Drug-and-Alcohol-Monthly-Testing-Report---Kentucky-Transportation- by akgame

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Drug-and-Alcohol-Monthly-Testing-Report---Kentucky-Transportation-

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									DRUG and ALCOHOL MONTHLY TESTING REPORT
Reports must be completed by the designated D&A contact person and returned by the 10th of the following month. Please stamp all D&A info to this office CONFIDENTIAL and mail to: Office of Transportation Delivery Attn: Kristi Broyles 200 Mero Street Frankfort, KY 40622 AGENCY: Information on Subcontractor:
(Name of subcontractor reporting on)

TESTING MONTH/YEAR: 2008

FTA-COVERED EMPLOYEES SUBJECT TO TESTING Category Operates Revenue Service Vehicles, including when not in revenue service: Maintains Revenue Service Vehicles and Equipment: Controls the Dispatch/Movement of Revenue Service Vehicles: Operates Nonrevenue Service Vehicles that require drivers to have CDL: Carries a Firearm for Security Purposes:
New Hires Terminations Total

Number of FTA Employees

**Supervisors, who may at any time perform one of the above functions, are classified as FTA Safety Sensitive and should be included in one of the above categories

ALCOHOL TESTING
Number who were Returned to Duty: Number of NonFatal Accidents with Test of .04 or greater: Number of Fatal Accidents with Test of .04 or greater: Number of Fatalities from accidents with Test of .04 or greater: Number who refused Random Test: Number who refused Non-Random Test: Number of Supervisors who completed for the first timetheir reasonable suspicion determination training: No. who violated other provisions of subpart B (Alcohol Misuse) Action Taken:

DRUG TESTING
Number who were Returned to Duty: Number of NonFatal Accidents with positive Drug Test: Number of Fatal Accidents with positive Drug Test: Fatalities from accidents with positive Drug Test: Number who refused Random Test: Number who refused Non-Random Test: Number of Supervisors who completed for the first timetheir reasonable suspicion determination training: Number of Employees who completed for the first timetheir drug education/training: Number with positive Drug Test for Multiple Drugs: Employee Category Employee Category Number of persons denied a position because of positive drug test: Drug Types Drug Types xxx

xxx

xxx xxx

Number given Drug and Alcohol tests at same time and tested positive for both drugs and .04 or greater for alcohol =

Drug and Alcohol Testing Report continued.....

1. Marijuana 2. Cocaine 3. Opiates

Prohibited Drug Categories 4. Amphetamines 5. Phencyclidine

ALCOHOL TESTING
No. of Screen Tests No. of Confirm Tests No. of Confirm Tests .02 - .039 No. of Confirm Tests .04 or greater No. of Specimens Collected

DRUG TESTING
No. of and No. of Negative Tests No. of Positive Tests 1 Type of Drug by Category for + 2 3 4 5

Pre-Employment: Operates Rev Veh Maintains Rev Veh Controls Dispatch Operates NonRev CDL Carries Firearm Random: Operates Rev Veh Maintains Rev Veh Controls Dispatch Operates NonRev CDL Carries Firearm Post-Accident: Operates Rev Veh Maintains Rev Veh Controls Dispatch Operates NonRev CDL Carries Firearm Reasonable Suspicion: Operates Rev Veh Maintains Rev Veh Controls Dispatch Operates NonRev CDL Carries Firearm Return To Duty: Operates Rev Veh Maintains Rev Veh Controls Dispatch Operates NonRev CDL Carries Firearm Follow-Up: Operates Rev Veh Maintains Rev Veh Controls Dispatch Operates NonRev CDL Carries Firearm

Signature

Date Submitted

Telephone Number


								
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