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XIII. Appendix <br />Post -Accident or Reasonable Cause/Suspicion <br />Supervisor Written Record <br />(Check one): ❑Pipeline (PI IMSA) ODriver(FMCSA) <br />Employee's Name Dept. Date <br />Employee IdH Job Title Time <br />Describe Accident/Incident: <br />1. Was EBT Breath Alcohol testing completed within two {2) hours of the accident, or -'the reasonable <br />cause/suspiclon 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 <br />(32) hours of the accident or <br />reasonable cause/suspiclon <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/suspiclon 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 />l!� (JAi ZONAL t;Oh7PL1.4NCE MANAGEMENT SERVICE, INC. (NGMSJ 2011 (upU2le 2021). The NCh15 plan is <br />Ilio suLiecl of 2 ,eglslereU copyrlgh! anU is plolecteU by copyUghl laws in the U.S. anU elae�•,hare. All ,(yhts <br />esetved <br />56 <br />