"Post Accident Testing Decision Report" - Georgia (United States)

Post Accident Testing Decision Report is a legal document that was released by the Georgia Department of Transportation - a government authority operating within Georgia (United States).

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POST ACCIDENT TESTING DECISION REPORT
**A separate sheet must be filled out for each covered employee that contributed to the accident**
System Name:
Date of Accident:
Time of Accident:
Time Employer was notified:
Location of Accident:
Safety-Sensitive Employee:
ID # and Position:
i.e. Driver, Dispatcher, etc
1. Did the accident involve a revenue service vehicle?
Yes
No
2. Did the accident involve the operation of the vehicle?
Yes
No
3. Was there loss of life as a result of the accident?
Yes
No
4. Did an individual suffer a bodily injury and immediately
Yes
No
receive medical treatment away from the scene?
5. Was there disabling damage to any of the involved vehicles?
Yes
No
6. a) Did you perform a drug and/or alcohol test?
Yes
Yes
No
FTA Authority
Company Authority
(Use Decision Tree on back of this form)
b) If no, why not?
7. a) Was an alcohol test performed within 2 hours?
N/A
Yes
No
b) If no, why:
8. If no alcohol test occurred, and more than 8 hours elapsed from the time of the accident, please explain:
9. a) Was a drug test performed within 32 hours?
N/A
Yes
No
b) If no, why:
10. a) Did the employee leave the scene of the accident without a reasonable explanation?
Yes
No
b) If Yes, please explain:
Test Determination:
Name of supervisor making determination:
Time employee was informed of determination:
Signature & Title
Date
For your files: attach test results summary, order to test, Custody and Control Form (USDOT) and alcohol testing form (USDOT)
POST ACCIDENT TESTING DECISION REPORT
**A separate sheet must be filled out for each covered employee that contributed to the accident**
System Name:
Date of Accident:
Time of Accident:
Time Employer was notified:
Location of Accident:
Safety-Sensitive Employee:
ID # and Position:
i.e. Driver, Dispatcher, etc
1. Did the accident involve a revenue service vehicle?
Yes
No
2. Did the accident involve the operation of the vehicle?
Yes
No
3. Was there loss of life as a result of the accident?
Yes
No
4. Did an individual suffer a bodily injury and immediately
Yes
No
receive medical treatment away from the scene?
5. Was there disabling damage to any of the involved vehicles?
Yes
No
6. a) Did you perform a drug and/or alcohol test?
Yes
Yes
No
FTA Authority
Company Authority
(Use Decision Tree on back of this form)
b) If no, why not?
7. a) Was an alcohol test performed within 2 hours?
N/A
Yes
No
b) If no, why:
8. If no alcohol test occurred, and more than 8 hours elapsed from the time of the accident, please explain:
9. a) Was a drug test performed within 32 hours?
N/A
Yes
No
b) If no, why:
10. a) Did the employee leave the scene of the accident without a reasonable explanation?
Yes
No
b) If Yes, please explain:
Test Determination:
Name of supervisor making determination:
Time employee was informed of determination:
Signature & Title
Date
For your files: attach test results summary, order to test, Custody and Control Form (USDOT) and alcohol testing form (USDOT)