Drug_and_Alcohol_Questionnaire.pdf
PDF 412 KB Posted
- Solicitation number
- 25/26-73
- Issued by
- Hartford County, Connecticut
About this file
This Drug and Alcohol Questionnaire is a compliance document required by the Town of Manchester, Connecticut for bidders responding to the snow plowing and de-icing services contract for the Downtown District. The questionnaire serves as a pre-qualification screening tool to assess bidder eligibility based on substance abuse policies and employee testing requirements. Bidders must complete and submit this form as part of their bid package, confirming their organization's compliance with drug and alcohol testing protocols and demonstrating that key personnel, particularly equipment operators and supervisory staff involved in winter maintenance operations, meet established substance abuse standards. The questionnaire typically requires attestation regarding the existence of a drug-free workplace policy, employee testing procedures, and the ability to provide documentation of compliance upon request. Failure to complete this questionnaire or providing false information may result in bid rejection or disqualification.
The questionnaire is a mandatory compliance requirement rather than a pricing or technical document, indicating that the Town of Manchester prioritizes safety and public protection in snow and ice control operations where operator vigilance and equipment handling are critical. Respondents must certify their commitment to maintaining a drug-free workforce and may be subject to post-award verification and auditing of their substance abuse prevention programs. This requirement is standard for government contracts involving public safety operations and applies uniformly to all bidders without set-asides or exemptions, establishing a baseline qualification criterion that must be satisfied regardless of bidder size or incumbent status.
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Text version
DRUG AND ALCOHOL TESTING PROGRAM COMPLIANCE
QUESTIONNAIRE
Date: ______________ Company/Municipality: _________________________________________________ Address: _____________________________________________________________ City: _____________________________________ State: ___________ Zip: ________________ Contact Name: _____________________________ Phone: _____________ Fax: _______________
Date: _____________ Company: ___________________________________________________________ Address: ____________________________________________________________ City: _____________________________________ State: ___________ Zip: ________________ Contact: __________________________________ Phone: _____________ Fax: _______________ Type: Owner/Operator Corporation Other Your Drug and Alcohol Program Manager (DAPM/DER): _____________________________________
IMPORTANT! If you presently have a program with Foley Services, Inc., please indicate here:
There is no need to complete the rest of the form.
If you plan on enrolling in a Foley Services' program, please indicate here:
There is no need to complete the rest of the form.
If you presently have a Third Party Administrator (C/TPA) managing your program with an outside provider, please provide the service agent’s name and complete the following information:
C/TPA: ______________________________________________________________________________ Address: _____________________________________________________________________________
City: ____________________________________ State: ___________ Zip: _______________ Contact Name: _____________________________ Phone: _____________ Fax: _______________
Compliance Questionnaire - Page 1 of 2
DA-18
R-1 P 1/2 Use to verify compliance of your vendors/contractors with drug and alcohol testing regulations.
Ref: 49 CFR 382.
EMPLOYER REQUESTING THIS INFORMATION
CONTRACTOR/VENDOR INFORMATION
DRUG AND ALCOHOL PROGRAM INFORMATION
V en d or/C on tractor C om p lian ce
R etain 5 years
DRUG AND ALCOHOL TESTING PROGRAM COMPLIANCE
QUESTIONNAIRE, CONTINUED
Controlled Substances and Alcohol Program managed:
In-house Consortium Other: _______
Number of CDL drivers: ____ Do you subcontract driving services? Yes No If yes, are they covered by your program? Yes No If you subcontract drivers, and you do not provide a program for these subcontractors, you must have them complete a separate questionnaire.
Please attach a copy of your Controlled Substances and Alcohol Testing Policy and associated educational materials for individuals who must be in a DOT mandated program.
Please describe the Reasonable-Suspicion training program for supervisors, and list the number of supervisors who have completed the Reasonable-Suspicion training program. _____________________ Number of Trained Supervisors: ______ Medical Review Officer Name: _________________________________ Telephone No.: ___________
Certifying Agency of Medical Review Officer: _______________________________________________
Substance Abuse Professional Name: ____________________________ Telephone No.: ___________
Address: _____________________________________________________________________________
City: ________________________________________________ State: ___ Zip: ________________
Certifying Agency of Substance Abuse Professional: __________________________________________
HHS-Certified Laboratory Name(s): _______________________________________________________
Drug collection site(s): ___________________ __________________ __________________
Alcohol testing site(s): ___________________ ___________________ ___________________
24 hour Post-Accident collection and testing procedure: ________________________________________ I certify that our plan meets all requirements set forth under applicable DOT regulations and that all safety sensitive employees are tested for both alcohol and controlled substances per applicable federal and/or state regulation/law. I understand it is our company's responsibility to implement all required controlled substances and alcohol testing components.
Date: _______ Company Name: ________________________________________________________
Company Official Name: ____________________ Signature (Co. Official): _____________________
Please send completed questionnaire and other requested information to:
V en d or/C on tractor C om p lian ce
DA-18
R-1 P 2/2
R etain 5 years
File details come from the government source that posted it. Updated .