You Must Fill out This Form for Every Prospective Bus Driver During the Application Process

Drug and Alcohol Testing Program

TITLE OF FORM: PREVIOUS PRE-EMPLOYMENT EMPLOYEE ALCOHOL AND DRUG TEST STATEMENT

You must fill out this form for every prospective bus driver during the application process. If they answer Yes to question #1, DO NOT HIRE THE EMPLOYEE.

For your convenience, this form is set up for you to fill out the District information on the computer. (You may also print the form and fill in the blanks by hand or on a typewriter.) You should then print the completed form and have the prospective employee sign it.

You should witness the signature and keep this form with all your pre-employment documentation.

If you’re filling this form out on the computer, merely tab to move from blank to blank. When you’re finished, print the form and obtain the signatures. When prompted to save the document, you may choose no – the form remains a blank for the next time you use it. If you would like to save it, you should save it as a different file name. If you have any questions, please contact Terri Prichard at 209-389-4054 or

PREVIOUS PRE-EMPLOYMENT

EMPLOYEE ALCOHOL AND DRUG TEST STATEMENT

Section 40.25(j). As the employer, you must also ask the employee whether he or she has tested positive, or refused to test on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years. If the employee admits that he or she had a positive test or a refusal to test, you mush not use the employee to perform safety-sensitive functions for you until and unless the employee documents successful completion of the return-to-duty process. (Section 40.25(b)(5) and (e))

School District Name:

Address:

City:

State, Zip:

Prospective Employee Name: ID Number:

The prospective employee is required by Section 40.25(j) to respond to the following questions:

1.  Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?

Check one: Yes No

2.  If you answered yes, can you provide/obtain proof that you’ve successfully completed the DOT return-to-duty requirements?

Check one: Yes No

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Prospective Employee Signature Date

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Witnessed By (Signature) Date