SIDE 2
SECTION 3:
TO BE COMPLETED BY PREVIOUS EMPLOYER
	"	~ 0	><.','",""".
DRUG AND ALCOHOL HISTORY
If driver was not subject to Department of Transportation testing requirements while employed by this employer, please check here D, fill in
the dates of employment from	to	, complete bottom of Section 3, sign, and return.
Driver was subject to Department of Transportation testing requirements from	to	YES	NO
	1. Has this person had an alcohol test with a result of 0.04 or higher alcohol concentration?	D	D
	2. Has this person tested positive or adulterated or substituted a test specimen for controlled substances?	D	D
3. Has this person refused to submit to a post-accident, random, reasonable suspicion, or follow-up alcohol or controlled
D
D
substance test?
4. Has this person committed other violations of Subpart B of Part 382, or Part 40?	D	D
5. If this person has violated a DOT drug and alcohol regulation, did this person complete a SAP-prescribed rehabilitation
D
D
program in your employ, including return-to-duty and follow-up tests? 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
D
D
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 obtained from prior previous employers in the
previous 3 years prior to the application date shown on side 1.
Name:
Company:
Street:
City, State, Zip:
Section 3 Completed by (Signature):
Telephone:
Date:
SECTION 4a:
TO BE COMPLETED BY PROSPECTIVE EMPLOYER
D Faxed to previous employer	D Mailed	D Emailed	D Other
This form was (check one)
By:
Date:
SECTION 4b:
TO BE COMPLETED BY PROSPECTIVE EMPLOYER
Complete below when information is obtained. Information received from:
Recorded by:
Date:
Method: D Fax D Mail D Email D Telephone
	D Other
INSTRUCTIONS TO COMPLETE THE SAFETY PERFORMANCE HISTORY RECORDS REQUEST
SIDE 1 SECTION 1: Prospective Employee
. Complete the information required in this section . Sign and date
. Submit to the Prospective Employer
SIDE 2 SECTION 3: Previous Employer
. Complete the information required in this section . Sign and date
. Retain Ply 2
. Return Ply 1 to Prospective Employer
SIDE 2 SECTION 4a: Prospective Employer
. Remove Ply 3
. Remove the adjacent carbon
. Complete the information
. Send Ply 1 and 2 to the Previous Employer
SIDE 2 SECTION 4b: Prospective Employer . Record receipt of the information
. Retain Ply 1
SIDE 1 SECTION 2: Previous Employer
. Complete the information required in this section
. Sign and date
. Remove the carbon
. Turn form over to complete SIDE 2 SECTION 3
@Copyright 2004 J. J. KELLER & ASSOCIATES, INC., Neenah, WI- USA - (800) 327-6868 - www.llkeller.com - Printed in the United States
850-FS-C3 9620