employees or the public. An employee who has been suspended
without pay must be reinstated with back pay if the outcome of the confirmatory
test or requested confirmatory retest is negative.
4. The
school district may not discharge, discipline, discriminate against, request,
or require rehabilitation of an employee on the basis of medical history
information revealed to the school district, unless the employee was under an
affirmative duty to provide the information before, upon, or after hire.
5. An
employee must be given access to information in the employeeÕs personnel file
relating to positive test result reports and other information acquired in the
drug and alcohol testing process and conclusions drawn from and actions taken
based on the reports or other acquired information.
B. Withdrawal
of ApplicantÕs Job Offer
If
a job applicant for a position that does not require a commercial driverÕs
license has received a job offer made contingent on the applicant passing drug
and alcohol testing, the school district may not withdraw the offer based on a
positive test result from an initial screening test that has not been verified
by a confirmatory test. In the
case of a positive test result on a confirmatory test, the school district may
withdraw the job offer.
EXPLANATION OF
POSITIVE TEST RESULT
I the undersigned
employee/job applicant of Independent School District No. _____,
_________________, Minnesota acknowledge receipt of a Notice of Test Results
and Various Rights. This includes
my right to explain the positive test result on a confirmatory test.
I
am currently taking or have recently taken:
G no
over-the-counter or prescription medications; or
G the
following over-the-counter or prescription medications:
I
also offer the following information relevant to the reliability of, or
explanation for, a positive test result: