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Appendix E - Controlled Substance and Alcohol Questionnaire

Have you ever tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?

If Yes >>>

Have you successfully completed the return-to-duty process?

If Yes >>>

Documentation MUST BE PROVIDED before any safety-sensitive transportation function is performed.


To be completed by the employer

Application reviewed for completeness by:

Application reviewed by:

Thank you for your submission!

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