"Request for Information From Former Employer" - Oklahoma

Request for Information From Former Employer is a legal document that was released by the Oklahoma State Department of Education - a government authority operating within Oklahoma.

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Clear Form
49 CFR Part 40.25: REQUEST FOR INFORMATION FROM FORMER EMPLOYER
TO:
FROM:
______________________________
COMPANY NAME
COMPANY NAME
______________________________
NAME
Title
NAME
Title
______________________________
ADDRESS
ADDRESS
______________________________
CITY
ST/ZIP
CITY
ST/ZIP
______________________________
PHONE # FAX #
PHONE #
FAX #
(Mr., Mrs., Ms.)
SS#
has made an application to our
company for a safety-sensitive function as outlined in 49CFR Part 40 and 49 CFR Part 382.
Pursuant to 49CFR Part 40.25: PLEASE COMPLETE THE FOLLOWING:
1. What were the dates of this applicant’s employment? From
To:
2. Was he/she employed in a safety-sensitive function? (Circle one) Yes/No
If yes, what position?
3. Was this applicant subject to alcohol testing or controlled substance testing pursuant to Part 40?
(Circle one) Yes/No
4. Did this applicant test positive during the preceding two years for:
Yes/No
a. Alcohol concentration of .04 or greater? (Circle one)
b. Verified positive for controlled substances covered under Part 40? (Circle one) Yes/No
c. Has this applicant any time in the past two years refused a required alcohol or controlled substance test
Yes/No
required under Part 382? (Circle one)
If positive (or refusal) was this applicant referred to a substance abuse professional? (Circle one) Yes/No
5. Did this applicant see a substance abuse professional? (Circle one) Yes/No
If yes, did the substance abuse professional recommend treatment? (Circle one) Yes/No
If treatment was recommended, did applicant complete treatment? (Circle one) Yes/No
6. Did applicant undergo a return-to-duty test? (Circle one) Yes/No
If yes, did the return-to-duty test indicate a verified negative result? (Circle one) Yes/No
7. Did this employee have any other violations of DOT agency drug or alcohol testing regulations? If yes, please
give details:
___________________________________________________________________________________________
___________________________________________________________________________________________
Pursuant to 49 CFR Part 40.25 requires that previous employers must provide this information regarding any
violations of 49 CFR Part 40 and Part 382 and transmit the answers back to the company named above.
RELEASE AUTHORIZATION
With my signature below, I am authorizing you to release information in regards to any alcohol and controlled
substance testing program to which I was a party to while in your employ, acting as your agent, under contract with you,
or acting as your representative in any capacity during the preceding two years from the date listed below.
This request is specific and to be released only to the company whose name appears below. Authorization of this
release will expire once the requested information has been sent to the company named below. This authorization may
not be used to provide information to any other persons.
Name of Company _________________________________________
Date _____________________________________________________
Name of Applicant _________________________________________
Signature of Applicant ______________________________________
Witness Signature __________________________________________
Clear Form
49 CFR Part 40.25: REQUEST FOR INFORMATION FROM FORMER EMPLOYER
TO:
FROM:
______________________________
COMPANY NAME
COMPANY NAME
______________________________
NAME
Title
NAME
Title
______________________________
ADDRESS
ADDRESS
______________________________
CITY
ST/ZIP
CITY
ST/ZIP
______________________________
PHONE # FAX #
PHONE #
FAX #
(Mr., Mrs., Ms.)
SS#
has made an application to our
company for a safety-sensitive function as outlined in 49CFR Part 40 and 49 CFR Part 382.
Pursuant to 49CFR Part 40.25: PLEASE COMPLETE THE FOLLOWING:
1. What were the dates of this applicant’s employment? From
To:
2. Was he/she employed in a safety-sensitive function? (Circle one) Yes/No
If yes, what position?
3. Was this applicant subject to alcohol testing or controlled substance testing pursuant to Part 40?
(Circle one) Yes/No
4. Did this applicant test positive during the preceding two years for:
Yes/No
a. Alcohol concentration of .04 or greater? (Circle one)
b. Verified positive for controlled substances covered under Part 40? (Circle one) Yes/No
c. Has this applicant any time in the past two years refused a required alcohol or controlled substance test
Yes/No
required under Part 382? (Circle one)
If positive (or refusal) was this applicant referred to a substance abuse professional? (Circle one) Yes/No
5. Did this applicant see a substance abuse professional? (Circle one) Yes/No
If yes, did the substance abuse professional recommend treatment? (Circle one) Yes/No
If treatment was recommended, did applicant complete treatment? (Circle one) Yes/No
6. Did applicant undergo a return-to-duty test? (Circle one) Yes/No
If yes, did the return-to-duty test indicate a verified negative result? (Circle one) Yes/No
7. Did this employee have any other violations of DOT agency drug or alcohol testing regulations? If yes, please
give details:
___________________________________________________________________________________________
___________________________________________________________________________________________
Pursuant to 49 CFR Part 40.25 requires that previous employers must provide this information regarding any
violations of 49 CFR Part 40 and Part 382 and transmit the answers back to the company named above.
RELEASE AUTHORIZATION
With my signature below, I am authorizing you to release information in regards to any alcohol and controlled
substance testing program to which I was a party to while in your employ, acting as your agent, under contract with you,
or acting as your representative in any capacity during the preceding two years from the date listed below.
This request is specific and to be released only to the company whose name appears below. Authorization of this
release will expire once the requested information has been sent to the company named below. This authorization may
not be used to provide information to any other persons.
Name of Company _________________________________________
Date _____________________________________________________
Name of Applicant _________________________________________
Signature of Applicant ______________________________________
Witness Signature __________________________________________