U.S. DEPARTMENT OF TRANSPORTATION: MOTOR CARRIER SAFETY PROGRAM ANNUAL REVIEW OF DRIVING RECORD

Transcription

1 U.S. DEPARTMENT OF TRANSPORTATION: MOTOR CARRIER SAFETY PROGRAM ANNUAL REVIEW OF DRIVING RECORD Driver s Full Name Social Security # This day I reviewed the driving record of the above named driver in accordance with of the Federal Motor Carrier Safety Regulations. I considered any evidence that the driver has violated applicable provisions of the Federal Motor Carrier Safety Regulations and the Hazardous Materials Regulations. I considered the driver s accident record and any evidence that he/she has violated laws governing the operation of motor vehicles, and gave great weight to violations, such as speeding, reckless driving and disregard for the safety of the public. Having done the above, I find that (check one): The driver meets the minimum requirements for safe driving. The driver is disqualified to drive a motor vehicle pursuant to Date of Review First Choice of Elkhart, Inc. Motor Carrier Reviewed by: Signature & Title Date of Review First Choice of Elkhart, Inc. Motor Carrier Reviewed by: Signature & Title Date of Review First Choice of Elkhart, Inc. Motor Carrier Reviewed by: Signature & Title ANNUAL REVIEW OF DRIVING RECORD 1

2 MOTOR VEHICLE DRIVER S CERTIFICATION OF VIOLATIONS (d) & (b)(6) I certify that the following is a true and complete list of traffic violations (other than parking violations) for which I have been convicted or forfeited bond or collateral during the past 12 months. DATE OFFENSE LOCATION TYPE OF VEHICLE If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violations required to be listed during the past 12 months. DATE OF CERTIFICATION REVIEWED BY: SIGNATURE DRIVER SIGNATURE TITLE FIRST CHOICE OF ELKHART, INC US HWY 12, WHITE PIGEON, MI I certify that the following is a true and complete list of traffic violations (other than parking violations) for which I have been convicted or forfeited bond or collateral during the past 12 months. DATE OFFENSE LOCATION TYPE OF VEHICLE If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violations required to be listed during the past 12 months. DATE OF CERTIFICATION REVIEWED BY: SIGNATURE DRIVER SIGNATURE TITLE FIRST CHOICE OF ELKHART, INC US HWY 12, WHITE PIGEON, MI I certify that the following is a true and complete list of traffic violations (other than parking violations) for which I have been convicted or forfeited bond or collateral during the past 12 months. DATE OFFENSE LOCATION TYPE OF VEHICLE If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violations required to be listed during the past 12 months. DATE OF CERTIFICATION REVIEWED BY: SIGNATURE DRIVER SIGNATURE TITLE FIRST CHOICE OF ELKHART, INC US HWY 12, WHITE PIGEON, MI Driver s Full Name Social Security # CERTIFICATE OF VIOLATIONS 2

3 SAFETY PERFORMANCE HISTORY RECORDS REQUEST-PART 1 SECTION 1: TO BE COMPLETED BY PROSPECTIVE DRIVER I, (print name): with Social Security #: hereby authorize Previous Employer: Phone: Address: Fax: City/State/Zip: to release and forward the information requested by Section 3 of this document concerning my Alcohol and Controlled Substances Testing records within the previous three (3) years from my application date of: To Prospective Employer: Company: First Choice of Elkhart, Inc. Phone: Attention: Safety Department Fax: Street: US Hwy 12 tonya@firstchoiceautohaul.com City/State/Zip: White Pigeon, MI In compliance with 40.25(g) and (h), release of this information must be made in a written form that ensures confidentiality such as fax, or letter. Applicant s Confidential Fax #: Applicant s Signature: Date: This information is being requested in compliance with 40.25(g) and (h). SECTION 2: TO BE COMPLETED BY PREVIOUS EMPLOYER EMPLOYMENT VERIFICATION & ACCIDENT HISTORY The driver named above was employed by us: Yes No Employed as (job title) from (m/y) to (m/y) Did he/she drive motor vehicle for you: Yes No If yes, what type? Straight Truck Tractor/Semitrailer Bus Cargo Tank Doubles/Triples Other (Specify) Would you consider this driver for rehire? Yes No If no, please explain: ACCIDENTS: Complete the following for any accidents included on your accident registrar (390.15(b)) that involved the applicant in the 3 years prior to the application date shown above, or check here if there are no registered accidents for this driver. DATE LOCATION # OF INJURIES # OF FATALITIES HAZMAT SPILL? Please provide information concerning any other accidents involving the applicant that were reported to government agencies, insurers or retained under internal company policies: Section 2 Completed by (print name): Title: Signature: Date: SAFETY PERFORMANCE HISTORY RECORDS REQUEST-PART 1 3

