Clearinghouse Reporting

Date of Alcohol Test

Reason For Test
—Please choose an option—Pre-employmentRandomPost-accidentReasonable SuspicionReturn to DutyFollow-up

Test Result

Documentation

Accepted file types: pdf, docx, Max. file size: 5 MB.

Date of Test

Test Type
—Please choose an option—DrugAlcohol

Reason For Test
—Please choose an option—Pre-employmentRandomPost-accidentReasonable SuspicionReturn to DutyFollow-up

Documentation of the Refusal

Upload Documentation
Accepted file types: pdf, docx, Max. file size: 5 MB.

Test Type
—Please choose an option—DrugAlcohol

Specimen ID #

Date of Test

Reason For Test
—Please choose an option—Return to Duty

Test Result
—Please choose an option—NegativePositiveRefusal

Date of Verified Result*

Documentation

Accepted file types: pdf, docx, Max. file size: 5 MB.

Date Drivers Follow up Plan has Been Successfully Completed

Documentation

Accepted file types: pdf, docx, Max. file size: 5 MB.

Date Employer Obtained Actual Knowledge: (date field)

Description of the violation:

Witnesses to the violation, include any contact information

Accepted file types: pdf, docx, Max. file size: 5 MB.

Evidence supporting each fact alleged in the description of the violation

Max. file size: 5 MB.
Evidence supporting each fact alleged in the description of the violation, which may include, but is not limited to, affidavits, photographs, video or audio recordings, employee statements (other than admissions pursuant to § 382.121), correspondence, or other documentation.

A certificate of service or other evidence showing that the employer provided the employee with all information reported.

Accepted file types: pdf, docx, Max. file size: 5 MB.