cdl-clearinghouseconsent.pdf
PDF 117 KB Posted
- Solicitation number
- 24-0321-ITQ
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This document is a General Consent form for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse, issued by Pinellas County Government in Florida. The form allows Pinellas County to conduct limited and potentially full queries of the FMCSA Clearinghouse to check drug and alcohol violation information for Commercial Driver's License (CDL) holders during the hiring and employment process. The form outlines the consent process for job applicants and employees, specifically for those in safety-sensitive positions involving commercial motor vehicle operation.
The consent form details the consequences of refusing to provide consent or having drug and alcohol violations in the Clearinghouse, including potential withdrawal of conditional job offers and prohibition from performing safety-sensitive functions. Pinellas County requires CDL applicants to register with the Clearinghouse and provides contact information (riskmgmt@pinellascounty.org, phone: (727) 464-3664) for submitting the signed form. The document is dated 2/17/20 and is part of Pinellas County's compliance with FMCSA drug and alcohol program regulations for employees in safety-sensitive transportation roles.
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Text version
2/17/20
General Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse
I, ________________________________________, hereby provide consent to Pinellas County Government to conduct a limited query of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse (Clearinghouse) to determine whether drug or alcohol violation information about me exists in the Clearinghouse. I consent to Pinellas County Government conducting multiple limited queries for the duration of any employment with Pinellas County Government.
I understand that if the limited query conducted by Pinellas County Government indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to Pinellas County Government without first obtaining additional specific consent from me. If additional information exists, I understand that I must be registered in the Clearinghouse and must give Pinellas County Government consent to do a full query in the Clearinghouse. If I refuse to allow the full query, I understand that I will be prohibited from performing safety-sensitive functions including driving a commercial motor vehicle and will be subject to dismissal from employment with Pinellas County Government.
I further understand that if I have a conditional job offer and refuse to provide consent for Pinellas County to conduct a limited query of the Clearinghouse, Pinellas County may withdraw the conditional job offer and must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations. In addition, the County may withdraw the conditional job offer based on information obtained from the query.
Signature Date
Hiring Manager: Review this form with Commercial Driver License (CDL) applicants and notify them to register with the Clearinghouse at https://clearinghouse.fmcsa.dot.gov.
Human Resources: Submit the signed form to Pinellas County Risk Management by email at riskmgmt@pinellascounty.org.
Questions? Call (727) 464-3664.
https://clearinghouse.fmcsa.dot.gov/ mailto:riskmgmt@pinellascounty.org
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