4 SAFETY PERFORMANCE HISTORY RECORDS REQUEST-PART 2 SECTION 3: TO BE COMPLETED BY PREVIOUS EMPLOYER DRUG AND ALCOHOL HISTORY If the driver was NOT subject to Department of Transportation testing requirements while employed by this employer, please check here. YES NO 1. Has this person had an alcohol test with a result of 0.04 or higher alcohol concentration? 2. Has this person tested positive, adulterated or substituted a test specimen for controlled substances? 3. Has this person refused to submit to a post-accident, random, reasonable suspicion, or follow-up alcohol or controlled substance test? 4. Has this person committed other violations of Subpart B, Part 382 or Part 40? 5. If this person has violated a DOT drug and alcohol regulation, did this person fail to undertake or complete a program prescribed by a Substance Abuse Professional (SAP) in your employ? If yes, please send documentation back with this form. 6. For a driver who successfully completed a SAP s rehabilitation referral and remained in your employ, did this driver subsequently have an alcohol test result of 0.04 or greater, a verified positive drug test or refuse to be tested? In answering these questions, include any required DOT drug or alcohol testing information from prior previous employers in the previous 3 (three) years prior to the application date shown in Section 1 of this form. Company: Street: City/State/Zip: Phone: Section 3 Completed by (print name): Title: Signature: Date: SECTION 4A: TO BE COMPLETED BY PROSPECTIVE EMPLOYER MODE OF COMMUNICATION This form was sent to the previous employer via: Fax Mail Other (Specify) By: Date: SECTION 4B: TO BE COMPLETED BY PROSPECTIVE EMPLOYER RECEIPT OF INFORMATION COMPLETE THE FOLLOWING WHEN THE REQUESTED INFORMATION IS SUBMITTED. Information received from: Recorded by: Date: Method: Fax Mail Phone Other (Specify) SAFETY PERFORMANCE HISTORY RECORDS REQUEST-PART 2 4

5 CERTIFICATE OF COMPLIANCE NOTICE TO DRIVERS: The Commercial Motor Vehicle act of 1986 provides a new set of controls over the drivers of commercial vehicles. The new law applies to all drivers operating vehicles and combinations with a gross vehicle weight rating over 26,000 pounds, and to any vehicle, regardless of weight, transporting hazardous materials. THE FOLLOWING PROVISIONS OF THE LEGISLATION BECAME EFFECTIVE JULY 1, No driver may possess more than one license and no motor carrier may use a driver having more than one license. A limited exception is made for drivers who are subject to non-resident licensing requirements of any state. This exception does not apply after December 31, Drivers convicted of a traffic violation (other than parking) must notify the motor carrier and the state which issued the license to that driver of such conviction within 30 days. 3. Any person applying for a job as a commercial vehicle driver must inform the prospective company of all previous employment as the driver of a commercial vehicle for the past 10 years in addition to any other required information about the applicant s employment history. 4. Any violation is punishable by a fine not to exceed $2,500. In addition, the Federal Motor Carrier Safety Regulations now require that a driver who loses any privilege to operate a commercial vehicle or who is disqualified from operating a commercial vehicle must advise the motor carrier the next business day after receiving such notification of such action. CERTIFICATION BY DRIVER: I hereby certify that I have read and understand the driver provisions of the Commercial Motor Vehicle Safety act of 1986, which is effective July, 1987 and is stated above. Driver s Name: Social Security #: Street: City/State/Zip: LICENSE: State: Type/Class: ID #: I further certify that the above commercial vehicle license is the only one held or that I have surrendered the following licenses to the state indicated. STATE TYPE/CLASS ID # Driver s Signature: Date: CERTIFICATE OF COMPLIANCE 5

6 DRIVER STATEMENT OF ON-DUTY HOURS Instructions: When motor carriers use a driver for the first time or intermittently, they shall obtain from the driver a signed statement giving the driver s total time on-duty during the immediately preceding 7 days and time at which such driver was last relieved from duty prior to beginning work for such carrier. (see Section 395.8(j) (2) Federal Motor Carrier Safety Regulations). Note: Hours for any compensated work during the 7 days, including work for a non-motor carrier entity, must be recorded on this form. Driver s Name: Social Security #: Driver s License Info State: Number: Class: Endorsements: Restrictions: Type of License: DAY # 1 (yesterday) DATE HOURS WORKED Total Hours: I hereby certify that the information given is correct to the best of my knowledge and belief, and that I was last relieved of duty from work at: A.M. P.M. On: Time (circle one) Day Month Year Driver s Signature: Date: DRIVER STATEMENT OF ON-DUTY HOURS 6

7 CONTROLLED SUBSTANCES AND ALCOHOL POLICY MANUAL It is the policy of this company to provide a drug and alcohol-free work environment for driver personnel. To insure we achieve that goal we have adopted the following policy, which meets Federal Motor Carrier Safety Regulations (FMCSR) on drug and alcohol abuse as set forth in 49 CFR parts 382 & 40 and/or applicable regulations, laws and ordinances. Prohibitions: The unlawful manufacture, distribution, possession or use of a controlled substance is prohibited on all company premises, in any company owned or leased motor vehicle, or any other location at which the driver is to perform work. FIRST CHOICE OF ELKHART, INC. (herein after referred to as the carrier) will not hire or retain any individual who uses or possesses any illegal drug, in any amount and regardless of frequency. 1. The drugs tested for are marijuana, cocaine, opiates, phencyclidine (PCP) and amphetamines. A driver shall not consume any of these controlled substances or derivatives thereof, while on or off duty. No driver shall consume or be under the influence of alcohol while on duty. 2. No driver shall report to work or drive while impaired by alcohol or any controlled substance. In addition, a driver shall not perform safety-sensitive functions within four hours after using alcohol prior to reporting for work. 3. No driver shall be in possession of alcohol on his/her person during any on-duty hours. Furthermore, no driver shall allow alcohol to be in his/her commercial motor vehicle at any time while under contract with the carrier. 4. A driver may use a substance administered by or under the direction of a physician only if advised that the substance will not affect their ability to safely operate a commercial motor vehicle. 5. Any driver who sells or otherwise dispenses illegal drugs to others on company premises, in or from the carrier s owned or leased motor vehicle, is subject to immediate termination. 6. Nothing herein shall restrict the carrier from conducting more stringent or additional controlled substance and/or alcohol testing. SEARCHES The carrier may conduct reasonable searches for illegal drugs on company premises or in company owned or leased motor vehicles. 1. No driver at any worksite or in any company vehicle or leased vehicle, will possess any quantity of any controlled substance, lawful or unlawful, which in sufficient quantity could result in impaired performance. The only exception being a substance administered by or under the direction of a physician. 2. Searches of drivers and their personal property may be conducted when there are reasonable grounds to believe the driver is in violation of this policy. 3. All drivers are expected to cooperate in such searches. A driver s refusal to cooperate or consent to such searches may result in disciplinary action including termination. Safety-sensitive Functions: In CFR Part , this is defined as all-time from the time a driver begins to work or is required to be in readiness to work until the time he/she is relieved from work and all responsibility for performing work. Safety sensitive functions shall include: 1. All time at any carrier or shipper plant, terminal, facility, or other property, or any other public property, waiting to be dispatched, unless the driver has been relieved from duty by the carrier. 2. All time inspecting equipment as required by CFR part & or otherwise inspecting, servicing or conditioning any commercial motor vehicle at any time. 3. All time spent at the driving controls of a commercial motor vehicle in operation. 4. All time, other than driving time, in or upon any commercial motor vehicle except time spent resting in a sleeper berth (a berth conforming to the requirements of of the FMSCR) 5. All time loading or unloading a vehicle, supervising or assisting in the loading or unloading, attending a vehicle being loaded or unloaded, remaining in readiness to operate the vehicle, or in giving or receiving of receipts for shipments loaded or unloaded. 6. All time spent repairing, obtaining assistance, or remaining in attendance of a disabled vehicle. CONTROLLED SUBSTANCES AND ALCOHOL POLICY MANUAL UPDATED 11/2015 7

