PREVIOUS PRE-EMPLOYMENT EMPLOYEE
ALCOHOL AND DRUG TEST STATEMENT



Sec. 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 must 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. (see Sec. 40.25(b)(5) and (e))

The prospective employee is required by Sec. 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?<

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

I certify that the information provided on this document is true and correct.

Witnessed By:                            

Date:                            

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