413 Form
Section Completed By:
Your Email
(Copy of this form will be sent to this email)
Driver Names
Your search should go back 3 years, whether or not you are testing the driver or getting exemption you still need the previous information on file.
To obtain a Pre Employment exemption the new employer must obtain the names and address of all drug and alcohol consertiums in which the previous companies were involved.
1. Did the driver participate in a random program?
Yes
No
2. Did the program comply with DOT requirements Part 40?
Yes
No
3. Is the driver qualified to drive under the rule of Part 382?
Yes
No
4. Name & Address of Consortium (TPA)?
Dates of Employment
From
To
Date of Last Test
Issued by Type of Test
Result
Under Part 382 & 391 testing requirements
5. Has this person ever tested positive for a controlled substance in the last 3 years?
Yes
No
6. Has this person ever had an alcohol test with a Breathe Alcohol Concentration 0.040 or greater in the last 3 years?
Yes
No
7. Has this person ever refused a required test for drugs and alcohol in the last 3 years?
Yes
No
8. Has this person completed any Return to Duty or Follow up Testing?
Yes
No
If yes to #5,6,7,8, or if applicant has completed a SAP assessment, please give all info applicable, such as dates of tests, results of tests, and information and letters regarding of SAP.
SAP Info
Name
Address
Telephone
Section2 Completed By
First Name
Last Name
Please fill first name & last name.
Print Name
Date
Address
Telephone
Company
