Phmsa Release Of Information Form - 49 Cfr Part 40 Drug And Alcohol Testing Appendix J
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1PHMSA Release of Information Form -- 49 CFR Part 40 Drug and Alcohol Testing Appendix J
Section I. To be completed by the new employer, signed by the employee, and transmitted to the previous employer:
Employee Printed or Typed Name: ________________________________________________________________
Employee SS or ID Number: _____________________________________________________________________
I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer, listed
in Section I-B, to the employer listed in Section I-A. This release is in accordance with DOT Regulation 49 CFR Part 40, Section 40.25. I understand that
information to be released in Section II-A 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: ____________________
I-A. New Employer :
Natural Gas Processing Company
Wyoming Gas Company
Zia Natural Gas Company
N G Transmission
Address: P. O. Box 541, Worland, Wyoming 82401
Phone #: 307-347-8221 Fax #: 307-347-3160
Designated Employer Representative: Gordon Neumann
I-B.
Previous Employer Name: _______________________________________________________________________
Address: _____________________________________________________________________________________
_____________________________________________________________________________________
Phone #: _______________________________________
Designated Employer Representative (if known): _____________________________________________________
Section II. To be completed by the previous employer and transmitted by mail or fax to the new employer:
II-A. In the two years prior to the date of the employee’s signature (in Section I), for DOT-regulated testing ~
YES ____ NO ____
1. Did the employee have alcohol tests with a result of 0.04 or higher?
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 rule
violation to you?
YES ____ NO ____
6. If you answered “yes” to any of the above items, did the
employee complete the return-to-duty process?
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), follow-up testing record).
II-B.
Name of person providing information in Section II-A: _______________________________________________
Title: ___________________________________________
Phone #: ________________________________________
Date: ___________________________________________
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