Employee Notification for Required Drug and Alcohol Testing
From:
To:
Test Date:
Test Place:
______________________________________________________________________________
(Example: Facility Name, City, and specific place to check in (i.e., use ER entrance, main door
off parking lot, etc.)
Test Reason: ☐ Random
☐ Pre-Employment ☐ Post-Accident
☐ Reasonable Suspicion
☐ Return-To-Duty (After previous violation - Direct Observation Required)
☐ Follow-Up (After previous violation - Direct Observation Required)
☐ Negative Dilute Retest - Direct Observation as directed by MRO §§ 40.155 and 40.197 (b)(1)
Be sure to also check the primary test reason the same as the initial test reason
Testing Authority: (check all that apply)
☐ DOT Drug Urine Specimen
☐ Non-DOT Drug Urine Specimen
☐ DOT Breath Alcohol
☐ Non-DOT Breath Alcohol
Employee Instructions:
Random Testing Information: Your name has been selected for drug and/or alcohol testing by a computerized
program of random selection. Your selection does not imply that (Employer Name) has a specific cause to
suspect you of using alcohol or prohibited drugs. Nonetheless, the FTA Alcohol Misuse and Prohibited Drug
Use regulations and (Employer Name)'s Drug & Alcohol Testing Program requires the random testing of urine
specimens and/or breath alcohol testing as required by DOT 49 CFR Part 655 (Federal Transit Administration)
and DOT 49 CFR Part 40.
You are to proceed immediately to the collection site. Should you fail to arrive within the reasonable amount of
time allowed, you will be deemed to have refused the test and will be removed from performing safety-sensitive
duties and referred to a Substance Abuse Professional (SAP). 49 CFR Part 40 Subpart O
Non-Observed Drug Specimen Collections: You may provide a urine specimen (at least 45 ml) in the privacy
of a stall.
Observed-Collections (after previous DOT violation or when instructed by an MRO): You will be asked to
provide a urine specimen (at least 45 ml) in view of a person of your same gender. You will be asked to raise
clothing above the waist, lower clothing worn below the waist, and turn around so the observer can detect the
use of any unauthorized device.
Urine Collections: If you are unable to provide a sufficient quantity of urine, you will be given a waiting period
and encouraged to drink liquids during such time. If you are unable to provide a sufficient urine specimen in
the allotted time you will need to be evaluated by a licensed physician or the Medical Review Officer (MRO) to
determine if there is a valid medical reason for the insufficient urine sample (“shy bladder”). If not, you will be
deemed to have refused to provide the required urine specimen. If you refuse to provide the required specimen,
adulterate the specimen, substitute the urine of another person, or the test result is positive for prohibited drugs,
you will be removed from performing safety sensitive duties and referred to a SAP.
This copy will be retained in your confidential DOT testing files along with the alcohol testing results and/or the
Medical Review Officer's final determination of any drug test results.
Please sign the bottom of this notice to acknowledge its receipt and return it to the (insert title here).
Date Notification Received: _____________________________
Employee Signature:
Time: _______________AM/PM
______________________________________________________________