TEXAS DEPARTMENT OF TRANSPORTATION



[pic] |DRUG AND ALCOHOL MANAGEMENT PROGRAM MONITORING FORM |Form PTN-102

(Rev. 6/2003)

(GSD-EPC)

Page 1 of 10 | |

|Name of Transit Agency: |

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|Address: |

|      |

|City, State, Zip: |

|      |

|Phone: |

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|Contact Person: |

|      |

|Name of Senior Agency (COG, CAA, RPC, or County, if applicable): |

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|Monitored By: |

|      |

|Date Monitored: |

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|TxDOT District: |

|      |

|In Compliance |Not In Compliance |

|Corrective Action Plan Due Date: |

|      |

|Describe Areas of Non-Compliance: |

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|POLICY STATEMENT ELEMENTS (§655.15) |YES |NO |

| 1. Has the policy statement been approved by the governing board or senior official of the transit agency? | | |

| 2. Are the approval date and any updates clearly identified? | | |

| 3. Has the policy statement been made available to every safety sensitive employee? | | |

| 4. Are there records of an employee signed Acknowledgment form or other documents to show the employee has received a copy or is aware| | |

|of the policy availability? | | |

| 5. Does the policy statement include the name and telephone number of the contact person to whom employees may ask questions about the| | |

|company drug and alcohol testing program? | | |

| 6. Does the policy statement identify the specific categories of Safety Sensitive Employees who are subject to drug and alcohol | | |

|testing? (655.4) | | |

|Does it include operating a revenue service vehicle? | | |

|Does it include maintaining a revenue service vehicle? | | |

|Does it include dispatching or controlling movement of a vehicle? | | |

|Does it include operating a non-revenue vehicle that requires a CDL? | | |

|Does it include carrying a firearm for security purposes? (May not apply) | | |

|Does it include Volunteer Employees? (May not apply) | | |

| 7. Does the policy statement include an analysis of safety sensitive job functions to determine which employees were designated to be | | |

|safety sensitive? | | |

| 8. Does the policy state that participation in the drug and alcohol testing program is a condition of employment for all safety | | |

|sensitive employees? (655.49) | | |

| 9. Does the policy state that an alcohol test may be conducted just before, during and just after performing a safety sensitive | | |

|function? (655.45) | | |

|10. Does the policy state that the use of illegal drugs is prohibited at all times and employees may be tested for drugs anytime while | | |

|on duty? (655.45) | | |

|11. Does the policy state that consumption of alcohol is prohibited when performing a safety sensitive function? (655.32) | | |

|12. Does the policy state that employees are prohibited from consuming alcohol 4 hours prior to performing safety sensitive functions? | | |

|(655.33) | | |

|13. Does the policy state that employees must not consume alcohol for 8 hours following an accident or until a post accident test is | | |

|conducted? (655.34) | | |

|14. Does the policy state that employees are prohibited from consuming alcohol while on call? (655.33) | | |

|15. Does the policy state that on-call employees will be given the opportunity to acknowledge the use of alcohol and the inability to | | |

|perform safety sensitive functions? (655.33) | | |

|16. Does the policy state that employees will be removed from safety sensitive duties if their breath alcohol test is 0.04 or above? | | |

|17. Does the policy state which prohibited substances the employees will be tested for? | | |

|POLICY STATEMENT ELEMENTS (§655.15) (cont.) |YES |NO |

|18. Does the policy statement identify specific circumstances for Pre-Employment Testing? | | |

|A negative drug test required prior to performing safety sensitive duties? (655.41) | | |

|Evidence of a successful rehab program for an employee/applicant who previously failed a DOT drug test? (655.41) | | |

|A negative drug test for a transferring employee? (655.41) | | |

|A pre-employment test for an employee who has been removed from safety sensitive duties and removed from the random testing pool for more| | |

|than 90 days? (655.41) | | |

|Circumstances for pre-employment alcohol testing if conducted? (655.42) | | |

|Note: Pre-Employment alcohol testing is optional. | | |

|19. Does the policy statement identify specific circumstances for Random Testing? (655.45) | | |

