RELEASE OF INFORMATION FORM 49 CFR Part 40 and Safety Performance History

One form must be signed per previous employer $40.321 (b) “Speci c written consent” means a statement signed by the employee that he or she agrees to the release of a particular piece of information to a particular, explicitly identi ed, person or organization at a particular time. “Blanket releases,” in which an employee agrees to a release of a category of information (e.g., all test results) or to release information to a category of parties (e.g., other employers who are members of a C/TPA, companies to which the employee may apply for employment), are prohibited under this part.

SECTION I

To be completed by the new employer, signed by the employee and transmitted to the previous employer.

I hereby authorize release of information from my Department of Transportation regulated drug and alcohol testing records by my previous employer, listed in Section I-B, to the employer listed in Section I-A. This release is in accordance with DOT Regulation 49 CFR Part 40, Section 40.25.

    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 palcohol 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
    7. Safety Performance History
    I certify that: (i) all information provided herein is complete and accurate; (ii) I have read and fully understand this Part I disclosure and authorization for release; (iii) prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction;(iv) I execute this authorization voluntarily and with the knowledge that the information obtained pursuant to this authorization could affect my eligibility for employment, promotion, retention or other lawful purpose; (v) I understand I may review this document with legal counsel prior to signing; and (vi) facsimile or photographic copies of this authorization are as valid as an original.
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