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April 18, 2011 (Regular Meeting) Page 393 • If you request a retest, you must specify in writing to which approved laboratory the sample is to be sent. • You must pay all expenses associated with the retest. If you have questions, please contact Human Resources at 704 - 920 -2200. Signature Title HR 4/20/2009 Date: FORM F CABARRUS COUNTY GOVERNMENT Company Name: Company Address: Subject: , Release of Information Form (Name of applicant /employee) Dear Human Resources Representative: The individual named above is being considered for a position with DOT safety- sensitive duties. We are requesting the information in Section 11 on the reverse side of this letter from DOT regulated employers who have employed this individual during the past two years as required by 49 CFR Part 40.25 Drug and Alcohol Testing Records. Please complete and return this form by mail or fax to: Cabarrus County Human Resources Department PO BOX 707 Concord NC 28026 Phone 704 - 920 -2200 Fax 704 - 920 -2250 Thank you for your assistance, Cabarrus County Representative signature Title Phone Cc: Human Resources FORM F Release of Information Form - 49 CFR Part 40.25 Drug and Alcohol Testing Records Section I: To be completed by the applicant /employee. Applicant /Employee Printed Name: Applicant /Employee Social Security Number: I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer (over) to Cabarrus County. This release is in accordance with DOT Regulation 49 CFR Part 40, Section 40.25. I understand that information to be released in Section II by my previous employer is limited to the following DOT - regulated testing items: 1. Alcohol tests with a result of 0.04 or higher; 2. Verified positive drug tests; 3. Refusals to be tested; 4. Other violations of DOT agency drug and alcohol testing regulations; 5. Information obtained from previous employers of a drug and alcohol rule violation; 6. Documentation, if any, of completion of the return -to -duty process following a rule violation. Applicant /Employee Signature: Date: