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Authorization For Release Of DOT Drug And Alcohol Testing Records FAA 8060-12 - Official Federal Forms
| Authorization For Release Of DOT Drug And Alcohol Testing Records Form. This is a national form and can be used in Federal Aviation Administration (FAA) . |
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Form Approved: OMB No. 2120-0607 06/30/2007 AUTHORIZATION FOR RELEASE OF DOT DRUG AND ALCOHOL TESTING RECORDS UNDER PRIA AND MAINTAINED UNDER TITLE 49 CODE OF FEDERAL REGULATIONS (49 CFR) PART 40 Pilot Records Improvement Act Of 1996 (PRIA) Title 49 U.S.C. § 44703(h), RECORDS OF EMPLOYMENT OF PILOT APPLICANTS, as amended Part I: To be completed by the new employer, signed by the applicant/employee, and transmitted to the previous employer. TO: (Previous Employer Name Printed) ___________________________________ ________ (Street Address) , (City) __________, _________, (State) __________ (Zip) I, ______________________________________________ SSN: ________________________ have applied for employment (Applicant/Employee Name Printed) (OPTIONAL See the attached Privacy Act statement) with ____________________________________________________, _______________________, and hereby authorize the (Hiring Air Carrier Name Printed) (Air Carrier Certificate Number) release of records from Department of Transportation-regulated drug and alcohol testing of me by my previous employer, to ______________________ __________________________________ FAX Number:__________________________ (Of the hiring Air Carrier) (Printed name of the Designated Employer Representative (DER) authorized to receive the released records) I understand that this release of 5 years of records by my previous employer satisfies the requirements of DOT Code of Federal Regulations 49 CFR § 40.25(a)-(i) and 49 CFR § 40.333, and is limited to the following DOT-regulated testing records: 1. 2. 3. 4. 5. 6. 7. 8. Confirmed alcohol test results indicating an alcohol concentration of 0.04 or greater; Verified positive drug test results; Documentation of refusals to take required alcohol and/or drug tests (including substituted or adulterated test results); Documentation of other violations of DOT agency drug and alcohol testing regulations; Substance Abuse Professional (SAP) reports; All follow-up test results and schedules for follow-up tests, including documentation of each return-to-duty test; Information obtained from previous employers under 49 CFR § 40.25 concerning drug and/or alcohol violations; Records of negative and cancelled drug test results, and confirmed alcohol test results with an alcohol concentration of less than 0.039. Date: ________________________ Applicant/Employee Signature: _____________________________________________ A reproduction of this authorization shall be deemed effective and valid as an original. Part II: To be completed by the previous employer (DER) and transmitted by mail or fax to the new employer. In the five year period, prior to the date of the employee's signature in Part I, for DOT regulated testing: 1. Did the employee have any confirmed alcohol tests with a concentration of 0.04 or higher? 2. Did the employee have any verified positive drug tests? 3. Did the employee refuse to be tested? 4. Did the employee have other violations of DOT agency drug and/or alcohol testing regulations? 5. Did a previous employer report a drug and/or alcohol rule violation to you? 6. If you answered `yes' to any of the above items, did the employee complete the `return-to-duty' process? YES_____ NO_____ YES_____ NO_____ YES_____ NO_____ YES_____ NO_____ YES_____ NO_____ N/A_____ YES_____ NO_____ If you answered `yes' to item 6, please provide the appropriate return-to-duty documentation (SAP reports and follow-up testing). 49 U.S.C. § 44703(h)(1)(B) requires `records' to be furnished. This includes records of positive as well as negative results. Name of the Designated Employer Representative (DER) providing the records:_______________________________________ Phone Number:_______________________Email or FAX Number:_____________________________ Date:_______________ PREVIOUS EMPLOYER: If the individual named in Part I above has requested a copy of their records pursuant to a PRIA records request on FAA Form 8060-11A, AIRMAN NOTICE AND RIGHT TO RECEIVE COPY -- AIR CARRIER AND OTHER RECORDS (PRIA), copies of the Drug and Alcohol records must be provided to the individual (Title 49 U.S.C. § 44703(h)(6)). Forward copies of the Drug and Alcohol records to the address provided by the individual on FAA Form 8060-11A. FAA Form 8060-12 (10-05) American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS FAA FORM 8060-12, AUTHORIZATION FOR RELEASE OF DOT DRUG AND ALCOHOL TESTING RECORDS UNDER PRIA AND MAINTAINED UNDER TITLE 49 CODE OF FEDERAL REGULATIONS (49 CFR) PART 40 Pilot Records Improvement Act Of 1996 (PRIA) Title 49 U.S.C. § 44703(h), RECORDS OF EMPLOYMENT OF PILOT APPLICANTS, as amended Air Carriers should use this form to request the appropriate records from current and/or past employers as contemplated under 49 U.S.C. § 44703(h), Records of Employment of Pilot Applicants, As Amended. NOTICE: This request is for the 5-year period preceding the date of the employee's signature in Part I of this form. This request will not be deemed valid unless Parts I and II are completed as specified. Pursuant to 49 U.S.C. § 44703(h)(5), a person who receives a request for records under 49 U.S.C. § 44703(h)(1) shall furnish a copy of all such requested records maintained by the person not later than 30 days after receiving the request. An additional copy must be furnished to the subject of this request only if that person has so indicated on the attached FAA Form 8060-11A, by checking the `YES' block. See the note to the previous employer at the bottom of FAA Form 8060-12. This form may be photocopied for use, or is available on the Internet at http://www.faa.gov/pilots/lic_cert/pria/ or http://forms.faa.gov/ This form is to be used as an attachment to FAA Forms 8060-11 and 8060-11A. A separate form must be used for each airman whose records are requested. Do not use with FAA Forms 8060-10 or 8060-10A. Part I: To be completed by the new employer and signed by the applicant/employee. All entries must be completed legibly with black or dark blue ink. 1. TO enter the name and address of the applicant/employee's previous employer. 2. Enter the name and SSN of the applicant/employee. (SSN is optional see Privacy Act statement below) 3. Enter the name and air carrier certificate number of the requesting employer. 4. Enter the name of the Designated Employer Representative authorized to receive the released records. 5. Signature signature of the applicant/employee. 6. Date enter the date of the request Part II: To b
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