8 CONTROLLED SUBSTANCES AND ALCOHOL POLICY MANUAL Testing: The Company will require drug and alcohol testing in accordance with all applicable FMCSR. The types of drug and alcohol tests to be performed are pre-placement, random, reasonable suspicion, post-accident, return to duty and follow up. 1. Prior to the first time a driver performs safety-sensitive functions for the carrier, the driver shall undergo a pre-placement controlled substances test and the carrier shall receive a negative pre-placement controlled substance test result. 2. Drivers are required to submit to random controlled substance testing and/or random alcohol testing in accordance with FMCSR requirements. 3. Post-accident testing must be performed as soon as possible following an occurrence involving a commercial motor vehicle operating on a public road in commerce. Failure of a driver to immediately contact the employer after an accident may be grounds for termination. Each carrier shall test for alcohol and controlled substances for each surviving driver A. Who was performing safety sensitive functions with respect to the vehicle if the accident involves the loss of human life; or B. Who receives a citation under state or local law for a moving traffic violation arising from the accident if the accident involves bodily injury to any person who, as a result of the injury, receives immediate treatment away from the scene of the accident; or one or more motor vehicles incurs disabling damage as a result of the accident requiring the motor vehicle to be transported away from the scene by a tow truck or other motor vehicle. If an alcohol test is not performed within 2 hours, the carrier must prepare and keep on file an explanation as to why it was not performed in that time period. If an alcohol test is not performed within 8 hours or a controlled substance test within 32 hours, the carrier shall cease to make the attempt and must prepare and keep on file an explanation as to why the tests were not performed. No driver required to take a post-accident alcohol test shall use alcohol for eight (8) hours following the accident or until he or she undergoes a post-accident alcohol test, whichever occurs first. 4. A carrier shall require a driver to submit to an alcohol and/or controlled substance test when the carrier has reasonable suspicion to believe that the driver has violated prohibitions of Subpart B of Parts thru The carrier s determination that reasonable suspicion exists to require the driver to undergo an alcohol and /or controlled substance test must be based on specific, contemporaneous, articulable observations concerning the appearance, behavior, speech or body odors of the driver. 5. The carrier shall ensure that before a driver returns to duty requiring the performance of a safety sensitive function after engaging in conduct prohibited by subpart B of FMCSR part 382 concerning alcohol concentration. The carrier shall ensure that before a driver returns to duty requiring the performance of a safety sensitive function after engaging in conduct prohibited by subpart B of FMCSR part concerning controlled substances, the driver shall undergo a return to duty controlled substance test with a result indicating a verified negative result for controlled substance use. A driver must go for a controlled substance or alcohol test immediately upon notification. Any driver who fails to show up for testing, refuses to take the designated test or fails to provide a proper urine specimen or breath amount, without a valid medical explanation, will be deemed a refusal. A diluted specimen is a specimen with creatinine and specific gravity values that are lower than expected for human urine. When the Medical Review Officer (MRO) informs the carrier that a negative controlled substance test was diluted, you may, but are not required to, direct the driver to take another test immediately. All contractors must be treated the same for this purpose. You must not retest some drivers and not others. An adulterated specimen is defined as a specimen that contains a substance that is not expected to be present in human urine or contains a substance expected to be present, but is at a concentration so high that it is not consistent with human urine. CONTROLLED SUBSTANCES AND ALCOHOL POLICY MANUAL UPDATED 11/2015 8

9 CONTROLLED SUBSTANCES AND ALCOHOL POLICY MANUAL A refusal to submit to testing, as well as the substitution or adulteration of a specimen will automatically be deemed a positive result and disqualify the driver from performing any safety sensitive functions. Laboratory & Testing Essentials: Only laboratories located in the United States that have been certified by Health and Human Services (HHS) under the National Laboratory Certification Program (NLCP) can be used for testing. The laboratory must also comply with all applicable requirements of HHS in testing D.O.T. specimens. Drug testing is performed using the donor s urine specimen. Two vials are collected, which is a split specimen collection. The lab uses one vial as the A bottle to perform the test. The initial test as well as any applicable confirmatory testing is performed using this vial. The second vial, labeled as the B bottle is left untouched with the seal intact. This is to be used in the event that a driver requests that it be tested following verified positive, adulterated or substituted test results of the primary specimen. The driver must request the second test within 72 hours of receiving notification from the MRO. The B bottle is sent to a different laboratory, which tests the specimen only for the drug(s)/ drug metabolite(s) detected in the primary specimen. If the second lab confirms the results of the first lab, the test stands as a positive result. If the second lab fails to reconfirm the results of the first lab, the test is cancelled. Therefore, the result is neither negative nor positive. Specimen collection procedures require using: A designated collection site staffed with trained collection personnel. Proper chain of custody documentation as well as integrity and identity of the specimen. Privacy during collection. Transportation to the laboratory. The lab must use cutoff concentrations, which are expressed in nanograms per milliliter (ng/ml), displayed in the table for initial and confirmatory tests: Type of drug or metabolite Initial Test Confirmation Test 1. Marijuana metabolites 50 a. Delta-9 tetrahydrocannabinol 9 carboxylic acid (THC) Cocaine metabolites Phencyclidine (PCP) Amphetamines 1000 a. Amphetamine 500 b. Methamphetamine Opiate metabolites 2000 a. Codeine 2000 b. Morphine 2000 c. 6-acetylmorphine (6-AM) 10 For an initial controlled substance test, a result that falls below the cutoff concentration is deemed negative. If the result is at or above the cutoff concentration, a confirmation test must be conducted. The confirmatory controlled substance test is the second analytical procedure that is performed on the urine, it is used to both identify and quantify the presence of a specific drug or drug metabolite. For a confirmation test, a result that falls below the cutoff concentration is deemed a negative. If the result is at or above the cutoff concentration it is now a confirmed positive. CONTROLLED SUBSTANCES AND ALCOHOL POLICY MANUAL UPDATED 11/2015 9