|Random selections are made using a scientifically valid method? | | |

|Testing will be spread reasonably throughout all periods of the calendar year? | | |

|Testing is conducted on all hours and days when safety sensitive duties are performed? | | |

|Testing is unannounced and immediate? | | |

|Allows no discretion by management personnel as to who is selected or notified? | | |

| | | |

|20. Does the policy statement identify specific circumstances for Post Accident Testing? | | |

|FTA post accident testing thresholds for fatalities? (655.4) | | |

|FTA post accident testing thresholds for bodily injury? (655.4) | | |

|FTA post accident testing thresholds for vehicle disabling damage? (655.4) | | |

|Testing safety sensitive employees whose performance could have contributed to the accident? (655.44) | | |

|Not testing employees whose performance can be completely discounted as a contributing factor? (655.44) | | |

|Conduct drug testing within 32 hours? (655.44) | | |

|Conduct alcohol testing within the 2-hour and 8-hour rules? (655.44) | | |

|Require an employee to remain readily available? (655.44) | | |

| | | |

| | | |

|21. Does the policy state employees involved in an accident are prohibited from consuming alcohol for at least 8 hours following an | | |

|accident, or until post-accident testing has taken place, which ever comes first? (655.34) | | |

|22. Does the policy statement identify specific circumstances for Reasonable Suspicion Testing? (655.43) | | |

|Determinations are made based on specific, contemporaneous, articulable observations concerning the appearance, behavior, speech and body| | |

|odor? | | |

|Determinations are made by one or more trained supervisors or company official? | | |

|23. Does the policy statement identify specific circumstances for Return To Duty and Follow Up Testing? | | |

|Is it clearly stated if the transit agency has a Zero Tolerance or Second Chance Policy? | | |

|Is it clearly stated that if there is a Second Chance Policy that all return to duty and follow up testing will be conducted as specified| | |

|in 49 CFR Part 40? (655.46) | | |

|POLICY STATEMENT ELEMENTS (§655.15) (cont.) |YES |NO |

|24. Does the policy state that all drug and alcohol testing will be conducted in accordance with 49 CFR Part 40? (655.15e and 655.51) | | |

|25. Does the policy state that Part 40 will be made available to employees upon request? (655 Subpart B Section A) | | |

|26. Does the policy statement identify specific circumstances for Dilute Negative test results? | | |

|Policy states whether or not the employee will be required to immediately take another unobserved drug test? (40.197) | | |

|Specifies if different types of tests follow different policies? (40.197) | | |

| | | |

|27. Does the policy state behavior that constitutes a Test Refusal? (655.15) | | |

|Failure to appear at the collection site in a reasonable time. (Does not apply to pre-employment) (40.191/.261) | | |

|Refusal to provide a specimen. (Verbal or physical absence) (40.191/.261) | | |

|Failure to provide a sufficient specimen with no medical explanation. (40.191/.261) | | |

|Failure to remain at the testing site until the testing process is completed. (Does not apply to pre-employment) (40.191/.261) | | |

|Failure to have a medical evaluation if required by an MRO. (40.191/.261) | | |

|Failure to cooperate with any part of the testing process. (40.191/.261) | | |

|Failure to allow monitoring or direct observation for drug testing. (40.191) | | |

|Failure to take a second test if directed to do so. (40.191) | | |

|MRO verification of a test as adulterated or substituted. (40.191) | | |

|Failure to sign Step 2 of the Alcohol Testing Form. (40.261) | | |

|Failure to remain available for testing following an accident. (655.44) | | |

|Policy states that refusing a non-DOT is not a refusal to take a DOT test. | | |

| | | |

| | | |

|28. Does the policy statement specify the consequences for positive drug test results or positive alcohol test results, or refusing to | | |

|submit to a test? (655.61) | | |

|The employee will be immediately removed from safety sensitive duties. (655.61) | | |

