Privacy Issues in the Community College Workplace

A PPENDIX H

A UTHORIZATION FOR R ELEASE OF DOT D RUG & A LCOHOL T ESTING R ECORDS

I,________________________, hereby authorize __________________________ to release the [employee name] [prior employer name]

information described below to the ___________________. This authorization is limited to the [hiring district]

following types of information: 1) alcohol tests with a result of 0.04 or higher alcohol concentration; 2) verified positive drug tests; 3) refusals to be tested (including verified adulterated or substituted drug test results); 4) other violations of Department of Transportation (DOT) district drug and alcohol testing regulations; and 5) documentation of ______________________________ successful [employee name’s] completion of DOT return-to-duty requirements (including follow-up tests). The __________________________ may use this information to assess my eligibility to perform [hiring district]

safety-sensitive duties pursuant to the U.S. Department of Transportation’s regulation 49 CFR § 40.25 regarding pre-employment drug and alcohol testing records review.

This authorization shall expire on ___________________________________

I understand that I have the right to receive a copy of this authorization upon my request. By placing my initials in the margin to the right of this clause, I hereby acknowledge that a copy of this authorization has been received.

Signature__________________________________________ Dated ______________________

Privacy Issues in the Community College Workplace ©2019 (c) Liebert Cassidy Whitmore 194