Test Supervisor File Note for Drug and Alcohol Testing
‘I [insert name] am a test supervisor under the provisions of the Passenger Transport (Drug & Alcohol Testing) Regulation, 2010. You are now required to submit to a [insert test type] in accordance with the regulation and State Transit’s Drug and Alcohol Procedure. Failure to undergo testing is considered a breach of the regulation and State Transit’s Procedure and could lead to prosecution and disciplinary action.’
OR
‘I [insert name] am a test supervisor and ask that you participate in a [insert test type]. Refusal to participate in this test could lead to prosecution and disciplinary action.’
(Circle test type below as appropriate)
Random Incident Reasonable Cause Targeted
Choose one of the following scripts and read it aloud to the worker when commencing the testing process.
‘I [insert name] am a test supervisor under the provisions of the Passenger Transport (Drug & Alcohol Testing) Regulation, 2010. You are now required to submit to a [insert test type] in accordance with the regulation and State Transit’s Drug and Alcohol Procedure. Failure to undergo testing is considered a breach of the regulation and State Transit’s Procedure and could lead to prosecution and disciplinary action.’
OR
‘I [insert name] am a test supervisor and ask that you participate in a [insert test type]. Refusal to participate in this test could lead to prosecution and disciplinary action.’
| Worker Name | Employee Number / Contractor Company | ||
| Worker Position | Depot/Site | ||
| Employee DOB | Driver Authority Card # | ||
| Employee Signature | |||
| Date & Time: | Location of test: | Tester (Name): | Tester Signature: | |
| Declaration of Drugs and/or Alcohol: | Includes: prescription/non-prescription medication | |||
| Test Type (Circle):
Drug Alcohol |
Test Type (Circle):
Saliva Urine Blood Breath |
Result (Circle, document detail):
Positive Negative
|
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| Refusal / Inability to provide (please detail) | ||||
| Comments (This section may include exchanged dialogue between the tester and worker):
NB: If positive, notify Worker’s Manager and Safety Professional, Safety Programs. |
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