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FORM F <br />Release of Information Form — 49 CFR Part 40.25 Drug and Alcohol Testing Records <br />Section I: To be completed by the applicant /employee. <br />Applicant /Employee Printed Name: <br />Applicant /Employee Social Security Number: <br />I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing <br />records by my previous employer (over) to Cabarrus County. This release is in accordance with DOT Regulation 49 CFR <br />Part 40, Section 40.25. I understand that information to be released in Section II by my previous employer is limited to the <br />following DOT - regulated testing items: <br />1. Alcohol tests with a result of 0.04 or higher; <br />2. Verified positive drug tests; <br />3. Refusals to be tested; <br />4. Other violations of DOT agency drug and alcohol testing regulations; <br />5. Information obtained from previous employers of a drug and alcohol rule violation; <br />6. Documentation, if any, of completion of the return-to -duty process following a rule violation. <br />Applicant /Employee Signature: <br />Date: <br />Section II: To be completed by the previous employer and transmitted by mail or fax to Cabarrus County. <br />hl the two years prior to the date of the employee's signature (in Section I), for DOT - regulated testing: <br />1. Did the employee have alcohol tests with a result of 0.04 or higher? YES NO <br />2. Did the employee have verified positive drug tests? YES NO <br />3. Did the employee refuse to be tested? YES NO <br />4. Did the employee have other violations of DOT agency drug and alcohol testing regulations? YES NO <br />5. Did a previous employer report a drug and alcohol rule violation to you? YES NO <br />6. If you answered "yes" to any of the above items, did the employee complete the return-to -duty process? N/A <br />YES NO <br />NOTE: If you answered "yes" to item 5, you must provide the previous employer's report. If you answered "yes" to item <br />6, you must also transmit the appropriate return -to -duty documentation (e.g., SAP report(s), follow -up testing record). <br />Signature of individual completing Section II <br />Printed Name and Title <br />Company Name: <br />Company Mail Address: <br />Phone #: <br />Date: <br />HRD 8/31/2009 <br />25 <br />Attachment number 1 <br />F -6 Page 136 <br />