|The employee will be referred to a Substance Abuse Professional. (655.62) | | |

|29. Does the policy state the consequences for a safety sensitive employee who has an alcohol concentration of 0.02 or above, but less | | |

|than 0.04? (655.35) | | |

|Temporary removal from safety sensitive duties until the next shift, but not less than 8 hours, or | | |

|Temporary removal from safety sensitive duties until verified alcohol concentration is less than 0.02. | | |

|Other company policies separate from DOT regulations. | | |

| | | |

|30. Does the policy state when employees are subject to drug or alcohol testing such as days of the week, hours, holidays, etc? | | |

|31. Does the policy statement describe the employee’s right to access his or her own drug and alcohol records? | | |

|32. Is the non-DOT, transit agency internal policy requirements not required by DOT, (i.e., Second Chance Policy, or non-DOT post | | |

|accident testing), clearly stated in the policy statement? | | |

|DRUG FREE WORKPLACE ACT |YES |NO |

|Note: The DFW Act applies to all employees in the transit agency. The FTA regulations apply only to the safety sensitive employees. The| | |

|regulations are separate, but similar in several ways. | | |

| 1. Is there a written policy notifying all employees of the prohibited behavior as specified in the Drug Free Workplace Act? | | |

| 2. Does the policy specify unlawful manufacture, distribution; dispensing, possession and use of controlled substances are prohibited | | |

|in the workplace? | | |

| 3. Is there a drug free awareness program to inform employees about the dangers of drug abuse in the workplace? Examples are posters,| | |

|brochures and training classes. | | |

| 4. Is there a drug free awareness program to inform employees about the company policy of maintaining a drug free workplace? | | |

| 5. Is there a drug free awareness program to inform employees about available drug counseling, rehabilitation programs and employee | | |

|assistance programs? | | |

| 6. Does the policy specify the actions to be taken against the employee for violations of the Drug Free Workplace policy? | | |

| 7. Is each employee given a copy of the policy statement? | | |

| 8. Does the policy state that compliance with the Drug Free Workplace is a condition of employment? | | |

| 9. Does the policy state that the employee must notify the employer within 5 days of any drug related convictions for violations in | | |

|the workplace? | | |

|10. Does the policy state the employer must notify TxDOT within 10 days of any drug related convictions for violations in the workplace?| | |

|11. Does the policy state the type of personnel actions that will be taken against employees who violate the Drug Free Workplace Act? | | |

|This must include either employee termination or referral to a substance abuse rehabilitation program. | | |

|12. Does the employer make a good faith effort to maintain a drug free workplace through implementation of the above requirements? | | |

|EDUCATION AND TRAINING PROGRAMS (§655.14) |YES |NO |

|1. Are drug and alcohol program information materials and employee assistance program (EAP) information displayed in the workplace? | | |

|2. Are drug and alcohol program information materials and employee assistance program (EAP) information distributed to every covered | | |

|employee? | | |

|3. Do all covered employees receive at least 60 minutes of training on the effects and consequences of drug use? | | |

|4. Does training include effects on personal health, safety, and the work environment and on the signs and symptoms that indicate | | |

|prohibited drug use? | | |

|5. Do all supervisors receive at least 60 minutes of training on the physical, behavioral, speech and performance indicators of probable| | |

|drug use? | | |

|6. Do all supervisors receive at least 60 minutes of training on the physical, behavioral, speech and performance indicators of alcohol | | |

|misuse? | | |

|7. Are there written records to verify employee training conducted? (655.71) | | |

|PRE-EMPLOYMENT DRUG TESTING (§655.41) |YES |NO |

| 1. Are new employees tested and verified negative for drug use prior to being allowed to perform safety sensitive functions? | | |

| 2. Is there a spread sheet or similar document used to provide written verification that negative test results are obtained before the| | |

|employee begins safety sensitive duties? | | |

| 3. Is the employee notified that Pre-Employment testing is required by Part 655? (655.17) | | |

| 4. Are previous non safety sensitive employees transferring into a safety sensitive position, tested and verified negative for drugs | | |

