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Please provide any additional information related to observations of unsafe commercial motor vehicle operation or <br />accidents involving the applicant that were reported to you, your organization, government agencies, or insurers or retained <br />under internal company policies: <br />Include any additional safety performance remarks <br />*Accident means an occutrence involving a commercial motor vehicle operating on a highway in interstate or intrastate <br />commerce which results in: <br />A A fatality; <br />A Bodily injury to a person who, as a result of the injury, immediately receives medical treatment away from the scene of <br />the accident; or <br />A One or more motor vehicles incurring disabling damage as a result of the accident, requiring the motor vehicles(s) to be <br />transported away from the scene by a tow truck or other motor vehicle. <br />Part 4: To Be Completed Bv Previous Emplover <br />DOT-Regulated Drug and Alcohol Testing History: <br />If the named applicant was not subject to DOT-regulated alcohol and controlled substance testing requirements while in your <br />employ check here n, complete the bottom portion of Part 4, sign and return this form. <br />The above named applicant was subject to DOT-regulated alcohol and controlled substance testing requirements while in your <br />employ fi'om _ to <br />l. Did the individual have an alcohol test with a blood alcohol concentration result of0.04 or higher? <br />tr <br />2. Didthe individual tested positive or adulterated or substitute atest for controlled substances? <br />NoE <br />3. Did the individual refuse to submit to a DOT-regulated alcohol or controlled substance test? <br />No! <br />4. Did the individual engage in conduct prohibited by 49 CFR Part382 - Subpart B, or Part 40? <br />NoE <br />5. Did the individual volunteer that he or she has an alcohol or controlled substance problem? <br />NoE <br />6. If "Yes" was checked for any question l-5, did this individual complete a SAP-prescribed rehabilitation program <br />while in your employ, including a return-to-duty and all follow up tests? Ifyes, please send documentation along <br />with this form. <br />Yes E No <br />Yes E <br />Yes D <br />Yes ! <br />Yes !