49 CFR PART 4025 REQUEST FOR INFORMATION FROM FORMER EMPLOYER

REQUEST FOR INFORMATION FROM FORMER EMPLOYER

TO:Company NameNameAddressCityPhone #/ Fax #

ST/ZipTitle

FROM:Hemet USD – Transportation Department

TitlePrint FormName

1791 W. Acacia AvenueHemet, CA 92545(951) 765-5100 Ext. 5880(951) 765-2585 FAX

SSN

(Mr./Mrs./Ms.)

Has made an application to our company for a safety-sensitive function as outlined in 49CFR Part 40 and 49 CFR Part 382.Pursuant to 49CFR Part 40.25: PLEASE COMPLETE THE FOLLOWING;

1.What were the dates of this applicant's employment?

YES / NO2.Was he/she employed in a safety-sensitive function? (Circle one) 3.Was the applicant subject to alcohol testing or controlled substance testing pursuant to Part 40?YES / NO4.Did this applicant test positive during the preceding two for:

a)Alcohol concentration of .04 or greater? YES / NOb)Verified positive for controlled substances covered under Part 40?YES / NO

c)Has this applicant any time in the past two years refused a required alcohol or controlled substance test requiredunder Part 382?YES / NOIf positive (or refusal) was this applicant referred to a substance abuse professional?YES / NO5.Did this applicant see a substance abuse professional?YES / NO

If yes, did the substance abuse professional recommend treatment?YES / NOIf treatment was recommended, did applicant complete treatment?YES / NO6.Did applicant undergo a return-to-duty test?YES / NO

If yes, did the return-to-duty test indicate a verified negative result?YES / NO7.Did this employee have any other violations of DOT agency drug or alcohol testing regulations?

YES / NOIf yes, please give details:Pursuant to 49 CFR Part 40.25 required that previous employers must provide this information regarding any violations of 49 CFR Part 40 and Part 382 and transmit the answers back to the company named above.

RELEASE AUTHORIZATION

With my signature below, I am authorizing you to release information in regards to any alcohol and controlled substance testing program to which I was a party to while in your employ, acting as your agent, under contract with you, or acting as your representative in any capacity during the preceding two years from the date listed below.

This request is specific and to be released only to the company whose name appears below. Authorization of this release will expire once the requested information has been sent to the company named below. This authorization may not be used to provide information to any other person.NAME OF COMPANY:DATE:

NAME OF APPLICANT:SIGNATURE OF APPLICANT:WITNESS SIGANTURE:

Hemet Unified School District, Transportation Department