Forms for Medical DOT

Transcription

1 Frms fr Medical DOT Please fill ut the fllwing frms in their entirety and fllw instructins as t where they are sent r taken. Fr questins, please call Staffing Administratin HQSBI at Frms A, B, C & E shuld be faxed within 24 hurs f receiving. Drug test must be taken by January 4, Frm A DOT Drug Screen Infrmatinal Sheet Emplyee is required t fill ut frm Emplyee is required t fax this frm t HQSBI at r StaffingAdministratin@cair.cm Frm B DOT Self-Disclsure Emplyee is required t fill ut frm Emplyee is required t fax this frm t HQSBI at r StaffingAdministratin@cair.cm Frm C DOT Medical Questinnaire Emplyee is required t fill ut frm If the answer is yes t any f the questins #2 - #5, have yur prvider explain thrugh cmpletin f an Absence Certificate and fax t OPCMD at alng with this dcument; therwise, fax this frm t HQSBI at Frm D Pst Offer Prtcl Authrizatin Emplyee is required t fill ut frm Emplyee is required t fax this frm t HQSBI at r StaffingAdministratin@cair.cm Emplyee shuld cntact the nearest Cncentra medical facility t cnfirm lcatin, hurs f peratin, and determine if they require an appintment Use the fllwing website t lcate the Cncentra medical facility clsest t yu: Emplyee is required t bring this frm t the medical facility fr Drug-Screen Medical facility will keep this frm Frm E DOT Authrizatin fr Release Emplyee is required t fill ut frm and fax t HQSBI at r t StaffingAdministratin@cair.cm Revised 10/8/2012

2 Frm A DOT Drug Screen Infrmatinal Sheet UNITED AIRLINES INFORMATIONAL SHEET FOR DRUG AND ALCOHOL TESTING FOR SAFETY- SENSITIVE POSITIONS I understand that the FAA requires airlines t cnduct pre-emplyment drug testing, which cnsists f a urinalysis f individuals applying fr r transferring int safety-sensitive psitins. I understand that my urine specimen will be tested fr the fllwing drugs: cannabinids (marijuana), ccaine, piates, PCP, and amphetamines. I understand that any ffer made t me f a safety-sensitive psitin as defined by FAA Regulatins will be cntingent upn my passing a drug test. I als understand that if placed in a safety-sensitive psitin, and if apprpriate circumstances exist, I will thereafter be subject t pst-accident, randm, reasnable cause, return t duty, and fllw-up drug and/r alchl testing. I understand that my refusal t submit t required testing is grunds fr discharge. I als understand that failure t reprt fr a required test r engaging in cnduct which bstructs the testing prcess will be cnsidered a refusal t submit t a test. Within the past tw (2) years, have yu tested psitive, r refused t test, n any preemplyment drug r alchl test administered by an emplyer t which yu applied fr, but did nt btain, safety-sensitive transprtatin wrk cvered by the U.S. Department f Transprtatin and/r its agencies drug and alchl testing rules? YES NO Scial Security Number Date Printed Name Signature Please fax t: United Airlines HQSBI at r StaffingAdministratin@cair.cm

