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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 />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 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: Date: <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 test(s) 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 />:,I TIQNAL COhtFUANCE •VA`,JF,GEMEPJT SERVICE. i?JC. (`tCrdS) 201'I (updble 20211, The NChdS plan is <br />the subject 4f a registered copynghl and is protected by copyright lava irn EIJe U.S. and elsewhere All rights <br />reserved, <br />56 <br />