ࡱ> E@ ~abjbj 3f(zU(((8`5Mh (    T 4I EdJLJLJLJLJLJL$NRPnLe   e e nL  L'''e :  E'e E''6-.  y-G;( :."/M05M.uQ 8uQ8/uQ/ e e 'e e e e e nLnLtztzDRUG AND ALCOHOL MANAGEMENT PROGRAM MONITORING FORMForm PTN-102 (Rev. 6/2003) (GSD-EPC) Page 1 of  NUMPAGES \* MERGEFORMAT 10 Name of Transit Agency:  FORMTEXT      Address:  FORMTEXT      City, State, Zip:  FORMTEXT      Phone:  FORMTEXT      Contact Person:  FORMTEXT      Name of Senior Agency (COG, CAA, RPC, or County, if applicable):  FORMTEXT      Monitored By:  FORMTEXT      Date Monitored:  FORMTEXT      TxDOT District:  FORMTEXT       In Compliance  FORMCHECKBOX  Not In Compliance  FORMCHECKBOX  Corrective Action Plan Due Date:  FORMTEXT       Describe Areas of Non-Compliance:  FORMTEXT       POLICY STATEMENT ELEMENTS (655.15)YESNO 1. Has the policy statement been approved by the governing board or senior official of the transit agency?  FORMCHECKBOX  FORMCHECKBOX  2. Are the approval date and any updates clearly identified? FORMCHECKBOX  FORMCHECKBOX  3. Has the policy statement been made available to every safety sensitive employee? FORMCHECKBOX  FORMCHECKBOX  4. Are there records of an employee signed Acknowledgment form or other documents to show the employee has received a copy or is aware of the policy availability? FORMCHECKBOX  FORMCHECKBOX  5. Does the policy statement include the name and telephone number of the contact person to whom employees may ask questions about the company drug and alcohol testing program? FORMCHECKBOX  FORMCHECKBOX  6. Does the policy statement identify the specific categories of Safety Sensitive Employees who are subject to drug and alcohol testing? (655.4) Does it include operating a revenue service vehicle? Does it include maintaining a revenue service vehicle? Does it include dispatching or controlling movement of a vehicle? Does it include operating a non-revenue vehicle that requires a CDL? Does it include carrying a firearm for security purposes? (May not apply) Does it include Volunteer Employees? (May not apply) FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  7. Does the policy statement include an analysis of safety sensitive job functions to determine which employees were designated to be safety sensitive? FORMCHECKBOX  FORMCHECKBOX  8. Does the policy state that participation in the drug and alcohol testing program is a condition of employment for all safety sensitive employees? (655.49) FORMCHECKBOX  FORMCHECKBOX  9. Does the policy state that an alcohol test may be conducted just before, during and just after performing a safety sensitive function? (655.45) FORMCHECKBOX  FORMCHECKBOX 10. Does the policy state that the use of illegal drugs is prohibited at all times and employees may be tested for drugs anytime while on duty? (655.45) FORMCHECKBOX  FORMCHECKBOX 11. Does the policy state that consumption of alcohol is prohibited when performing a safety sensitive function? (655.32) FORMCHECKBOX  FORMCHECKBOX 12. Does the policy state that employees are prohibited from consuming alcohol 4 hours prior to performing safety sensitive functions? (655.33) FORMCHECKBOX  FORMCHECKBOX 13. Does the policy state that employees must not consume alcohol for 8 hours following an accident or until a post accident test is conducted? (655.34) FORMCHECKBOX  FORMCHECKBOX 14. Does the policy state that employees are prohibited from consuming alcohol while on call? (655.33) FORMCHECKBOX  FORMCHECKBOX 15. Does the policy state that on-call employees will be given the opportunity to acknowledge the use of alcohol and the inability to perform safety sensitive functions? (655.33) FORMCHECKBOX  FORMCHECKBOX 16. Does the policy state that employees will be removed from safety sensitive duties if their breath alcohol test is 0.04 or above? FORMCHECKBOX  FORMCHECKBOX 17. Does the policy state which prohibited substances the employees will be tested for? FORMCHECKBOX  FORMCHECKBOX  POLICY STATEMENT ELEMENTS (655.15) (cont.)YESNO18. Does the policy statement identify specific circumstances for Pre-Employment Testing? A negative drug test required prior to performing safety sensitive duties? (655.41) Evidence of a successful rehab program for an employee/applicant who previously failed a DOT drug test? (655.41) A negative drug test for a transferring employee? (655.41) A pre-employment test for an employee who has been removed from safety sensitive duties and removed from the random testing pool for more than 90 days? (655.41) Circumstances for pre-employment alcohol testing if conducted? (655.42) Note: Pre-Employment alcohol testing is optional.  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX 19. Does the policy statement identify specific circumstances for Random Testing? (655.45) Random selections are made using a scientifically valid method? Testing will be spread reasonably throughout all periods of the calendar year? Testing is conducted on all hours and days when safety sensitive duties are performed? Testing is unannounced and immediate? Allows no discretion by management personnel as to who is selected or notified?  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX 20. Does the policy statement identify specific circumstances for Post Accident Testing? FTA post accident testing thresholds for fatalities? (655.4) FTA post accident testing thresholds for bodily injury? (655.4) FTA post accident testing thresholds for vehicle disabling damage? (655.4) Testing safety sensitive employees whose performance could have contributed to the accident? (655.44) Not testing employees whose performance can be completely discounted as a contributing factor? (655.44) Conduct drug testing within 32 hours? (655.44) Conduct alcohol testing within the 2-hour and 8-hour rules? (655.44) Require an employee to remain readily available? (655.44)  FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX 21. Does the policy state employees involved in an accident are prohibited from consuming alcohol for at least 8 hours following an accident, or until post-accident testing has taken place, which ever comes first? (655.34) FORMCHECKBOX  FORMCHECKBOX 22. Does the policy statement identify specific circumstances for Reasonable Suspicion Testing? (655.43) Determinations are made based on specific, contemporaneous, articulable observations concerning the appearance, behavior, speech and body odor? Determinations are made by one or more trained supervisors or company official?  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX 23. Does the policy statement identify specific circumstances for Return To Duty and Follow Up Testing? Is it clearly stated if the transit agency has a Zero Tolerance or Second Chance Policy? Is it clearly stated that if there is a Second Chance Policy that all return to duty and follow up testing will be conducted as specified in 49 CFR Part 40? (655.46)  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  POLICY STATEMENT ELEMENTS (655.15) (cont.)YESNO24. Does the policy state that all drug and alcohol testing will be conducted in accordance with 49 CFR Part 40? (655.15e and 655.51) FORMCHECKBOX  FORMCHECKBOX 25. Does the policy state that Part 40 will be made available to employees upon request? (655 Subpart B Section A) FORMCHECKBOX  FORMCHECKBOX 26. Does the policy statement identify specific circumstances for Dilute Negative test results? Policy states whether or not the employee will be required to immediately take another unobserved drug test? (40.197) Specifies if different types of tests follow different policies? (40.197)  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX 27. Does the policy state behavior that constitutes a Test Refusal? (655.15) Failure to appear at the collection site in a reasonable time. (Does not apply to pre-employment) (40.191/.261) Refusal to provide a specimen. (Verbal or physical absence) (40.191/.261) Failure to provide a sufficient specimen with no medical explanation. (40.191/.261) Failure to remain at the testing site until the testing process is completed. (Does not apply to pre-employment) (40.191/.261) Failure to have a medical evaluation if required by an MRO. (40.191/.261) Failure to cooperate with any part of the testing process. (40.191/.261) Failure to allow monitoring or direct observation for drug testing. (40.191) Failure to take a second test if directed to do so. (40.191) MRO verification of a test as adulterated or substituted. (40.191) Failure to sign Step 2 of the Alcohol Testing Form. (40.261) Failure to remain available for testing following an accident. (655.44) Policy states that refusing a non-DOT is not a refusal to take a DOT test.  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX 28. Does the policy statement specify the consequences for positive drug test results or positive alcohol test results, or refusing to submit to a test? (655.61) The employee will be immediately removed from safety sensitive duties. (655.61) The employee will be referred to a Substance Abuse Professional. (655.62)   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX 29. Does the policy state the consequences for a safety sensitive employee who has an alcohol concentration of 0.02 or above, but less than 0.04? (655.35) Temporary removal from safety sensitive duties until the next shift, but not less than 8 hours, or Temporary removal from safety sensitive duties until verified alcohol concentration is less than 0.02. Other company policies separate from DOT regulations.  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX 30. Does the policy state when employees are subject to drug or alcohol testing such as days of the week, hours, holidays, etc? FORMCHECKBOX  FORMCHECKBOX 31. Does the policy statement describe the employees right to access his or her own drug and alcohol records? FORMCHECKBOX  FORMCHECKBOX 32. Is the non-DOT, transit agency internal policy requirements not required by DOT, (i.e., Second Chance Policy, or non-DOT post accident testing), clearly stated in the policy statement? FORMCHECKBOX  FORMCHECKBOX  DRUG FREE WORKPLACE ACTYESNONote: The DFW Act applies to all employees in the transit agency. The FTA regulations apply only to the safety sensitive employees. The regulations are separate, but similar in several ways. 1. Is there a written policy notifying all employees of the prohibited behavior as specified in the Drug Free Workplace Act? FORMCHECKBOX  FORMCHECKBOX  2. Does the policy specify unlawful manufacture, distribution; dispensing, possession and use of controlled substances are prohibited in the workplace? FORMCHECKBOX  FORMCHECKBOX  3. Is there a drug free awareness program to inform employees about the dangers of drug abuse in the workplace? Examples are posters, brochures and training classes. FORMCHECKBOX  FORMCHECKBOX  4. Is there a drug free awareness program to inform employees about the company policy of maintaining a drug free workplace? FORMCHECKBOX  FORMCHECKBOX  5. Is there a drug free awareness program to inform employees about available drug counseling, rehabilitation programs and employee assistance programs? FORMCHECKBOX  FORMCHECKBOX  6. Does the policy specify the actions to be taken against the employee for violations of the Drug Free Workplace policy? FORMCHECKBOX  FORMCHECKBOX  7. Is each employee given a copy of the policy statement? FORMCHECKBOX  FORMCHECKBOX  8. Does the policy state that compliance with the Drug Free Workplace is a condition of employment? FORMCHECKBOX  FORMCHECKBOX  9. Does the policy state that the employee must notify the employer within 5 days of any drug related convictions for violations in the workplace? FORMCHECKBOX  FORMCHECKBOX 10. Does the policy state the employer must notify TxDOT within 10 days of any drug related convictions for violations in the workplace? FORMCHECKBOX  FORMCHECKBOX 11. Does the policy state the type of personnel actions that will be taken against employees who violate the Drug Free Workplace Act? This must include either employee termination or referral to a substance abuse rehabilitation program. FORMCHECKBOX  FORMCHECKBOX 12. Does the employer make a good faith effort to maintain a drug free workplace through implementation of the above requirements? FORMCHECKBOX  FORMCHECKBOX  EDUCATION AND TRAINING PROGRAMS (655.14)YESNO1. Are drug and alcohol program information materials and employee assistance program (EAP) information displayed in the workplace? FORMCHECKBOX  FORMCHECKBOX 2. Are drug and alcohol program information materials and employee assistance program (EAP) information distributed to every covered employee? FORMCHECKBOX  FORMCHECKBOX 3. Do all covered employees receive at least 60 minutes of training on the effects and consequences of drug use? FORMCHECKBOX  FORMCHECKBOX 4. Does training include effects on personal health, safety, and the work environment and on the signs and symptoms that indicate prohibited drug use? FORMCHECKBOX  FORMCHECKBOX 5. Do all supervisors receive at least 60 minutes of training on the physical, behavioral, speech and performance indicators of probable drug use? FORMCHECKBOX  FORMCHECKBOX 6. Do all supervisors receive at least 60 minutes of training on the physical, behavioral, speech and performance indicators of alcohol misuse? FORMCHECKBOX  FORMCHECKBOX 7. Are there written records to verify employee training conducted? (655.71) FORMCHECKBOX  FORMCHECKBOX  PRE-EMPLOYMENT DRUG TESTING (655.41)YESNO 1. Are new employees tested and verified negative for drug use prior to being allowed to perform safety sensitive functions? FORMCHECKBOX  FORMCHECKBOX  2. Is there a spread sheet or similar document used to provide written verification that negative test results are obtained before the employee begins safety sensitive duties? FORMCHECKBOX  FORMCHECKBOX  3. Is the employee notified that Pre-Employment testing is required by Part 655? (655.17) FORMCHECKBOX  FORMCHECKBOX  4. Are previous non safety sensitive employees transferring into a safety sensitive position, tested and verified negative for drugs prior to being allowed to perform safety sensitive functions? FORMCHECKBOX  FORMCHECKBOX  5. Are employees who have not been in a safety sensitive function for 90 days, and have not been in the random selection pool, administered a Pre-Employment test with a verified negative result before being allowed to perform safety sensitive functions?  FORMCHECKBOX  FORMCHECKBOX  6. If a transfer employee was working in a safety sensitive position within the past 2 years, was drug and alcohol information requested from the previous employer? (40.25) FORMCHECKBOX  FORMCHECKBOX  7. Does the new employee provide written permission to contact the previous employer about drug and alcohol information? (40.25) FORMCHECKBOX  FORMCHECKBOX  8. Does the request to the previous employer include requests for information on: alcohol tests greater than 0.04, positive drug test results, test refusals, other violations of DOT drug and alcohol testing regulations, documentation of any return to duty process? (40.25b) FORMCHECKBOX  FORMCHECKBOX  9. Is there documentation showing good faith effort in attempting to obtain drug and alcohol information from any previous employers? (40.25) FORMCHECKBOX  FORMCHECKBOX 10. If for some reason a Pre-Employment test is canceled, is the employee required to take another Pre-Employment test before beginning safety sensitive duties?  FORMCHECKBOX  FORMCHECKBOX 11. If Pre-Employment alcohol testing is conducted, is testing conducted prior to allowing the employee to perform safety sensitive functions, and is testing conducted using procedures set forth in Part 40? Note: Pre-Employment Alcohol Testing is not required. (655.42) FORMCHECKBOX  FORMCHECKBOX  REASONABLE SUSPICION TESTING (655.43)YESNO1. Are employees tested for drug and/or alcohol when the employer believes the employee has used drugs and/or alcohol? FORMCHECKBOX  FORMCHECKBOX 2. Does a trained supervisor or company official make the required observations? A supervisor or company official must be trained in detecting signs and symptoms of drug and alcohol misuse. (655.14b) FORMCHECKBOX  FORMCHECKBOX 3. Is there a supervisor checklist that states that reasonable suspicion testing must be based on specific, contemporaneous (current), articulable (describable) observations that check for appearance, behavior, speech or body odors? FORMCHECKBOX  FORMCHECKBOX 4. Is alcohol testing permitted only if the observations are conducted just proceeding, during or just after the workday of the safety sensitive employee? FORMCHECKBOX  FORMCHECKBOX 5. Is the alcohol testing conducted within 2 hours of being observed and determined to be using alcohol? FORMCHECKBOX  FORMCHECKBOX 6. Are attempts to conduct the alcohol testing ceased after the 8-hour time limit has expired? FORMCHECKBOX  FORMCHECKBOX  REASONABLE SUSPICION TESTING (655.43) (cont.)YESNO7. Are there written records explaining the delays and actions taken if the testing can not be conducted after the 2-hour and 8-hour time limits? Note: Alcohol testing may be conducted between 2 hours and 8 hours if the delay can be justified in writing. FORMCHECKBOX  FORMCHECKBOX 8. Are Reasonable Suspicion referral documents maintained on file? (655.71) FORMCHECKBOX  FORMCHECKBOX  POST-ACCIDENT TESTING (655.44)YESNO1. Is drug and alcohol testing conducted as soon as practicable following a Fatal accident? Note: Testing is mandatory. FORMCHECKBOX  FORMCHECKBOX 2. Are DOT forms used for the non-fatal accidents that meet the FTA testing criteria, and non-DOT forms used for post accident testing that is required by the transit agency? (40.47a) (40.227a) (40.13f) FORMCHECKBOX  FORMCHECKBOX 3. If post-accident testing is conducted under non-DOT criteria, (transit agency policy) is the employee informed that it is a non-DOT test? FORMCHECKBOX  FORMCHECKBOX 4. If the incorrect CCF or ATF is used, does the transit agency know how to make the necessary corrections? (40.205b) (40.271b) FORMCHECKBOX  FORMCHECKBOX 5. If the transit agency determines drug and alcohol testing is not required, are written details filed to include how such a decision was made, and is there a designated person to make such a decision? (655.44d) (655.71c) (40.3) FORMCHECKBOX  FORMCHECKBOX 6. Are other employees who may have contributed to a fatal or non-fatal accident tested for drugs and alcohol? (655.44a) FORMCHECKBOX  FORMCHECKBOX 7. Does the transit agency comply with the 32 hour rule for drug testing and the 2 and 8-hour rules for alcohol testing? FORMCHECKBOX  FORMCHECKBOX  RANDOM TESTING (655.45)YESNO1. Are random test selections or draws conducted at least once a quarter? (655.45e) (Preamble to 655) FORMCHECKBOX  FORMCHECKBOX 2. Is the employee roster updated prior to the draw or selection being conducted?  FORMCHECKBOX  FORMCHECKBOX 3. Does the transit agency (or C/TPA) use a computer based random number generator or similar scientific method to select employees who must test? (655.45e) FORMCHECKBOX  FORMCHECKBOX 4. Are non-DOT employees placed in a separate random testing pool from the pool of safety sensitive employees? (655.45) (40.347) FORMCHECKBOX  FORMCHECKBOX 5. Are random drug and alcohol test dates unannounced, unpredictable, and spread reasonably throughout the year? (655.45g) FORMCHECKBOX  FORMCHECKBOX 6. Is random drug testing conducted at all times of the day when safety sensitive functions are being performed to include nights, weekends, and holidays? (655.45g) FORMCHECKBOX  FORMCHECKBOX 7. Is there an Order for Testing form, and/or a spreadsheet or similar documentation used to track critical dates and times in the random testing process? Documentation must clearly demonstrate the employee arrived at the collection site in a timely manner. (655.45h) (40.191) (40.61a) FORMCHECKBOX  FORMCHECKBOX 8. Are complete random testing documents available that clearly show all steps in the process from employee selection to verified test results? (655.71c)  FORMCHECKBOX  FORMCHECKBOX 9. Do employees selected and notified for random testing immediately cease safety sensitive duties and proceed immediately to the test site? (655.45h) FORMCHECKBOX  FORMCHECKBOX  RANDOM TESTING (655.45) (cont.)YESNO10. Are excused employees who were legitimately not available for random testing, then tested when they return to work? (655.45e)  FORMCHECKBOX  FORMCHECKBOX 11. Are records kept explaining why a selected employee may not have been available for a random test? (655.45e) (655.71) FORMCHECKBOX  FORMCHECKBOX  RETURN TO DUTY AND FOLLOW-UP (655.62)YESNO1. Does the transit agency clearly state to employees that they have a Zero Tolerance Policy or a Second Chance Policy? FORMCHECKBOX  FORMCHECKBOX 2. Does the transit agency maintain a list of qualified SAPs? (655.62a) (40.287) FORMCHECKBOX  FORMCHECKBOX 3. Are employees required to complete a course of education and /or treatment recommended by the SAP before they can be returned to a safety sensitive position? (40.289) FORMCHECKBOX  FORMCHECKBOX 4. Are employees required to complete a return to duty test with verified negative results before they can resume safety sensitive functions? (40.305) FORMCHECKBOX  FORMCHECKBOX 5. Does the SAP provide a follow-up treatment plan? (40.307) (40.311) FORMCHECKBOX  FORMCHECKBOX 6. Does the transit agency follow the SAP recommendations and decide the actual dates of all testing? (40.309) FORMCHECKBOX  FORMCHECKBOX 7. Is a minimum of 6 follow-up tests conducted in the first 12 months the employee is returned to safety sensitive duties? (40.307) FORMCHECKBOX  FORMCHECKBOX 8. Does the employer make a decision to return the employee to work following a successful treatment program and negative test? Note: The employer is not required to return the employee to safety sensitive duties. (40.305) FORMCHECKBOX  FORMCHECKBOX  TEST RESULTSYESNO1. Does the transit agency receive immediate alcohol test results from the BAT by either secure phone or fax? (40.255) FORMCHECKBOX  FORMCHECKBOX 2. Does the transit agency receive drug test results from the MRO in a reasonable amount of time (usually 2-4 business days)? (40.167) FORMCHECKBOX  FORMCHECKBOX 3. Does the MRO office provide verbal test results followed by documentation? (40.163) FORMCHECKBOX  FORMCHECKBOX 4. Is there a password or verification method to ensure that verbal transmission of positive test results between the MRO and the DER/DAPM is secure? (40.167) FORMCHECKBOX  FORMCHECKBOX 5. Does the transit agency use a spreadsheet or similar method to track the