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XIII. Appendix F <br />Post -Accident or Reasonable Cause/Suspicion <br />Supervisor Written Record <br />(Check one): ❑Pipeline (PHMSA) ❑Driver(FMCSA) <br />Employee's Name <br />Employee Id# <br />Describe Accident/Incident: <br />Dept. Date <br />Job Title Time <br />I. Was EBT Breath Alcohol testing completed within two (2) hours of the accident, or'the reasonable <br />cause/suspicion situation? _Yes No If not, why? (Examples — received notification too late, employee <br />removed from the scene for medical treatment, EBT device not available, injuries precluded testing, breath <br />alcohol technician not available) <br />2. Was EBT <br />Breath Alcohol testing completed within eight (8) hours? <br />'_Yes _No <br />If not, why? (Examples — <br />received <br />notification too late, employee removed from the scene <br />for medical <br />treatment, EBT device not <br />available, <br />injuries precluded testing, breath alcohol technician not <br />available) <br />3. Was urine <br />drug testing <br />completed <br />within <br />thirty-two (32) hours of the accident or reasonable cause/suspicion <br />situation? <br />_Yes <br />No If not, <br />why? <br />Supervisor's Name: <br />Supervisor's <br />Second Supervisor's Signature (if applicable): <br />***IMPORTANT *** <br />The above report is required in Post -Accident or Reasonable Cause/Suspicion testing when the tests) times <br />were not met. <br />The written report of Post -Accident or Reasonable Cause/Suspicion testing must be completed and signed by <br />the supervisor within 48 hours of the incident and subsequently faxed or e-mailed to the Company <br />Designated Employer Representative (DER). <br />Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN <br />NATIONAL COMPLIANCE MANAGEMF.�IT SERVICE, INC. (NCMS) 201� (update 2021i. the NGMS plan Is <br />the subject of e registered copyngpl and is protected Uy copYr�9hI lays In the U.S. antl elsawhore. All h9hts <br />reserved. 56 <br />