DOT DRUG & ALCOHOL POLICY Questionnaire
Please fill in all the required fields to complete the process.
Back
Start
BUSINESS INFO
Company Name:
*
DER or Main Contact Person:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Fax
Enter you Fax #
Email
*
example@example.com
Back
Next
TYPE OF POLICY
Type of Policy
*
DOT
Non DOT
DOT No #
*
Enter your DOT no
Agency:
*
FMCSA
FAA
FRA
FTA
PHMSA
USCG
State
*
Enter the state
# of Covered Employees:
*
# of Non DOT Employees:
Back
Next
CONSEQUENCES FOR POSITIVE DRUG TEST
CONSEQUENCES FOR POSITIVE DRUG TEST
*
Immediate Termination
Second Chance - (Employee must get assistance for the substance abuse problem, will be subject to a second chance agreement and any future refusal or positive drug or alcohol test will result in immediate termination.)
Other
Other
Please be clear and specific
Back
Next
CONSEQUENCES FOR POSITIVE ALCOHOL TEST
CONSEQUENCES FOR POSITIVE ALCOHOL TEST
*
Second Chance
Other
Other
Please be clear and specific
Back
Next
CONSEQUENCES FOR REFUSAL TO TEST
CONSEQUENCES FOR REFUSAL TO TEST
*
Immediate Termination
Second Chance
Other
Other
Please be clear and specific
Back
Next
Additional Details
What is the company policy with regard to a negative dilute specimen on an existing employee?
*
Result is accepted As-Is
Employee must go for a retest upon immediate notification and be escorted by supervisor.
What is the company policy with regard to a negative dilute specimen on an applicant?
*
Result is accepted As-Is
Applicant will have 24 hours to have a retest, result must not be dilute if it is, offer for employment will be rescinded. Instructions on avoiding a dilute specimen will be provided.
Non DOT - Is random testing part of the program:
*
Yes
No
Period
*
Monthly
Quarterly
Annual Percentage
Will the company test all employees after sixty day notice?
*
Yes
No
Special Notes for Random Testing
Be Clear and Precise
Back
Next
Substance Abuse Program (SAP)
Does the company have a specific Substance Abuse Program (SAP) ?
*
Yes
No
Please provide complete contact information and how your employee access this program.
*
How your Employees Access this Program?
Name of Agency
*
Enter name of your Agency
Contact Person
*
Enter name of Contact Person
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Back
Next
Employee Assistance Program (EAP)
Does the company have an Employee Assistance Program (EAP) ?
*
Yes
No
Please provide complete contact information and how your employee access this program.
*
How your Employees Access this Program?
Name of Agency
*
Enter name of your Agency
Contact Person
*
Enter name of Contact Person
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Back
Next
Medical Clinic Details
Is there a medical clinic you normally use for injury treatment when an employee has an accident ?
*
Yes
No
Name of Clinic
*
Enter name of the clinic
Contact Person
*
Enter name of Contact Person
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Back
Next
Special Instructions
Special Notes for this Policy
Please enter clear and precise instructions if you have any!
Completion Date
-
Month
-
Day
Year
Please select a date.
Submit
Should be Empty: