— DRIVER ACKNOWLEDGMENT —
DRUG AND ALCOHOL TESTING POLICY AND MATERIALS
I have received a copy of the Drug and Alcohol Testing Policy of Independent School District No. ____, _______________, Minnesota and have read it in its entirety. I understand that I am subject to the provisions of Article III of the policy, entitled Drug and Alcohol Testing for Bus Drivers, because the position involves operating a commercial motor vehicle and requires a commercial driver’s license.
The District’s policy was provided to me:
G Upon adoption of the policy. (employee).
G Upon my hire. (job applicant/new employee).
G After receipt of my conditional job offer, before any testing if my job offer is contingent upon my passing of drug and alcohol testing. (job applicant).
I also received materials concerning the effects of alcohol and controlled substances use on an individual’s health, work, and personal life; signs and symptoms of an alcohol or drug problem; and available methods of intervening when an alcohol or drug problem is suspected.
I have been advised that the Alcohol and Controlled Substances Testing Program Manager is _____________________________ and that any questions I may have concerning the Policy should be directed to the Program Manager.
Signature of Employee/Applicant
Typed or Printed Name
— BUS DRIVER OR DRIVER APPLICANT —
AUTHORIZATION TO RELEASE INFORMATION
Section I. To be completed by the school district, signed by the bus driver, or driver applicant, 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: ____________________
School District Name: __________________________________________________________________________
Phone #: _______________________________________ Fax #: _______________________________________
Designated Employer Representative: ______________________________________________________________
Previous Employer Name: _______________________________________________________________________
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:
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 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).
Name of person providing information in Section II-A: _______________________________________________
Phone #: ________________________________________
— BUS DRIVER OR DRIVER APPLICANT —
REFUSAL TO SUBMIT TO TESTING
I hereby refuse to submit to drug/alcohol testing by doing the following:
G Failing to appear for any test within a reasonable time, as determined by the school district, consistent with applicable DOT regulations, after being directed to do so;
G Failing to remain at the testing site until the testing process is complete;
G Failing to provide a urine specimen or an adequate amount of saliva or breath for any DOT drug or alcohol test;
G Failing to permit the observation or monitoring of any provision of a specimen in the case of a directly observed or monitored collection in a drug test;
G Failing to provide a sufficient breath specimen or sufficient amount of urine when directed and it has been determined that there was no adequate medical explanation for the failure;
G Failing or declining to take a second test as directed;
G Failing to undergo a medical examination or evaluation, as directed by the Medical Review Officer (MRO) or the Designated Employer Representative (DER);
G Failing to cooperate with any part of the testing process (e.g., refusing to empty pockets when so directed by the collector, behaving in a confrontational way that disrupts the collection process, failing to sign the certification on the form; or
G Having a verified adulterated or substituted test as reported by the MRO.
[An applicant who fails to appear for a preemployment test, who leaves the testing site before the preemployment testing process commences, or who does not provide a urine specimen because he or she left before it commences, is not deemed to have refused to submit to testing.]
I recognize that my refusal subjects me to the consequences specified in federal law and regulations. It also constitutes a presumption of a positive result. I further recognize that if I am an applicant, I will be disqualified from consideration for the conditionally-offered position. If I am an employee, I will not be permitted to perform safety-sensitive functions, and will be considered insubordinate and subject to disciplinary action, up to and including dismissal. If the school district offers me an opportunity to return to a DOT safety-sensitive function, I understand I will be evaluated by a substance abuse professional, and will be required to submit to a return-to-duty test prior to being considered for reassignment to safety-sensitive functions.
Signature of Employee/Applicant
G Employee refusal to sign Supervisor’s Initials:
— PRETEST NOTICE —
I the undersigned employee/job applicant of Independent School District No. ____, _______________, Minnesota (“School District”) do hereby acknowledge that I have been provided a copy of the School District’s Drug and Alcohol Testing Policy.
Signature of Employee/Job Applicant
Typed or Printed Name
RE: Drug and/or Alcohol Test
[Date of Testing]
NOTICE OF TEST RESULTS AND VARIOUS RIGHTS
Independent School District No. ___, ____________________, Minnesota has received the test result report from the testing laboratory:
G Your initial screening test result was negative.
G Your confirmatory test result was negative.
G Your confirmatory test result was positive.
Test Result Report:
You have the right to request and receive from the school district a copy of the test result on any drug or alcohol test.
Right to Explain Positive Test Result:
In the case of a positive test result on a confirmatory test, you have the right to explain the results. You may, within three (3) working days after notice of a positive test result on a confirmatory test, submit information to the school district, in addition to any information already submitted, to explain that result. Attached to this Notice is a document entitled “Explanation of Positive Test Result” for this purpose.
Right to Request Confirmatory Retests:
In the case of a positive test result on a confirmatory test, you have the right to request a confirmatory retest of the original sample at your own expense.
Within five (5) working days after notice of the confirmatory test result, you must notify the school district in writing of your intention to obtain a confirmatory retest.
Within three (3) working days after receipt of the notice, the school district shall notify the original testing laboratory that you have requested the laboratory to conduct the confirmatory retest or to transfer the sample to another laboratory licensed under Minn. Stat. § 181.953, Subd. 1 to conduct the confirmatory retest. The original testing laboratory shall ensure that appropriate chain-of-custody procedures are followed during transfer of the sample to the other laboratory. The confirmatory retest must use the same drug or alcohol threshold detection levels as used in the original confirmatory test. If the confirmatory retest does not confirm the original positive test result, no adverse personnel action based on the original confirmatory test may be taken against you.
In the case of a positive test result on a confirmatory test, you may have other rights provided under the sections detailed below.
A. Employee Discharge and Discipline
1. The school district may not discharge, discipline, discriminate against, request or require rehabilitation of an employee whose position does not require a commercial driver’s license on the basis of a positive test result from an initial screening test that has not been verified by a confirmatory test.
In the case of a positive test result on a confirmatory test, the employee shall be subject to discipline which includes, but is not limited to, immediate suspension without pay and immediate discharge, pursuant to the provisions of this policy.
2. The school district may not discharge an employee whose position does not require a commercial driver’s license for whom a positive test result on a confirmatory test was the first such result for the employee on a drug or alcohol test requested by the school district, unless the following conditions have been met:
a. The school district has first given the employee an opportunity to participate in, at the employee’s own expense or pursuant to coverage under an employee benefit plan, either a drug or alcohol counseling or rehabilitation program, whichever is more appropriate, as determined by the school district after consultation with a certified chemical use counselor or a physician trained in the diagnosis and treatment of chemical dependency; and
b. The employee has either refused to participate in the counseling or rehabilitation program or has failed to successfully complete the program, as evidenced by withdrawal from the program before its completion or by a positive test result on a confirmatory test after completion of the program.
3. Notwithstanding Paragraph 1., the school district may temporarily suspend the tested employee or transfer that employee to another position at the same rate of pay pending the outcome of the confirmatory test and, if requested, the confirmatory retest, provided the school district believes that it is reasonably necessary to protect the health or safety of the employee, co-employees or the public. An employee who has been suspended without pay must be reinstated with back pay if the outcome of the confirmatory test or requested confirmatory retest is negative.
4. The school district may not discharge, discipline, discriminate against, request, or require rehabilitation of an employee on the basis of medical history information revealed to the school district, unless the employee was under an affirmative duty to provide the information before, upon, or after hire.
5. An employee must be given access to information in the employee’s personnel file relating to positive test result reports and other information acquired in the drug and alcohol testing process and conclusions drawn from and actions taken based on the reports or other acquired information.
B. Withdrawal of Applicant’s Job Offer
If a job applicant for a position that does not require a commercial driver’s license has received a job offer made contingent on the applicant passing drug and alcohol testing, the school district may not withdraw the offer based on a positive test result from an initial screening test that has not been verified by a confirmatory test. In the case of a positive test result on a confirmatory test, the school district may withdraw the job offer.
EXPLANATION OF POSITIVE TEST RESULT
I the undersigned employee/job applicant of Independent School District No. _____, _________________, Minnesota acknowledge receipt of a Notice of Test Results and Various Rights. This includes my right to explain the positive test result on a confirmatory test.
I am currently taking or have recently taken:
G no over-the-counter or prescription medications; or
G the following over-the-counter or prescription medications:
I also offer the following information relevant to the reliability of, or explanation for, a positive test result: