DRUG AND ALCOHOL
MANAGEMENT PROGRAM
MONITORING FORM
Name of Transit Agency:
Address:
City, State, Zip:
Phone:
Contact Person:
Name of Senior Agency (COG, CAA, RPC, or County, if applicable):
Monitored By:
Date Monitored:
TxDOT District:
In Compliance
Not In Compliance
Corrective Action Plan Due Date:
Describe Areas of Non-Compliance:
Form PTN-102
(Rev. 6/2003)
(GSD-EPC)
Page 1 of 10
Form PTN-102
(Rev. 6/2003)
Page 2 of 10
POLICY STATEMENT ELEMENTS (§655.15)
YES
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?
NO
Form PTN-102
(Rev. 6/2003)
Page 3 of 10
POLICY STATEMENT ELEMENTS (§655.15) (cont.)
YES
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 postaccident 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)
NO
Form PTN-102
(Rev. 6/2003)
Page 4 of 10
POLICY STATEMENT ELEMENTS (§655.15) (cont.)
YES
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?
NO
Form PTN-102
(Rev. 6/2003)
Page 5 of 10
DRUG FREE WORKPLACE ACT
YES
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?
NO
EDUCATION AND TRAINING PROGRAMS (§655.14)
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)
NO
YES
Form PTN-102
(Rev. 6/2003)
Page 6 of 10
PRE-EMPLOYMENT DRUG TESTING (§655.41)
YES
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)
NO
REASONABLE SUSPICION TESTING (§655.43)
YES
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?
NO
Form PTN-102
(Rev. 6/2003)
Page 7 of 10
REASONABLE SUSPICION TESTING (§655.43) (cont.)
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)
YES
NO
POST-ACCIDENT TESTING (§655.44)
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?
YES
NO
RANDOM TESTING (§655.45)
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)
YES
NO
Form PTN-102
(Rev. 6/2003)
Page 8 of 10
RANDOM TESTING (§655.45) (cont.)
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)
YES
NO
RETURN TO DUTY AND FOLLOW-UP (§655.62)
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)
YES
NO
TEST RESULTS
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)
YES
NO
ADMINISTRATIVE REQUIREMENTS (§655.71)
YES
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)
NO
Form PTN-102
(Rev. 6/2003)
Page 9 of 10
ADMINISTRATIVE REQUIREMENTS (§655.71) (cont.)
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)
YES
NO
Form PTN-102
(Rev. 6/2003)
Page 10 of 10
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.