3 Frm B DOT Self-Disclsure TO BE COMPLETED BY EMPLOYEES APPLYING FOR, TRANSFERRING, OR RETURNING TO POSITIONS SUBJECT TO DOT DRUG AND ALCOHOL TESTING PRINT Name: Jb Title: Please answer the fllwing questins: 1. Have yu ever tested psitive n r refused a Department f Transprtatin drug test since Sept.19, 1994? Yes N If yes, list name f cmpany r emplyer and date f test(s) 2. Have yu ever tested psitive n r refused a Department f Transprtatin alchl test since Jan.1, 1995? Yes N If yes, list name f cmpany r emplyer and date f test(s) 3. Have yu ever been Permanently Barred (tw psitive and verified drug tests r tw alchl test results f 0.04 r greater) frm the perfrmance f safety-sensitive jb functins by an emplyer r cmpany under Federal Aviatin Administratin (FAA) drug/alchl regulatins? Yes N If yes, list name f emplyer r cmpany, date f test(s), and jb functin at time f the Permanent Bar I, the undersigned, state that all infrmatin given by me n this questinnaire is true t the best f my knwledge. In additin, if I marked "Yes" t any f the abve questins, I hereby authrize release f infrmatin frm my Department f Transprtatin regulated drug and alchl testing recrds by a cmpany r by my previus emplyer, listed abve t United Airlines Medical Department - WHQMD, 1200 E. Algnquin Rad, Elk Grve, IL 60007, Fax number I understand that infrmatin t be released by a cmpany r by my previus emplyer is limited t the fllwing DOT-regulated testing items: 1. Alchl tests with a result f 0.04 r higher; 2. Verified psitive drug tests; 3. Refusals t be tested; 4. Other vilatins f DOT agency drug and alchl testing regulatins; 5. Infrmatin btained frm previus emplyers f a drug and alchl rule vilatin; 6. Dcumentatin, if any, f cmpletin f the return-t-duty prcess fllwing a rule vilatin. Emplyee Signature Scial Security Number Date Ntice t Candidates: If United Airlines is unable t btain yur drug and alchl testing recrds frm a cmpany r by yur previus emplyer(s) and/r health care prvider(s), the cnditinal ffer f emplyment may be rescinded. Ntice t Califrnia Residents: 1. Medical infrmatin t be btained is t be used fr the purpses f evaluating emplyment and benefits. 2. The signer is entitled t keep a cpy f this questinnaire. Please fax t: United Airlines HQSBI at r StaffingAdministratin@cair.cm

4 Frm C DOT Medical Questinnaire GENERAL INFORMATION Name Scial Security Number Phne Address/City/State Jb Title Please refer t the jb descriptin fr the psitin yu have accepted r are returning t with United Airlines in rder t cmplete the fllwing statements and questins. If a jb descriptin is nt available t yu, please cntact r StaffingAdministratin@cair.cm. 1. I have reviewed the jb descriptin and fully understand the varius requirements and functins f the psitin fr which United Airlines has given me a cnditinal ffer f emplyment. Yes N 2. D yu currently have any medical restrictins r suffer frm any medical cnditin which may impact r limit in any way yur ability t fully and effectively perfrm the functins f the psitin listed in the jb descriptin? Yes N If yes, have yur prvider explain thrugh cmpletin f an Absence Certificate and fax t OPCMD at alng with this dcument 3. If the jb descriptin cntains safety-sensitive duties and/r requires the peratin r maintenance f any mtr vehicles, are yu currently taking r have yu been prescribed any f the fllwing classes r types f medicatin: prescriptin painkillers, tranquilizers r sedatives, diabetes medicatin (including insulin), r anti-seizure medicatins? Yes N If yes, have yur prvider explain thrugh cmpletin f an Absence Certificate and fax t OPCMD at alng with this dcument 4. Are yu currently taking r have yu been prescribed medicatins that may impact, limit, r impair yur ability t fully, safely, and effectively perfrm the functins f the psitin listed in the jb descriptin? Yes N If yes, have yur prvider explain thrugh cmpletin f an Absence Certificate and fax t OPCMD at alng with this dcument 5. If the jb descriptin requires yu t drive, perate, r maintain a mtr vehicle, d yu have any medical restrictins r take any medicatins which prevent r limit yu in any way frm hlding a state issued driver s license r frm perating a mtr vehicle? Yes N If yes, have yur prvider explain thrugh cmpletin f an Absence Certificate and fax t OPCMD at alng with this dcument 6. Please check ne f the fllwing: A. I am able t perfrm all f the functins f the jb as listed in the descriptin. B. I am unable t perfrm all f the functins f the jb as listed in the descriptin. C. I am unsure if I am able t perfrm ne r mre f the functins f the jb as listed in the descriptin. 7. If yu selected B r C in the abve questin, please describe r list the functins at issue. I hereby certify that all respnses and statements prvided by me in this questinnaire frm are cmplete and true t the best f my knwledge. I further understand and agree that falsificatin f the abve may be cnsidered sufficient cause fr terminatin f my emplyment at any time during my emplyment with United Airlines. Candidate Signature Date Please fax t: United Airlines HQSBI at r StaffingAdministratin@cair.cm