10 CONTROLLED SUBSTANCES AND ALCOHOL POLICY MANUAL Drug Test Results: A Medical Review Officer (MRO) will review all test results. This is a licensed physician who is responsible for receiving and reviewing lab results generated by a carrier s controlled substance testing program and evaluating explanations for certain drug test results. Upon receipt of a positive result, the MRO will discuss the results with the driver and present him/her the opportunity to provide documentation of legally prescribed medication that he/she is consuming. For all positive results, the MRO will speak directly with the designated employee representative (DER). A DER is an employee authorized by the carrier to take immediate action to remove drivers from safety sensitive duties or cause drivers to be removed from these covered duties and to make required decisions in the testing and evaluation processes. The DER also receives test results and other communications for the carrier. Controlled Substance Test Refusal: A refusal to submit to a controlled substance test is dictated within the following items according to 49 CFR Part Failing to appear for any test within a reasonable time, as determined by the carrier, consistent with applicable DOT agency regulations, after being directed to do so by the carrier. 2. Failing to remain at the testing site until the testing process is complete. 3. Failing to provide a urine specimen for any controlled substance test required by DOT agency regulations. 4. In the case of a directly observed or monitored collection in a controlled substance test, failing to permit the observation or monitoring of your provision of a specimen. 5. Failing to provide a sufficient amount of urine when directed, and it has been determined, through a required medical evaluation, that there was no adequate medical explanation for the failure. 6. Failing or declining to take a second test the carrier or collector has directed you to take. 7. Failing to undergo a medical examination or evaluation, as directed by the MRO as part of the verification process. 8. Failing to cooperate with any part of the testing process (e.g. refusal to empty your pockets when directed by the collector, confrontational behavior that disrupts the collection process, etc.). 9. As a contractor, if the MRO reports that you have a verified adulterated or substituted test results, you have refused to take a controlled substance test. 10. As a contractor, if you refuse to take a drug test, you incur the consequences specified under DOT agency regulations for a violation of those DOT agency regulations. Breath Alcohol Tests: A breath test measures the concentration of alcohol in the breath, which relates directly to the alcohol concentration in the blood. If the driver to be tested is also subject to a controlled substance test, The Breath Alcohol Technician (BAT) will, to the greatest extent possible, conduct and complete the alcohol test first. 1. Before an alcohol test is performed the driver must show a picture ID to the BAT. This technician will, in turn, write the driver s name, social security number and the required information on the testing form. 2. The driver will read step 2 of the alcohol testing form. After that, the driver will sign their name and write the date. This constitutes verification that he or she is submitting to the test as well as that the information the BAT has written is true and correct. 3. The BAT will enter the driver s social security number into the alcohol machine. Once the data has been entered, the EBT will perform an air blank. This is a reading of the device s internal standard, which ensures that there is no alcohol in the system prior to the test. All air blanks should read zero. 4. A mouthpiece, wrapped in plastic, will be opened in front of the driver. 5. For a breath alcohol test, the driver will blow steadily and forcefully into the mouthpiece of an evidential breath tester for as long as possible. 6. The EBT will detect whether there is any alcohol in the subjects breath. If there is no trace of alcohol, the machine will print out a result. Once a negative test is issued from the EBT, the BAT will advise the driver of the result and complete Step 3 of the form. 7. The driver and the technician will both sign the receipt that is printed out from the alcohol device. The BAT will then tape one result receipt to the front side of each of the three copies of the alcohol form. One copy of which is given to the driver at the completion of the test. 8. EBTs are to be calibrated once every thirty days or after every positive confirmation test. This proves that the machine is accurate and ensures the validity of the test performed. CONTROLLED SUBSTANCES AND ALCOHOL POLICY MANUAL UPDATED 11/

11 CONTROLLED SUBSTANCES AND ALCOHOL POLICY MANUAL Breath Alcohol Confirmation Test: Following a screening test with a result of.02 or greater, a confirmation test must be performed to provide quantitative data about alcohol concentration. 1. If the EBT detects alcohol, the initial reading will begin to appear immediately and will then increase numerically until a final reading has been reached. After the reading has been reached, the machine will flush the fuel cell in preparation of another test. This flushing process clears out any lingering traces of alcohol from the instrument s sampling system. 2. Upon receipt of a positive result, the BAT will advise the driver of the outcome of the test. A confirmation test is normally completed 15 minutes after the initial test. This allows any residual alcohol to dissipate within this time frame. 3. The confirmatory test will be completed in the same manner as the initial test. 4. If the confirmatory test issues a reading that is lower than.02, nothing further is required of the driver. The BAT will sign and date step If the confirmatory test issues a reading that is.02 or higher, the BAT will instruct the driver to read and sign step 4 of the alcohol form. 6. The BAT will inform the DER of the result via phone or secure fax. 7. Any driver having an alcohol concentration in the range of to is not to perform or continue to perform safety sensitive functions, until the start of the driver s next regularly scheduled duty period, but not less than 24 hours following the alcohol test. Temporary removal is necessary to ensure safety. An SAP evaluation is not required. 8. Any driver having an alcohol concentration in the range of.04 or greater cannot return to safety sensitive duties until following the procedure outlined in the referral, evaluation and treatment section. Alcohol Test Refusal: A refusal to submit to an alcohol test is dictated within the following item according to 49 CFR Part Failing to appear for any test within a reasonable time, as determined by the employer consistent with applicable DOT agency regulations after being directed to do so by the employer. 2. Failing to remain at the testing site until the testing process is complete. 3. Failing to provide an adequate amount of saliva or breath for any alcohol test required by DOT agency regulations. 4. Failing to undergo a medical examination or evaluation as directed by the employer as part of the insufficient breath procedures. 5. Failing to sign the certification at step 2 of the alcohol testing form. 6. Failing to cooperate with any part of the testing process. Consequences of Violations: Any driver that is engaged in conduct that is prohibited by Part 382, Subpart B of the FMCSR or an alcohol or controlled substances rule of another D.O.T. agency shall be removed immediately from performing safety sensitive functions. That includes driving a commercial motor vehicle. 1. A driver that has an alcohol concentration of.04 or greater or a verified positive, adulterated or substituted controlled substance result cannot return to safety sensitive duties until the following procedures outlined in the referral, evaluation and treatment section listed below have been completed. 2. Any driver, who is found to be in possession of alcohol on his/her person during any on-duty hours or in possession of alcohol in his/her commercial motor vehicle at any time, will be removed from service and shall not return to safety sensitive duties until the following procedures outlined in the referral, evaluation and treatment section listed below have been completed. 3. Any driver that violates the controlled substance and/or alcohol regulations is subject to meet the requirements of Part before returning to perform safety sensitive functions. 4. Any driver having an alcohol concentration in the range of 0.02 to is not to perform or continue to perform safety sensitive functions until the start of the driver s next regularly scheduled duty period, but not less than 24 hours following the alcohol test. Temporary removal is necessary to ensure safety. An SAP evaluation is not required. 5. Upon receiving a controlled substance test result that indicates that a driver s specimen was invalid and that a second collection must take place under direct observation you must: a) Immediately direct the driver to provide a new specimen under direct observation b) Do not attach any consequences to the finding that the test was valid other than collecting a specimen under observation c) The driver is not to be given advance notice of this test requirement and d) the collector of the controlled substance test will note the same reason for the test as for the original test (e.g. random, post-accident) 6. Upon receiving a cancelled test result when a negative result is required (e.g. pre-placement, return to duty or follow up) the driver must be directed to provide another specimen without delay. 7. Suspensions, as a result of a positive controlled substance and/or alcohol test, will be without pay and no seniority will accrue during suspension. If the driver is accepted back into the carrier s fleet after rehabilitation, he may be returned without seniority. The carrier shall not be responsible for service fees for rehabilitation and any post-care testing. 8. Personnel testing positive a second time will immediately be terminated and shall not be considered for hire in the future. CONTROLLED SUBSTANCES AND ALCOHOL POLICY MANUAL UPDATED 11/

12 CONTROLLED SUBSTANCES AND ALCOHOL POLICY MANUAL Referral, evaluation and treatment following a positive result: Each driver who has tested positive for a controlled substance and/or alcohol, has refused a test or adulterated a test shall be advised by the carrier of the resources that are available in evaluating and resolving this problem 1. As per part of the FMCSR, a Substance Abuse Professional (SAP) must evaluate each driver who has engaged in conduct that is prohibited under Subpart B of the regulations. The SAP will access and determine what assistance, in education, treatment, follow up testing and after care that the driver needs in resolving problems that are associated with alcohol and/or controlled substance misuse. 2. As the carrier, if you decide that you want to permit the driver to return to the performance of safety sensitive functions, you must ensure that the driver takes a return to duty test. This test cannot occur until after the SAP has determined that the driver has successfully complied with prescribed education and/or treatment. The driver must have a negative controlled substance test result and/or alcohol test with an alcohol concentration of less than 0.02 before resuming performance of safety sensitive duties. 3. If the driver had a positive controlled substance test, but the SAP s evaluation or the treatment program professional determined that the driver had an alcohol problem as well, the SAP may require that the driver have return to duty and follow up tests for both controlled substances and alcohol. 4. Follow up tests are mandatory and all tests are to be unannounced. The SAP is the only person that determines the amount of tests that are necessary. The minimum allowed is six tests within the first twelve months following the driver s return to duty. Follow up testing shall not exceed sixty months from the date of the driver s return to duty. 5. The cost of a return to duty test, any follow up tests, counseling as well as any SAP evaluations are not the responsibility of the carrier. The driver is held accountable for any out of pocket expenses that are incurred in order to meet the mandatory D.O.T. requirements to facilitate the return to the performance of safety sensitive functions. CONTROLLED SUBSTANCES AND ALCOHOL POLICY MANUAL UPDATED 11/

