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XIll. Appendix F <br />Post -Accident or Reasonable Cause/Suspicion <br />Supervisor Written Record <br />(Check one): ❑Pipeline (PHMSA) ❑Driver(FMCSA) <br />Employee's Name Dept. Date <br />Employee Id# Job Title Time <br />Describe Accident/Incident: <br />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 />emoved 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 drug testing completed within thirty-two (32) hours of the accident or reasonable cause/suspicion <br />situation? _Yes -No If not, why? <br />Supervisor's Name: <br />Supervisor's Signature: <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/AICOHOI PLAN <br />l� NATIONAL COMPLIANCE PAANAGEMEN'r SERVICE, ING. (NCMS) 2011 (uptlale 2021). The NCIv15 plan is <br />the subiecl o[ a registeretl copyrlgh! and is prolacted by copyhghl lays in the U S. and elsewM1ere_ All rlyhts <br />reserved <br />FY�3 <br />