Employee Drug and Alcohol Statement
DOT Rule 49 CFR Part 40 Section 40.25
(j) As the employer, you must also ask the employee whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years. If the employee admits that he or she had a positive test or a refusal to test, you must not use the employee to perform safety-sensitive functions for you, until and unless the employee documents successful completion of the return-to-duty process (see paragraphs (b)(5) and (e) of this section).
Signature of Employee                                                                    Date
Signature of Witness                                                                       Date
Please mail the signed form, with any other forms that require your signature to our main office:
174 Route 17 North Suite 213
Rochelle Park, NJ 07662