13 CONTROLLED SUBSTANCES AND ALCOHOL POLICY RECEIPT Receipt of controlled substance and alcohol testing policy manual: I, (print name):, certify that I have received, read and understand the Controlled Substance and Alcohol Policy issued by First Choice of Elkhart, Inc. I further accept and consent to the provisions thereof. I hereby accept this policy as condition of contract with First Choice of Elkhart, Inc. I also understand that I will be required to take and successfully pass urine controlled substance tests as a condition of my lease. I agree to comply with all requirements of the Federal Motor Carrier Safety Regulations Parts 382 and 40 and that failure to do so are grounds for termination of my contract. Driver Signature: Date: Witness Signature: Date: CONTROLLED SUBSTANCES AND ALCOHOL POLICY RECEIPT UPDATED 11/

14 MOBILE PHONE POLICY FOR COMMERICIAL MOTOR VEHICLE DRIVERS While Operating a Commercial Motor Vehicle (CMV), mobile phone use (with either a personal or company issued phone) by CMV drivers leased to First Choice of Elkhart, shall be subject to the following restrictions: 1. The Mobile phone must have a hands-free method of operation. This can include, but is not limited to: a. A blue-tooth headset; b. A vehicle-integrated communication system; or c. A mobile hands-free speak/microphone device. 2. Before commencing travel, the mobile phone must be configured so that it can receive and make a call either through voice activation, or with the push of a single button. 3. The mobile phone must also be located either on the driver, or within easy reach (i.e. affixed to the dash, visor, driver s side seat, etc.). 4. If the phone is going to be used as a GPS device to provide travel or mapping directions, it must be set up and running before commencing travel. Unless the driver pulls off the road and parks in a safe location, drivers are prohibited from: 1. Sending or reading text messages or photos; 2. Taking or viewing photos; 3. Manually dialing a phone number; 4. Looking up a contact number in the phone s directory; 5. Manipulating the GPS phone function in any way; or 6. Browsing the internet, or using any other phone application beyond taking and receiving calls. If a driver pulls off the road and parks in a safe location to engage in any of these mobile-phone related activities, they must note it in their travel log. In the case of making a phone call, the driver may commence driving again while they are still on the call, as long as a hands-free device is used. In the event that a driver is cited by DOT Authorities for use of a cellular phone in any of the afore mentioned manners, the driver will additionally be placed on a year probationary period subject to no further incidents. Driver Signature: Date: Witness Signature: Date: MOBILE PHONE POLICY 14

15 BRAKE INSPECTOR CERTIFICATION I, herby certify that I understand the brake service or inspection requirements of the Federal Motor Carrier Safety Regulations 49 CFR Part , and can perform such brake service or inspections by virtue of my training and/or experience. I hereby agree to comply with all such regulations governing brake service or inspections. I am qualified to perform the following brake duties: Adjust and inspect brakes and brake system components. Replace and repair brakes and brake system components. By reason of one or more of the following requirements (please check ALL that apply): I have completed an apprenticeship program sponsored by a State, a Canadian Province, a Federal Agency, a labor union, or a training program approved by a State, Provincial or Federal Agency, or have a certificate from a State or Canadian Province which qualifies me to perform brake service or inspection tasks. (This includes passage of Commercial Driver s License air brake tests in the case of a brake inspection). I have attached proof of completion of this program or training. I have completed at least one year of training and/or experience in a commercial training program sponsored by a vehicle manufacturer or similar commercial training program. This program was designed to train me in brake maintenance or inspection similar to the brake service or inspection tasks that I will perform. I have attached proof of this training or experience. I have at least one year of experience in performing brake maintenance or inspection similar to the brake service or inspection task I will be performing in a motor carrier maintenance program. Description: Years of Experience: I have at least one year of experience in performing brake maintenance or inspection similar to the brake service or inspection task that I will be performing at a commercial garage, fleet leasing company or a similar company. Description: Company Name: Address: City: State: Zip: Phone: From: / / to / / The above statements are true and correct to the best of my knowledge and I understand the information contained herein. I further certify that my experience meets or exceeds the requirements for qualified brake inspectors as stated in 49 CFR (d) of the Federal Motor Carrier Safety Regulations. Signature: Date: BRAKE INSPECTOR CERTIFICATION 15

16 WORKERS COMPENSATION INDEPENDENT CONTRACTOR WORKSHEET TO BE COMPLETED BY THE INDEPENDENT CONTRACTOR Policyholder Name form is being filled out for: Subcontractor Name: Doing Business as (DBA): If DBA is filed, attach a copy. 1. I operate as a : Sole Proprietor Partnership Corporation Limited Liability Company Note: If indicating Partnership, Corporation or Limited Liability Company, a Certificate of Workers Compensation Insurance or a properly filed Form BWC-337 must be submitted. 2. The type of work I perform can be described as: 3. I hire employees or casual laborers to complete work for the named policyholder: Yes No Number hired (Attach Certificate of Workers Compensation Insurance) Form 1040 SCHEDULE C (Profit or Loss from Business) may be provided as verification. 4. I hire subcontractors to complete work for the named policyholder: Yes No If yes, additional information may be required. 5. I have General Liability coverage: Yes No If yes, a Certificate of General Liability Insurance is required. 6. To validate my standing as an independent contractor, I state that I do not exclusively depend upon the payments of the named policyholder and have worked for the following general contractors or clients during the past twelve months. NAME CITY PHONE I acknowledge that as a sole proprietor, I am by law not covered by or subject to the Workers Disability Compensation Act. I certify the above represents a true and complete statement of my status as an Independent Contractor. I understand a company representative may verify this statement at any time. If requested, I agree to provide documentation to verify my status as a sole proprietor. Signed: Date: Phone Number: (required) Address: This form is utilized as a test of the above individual s independent status. By completing this form, it does not automatically remove the above individual s exposure from the audit of the policy period in question. Additional information may be required. If independent status is proven, the exposure will not be charged. INDPENDENT CONTRACTOR WORKSHEET 16

17 WORKERS COMPENSATION INDEPENDENT CONTRACTOR WORKSHEET 2 TO BE COMPLETED BY THE SOLE PROPRIETOR OWNER OPERATOR TRUCK DRIVER Please provide the following information on your operation: Do you own your own vehicle? Yes No If you lease the vehicle, who do you lease it from? What types of insurance do you carry as a trucking service? Do you have a signed contract in place with who you haul for? Yes No If yes, please attach a copy. How are you compensated? Hourly By the mile By the load other method, explain: Can you refuse to accept a given load? Yes No Who purchases the fuel for your vehicle? Who is responsible for maintenance cost of the vehicle? I acknowledge that as a sole proprietor, I am by law not covered by or subject to the Workers Disability Compensation Act. I certify the above represents a true and complete statement of my status as an Independent Contractor. I understand a company representative may verify this statement at any time. If requested, I agree to provide documentation to verify my status as a sole proprietor. Signed: Date: Phone Number: Address: (required) This form is utilized as a test of the above individual s independent status. By completing this form, it does not automatically remove the above individual s exposure from the audit of the policy period in question. Additional information may be required. If independent status is proven, the exposure will not be charged. INDPENDENT CONTRACTOR WORKSHEET 2 17

18 ACCIDENT KIT RECEIPT I,, have received my accident kit and will keep it in my truck at all times. Kit Contains: 1. Yellow Accident Camera 2. Auto Accident Report 3. Insurance ID Card 4. Urine Specimen Collection Kit 5. Federal Drug Testing Custody & Control Form 6. FedEx Clinical Shipping Pak 7. FedEx Shipping Label 8. First Choice Stick Pen Driver Signature Witness Signature Date Date Please contact Tonya, the Safety Manager, in any event the accident kit is used. Once opened, it must be replaced the next time you are in the office. Thank you, Tonya Christner Tonya Christner (269) Weekend/After Hours Contact Misty Campagna ACCIDENT KIT RECEIPT 18

19 DIRECT DEPOSIT AUTHORIZATION Authorization Agreement I hereby authorize First Choice of Elkhart, Inc. to initiate automatic deposits to my account at the financial institution named below. I also authorize First Choice of Elkhart, Inc. to make withdrawals from this account in the event that a credit entry is made in error. Further, I agree not to hold First Choice of Elkhart, Inc. responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in deposition funds to my account. This agreement will remain in effect until First Choice of Elkhart, Inc. receives a written notice of cancellation from me or my financial institution, or until I submit a new direct deposit form to the Payroll Department. Account Information Name of Financial Institution: Routing Number: Account Number: Checking Savings Signature Authorized Signature: Date: Print Name: Please attach a voided check or deposit slip, if available. DIRECT DEPOSIT AUTHORIZATION 19