Release of Drug & Alcohol Testing Information From Co/Previous Employer

This Form Must Be Completed in Its Entirety

In accordance with 49 CFR Part 391.23, the co/previous employer shall release within 30 days, pursuant to this driver’s written authorization, the following information for the previous 3 years from the date of application to this employer or date of transfer, which will automatically comply with the requirements in 49 CFR Parts 40 and 382. The co/previous employer shall also release, pursuant to this driver’s written authorization the following information in accordance with 49 CFR Part 382.301(b)(c):

To Be Completed by Driver
I understand my co/previous employer listed below may release any drug or alcohol test information in their possession from any other previous employers under Part 40 or other applicable DOT regulations. If I have violated a DOT drug and alcohol regulation, I authorize my co/previous employer to release all documentation of my successful completion of the DOT return to duty requirements, including follow-up tests, to the employer named below. If I successfully completed the DOT return to duty requirements on my own, I agree to provide the documentation to the employer named below. I authorize my previous employer to release all information requested on this form, including drug & alcohol test results, to the subsequent employer named below.

"*" indicates required fields

This field is for validation purposes and should be left unchanged.
Driver’s Signature
Clear Signature
Driver’s Printed Name
Clear Signature

To Be Completed by Previous Employer

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Co/Prev. Signature
Clear Signature

In compliance with Part 391.23, for the previous 3 years from the date of application or date of transfer, has the driver:

NO YES If Yes, enter Dates
Had an alcohol test result of .04 breath alcohol concentration (BAC) or greater?
Had a verified positive drug test?
Refused to test (including verified adulterated or substituted drug test results)?
Had a verified positive drug test?
Violated the alcohol & controlled substances prohibitions under Subpart B of Part 382 or Part 40?
Completed a SAP-prescribed rehabilitation program while under your employ, including return-toduty and follow-up tests if the driver had violated a DOT drug and alcohol regulation?
Had a subsequent alcohol test result of 0.04 or greater, a verified positive drug test, or refuse to be tested after he/she successfully completed a SAP’s rehabilitation referral and remained under your employ?

In compliance with Part 382.301 (b)(c)

Within the previous 30 days, has the driver participated in a controlled substance testing program that meets the requirements of 49 CFR Parts 382 and 40?
While participating in your program
Do you have knowledge from a prior employer that the driver had violated the controlled substances use rule of 49 CFR Part 382 or the controlled substances use rule of another DOT agency in the previous 6 months?
Is the driver qualified to perform safety sensitive functions under 49 CFR Part 382, including that the driver has not refused to be tested for controlled substances?
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To Be Completed by Subsequent Employer

(*Note: Subsequent Employer must attempt to get this information within 30 days)
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