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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