DOT DRUG AND ALCOHOL RELEASE
In accordance with DOT Regulation 49 CFR Part 391.23, I authorize the release of information from my DOT regulated drug and alcohol testing records by the carriers (company/school) listed above to HireRight (formerly USIS) for the sole purpose of transmitting such records to Rapid Response, Inc. I authorize release of the following information concerning DOT drug and alcohol testing violations including pre-employment tests during the past three years: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested (including verified adulterated or substituted results); (iv) other violations of DOT drug and alcohol testing regulations; (v) information obtained from previous employers of a drug and alcohol rule violation(s); and (vi) documents, if any, of completion of a return-to-duty process following a rule violation.
I hereby authorize, without liability, any person or organization whose name I have given as a reference, or by whom I have been previously employed or contracted with, to furnish Rapid Response, Inc. any information they may have concerning my safety performance, all accidents, including those defined in 390.5 of FMCSR, all drug and alcohol testing violations (in compliance with 49 C.F.R. Sections 382 sub part B, 382.405, 382.413, 391.89, 392.4, 392.5, 40.37 and 40.81 (1), refusals or completed rehabilitations, character, habits, ability, financial responsibility, job performance or other work-related characteristics, reason for leaving employment/lease and all information concerning my employment/lease. I hereby release all such persons and organizations from any claims for damages of any kind which may occur to be my reason of furnishing such information.
The information that I have authorized HireRight to review involves tests required by DOT. If any carrier (company/school) listed above furnishes HireRight with information concerning items (i) through (vi) above, I also authorize that carrier (company/school) to release and furnish the dates of my negative drug and/or alcohol tests and/or tests with results below 0.04 during the three year period and the name and phone number of any substance abuse professional who evaluated me during the past three years.
I hereby authorize you to release the aforementioned information, including Drug & Alcohol testing, to Rapid Response, Inc. for the purpose of investigation as required by Section 391.23 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability, which may result from furnishing suchinformation.