|prior to being allowed to perform safety sensitive functions? | | |

| 5. Are employees who have not been in a safety sensitive function for 90 days, and have not been in the random selection pool, | | |

|administered a Pre-Employment test with a verified negative result before being allowed to perform safety sensitive functions? | | |

| 6. If a transfer employee was working in a safety sensitive position within the past 2 years, was drug and alcohol information | | |

|requested from the previous employer? (40.25) | | |

| 7. Does the new employee provide written permission to contact the previous employer about drug and alcohol information? (40.25) | | |

| 8. Does the request to the previous employer include requests for information on: alcohol tests greater than 0.04, positive drug test | | |

|results, test refusals, other violations of DOT drug and alcohol testing regulations, documentation of any return to duty process? | | |

|(40.25b) | | |

| 9. Is there documentation showing good faith effort in attempting to obtain drug and alcohol information from any previous employers? | | |

|(40.25) | | |

|10. If for some reason a Pre-Employment test is canceled, is the employee required to take another Pre-Employment test before beginning | | |

|safety sensitive duties? | | |

|11. If Pre-Employment alcohol testing is conducted, is testing conducted prior to allowing the employee to perform safety sensitive | | |

|functions, and is testing conducted using procedures set forth in Part 40? Note: Pre-Employment Alcohol Testing is not required. | | |

|(655.42) | | |

|REASONABLE SUSPICION TESTING (§655.43) |YES |NO |

|1. Are employees tested for drug and/or alcohol when the employer believes the employee has used drugs and/or alcohol? | | |

|2. Does a trained supervisor or company official make the required observations? A supervisor or company official must be trained in | | |

|detecting signs and symptoms of drug and alcohol misuse. (655.14b) | | |

|3. Is there a supervisor checklist that states that reasonable suspicion testing must be based on specific, contemporaneous (current), | | |

|articulable (describable) observations that check for appearance, behavior, speech or body odors? | | |

|4. Is alcohol testing permitted only if the observations are conducted just proceeding, during or just after the workday of the safety | | |

|sensitive employee? | | |

|5. Is the alcohol testing conducted within 2 hours of being observed and determined to be using alcohol? | | |

|6. Are attempts to conduct the alcohol testing ceased after the 8-hour time limit has expired? | | |

|REASONABLE SUSPICION TESTING (§655.43) (cont.) |YES |NO |

|7. Are there written records explaining the delays and actions taken if the testing can not be conducted after the 2-hour and 8-hour | | |

|time limits? Note: Alcohol testing may be conducted between 2 hours and 8 hours if the delay can be justified in writing. | | |

|8. Are Reasonable Suspicion referral documents maintained on file? (655.71) | | |

|POST-ACCIDENT TESTING (§655.44) |YES |NO |

|1. Is drug and alcohol testing conducted as soon as practicable following a Fatal accident? Note: Testing is mandatory. | | |

|2. Are DOT forms used for the non-fatal accidents that meet the FTA testing criteria, and non-DOT forms used for post accident testing | | |

|that is required by the transit agency? (40.47a) (40.227a) (40.13f) | | |

|3. If post-accident testing is conducted under non-DOT criteria, (transit agency policy) is the employee informed that it is a non-DOT | | |

|test? | | |

|4. If the incorrect CCF or ATF is used, does the transit agency know how to make the necessary corrections? (40.205b) (40.271b) | | |

|5. If the transit agency determines drug and alcohol testing is not required, are written details filed to include how such a decision | | |

|was made, and is there a designated person to make such a decision? (655.44d) (655.71c) (40.3) | | |

|6. Are other employees who may have contributed to a fatal or non-fatal accident tested for drugs and alcohol? (655.44a) | | |

|7. Does the transit agency comply with the 32 hour rule for drug testing and the 2 and 8-hour rules for alcohol testing? | | |

|RANDOM TESTING (§655.45) |YES |NO |

|1. Are random test selections or draws conducted at least once a quarter? (655.45e) (Preamble to 655) | | |

|2. Is the employee roster updated prior to the draw or selection being conducted? | | |

