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X111, 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. <br />Job T <br />Date <br />Time <br />1. 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 Breath Alcohol testing completed within eight (8) hours? '_Yes No If not, why? (Examples — <br />received notification too late, employee removed from the scene for medical treatment, EBT device not <br />available, injuries precluded testing, breath alcohol technician not 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 -No <br />If not, <br />why? <br />Supervisor's Name: <br />Supervisor's <br />Second Supervisor's Signature (if applicable): <br />Date: <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 MANAGEMENT SERVICE, LNG. (NCMSJ 20� � (uptla�a 2021J. The NGMS plan is <br />the subject ora tegisle[etl copynyhl antl is pro�oolotl by copyright levis In the U.S. and elsev(nere. All ri9M1is <br />eselved <br />56 <br />