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Pre-Employment Drug and Alcohol Questionnaire

Required DOT applicant disclosure regarding drug and alcohol testing history over the prior two years, including return-to-duty status and documentation.

Full Name*

Phone Number*

Email Address*

Applicant

Full Legal Name*

Applicant Tracking ID*

Application Date*

Required Questions

During the prior 2 years, did you test positive or refuse a DOT pre-employment drug or alcohol test for safety-sensitive transportation work that you did not obtain?*

Yes

If yes, have you successfully completed the required return-to-duty process?*

Not Applicable

Yes - documentation attached

If yes to the first question, provide employer / testing program and dates

Return-to-duty completion documentation if applicable

I agree

Upload / Received Date (Return-to-duty)

Verified By (Return-to-duty)

Substance Abuse Professional documentation if applicable

I agree

Upload / Received Date (SAP)

Verified By (SAP)

Certification

Applicant Printed Name*

Applicant Signature*

By typing your name, you are electronically signing this document.

Date*