|3. Does the transit agency (or C/TPA) use a computer based random number generator or similar scientific method to select employees who | | |

|must test? (655.45e) | | |

|4. Are non-DOT employees placed in a separate random testing pool from the pool of safety sensitive employees? (655.45) (40.347) | | |

|5. Are random drug and alcohol test dates unannounced, unpredictable, and spread reasonably throughout the year? (655.45g) | | |

|6. Is random drug testing conducted at all times of the day when safety sensitive functions are being performed to include nights, | | |

|weekends, and holidays? (655.45g) | | |

|7. Is there an Order for Testing form, and/or a spreadsheet or similar documentation used to track critical dates and times in the | | |

|random testing process? Documentation must clearly demonstrate the employee arrived at the collection site in a timely manner. (655.45h)| | |

|(40.191) (40.61a) | | |

|8. Are complete random testing documents available that clearly show all steps in the process from employee selection to verified test | | |

|results? (655.71c) | | |

|9. Do employees selected and notified for random testing immediately cease safety sensitive duties and proceed immediately to the test | | |

|site? (655.45h) | | |

|RANDOM TESTING (§655.45) (cont.) |YES |NO |

|10. Are excused employees who were legitimately not available for random testing, then tested when they return to work? (655.45e) | | |

|11. Are records kept explaining why a selected employee may not have been available for a random test? (655.45e) (655.71) | | |

|RETURN TO DUTY AND FOLLOW-UP (§655.62) |YES |NO |

|1. Does the transit agency clearly state to employees that they have a Zero Tolerance Policy or a Second Chance Policy? | | |

|2. Does the transit agency maintain a list of qualified SAPs? (655.62a) (40.287) | | |

|3. Are employees required to complete a course of education and /or treatment recommended by the SAP before they can be returned to a | | |

|safety sensitive position? (40.289) | | |

|4. Are employees required to complete a return to duty test with verified negative results before they can resume safety sensitive | | |

|functions? (40.305) | | |

|5. Does the SAP provide a follow-up treatment plan? (40.307) (40.311) | | |

|6. Does the transit agency follow the SAP recommendations and decide the actual dates of all testing? (40.309) | | |

|7. Is a minimum of 6 follow-up tests conducted in the first 12 months the employee is returned to safety sensitive duties? (40.307) | | |

|8. Does the employer make a decision to return the employee to work following a successful treatment program and negative test? Note: | | |

|The employer is not required to return the employee to safety sensitive duties. (40.305) | | |

|TEST RESULTS |YES |NO |

|1. Does the transit agency receive immediate alcohol test results from the BAT by either secure phone or fax? (40.255) | | |

|2. Does the transit agency receive drug test results from the MRO in a reasonable amount of time (usually 2-4 business days)? (40.167) | | |

|3. Does the MRO office provide verbal test results followed by documentation? (40.163) | | |

|4. Is there a password or verification method to ensure that verbal transmission of positive test results between the MRO and the | | |

|DER/DAPM is secure? (40.167) | | |

|5. Does the transit agency use a spreadsheet or similar method to track the test results from the MRO or TPA? (40.17) | | |

|6. Are employees who have tested positive for drugs and/or alcohol referred to a Substance Abuse Professional (SAP) regardless if the | | |

|employee is terminated or retained? (655.62a) (40.287) | | |

|ADMINISTRATIVE REQUIREMENTS (§655.71) |YES |NO |

|1. Does the transit agency have a secured location with controlled access for all drug and alcohol records? (655.71a) | | |

|2. Does the agency have a controlled means, such as a designated fax machine, or password protected e-mail, to receive test results? | | |

|3. Is documentation available to verify the professional credentials of all service agents to include the MRO, SAP, the lab and all | | |

|collectors? Note: the C/TPA may keep this on file but the certificates must be readily available upon request. (40.15) | | |

|ADMINISTRATIVE REQUIREMENTS (§655.71) (cont.) |YES |NO |

| 4. Are the DOT CCF and ATF only used for DOT mandated drug and alcohol tests? (40.13) | | |