test results from the MRO or TPA? (40.17) FORMCHECKBOX  FORMCHECKBOX 6. Are employees who have tested positive for drugs and/or alcohol referred to a Substance Abuse Professional (SAP) regardless if the employee is terminated or retained? (655.62a) (40.287) FORMCHECKBOX  FORMCHECKBOX  ADMINISTRATIVE REQUIREMENTS (655.71)YESNO1. Does the transit agency have a secured location with controlled access for all drug and alcohol records? (655.71a) FORMCHECKBOX  FORMCHECKBOX 2. Does the agency have a controlled means, such as a designated fax machine, or password protected e-mail, to receive test results? FORMCHECKBOX  FORMCHECKBOX 3. Is documentation available to verify the professional credentials of all service agents to include the MRO, SAP, the lab and all collectors? Note: the C/TPA may keep this on file but the certificates must be readily available upon request. (40.15)  FORMCHECKBOX  FORMCHECKBOX  ADMINISTRATIVE REQUIREMENTS (655.71) (cont.)YESNO 4. Are the DOT CCF and ATF only used for DOT mandated drug and alcohol tests? (40.13) FORMCHECKBOX  FORMCHECKBOX  5. Are non-DOT CCF and non-DOT ATF used for the non-DOT drug and alcohol testing? (40.13) FORMCHECKBOX  FORMCHECKBOX  6. Are DOT records and non-DOT records filed separately from one another? (40.13a) FORMCHECKBOX  FORMCHECKBOX  7. Does the Notification to Test Form or similar document clearly state that the drug and/or alcohol test to be administered is DOT or non-DOT so that this information is apparent to both the employee and the collection site? (655.17) FORMCHECKBOX  FORMCHECKBOX  8. Has the transit agency made arrangements for collections that must be conducted after normal duty hours and on weekends? (655.45) FORMCHECKBOX  FORMCHECKBOX  9. Are covered employees granted access to review their own records pertaining to drug and alcohol misuse? (Employees must request access in writing) (655.73) FORMCHECKBOX  FORMCHECKBOX 10. Are subsequent employers given information on the employees drug and alcohol records only if the employee has signed a consent form? (655.73) FORMCHECKBOX  FORMCHECKBOX 5 Year Records11. Are employee records of positive drug test results kept on file for 5 years? (40.333) FORMCHECKBOX  FORMCHECKBOX 12. Are employee records of positive alcohol tests (0.02 or greater) kept on file for 5 years? FORMCHECKBOX  FORMCHECKBOX 13. Are employee records of test refusals (drug and/or alcohol) kept on file for 5 years? FORMCHECKBOX  FORMCHECKBOX 14. Are records of employee disputes kept on file for 5 years? FORMCHECKBOX  FORMCHECKBOX 15. Are calibrations tests for the Evidential Breath Test device (EBT) kept on file for 5 years?  FORMCHECKBOX  FORMCHECKBOX 16. Are all Substance Abuse Professional (SAP) reports, referrals, follow-up test results and follow-up schedules kept on file for 5 years? (40.333) (40.311) FORMCHECKBOX  FORMCHECKBOX 17. Are annual copies of the required DAMIS reports kept on file for 5 years? FORMCHECKBOX  FORMCHECKBOX 3 Year Records18. Are records from previous employers kept on file for 3 years? (40.333) FORMCHECKBOX  FORMCHECKBOX 2 Year Records19. Are employee records of the collection process, to include collection logbooks (if used), kept on file for 2 years? FORMCHECKBOX  FORMCHECKBOX 20. Are records of all training programs kept on file for 2 years? FORMCHECKBOX  FORMCHECKBOX 21. Are documents related to post-accident drug and alcohol testing kept on file for 2 years? FORMCHECKBOX  FORMCHECKBOX 1 Year Records22. Are records of negative or canceled drug and/or alcohol test results kept on file for 1 year? FORMCHECKBOX  FORMCHECKBOX References23. Is there a copy of 49 CFR Part 40? (Aug-01) FORMCHECKBOX  FORMCHECKBOX 24. Is there a copy of 49 CFR Part 655? (Aug-01) FORMCHECKBOX  FORMCHECKBOX 25. Is there a copy of the Implementation Guidelines book? (Aug-02) FORMCHECKBOX  FORMCHECKBOX 26. Is there a copy of the Best Practices Manual? (Mar-02) FORMCHECKBOX  FORMCHECKBOX 27. Is there a copy of the DOT Urine Specimen Collection Guidelines, Version 1.01? (Aug-01) FORMCHECKBOX  FORMCHECKBOX 28. Is there a copy of the FTA Audit Questionnaire? (Feb-03) FORMCHECKBOX  FORMCHECKBOX 29. Is there a copy of the TxDOT PTN Form 102 Monitoring Form? 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Under 552.021 and 552.023 of the Texas Government Code, you also are entitled to receive and review the information. Under 559.004 of the Government Code, you are also entitled to have us correct information about you that is incorrect. For inquiries call 512-463-8585. 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Load LongDFo rm.Sho@w End K*s  rU~~~~~~~~~~~~_ ]:&@K@3h     Qi   )   I 1Q YyyProject1TemplateProject ThisDocumentModule1AutoNewAutoOpenFormsLockAndProtectFormsUnlockWithPasswordHelp LongHelpForm SpellCheckToolsProtectDocumentUpdatePageNumbersF /D:\PROGRA~1\COMMON~1\MICROS~1\VBA\VBA6\VBE6.DLLVBA  I0 F5D:\Program Files\Microsoft Office\Office10\MSWORD.OLBWord  @0FD:\WINDOWS\System32\stdole2.tlbstdole aPL-[DR?D:\Program Files\Common Files\Microsoft Shared\Office10\MSO.DLLOffice `.E .`M D:\WINDOWS\System32\FM20.DLLMSForms apD [$EǤ$^{ 1D:\DOCUME~1\SMOORE1\LOCALS~1\Temp\VBE\MSForms.exd  aMain FormLock FormUnlock SpellCheckerRrU    trU~| krU $`nrU~| __SRP_1Yv__SRP_2 [T__SRP_3]g__SRP_4 _TkrU $`nrU~| krU $`nrU~| __SRP_5ag__SRP_6cT__SRP_7eg__SRP_8gTkrU $`nrU~|  krU $ `n\cwO__SRP_9ig__SRP_akT__SRP_bmgAutoOpeno xMEH 8 " B P `px;This form opens the Help menu when this template is opened., A@ocu B@  anoAttribute VB_Name = "AutoOpen" Public Sub Main() 'This form oLs the Help menu when$DtemplaRed. Load Lon:gjFH.Show End{ SpellCheckwLongHelpFormzThisDocument_VBA_PROJECTOۧ xME(6 << <x @`>p%H@>@$*\Rffff*0M403e16ee " , 8 X h x  ( % Macro recorded 11/19/2002 by GHARRISlockepc, (B@6x BB@D B(F H(Jx L!NM (B@PXdP (B@Ration k8lockepc,. 0l (B@*okAttribute VB_Name = "SpellCheck" Public Sub der()p' Macro recorded 11/19/2002 by GHAR(RISR ActiveDocument.Unprotect Passw@:="lockepcz1Selion.WholeSt ory NoProofingAFalse!Adppat=L@anguagTru%If Op s.GrammarWithw+ Then-@ f ED0nd If-o, NoRe set:=Q, Type:=wdAllowOnlyFormFields E1LGO_xME(S<S<S<S<0{A53EBB1F-EBA6-40A9-AB3D-40B38EBEB215}{C0C26884-25F9-4C8A-A70C-EB31EC4FE08A}0(%X0 % :X``0 "(8` A@r Unloads formoPH)Attribute VB_Name = "LongHelpForm" Bas0{A53EBB1F-EBA6-40A9-AB3DB38EBEB215}{C0C26884-25F9-4C8@A-A70Ch31EC4FE08A} dGlobaBlSpacoFalse Cre atablPr@edeclaI"dTru BEx0pose0TemplateDerivCustomizD P Sub ExitMenu_Click() Unload ' s f End" Oۮ#xME (SLSS<N0{00020906-0000-0000-C000-000000000046}8(%HxAttribute VB_Name = "ThisDocument" Bas0{00020P906-0C$0046} |GlobalSpacFalse dCreatablPredeclaIdTru BExposeTemplateDerivBustomizD2as  *\G{000204EF-0000-0000-C000-000000000046}#4.0#9#D:\PROGRA~1\COMMON~1\MICROS~1\VBA\VBA6\VBE6.DLL#Visual Basic For Applications*\G{00020905-0000-0000-C000-000000000046}#8.2#0#D:\Program Files\Microsoft Office\Office10\MSWORD.OLB#Microsoft Word 10.0 Object Library*\G{00020430-0000-0000-C000-000000000046}#2.0#0#D:\WINDOWS\System32\stdole2.tlb#OLE Automation(*\G{2DF8D04C-5BFA-101B-BDE5-00AA0044DE52}#2.2#0#D:\Program Files\Common Files\Microsoft Shared\Office10\MSO.DLL#Microsoft Office 10.0 Object Library*\G{0D452EE1-E08F-101A-852E-02608C4D0BB4}#2.0#0#D:\WINDOWS\System32\FM20.DLL#Microsoft Forms 2.0 Object Library*\G{145B0D44-E886-4524-95C7-A4245E87D27B}#2.0#0#D:\DOCUME~1\SMOORE1\LOCALS~1\Temp\VBE\MSForms.exd#Microsoft Forms 2.0 Object Library.E .`M  >@ O ThisDocument0:403e16ceThisDocument%AutoNew0I403e16dfAutoNew4AutoOpen0A403e16d8"AutoOpen0}&FormsLockAndProtect0J403e16e0$&FormsLockAndProtect{H.FormsUnlockWithPassword0K403e16e72.FormsUnlockWithPasswordQ;`Help0D403e16d88Helpx]LongHelpForm0E403e16d8LongHelpForm_MSpellCheck0M403e16ee>SpellCheck (ToolsProtectDocument0G403e16d9T(ToolsProtectDocumentM"UpdatePageNumbers0L403e16eaX"UpdatePageNumbers`x0Hy,J,3RQx=AKt_)80A̽VA L=ӥT[ [@oDŽlCCZLm;2'N`!tji`>{EOB$zyF<@QL]S$iKb$@A.WordkVBAWin16~Win32MacVBA6#Project1 stdole`TemplateProjectE ThisDocument< _EvaluateOfficeuModule1bAutoNew\3Main, LongHelpFormShowAutoOpen*FormsLockAndProtect\FormLockActiveDocument\ProtectfPasswordNoResetgwdAllowOnlyFormFields!FormsUnlockWithPassword FormUnlock  Unprotect?HelpfExitMenu_ClickMSFormsC SpellCheck  SpellCheckerC SelectionZ WholeStory NoProofing] Application* CheckLanguageOptionsCheckGrammarWithSpelling CheckGrammar CheckSpellingWToolsProtectDocument-0ToolsProtectionUpdatePageNumbers3 ActiveWindow+ViewI SplitSpecial wdPaneNone= Panes ActivePane_ wdNormalView wdOutlineViewk wdMasterView wdPageViewvSeekView$wdSeekCurrentPageHeader;Fields7UpdatewdSeekMainDocumentMoveUpUnitwdScreenCount0vDocumentjU Y  #%39<? UpdatePageNumbers$ FormsLockAndProtect(ToolsProtectDocument*FormsUnlockWithPassword0OیxME(6 << <x X`Xp%H@>@$*\Rffff*0L403e16ea " J LXTXpx  \ X((DUpdate automatic numbering fields by copying part of this macro intoFthe AutoNew macro if necessary, or as a run-on-exit from a form field.lockepc, (B@6s Z!\!^ ` Z%bB@Bk  Z!d!\!l f Z!d!\!l h Z!d!\!l j l Z!d!\(lk p Z!d!\(n BB@D B!rB@t v Z!d!\(nUSelection.GoTo What:=wdGoToBookmark, Name:="Page" 'Uncomment these lines if you haveRSelection.Fields.Update 'fields outside of the headers. |z~ BB@xlockepc,. 0l (B@*o0(Attribute VB_Name = "UpdatePageNumbers" Publi@c Sub () '* automatTnzing fields by copy"part of this macro intoFthe ACNewf necessary, or as a run-on-exit fromformk. ActiveDocument.Unprotect Password:="l@ockepco If Window.View.SplitSpecial <> wdPaneNone Then<  s(2).CloseEnd If 5:TypHwdNialD Or O _%>Outline :wdMaster;/A*@ ZSeek=\CurrqHeade"rSeltion.WholeSPtoryMF.MainőGoTo What:=wdBookmarkD, :="+" 'UncomCese ds if you hav'J,w'outsiDdee hBHsMoveUp UniB+Screen, Coujn1ePeoRTrue, UA Allow`OnlyFV  a> Oۂ{xME(6 << <x &`$p%H@>@$*\Rffff*0J403e16e0 " 6(@hx/Apply the Ctrl+L or Ctrl+Shift+L to this macro.lockepc,. 0l (B@*oݰAttribute VB_Name = "FormsLockAndProtect" Public Sub () 'Apply the Ctrl+L orShift to:is macro. ActiveDocument.g Passwo@rd:="lepc", NoReset:=True, Type:=wdAllo wOnlyFields End GOxME      !"#$%'()*+,-./012356789:<=?@ABCDEFHIJKLMNOPQRSTUVWXYZ[\]^`bdefgi V@p'Sets protection for the active document)TemplateProject.ToolsProtectDocument.MAINX " R V`(KThis macro overrides the Tools:Protect Document from the Tools menu so thatۂOthe user can't accidentally clear out all of their form fields when protecting.rlockepc,. 0l (B@*oAttribute VB_Name = "ToolsProtectDocument" Public Sub ion()   8.Des`criptVS`ets pfor the active duUcDataaInvoke_Funcemplate"j. A.MAINl'This macro overridesG:!  from u so at 'duser can'tic'ntally clear ou ll of"ir m fields whenng. : A\IPassword:="lockepc", NoReset:=True, Type:=wdAllowOnlyFormFA6 Endt OQ;xME(6 << <x 4`2p%H@>@$*\Rffff*0K403e16e7 " 6@`p/Apply the Ctrl+U or Ctrl+Shift+U to this macro.lockepc, (B@6oAttribute VB_Name = "FormsUnlockWithPassword" Public 0Sub () 'Apply the Ctr@l+U orShiftto:is macro. ActiveDocument.Unpr@otect t:D="epc~Endy ID="{59E90491-FA8F-4F3D-A3F5-4219B5AD893F}" Document=ThisDocument/&H00000000 Module=AutoNew Module=AutoOpen Module=FormsLockPROJECT!&WPROJECTwm"4LongHelpForm$y-G;y-G;f;AndProtect Module=FormsUnlockWithPassword Module=Help BaseClass=LongHelpForm Module=SpellCheck Module=ToolsProtectDocument Module=UpdatePageNumbers Name="TemplateProject" HelpContextID="0" VersionCompatible32="393222000" CMG="181A191F1D1F1D1F1D1F1D" DPB="3032313232323232" GC="484A494A4A4A4AB5" [Host Extender Info] &H00000001={3832D640-CF90-11CF-8E43-00A0C911005A};VBE;&H00000000 [Workspace] ThisDocument=0, 0, 0, 0, C AutoNew=0, 0, 0, 0, C AutoOpen=0, 0, 0, 0, C FormsLockAndProtect=0, 0, 0, 0, C FormsUnlockWithPassword=0, 0, 0, 0, C Help=0, 0, 0, 0, C LongHelpForm=0, 0, 0, 0, C, 88, 116, 692, 580, Z SpellCheck=0, 0, 0, 0, C ToolsProtectDocument=0, 0, 0, 0, C UpdatePageNumbers=0, 0, 0, 0, C ThisDocumentThisDocumentAutoNewAutoNewAutoOpenAutoOpenFormsLockAndProtectFormsLockAndProtectFormsUnlockWithPasswordFormsUnlockWithPasswordHelpHelpLongHelpFormLongHelpFormSpellCheckSpellCheckToolsProtectDocumentToolsProtectDocumentUpdatePageNumbersUpdatePageNumbers(H  @},$Y#R KQTahoma0J( #InfoFrameme. S,J   } R KQ$Tahoma $<ExitMenu o#)i04' n``y-G;y-G;f>1o&(G$tTextBox1$`TextBox2E$`TextBox3q$TextBox4E$ LTextBox5E$ LTextBox6O$ LTextBox7O( LTextBox183tw(2L Label1x7 (2$ Label2x7k S(Exit>  @TahomacT@H,4fThe following Hot-Keys will help you with this form:5Tahomac@@H, f-- To reactivate this help menu.5Tahomac@@H,f-- To spell-check the document.5Tahomac@HPlease contact Karen Koopmann at the Electronic Publishing Center (EPC) if you have questions or suggestions for improvements: 512-416-2362.5Tahomac(@H,fNote: c@Tahomac(@H,Ctrl-Sc@Tahomac(@H,Ctrl-F1@Tahoma1,@H, }EU: 6/2003t5xTahoma1(*Privacy Statement: @Tahoma1*The Texas Department of Transportation maintains the information collected through this form. With few exceptions, you are entitled on request to be informed about the information that we collect about you. Under Sections 552.021 and 552.023 of the Texas Government Code, you also are entitled to receive and review the information. Under Section 559.004 of the Government Code, you are also entitled to have us correct information about you that is incorrect. For inquiries call 512-463-8585. 5Tahoma1 n``Microsoft Forms 2.0 FrameEmCompObj_pCompObj%*aaVBFramec%CompObjhjbedded ObjectForms.Frame.19q Microsoft Forms 2.0 FormEmbedded Object9qVERSION 5.00 Begin {C62A69F0-16DC-11CE-9E98-00AA00574A4F} LongHelpForm Caption = "Welcome" ClientHeight = 5130 ClientLeft = 30 ClientTop = 270 ClientWidth = 5250 StartUpPosition = 1 'CenterOwner TypeInfoVer = 22 End   FMicrosoft Word Document MSWordDocWord.Document.89q