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Applicant Acknowledgement of Pre-Employment Drug Testing & Informed Consent Regarding County Drug & Alcohol Testing

Program for Commercial Drivers

CDL Driver Drug and Alcohol Testing Policy and Program:

I acknowledge that I have received and understand [County Name’s] DOT Drug and Alcohol Testing for Commercial Drivers Policy.

I agree to comply with the County’s DOT Drug and Alcohol Testing for Commercial Drivers Policy and understand that as an applicant, my conditional job offer will be withdrawn if I refuse to test, or test positive for a controlled substance, or otherwise fail to meet the requirements of this policy and/or the County’s applicant selection process.

I understand that as required by the Federal Motor Carrier Safety Administration Regulations, Title 49 Code of Federal Regulations, Section 382.301, all driver-applicants of this employer must be tested for controlled substances, as a pre-condition for employment. I hereby consent to undergo controlled substance and alcohol testing pursuant to this policy, and I authorize collection of urine and/or breath samples from me for these purposes. I understand that the procedures employed in this process will ensure the integrity of the sample and are designed to comply with medical and legal requirements.

The Medical Review Officer (MRO) will maintain the results of my controlled substance test. Negative and positive results will be reported to [County Name]. If the results are positive, the controlled substance will be identified. The results will not be released to any other parties without my written authorization or as allowed in 49 CFR § 40 and § 382 or in accordance with other applicable state or federal law.

I consent to the release of the controlled substance and/or alcohol test results in accordance with the County’s DOT Drug and Alcohol Testing Policy to the selected Medical Review Officer (MRO) [OR third party administrator designated by the County], and within the County to designated County employees who need to access this information as required to perform the duties of their job, and to additional parties in accordance with written authorization, and/or as otherwise required by applicable state or federal law.

I understand that a verified positive test result for controlled substances will render me unqualified to operate a commercial motor vehicle or perform other safety-sensitive functions. Under County authority, if I receive a confirmed/MRO verified positive result on a controlled substance test, my job offer will be withdrawn and I will be disqualified for employment with [County Name] for a period of 120 days. Evidence of the absence of drug dependency from a Substance Abuse Professional (SAP) that meets the approval of the County and a negative pre-employment drug test will be required prior to future consideration for employment. The cost for assessment and any subsequent treatment will be my responsibility.

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Current and Previous Employer Request for Drug and Alcohol Program Compliance:

In accordance with 49 CFR § 40.25 and § 382.413(a), [County Name] is required to contact my current and previous DOT-regulated employers within the previous 3 years to request the information related to my prior DOT drug and alcohol program compliance. I may refuse to provide consent, but if I do so, I may not perform safety-sensitive functions and my [County Name] job offer will be withdrawn. I understand that the County will request that I provide current and previous employer information and authorizations related to the prior history check in a separate packet.

Federal Motor Carrier Safety Administration (FMCSA) Clearinghouse Pre-Employment Query Process:

[County Name] is required to conduct a full query in the FMCSA Clearinghouse for which I will be asked to provide electronic consent in the FMCSA Clearinghouse database. I may refuse to provide consent, but if I do so, I may not perform safety-sensitive functions and my [County Name] job offer will be withdrawn.

As an applicant, I understand that I am required to register with the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse before I can access my driver record or respond to employer consent requests in the FMCSA Clearinghouse.

To register, click here to access the FMCSA Clearinghouse [OR go to https://clearinghouse.fmcsa.dot.gov/register] and then click “Go to login.gov” to create your account When you register, be sure to have your current commercial driver’s license (CDL) or commercial learner’s permit (CLP) information available. (or log into your existing account

The County is required to enter and verify driver information in the Clearinghouse system to request your consent and conduct the required pre-employment full query. Please provide the following information associated with your current commercial driver’s license (CDL) or commercial learner’s permit (CLP) so that the County can initiate this process:

First Name: ____________________________________________________________________Last Name: ____________________________________________________________________Date of Birth (month/day/year): ___________________________________________________CDL/CLP Number: _______________________________________________________________Country of Issuance: _____________________________________________________________State of Issuance: _______________________________________________________________

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Prior Pre-Employment Drug and Alcohol Testing History:[County Name] is also required to ask me whether I have tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which I applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past three years. Please check “yes” or “no” below and sign to acknowledge that you understand the requirements herein.

NO, I have not tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which I applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past three years.

YES, I have tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which I applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past three years.

If yes, have you successfully completed the return-to-duty process? YES NO

Data Collection Notice:

The information collected pursuant to this policy is used to determine eligibility for employment and the performance of certain safety-sensitive functions. Applicants are not required to provide information and submit to the tests, but failure to do so will result in the County withdrawing the conditional job offer, or an employee may be disciplined up to and including termination of employment, whichever may apply. The results of the tests performed will be private data and will not be released to other employers, governmental agencies, or persons without the written consent of the employee tested, except as otherwise provided by regulation and law, or pursuant to a court order. In addition, designated County employees will have access to test results and related information as required to perform the duties of their job.

Acknowledgement and Informed Consent:

________________________________ ________________________________Signature of Applicant Printed Name of Applicant

_________________________________ ________________________________Date Signature of Witness Refusal of Consent:

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I hereby refuse to submit to the drug and alcohol testing process. I have received a copy of the County’s DOT Drug and Alcohol Testing for Commercial Drivers Policy. I understand that if I am an applicant, my refusal to submit to testing will subject me to withdrawal of the County’s conditional offer of employment. If I am an employee, my refusal to submit to testing will subject me to disciplinary proceedings including, but not limited to, discharge from employment.

______________________________ _________________________________Signature of Applicant Printed Name of Applicant

______________________________ ________________________________Date Signature of Witness

If applicant refuses to sign the Acknowledgement of Pre-Employment Drug Testing & Informed Consent Regarding County Drug and Alcohol Testing Program for Commercial Drivers and the Drug & Alcohol Screening Refusal of Consent, indicate “Refused to sign” on Applicant line, and the witness is to sign and date remaining sections.

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