| 5. Are non-DOT CCF and non-DOT ATF used for the non-DOT drug and alcohol testing? (40.13) | | |

| 6. Are DOT records and non-DOT records filed separately from one another? (40.13a) | | |

| 7. Does the Notification to Test Form or similar document clearly state that the drug and/or alcohol test to be administered is DOT or| | |

|non-DOT so that this information is apparent to both the employee and the collection site? (655.17) | | |

| 8. Has the transit agency made arrangements for collections that must be conducted after normal duty hours and on weekends? (655.45) | | |

| 9. Are covered employees granted access to review their own records pertaining to drug and alcohol misuse? (Employees must request | | |

|access in writing) (655.73) | | |

|10. Are subsequent employers given information on the employee’s drug and alcohol records only if the employee has signed a consent | | |

|form? (655.73) | | |

|5 Year Records | | |

|11. Are employee records of positive drug test results kept on file for 5 years? (40.333) | | |

|12. Are employee records of positive alcohol tests (0.02 or greater) kept on file for 5 years? | | |

|13. Are employee records of test refusals (drug and/or alcohol) kept on file for 5 years? | | |

|14. Are records of employee disputes kept on file for 5 years? | | |

|15. Are calibrations tests for the Evidential Breath Test device (EBT) kept on file for 5 years? | | |

|16. Are all Substance Abuse Professional (SAP) reports, referrals, follow-up test results and follow-up schedules kept on file for 5 | | |

|years? (40.333) (40.311) | | |

|17. Are annual copies of the required DAMIS reports kept on file for 5 years? | | |

|3 Year Records | | |

|18. Are records from previous employers kept on file for 3 years? (40.333) | | |

|2 Year Records | | |

|19. Are employee records of the collection process, to include collection logbooks (if used), kept on file for 2 years? | | |

|20. Are records of all training programs kept on file for 2 years? | | |

|21. Are documents related to post-accident drug and alcohol testing kept on file for 2 years? | | |

|1 Year Records | | |

|22. Are records of negative or canceled drug and/or alcohol test results kept on file for 1 year? | | |

|References | | |

|23. Is there a copy of 49 CFR Part 40? (Aug-01) | | |

|24. Is there a copy of 49 CFR Part 655? (Aug-01) | | |

|25. Is there a copy of the Implementation Guidelines book? (Aug-02) | | |

|26. Is there a copy of the Best Practices Manual? (Mar-02) | | |

|27. Is there a copy of the DOT Urine Specimen Collection Guidelines, Version 1.01? (Aug-01) | | |

|28. Is there a copy of the FTA Audit Questionnaire? (Feb-03) | | |

|29. Is there a copy of the TxDOT PTN Form 102 Monitoring Form? (June-03) | | |

|SERVICE AGENTS |

|Medical Review Officer (MRO):       |

|Address:       |

|Phone Number:       |

|Copies of license and certifications on file       |

|DHHS Certified Lab:       |

|Address:       |

|Phone Number:       |

|Copy of certification on file       |

|Substance Abuse Professional (SAP):       |

|Address:       |

|Phone:       |

|Copies of license and certifications on file       |

|Breath Alcohol Technician:       |

|Address:       |

|Phone Number:       |

|Copy of certification on file       |

|Consortium / Third Party Administrator (C/TPA):       |

|Contact Person:       |

|Address:       |

|Phone Number:       |

|Services Provided:       |

|Collection Site:       |

|Address:       |

|Phone Number:       |

|Hours of Operation:       |

|Collection Site:       |

|Address:       |

|Phone Number:       |

|Hours of Operation:       |

|Privacy Statement |

|The Texas Department of Transportation maintains the information collected through this form. With few exceptions, you are entitled on request to be informed|

|about the information that we collect about you. Under §§ 552.021 and 552.023 of the Texas Government Code, you also are entitled to receive and review the |

|information. Under § 559.004 of the Government Code, you are also entitled to have us correct information about you that is incorrect. For inquiries call |

|512-463-8585. |

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