POSITIVE CONTROLLED SUBSTANCE TEST RESULT REPORT



Title of Form: POSITIVE CONTROLLED SUBSTANCE TEST RESULT REPORT

California Vehicle Code Sections 13376(b)(1)- 13376(b)(4) require employers who provide pupil transportation to report to the Department of Motor Vehicles (DMV), any driver or applicant who has tested positive for a controlled substance; when a rehabilitation or return to duty program is imposed; any subsequent positive controlled substance test results; and if a participant is dropped from a rehabilitation/return to duty program. The employer must report within five days of receiving notification of a positive test result.

Please use this form to report such drivers or applicants to the DMV. If an employee was dismissed for cause due to a positive controlled substance test, you must use this form. DO NOT use a Dismissal for Reason Involving Pupil Transportation Safety form (DL 128).

Mail completed forms to the:

Driver Safety Actions Unit

P.O. Box 187010-7010

Sacramento, CA 95818-7010

Attn: MS-J256 Special Certificate.

You will be notified of the action taken by the department.

Submit a copy of this form to your local CHP Office:

Atwater Office:

California Highway Patrol Office

Attn: School Bus Office/Coordinator

1500 Bell Drive

Atwater, CA 95301

Los Banos Office

California Highway Patrol Office

Attn: School Bus Office/Coordinator

706 W. Pacheco Blvd.

Los Banos, CA 93635

POSITIVE CONTROLLED SUBSTANCE TEST RESULT REPORT

California Vehicle Code Sections 13376(b)(1)- 13376(b)(4) require employers who provide pupil transportation to report to the Department of Motor Vehicles (DMV), any driver or applicant who has tested positive for a controlled substance; when a rehabilitation or return to duty program is imposed; any subsequent positive controlled substance test results; and if a participant is dropped from a rehabilitation/return to duty program. The employer must

report within five days of receiving notification of a positive test result.

Please use this form to report such drivers or applicants to the DMV. If an employee was dismissed for cause due to a positive controlled substance test,

you must use this form. DO NOT use a Dismissal for Reason Involving Pupil Transportation Safety form (DL 128).

Mail completed forms to the Driver Safety Actions Unit, P.O. Box 187010-7010, Sacramento, CA 95818-7010, Attn: MS-J256 Special Certificate. You will be notified of the action taken by the department.

Submit a copy of this form to your local California Highway Patrol Office, Attn: School Bus Office/Coordinator

Programs and testing must comply with the requirements specified in Section 382 of Title 49 of the Code of Federal Regulations.

PLEASE TYPE OR PRINT LEGIBLEY THEFOLLOWING INFORMATION:

|DRIVER’S FULL NAME (FIRST) (MIDDLE) (LAST) |BIRTHDATE |DRIVER LICENSE NUMBER |

|      |      |      |

|ADDRESS (STREET) (CITY) (STATE) ZIP CODE |TELEPHONE NUMBER |

|      |(     )       |

|CURRENT CERTIFICATE EXPIRATION DATE (RENEWAL) |CERTIFICATE APPLICATION DATE (ORIGINAL) |CERTIFICATE TYPE |

|      |      |      |

|AGENCYNAME/ADDRESSADMINISTERING TEST (STREET) (CITY) (STATE) (ZIP CODE) |

|      |

|REASON FOR TEST (PRE-EMPLOYMENT, POST ACCIDENT, REASONABLE SUSPICIAN, RANDOM, RETURN TO DUTY, FOLLOW UP) |TEST DATE |TEST RESULTS/TEST REFUSED |

|      |      |(     )       |

|EMPLOYER NAME/ADDRESS (PLEASED PRINT) (STREET) (CITY) (STATE) (ZIP CODE) |EMPLOYER’S TELEPHONE NUMBER |

|      |(     )       |

| |

|REHABILITATION/RETURN TO DUTY PROGRAM INFORMATION |

|(FOR EXISTING CERTIFICATE HOLDERS ONLY) |

|REHABILITATION/RETURNTO DUTY PROGRAM NAME/ADDRESS (STREET) (CITY) (STATE) (ZIP CODE) |

|      |

|PROGRAM LENGTH |DATE PROGRAM BEGINS |

|      |      |

|EMPLOYER IMPOSTING PROGRAM PARTICIPATION (PLEASE PRINT) |CURRENT DATE |EMPLOYER’S TELEPHONE NUMBER |

|      |      |(     )       |

| |

|POST PROGRAM DROPS |

|POSITIVE RESULTS SHOWN |DATE OF POSITIVE TEST RESULTS |

|      |      |

|REASON DRIVER WAS DROPPED |DATE DRIVER DROPPED |

|      |      |

|NAME/AGENCYOF INDIVIDUAL REPORTING DROP INFORMATION CURRENT DATE |TELEPHONE NUMBER |

|      |(     )       |

| |

|I am reporting this driver as required Section 13376(b)(1) of the California Vehicle Code. |

|PERSON REPORTING APPLICANT/DRIVER (PLEASE PRINT) |SIGNATURE |DATE |

| | |      |

DS 334 (NEW 5/98)

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