5 Frm D Pst Offer Prtcl Authrizatin United Airlines Pst Offer Prtcl Authrizatin (Must Present Pht ID at the Time f Service) Nte t Medical Vendr: United Airlines uses LabCrp fr lab facilities and FirstLab as the MRO. If yu d nt have the prper Chain f Custdy frms fr these cmpanies, please cntact FirstLab at (d nt leave a vice message, but return t the FirstLab peratr t be redirected); they can explain the prcess fr altering a frm and prvide accunt numbers fr United Airlines at LabCrp. Please DO NOT turn away any United pre-emplyment candidates! Emplyee Name: Scial Security Number: Address Cde: United Staffing Representative - PLEASE INDICATE POSITION APPLIED FOR: POSITION DRUG SCREEN TESTING X Flight Attendant DOT-FAA -pre emplyment Nt Required Onbard Supervisr DOT-FAA -pre emplyment Audigram/Visin/Tympangram Aircraft Mechanic DOT-FAA -pre emplyment Audigram/Visin Titmus Pilt / Flight Instructr DOT-FAA -pre emplyment n/a Dispatch / Lad Planner DOT-FAA -pre emplyment n/a Bus Driver DOT-FMCSA pre emplyment DOT Preplacement Grund/Facilities Mechanic Nn DOT -pre emplyment Audigram/Visin Titmus Ramp Services Nn DOT -pre emplyment Audigram/Visin Titmus Line Statin CSR Nn DOT -pre emplyment Audigram/Visin Titmus Hub CSR Nn DOT -pre emplyment n/a Salaried and Management Nn DOT -pre emplyment n/a Strekeeper Nn DOT -pre emplyment n/a Reservatins Nn DOT pre emplyment n/a UA Representative: Jan Hgan Phne Number: Date: Cpy f Chain f Custdy shuld be faxed t: United Airlines HQSBI at r StaffingAdministratin@cair.cm T rder additinal Chain f Custdy frms, please cntact FirstLab at

6 Frm E Authrizatin fr Release Authrizatin Fr Release f Anti-Drug and Alchl Misuse Preventin Prgram Infrmatin Psitin (circle): Flight Attendant / Inflight Mgr-Supv / Mechanic / Dispatch / Lad Planner / GSC Sectin I. T be cmpleted by emplyee: Emplyee Printed r Typed Name: Emplyee SS r ID Number: I hereby authrize release f infrmatin frm my Department f Transprtatin regulated drug and alchl testing recrds by my previus emplyer, listed in Sectin I-B, t the emplyer listed in Sectin II. This release is in accrdance with DOT Regulatin 49 CFR Part 40, Sectin I understand that infrmatin t be released in Sectin III-A by my previus emplyer, is limited t the fllwing DOT-regulated testing items: 1. Alchl tests with a result f 0.04 r higher; 2. Verified psitive drug tests; 3. Refusals t be tested; 4. Other vilatins f DOT agency drug and alchl testing regulatins; 5. Infrmatin btained frm previus emplyers f a drug and alchl rule vilatin; 6. Dcumentatin, if any, f cmpletin f the return-t-duty prcess fllwing a rule vilatin. Emplyee Signature: Date: I-B. Identify whether yu have been emplyed r applied fr a psitin in the past tw years by an emplyer that is required t cnduct drug/alchl testing fr the Department f Transprtatin. N, I have nt wrked r applied fr a cmpany in the past tw years that the Department f Transprtatin required drug/alchl testing. FAX TO r StaffingAdministratin@cair.cm. Separate frm must be used fr each cmpany. Yes, I have wrked r applied fr a cmpany in the past tw years that the Department f Transprtatin required drug/alchl testing. (include emplyer infrmatin belw) FAX TO r StaffingAdministratin@cair.cm. Previus Emplyer Name: Address: Phne # : Psitin Held: Dates f Emplyment: Frm: T: Designated Emplyer Representative (if knwn): Sectin II. Once sectin III is cmpleted by the emplyer FAX TO r StaffingAdministratin@cair.cm. Sectin III. T be cmpleted by the previus emplyer and transmitted by mail r fax t United Airlines: III-A. In the tw years prir t the date f the applicant's signature (in Sectin I), fr DOT-regulated testing ~ 1. Did the applicant have alchl tests with a result f 0.04 r higher? YES NO 2. Did the applicant have verified psitive drug tests? YES NO 3. Did the applicant refuse t be tested? YES NO 4. Did the applicant have ther vilatins f DOT agency drug and alchl testing regulatins? 5. Did a previus emplyer reprt a drug and alchl rule vilatin t yu? If yes prvide previus emplyers reprt 6. If yu answered yes t any f the abve items, did the emplyee cmplete the return-t-duty prcess? YES NO YES NO N/A YES NO if yes, transmit apprpriate Return-t-duty dcumentatin Name & Title f persn prviding Sectin III infrmatin: Phne Cntact: Date:

