DOT DRUG & ALCOHOL POLICY Questionnaire
Please fill in all the required fields to complete the process.
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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.
Fax
Enter you Fax #
Email
*
example@example.com
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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:
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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
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CONSEQUENCES FOR POSITIVE ALCOHOL TEST
CONSEQUENCES FOR POSITIVE ALCOHOL TEST
*
Second Chance
Other
Other
Please be clear and specific
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CONSEQUENCES FOR REFUSAL TO TEST
CONSEQUENCES FOR REFUSAL TO TEST
*
Immediate Termination
Second Chance
Other
Other
Please be clear and specific
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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Applicant will have 24 hours to have a retest, result must not be dilute if it is, offer for employment will be rescinded.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
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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.
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
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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.
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
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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.
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
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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.
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