Code No. 4O3.10E3
CONSENT FOR RELEASE OF INFORMATION
Name (print):________________________________________________________________
Social Security Number:______________________________________________________
The following records should be on file prior to, and must be no later than 14 days of, your performing a safety-sensitive function for the school district. Without these records from your prior employers you will be unable to perform a safety-sensitive function for the school district and will no longer be employed by the school district at the expiration of the 14-day period.
I authorize release of the following records related to my participation in a U.S. DOT approved and/or other drug and alcohol testing program for the prior two years:
1. Alcohol test results of 0. 04 breath alcohol concentration or greater;
2. Positive drug test results;
3. Refusals to be tested for drugs or alcohol;
4. Substance abuse evaluations;
5. Recommended treatment by a substance abuse professional;
6. Completion of treatment recommended by a substance abuse professional; and
7. Other information related to violations of U. S .DOT drug and alcohol regulations.
Signature:___________________________________________________________________
Date:________________________________________________________________________
RECORDS TO BE RELEASED FROM:
Company Name: _______________________________________________________________
Address: ____________________________________________________________________
Telephone/other: ____________________________________________________________
RECORDS TO BE RELEASED TO:
School District Contact Person: Vicki Palmer
Address: Riverside Community School District, P .0. Box 218, Carson, IA 51525
Requested information enclosed
I certify, to the best of my knowledge, the company named above has a U .S. DOT drug and alcohol testing program conforming to U.S. DOT requirements in place and the above named individual participated in such program from (date) to (date) and, within the two years preceding this request, had no alcohol test results of 0. 04 breath alcohol concentration or greater, no positive drug test results, no refusals to be tested for drugs or alcohol, no substance abuse professional evaluations, no recommended treatment for substance abuse, or other violations related to the U.S. DOT drug and alcohol regulations.
Name ________________________________________________________________________
Signature ___________________________________________________________________
Title _______________________________________________________________________
Date ________________________________________________________________________
Revised 7-17-23