7 Frm E Authrizatin fr Release United Airlines Authrizatin fr Release f Anti-Drug and Alchl Misuse Preventin Prgram Infrmatin Directins: Circle psitin Flight Attendant. Sectin I: 1. Emplyee must print their name and scial security number r ID number. 2. Emplyee must sign and date. Sectin I A Nthing required t be filled ut. Sectin I B If emplyee HAS NOT wrked fr a cmpany in a safety-sensitive psitin that is DOT regulated within the last 2 years, please check the N r nn-applicable line. If the emplyee HAS wrked fr a cmpany (including previus United emplyee) in a safetysensitive psitin that is DOT regulated within the last 2 years, please prvide the previus emplyer s name, address, phne number, dates f emplyment and designated emplyer representative s name. NOTE: A separate frm MUST be filled ut fr each past emplyer. Yu may nt list mre than ne cmpany n a single frm. DOT regulated psitins include (but are nt limited t): FAA (Federal Aviatin Administratin) : Pilt, Chief Pilt, Flight Manager, Flight Attendant, Onbard Service Supervisrs, Mechanic, Dispatcher, Grund Security Crdinatr, Flight Instructr, Security Screeners r Air Traffic Cntrllers. FMCSA (Federal Mtr Carrier Safety Administratin) : A persn wh perates (i.e. drives) a Cmmercial Mtr Vehicle (CMV) weighing 26,001 punds r greater, r is designed t transprt 16 r mre ccupants (t include the driver); r is f any size and is used in the transprt f hazardus materials that require the vehicle t be placarded. FRA (Federal Railrad Administratin) : A persn wh perfrms hurs f service functins at a rate sufficient t be placed int the railrad s randm testing prgram. Categries f persnnel wh nrmally perfrm these functins are engineers, cnductrs, signalmen, peratrs, dispatchers, and switchmen. FTA (Federal Transit Administratin) : A persn wh perfrms a revenue vehicle peratin, revenue vehicle and equipment maintenance; revenue vehicle cntrl r dispatch, Cmmercial Driver s license nn-revenue vehicle peratin r armed security duties. USCG (United States Cast Guard) : A persn wh is n bard a vessel acting under the authrity f a license, certificate f registry, r merchant mariner s dcument. Als, a persn engaged r emplyed n bard a U.S. wned vessel and such vessel is required t engage, emply r be perated by a persn hlding a license, certificate f registry, r merchant mariner s dcument. RSPA (Research and Special Prgrams Administratin) : A persn wh perfrms n a pipeline r liquefied natural gas (LNG) facility an peratin, maintenance, r emergencyrespnse functin. Sectin II & III D nt fill in these areas. If yu inadvertently fill this ut, please ask fr a new frm.