cdl-release.pdf

Pinellas County Government Release of Information Form:

Drug and Alcohol Background Check (49 CFR Part 40.25)

Hiring Manager: Review this form with all Commercial Driver License (CDL) candidates during the interview.

Human Resources: Submit the selected applicant’s completed form (Employee section only) to Risk Management.

EMPLOYEE

To receive consideration for a position within Pinellas County Government which requires a Commercial Driver License you must provide the information below. Failure to provide the information will result in your removal from further consideration.

Falsification of the requested information will result in your removal from further consideration for vacant positions and your termination, if hired. By law we must obtain this information from your employers for the last three (3) years.

I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer, listed below, to the employer listed in Section I. This release is in accordance with DOT Regulation 49 CFR Part 40, Section 40.25. I understand that information to be released by my previous employer is limited to the following DOT-regulated testing items:

1. Alcohol tests with a result of 0.04 or higher;

2. Verified positive drug tests;

3. Refusals to be tested;

4. Other violations of DOT agency drug and alcohol testing regulations;

5. Information obtained from previous employers of a drug and alcohol rule violation;

6. Documentation, if any, of completion of the return-to-duty process following a rule violation.

Employee Signature: ________________________________________________________ Date:_______________ Employee Name (print or type): _______________________________________________________________ Employee SS Number (last 4 digits only): ____ ____ ____ ____ Previous Employer #1 Name: ________________________________________________________________________________ Address: ________________________________________________________________________________________________ Phone #: _______________________________________ Dates Employed (month/year): _______________________________ Previous Employer #2 Name: ________________________________________________________________________________ Address: ________________________________________________________________________________________________ Phone #: _______________________________________ Dates Employed (month/year): _______________________________

Section I. NEW EMPLOYER To be completed by the new employer and transmitted to the previous employer

New Employer Name: __________________________________________________________________________________

Designated Employer Representative: ______________________________________________________________________

Signature: _____________________________________________ Date: ________________________

Section II. PREVIOUS EMPLOYER To be completed by the previous employer and transmitted by mail or fax to the new employer (see below)

Employer Name:_______________________________________________________________________________________________ Your Name: ___________________________________________ Title: ___________________________________________ Phone #: ________________________________________ Date: ___________________________________________ In the three years prior to the date of the employee’s signature above, for DOT-regulated testing:

1. Did the employee have alcohol tests with a result of 0.04 or higher? YES ____ NO ____

2. Did the employee have verified positive drug tests? YES ____ NO ____

3. Did the employee refuse to be tested? YES ____ NO ____

4. Did the employee have other violations of DOT agency drug and alcohol testing regulations? YES ____ NO ____

5. Did a previous employer report a drug and alcohol policy violation to you? YES ____ NO ____

6. If you answered “yes” to any of the above items, did the employee complete the Substance Abuse Professional evaluation, treatment and return-to-duty process in accordance with 49 CFR Part 40? N/A ____ YES ____ NO ____ NOTE: If you answered “yes” to item 5, you must provide the previous employer’s report. If you answered “yes” to item 6, you must also transmit the appropriate return-to-duty documentation (e.g., SAP report(s), return to duty and follow-up testing record).

Submit completed form to Pinellas County Risk Management by email at riskmgmt@pinellascounty.org, fax to

(727) 464-4023, or mail to 400 S. Ft. Harrison Avenue, Clearwater, FL 33756. Questions? Call (727) 464-3664.

1/8/20 mailto:riskmgmt@pinellascounty.org mailto:riskmgmt@pinellascounty.org