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Positive Controlled Substance DS-334 - California
| Positive Controlled Substance Form. This is a California form and can be used in Administrative Hearings And Reexaminations Statewide . |
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STATE OF CALIFORNIA DEPARTMENT OF MOTOR VEHICLES ® A Public Service Agency Mail this form no later than five days after receiving notification of a positive result to: Driver Safety Actions Unit Attn: Special Certificate 2570 24th Street, MS J234 Sacramento, CA 95818-2526 POSITIVE CONTROLLED SUBSTANCE TEST RESULT REPORT California Vehicle Code Section (VC) 13376(b)(1) requires employers who provide pupil transportation, general public paratransit, or transportation of developmentally disabled persons to report to the Department of Motor Vehicles (DMV), any driver or applicant who fails to comply with the testing requirements for, or receives a positive test for a controlled substance. The employer, or rehabilitation, or return to duty program shall report any subsequent positive test result or drop from the program to DMV on a form approved by the department. According to section 13376(b)(3) VC, the carrier that requested the test shall report the refusal, failure to comply, or positive test result to the department not later than five days after receiving notification of the test result on a form approved by the department. This is the form approved by DMV for use to report such drivers or applicants. Mail the original to the above address and submit a copy to your local California Highway Patrol Area Office, Attn: School Bus Officer/ Coordinator. Programs and testing must comply with the requirements specified in Part 382 (commencing with Section 382.101) of Title 49 of the Code of Federal Regulations SECTION 1 -- DRIVER INFORMATION (TYPE OR PRINT LEGIBLY) DRIVER'S FULL NAME BIRTHDATE DRIVER LICENSE NUMBER ADDRESS (STREET) CITY STATE ZIP CODE TELEPHONE NUMBER ( CURRENT CERTIFICATE EXPIRATION DATE (RENEWAL) CERTIFICATE APPLICATION DATE (ORIGINAL) AGENCY NAME ADMINISTERING TEST ) CERTIFICATE TYPE TELEPHONE NUMBER ( AGENCY ADDRESS ADMINISTERING TEST CITY STATE REASON FOR TEST (PRE-EMPLOYMENT, POST ACCIDENT, REASONABLE SUSPICION, RANDOM, RETURN TO DUTY, FOLLOW-UP) TEST DATE ) ZIP CODE TEST RESULTS/TEST REFUSED EMPLOYER NAME (PLEASE PRINT) EMPLOYERS TELEPHONE NUMBER ( EMPLOYER ADDRESS (PLEASE PRINT) CITY STATE ) ZIP CODE SECTION 2 -- REHABILITATION/RETURN TO DUTY PROGRAM INFORMATION (FOR EXISTING CERTIFICATE HOLDERS ONLY) REHABILITATION/RETURN TO DUTY PROGRAM NAME/ADDRESS CITY STATE ZIP CODE PROGRAM LENGTH PROGRAM START DATE EMPLOYER IMPOSING PROGRAM PARTICIPATION (PLEASE PRINT) CURRENT DATE EMPLOYER'S TELEPHONE NUMBER ( SECTION 3 -- POST PROGRAM DROPS POSITIVE RESULTS SHOWN ) DATE OF POSITIVE TEST RESULTS REASON DRIVER DROPPED DATE DRIVER DROPPED NAME/AGENCY OF INDIVIDUAL REPORTING DROP INFORMATION CURRENT DATE TELEPHONE NUMBER ( PERSON REPORTING APPLICANT/DRIVER (PLEASE PRINT) SIGNATURE ) DATE I, the under signed, do hereby report the driver noted above as required according to Section 13376(b)(1) of the California Vehicle Code. X DS 334 (REV. 1 /2010) WWW American LegalNet, Inc. www.FormsWorkFlow.com
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