HomeMy WebLinkAboutOpening of Bids - Traffic Signal Detection Improvements Proj No. 120-046 - TGB Unlimited, Inc.CITY OF SOUTH BEND, INDIANA
CONTRACTOR'S BID FOR PUBLIC WORK
CHECKLIST FOR BIDDERS
Project Name Traffic Signal Detection Improvements
Project No.
For Bids Due
120-046
October 26, 2021
From time to time the South Bend Board of Public Works finds it necessary to reject a bid because
it does not comply with statutory requirements. In preparing your bid, please use the following
checklist in order to make sure that your bid is done in the proper manner.
JProper bid security included. The bidder has the option of providing either a Certified Check
or Bid Bond.
Bid prepared on the City of South Bend Contractor's Bid for Public Work Form, completely
executed.
Contractor's Non -Collusion and Non -Debarment Affidavit, Certification Regarding Investments
with Iran, Employment Eligibility Verification, Non -Discrimination Commitment, and
V Certification of use of United States Steel Products or Foundry Products.
Proof of MBE/WBE Participation Goal Form [MWBE-1.0]. If minimum participation goal is not
met, also provide Evidence of Good Faith Efforts Form [MWBE-2.0] and MBE/WBE Contacted
V Form [MWBE-2.1].
V Acknowledge Receipt of 1 Addendum(s) included with the bid.
All required additional information is included with the bid.
Proposal statements and other affidavits all signed by the proper party with name either
printed or typed underneath signature.
This checklist submitted with the Bid.
This checklist is provided for bidder's use in assuring compliance with required
documentation; however, it does not include all specifications requirements and does not
relieve the bidder of the need to read and comply with the specifications.
Bidder: TGB Unlimited, Inc. (dba) SIT Bancroft Electric
By Authorized Represent tive:
Signature:
Print Name & Title. Gene Mann, Vice President of Operations
Version 08/25/2021 Contractor's Bid for Public Works - 1
Date: 10-26-2021
CITY OF SOUTH BEND, INDIANA
CONTRACTOR'S BID FOR PUBLIC WORK
Project Name
Project No.
For Bids Due
Date:
Address:
Traffic Signal Detection Improvements
120-046
October 26, 2021
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PART I
(Must be completed for all bids. Please type or print)
10-26-2021 Bidder (Firm): TGB Unlimited, Inc. (dba) S/T Bancroft Electric
25020 State Road 2
City/State/Zip: South Bend, IN 46619 Telephone Number: ( 574 ' 968-2040
Agent of Bidder (if Applicable): N/A
Pursuant to notices given, the undersigned offers to furnish labor and/or material necessary to complete the
public works project of:
Traffic Signal Detection Improvments
the City of South Bend, Indiana, in accordance with plans and specifications prepared by.-
Jones
y:Jones Petrie ✓£ Rafinski
and dated
9-10-2021
for the sum of (enter the Total Bid as shown on the Proposal)
Two Hundred Forty Two Thousand Four Hundred Fi Two Dollars and 00/100 i$ 242,452.00
(Enter sum of All Divisions shown on Proposal) (Numerical)
The undersigned further agrees to furnish a bond or certified check with this bid for an amount specified in
the notice of the letting. If alternative bids apply, the undersigned submits a proposal for each in accordance
with the notice. Any addendums attached will be specifically referenced at the applicable page.
If additional units of material included in the contract are needed, the cost of units must be the same as that
shown in the original contract if accepted by the City of South Bend. If the bid is to be awarded on a unit
basis, the itemization of the units shall be shown on separate attachment.
v�
By
(Signature)
Gene Mann, Vice President of Operations
(Printed Name of Person Signing)
ACCEPTANCE
The above bid is accepted this day of 20
Subject to the following conditions:
BOARD OF PUBLIC WORKS
Elizabeth A. Maradik, President Joseph R. Molnar, Member
Gary A. Gilot, Member Jordan V. Gathers, Member
Murray L. Miller, Member Attest: Anne Fuchs, Clerk
Version 08/25/2021 Contractor's Bid for Public Works - 2
See Bid Form 96
PART II
(For projects of $100,000 or more - IC 36-1-12-4)
These statements to be submitted under oath by each bidder with and as part of his/her/its bid.
Attach additional pages for each section as needed.
SECTION I EXPERIENCE QUESTIONNAIRE
1. Attach information regarding projects your organization has completed for the period of one
(1) year prior to the date of the current bid.
2. Attach a listing of public works projects currently in process of construction by your
organization.
3. Attach information regarding any failure to complete any work awarded to you and the
location thereof. NSA
4. Attach references from private firms for which you have performed work.
SECTION II PLAN AND EQUIPMENT QUESTIONNAIRE
1. Attach an explanation of your plan or layout for performing proposed work. (Examples could
include a narrative of when you could begin work, complete the project, number of workers,
etc. and any other information which you believe would enable the City of South Bend to
consider your bid.)
2. Attach a listing of the names and addresses of all subcontractors (i.e. persons or firms outside
your own firm who have performed part of the work) that you have used on public works
projects during the past five (5) years along with a brief description of the work done by each
subcontractor.
3. If you intend to sublet any portion of the work, attach the name and address of each
subcontractor, equipment to be used by the subcontractor, and whether you will require a
bond. However, if you are unable to currently provide a listing, please understand a listing
must be provided prior to contract approval. Until the completion of the proposed project, you
are under a continuing obligation to immediately notify the City of South Bend in the event that
you subsequently determine that you will use a subcontractor on the proposed project.
4. Attach a listing of equipment you have available to use for the proposed project.
5. Have you entered into contracts or received offers for all materials which substantiate the
prices used in preparing your proposal? If not, attach an explanation for the rationale used
which would corroborate the prices listed.
SECTION III CONTRACTOR'S FINANCIAL STATEMENT
Attachment of bidder's financial statement is mandatory. Any bid submitted without said
financial statement as required by statute shall thereby be rendered invalid. The financial
statement provided hereunder to the City of South Bend awarding the contract must be specific
enough in detail so that said City of South Bend can make a proper determination of the bidder's
capability for completing the project if awarded.
Version 08/25/2021 Contractor's Bid for Public Works - 3
When the prospective Contractor is unable to certify to any of the statements below, it shall attach an explanation to this AfdaviL
CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, CERTIFICATION
REGARDING INVESTMENT WITH IRAN, EMPLOYMENT ELIGIBILITY VERIFICATION, NON-
DISCRIMINATION COMMITMENT AND CERTIFICATION OF USE OF UNITED STATES STEEL
PRODUCTS OR FOUNDRY PRODUCTS
(Must be completed for all quotes and bids. Please type or print)
STATE OF Indiana )
SS:
St. Joseph_ COUNTY )
The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of perjury
that:
1. Contractor has not, nor has any other member, representative, or agent of the firm, company,
corporation or partnership represented by him, entered into any combination, collusion or agreement with
any person relative to the price to be bid by anyone at such letting nor to prevent any person from bidding
nor to induce anyone to refrain from bidding, and that this bid is made without reference to any other bid and
without any agreement, understanding or combination with any other person in reference to such bidding.
Contractor further says that no person or persons, firms, or corporation has, have or will receive directly or
indirectly, any rebate, fee, gift, commission or thing of value on account of such sale; and
2. Contractor certifies by submission of this proposal that neither contractor nor any of its principals
are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from
participation in this transaction by any Federal department or agency; and
3. Contractor has not, nor has any successor to, nor an affiliate of, Contractor, engaged in
investment activities in Iran.
a. For purposes of this Certification, "Iran" means the government of Iran and any agency
or instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-5, as
amended from time -to -time.
b. As provided by Ind. Code § 5-22-16.5-8, as amended from time -to -time, a Contractor
is engaged in investment activities in Iran if either:
i. Contractor, its successor or its affiliate, provides goods or services of twenty
million dollars ($20,000,000) or more in value in the energy sector of Iran;
or
ii. Contractor, its successor or its affiliate, is a financial institution that extends
twenty million dollars ($20,000,000) or more in credit to another person for
forty-five (45) days or more, if that person will (i) use the credit to provides
goods and services in the energy sector in Iran; and (ii) at the time the
financial institution extends credit, is a person identified on list published by
the Indiana Department of Administration.
4. Contractor does not knowingly employ or contract with an unauthorized alien, nor retain any
employee or contract with a person that the Contractor subsequently learns is an unauthorized alien.
Version 08/25/2021 Contractor's Bid for Public Works - 4
Contractor agrees that he/she/it shall enroll in and verify the work eligibility status of all of Contractor's
newly hired employees through the E -Verify Program as defined by I.C. 22-5-1.7-3. Contractor's
documentation of enrollment and participation in the E -Verify Program is included and attached as part of
this bid/quote; and
5. Contractor shall require his/her/its subcontractors performing work under this public contract to
certify that the subcontractors do not knowingly employ or contract with an unauthorized alien, nor retain
any employee or contract with a person that the subcontractor subsequently learns is an unauthorized alien,
and that the subcontractor has enrolled in and is participating in the E -Verify Program. The Contractor agrees
to maintain this certification throughout the term of the contract with the City of South Bend, and understands
that the City may terminate the contract for default if the Contractor fails to cure a breach of this provision
no later than thirty (30) days after being notified by the City.
6. Persons, firms, partnerships, corporations, associations, or joint venturers awarded a contract by the
City of South Bend through its agencies, boards, or commissions shall not discriminate against any employee
or applicant for employment in the performance of a City contract with respect to hire, tenure, terms,
conditions, or privileges of contract or employment, or any matter directly or indirectly related to contracting
or employment because of race, sex, religion, color, national origin, ancestry, gender expression, gender
identity, sexual orientation, or due to age or disability that does not affect that person's ability to perform the
work.
In awarding contracts for the purchase of work, labor, services, supplies, equipment, materials, or any
combination of the foregoing including, but not limited to, public works contracts awarded under public
bidding laws or other contracts in which public bids are not required by law, the City, its agencies, boards,
or commissions will consider the Contractor's good faith efforts to obtain participation by those
subcontractors certified by the State of Indiana as a Minority Business ("MBE") or as a Women's Business
Enterprise ("WBE") as a factor in determining the lowest, responsible, responsive bidder.
Contractors seeking the award of a City contract cannot be required to award a subcontract to an MWBE;
however, they may not unlawfully discriminate against said MBE/WBE. On goal -eligible contracts,
Contractors are required to either meet both MBE and WBE utilization goals or demonstrate that the
Contractor has made good faith efforts to obtain participation from MBE and WBE subcontractors. A finding
of noncompliance or a discriminatory practice shall prohibit that Contractor from being awarded a City
contract for a period of one (1) year from the date of such determination, and such determination may also
be grounds for terminating the contact to which the discriminatory practice or noncompliance pertains.
7. The undersigned Contractor agrees that the following nondiscrimination commitment shall be made
a part of any contract which it may henceforth enter into with the City of South Bend, Indiana or any of its
agencies, boards or commissions.
Contractor agrees not to discriminate against or intimidate any employee or applicant for employment in the
performance of this contract with privileges of employment, or any matter directly or indirectly related to
employment, because of race, religion, color, sex, gender expression, gender identity, sexual orientation,
handicap, national origin or ancestry. Breach of this provision may be regarded as material breach of
contract.
I, the undersigned bidder or agent as contractor on a public works project, understand my statutory
obligations to the use of steel products or foundry products made in the United States (I.C. 5-16-8-1). I hereby
certify that I and all subcontractors employed by me for this project will use steel products or foundry
products made in the United States on this project if awarded. l understand I have an affirmative duty to
notify the City in my bid that my proposal does not include the use of steel products or foundry products
made in the United States. I understand it is my sole obligation and responsibility to provide a justification
to the City, subject to review and approval, why the cost of United States made steel or foundry products is
unreasonable. Prior to award and upon submission of bid which does not use steel products or foundry
products made in the United States, the City, through its director of public works, shall make a determination
if the price of United States made steel or foundry is unreasonable. I understand that violations hereunder
Version 08/25/2021 Contractor's Bid for Public Works - 5
may result in forfeiture of contractual payments.
I hereby affirm under the penalties of perjury that the facts and information contained in the foregoing bid
for public works are true and correct.
Dated this 26th �y of October . 20 21
Subscribed and sworn to before me this 26th
My Commission Expires June 18, 2023
County of Residence
TGB Unlimited, Inc. (dba) SIT Bancroft Electric
Contractor/Bidder (Firm)
Signature of Contractor/Bidder or Its Agent
Gene Mann. Vice President of Operations
Printed Name and Title
.day of O
2021
Notary Publ
LaPorte
LYNN SARTI
lea
�,��P....
'r Notary
Public, State of Indiana
SEAL; =
LaPorte County
*'• *F
My Commission Expires
n��r�`
June 18, 2023
Version 08/25/2021 Contractor's Bid for Public Works - 6
FSTBEND
AL INSURANCE COMPANY*
Bond Number 2504270
Bid Bond
KNOW ALL BY THESE PRESENTS, That We, TGB Unlimited, Inc. dba SR Bancroft Electric as Principal,
and WEST BEND MUTUAL INSURANCE COMPANY, a corporation organized under the laws of the State of Wisconsin
and having its principal office in Middleton, Wisconsin, in said State, as Surety, are held and firmly bound unto
City of south Bend as Owner, in the full and just sum of
Five Percent ( 5 %) of amount bid for the payment
whereof said Principal binds its heirs, administrators, and executors and said Surety binds itself, its successors
and assigns firmly by these presents
WHEREAS, said Principal has submitted to said Owner a bid or proposal for
Traffic Signal Detection Improvements
NOW THEREFORE, THE CONDITION OF THIS OBLIGATION IS SUCH that if within Sixty days hereof and in
accordance with said proposal a contract shall be awarded to said Principal and the said Principal shall enter into a
contract for said work and shall furnish bond with surety as required for its faithful performance then this obligation
shall be void, otherwise remain in full force and virtue.
Signed and Sealed this 26
Witness
Witness
day of _ October , 20 21
Agency Name:
Address:
Principal:
TGB Unlimited, Inc. dba SR Bancroft Electric
B : r7 (SEAL)
e T ed: Ty G Bancroft, President
Title
Surety:
West Bond Mutual Insurance C mpany
By- J : / _ (SEAL)
Name Typed: TARA PATTERSON Attorney -In -Fact
DAN BERRY INSURANCE AGENCY INC
54101 IRONWOOD RD
SOUTH BEND, IN 46635
Phone Number: (574) 255-6222
Title
MICHIGAN ONLY: This policy is exempt from the filing requirements of Section 2236 of the Insurance Code of 1956,
1956 PA 218 and MCL 500.2236.
NB 0192 11 17 Page 1 of 1
PO Box 620976 1 Middleton, WI 53562 Phone: (608) 410-3410 1 Fax: (877) 674-2663 1 www.thesilverlining.com
"-.02WEST BEND
A MUTUAL INSURANCE COMPANY'
POWER OF ATTORNEY
THE SILVER LINING®
Bond No. 2504270
Know all men by these Presents, That West Bend Mutual Insurance Company, a corporation having its principal office in the City of West Bend,
Wisconsin does make, constitute and appoint:
TARA PATTERSON
lawful Attomey(s)-in-fact, to make, execute, seal and deliver for and on its behalf as surety and as its act and deed any and all bonds, undertakings
and contracts of suretyship, provided that no bond or undertaking or contract of suretyship executed under this authority shall exceed in amount the
sum of: Ten Million Dollars ($10,000,000)
This Power of Attorney is granted and is signed and sealed by facsimile under and by the authority of the following Resolution adopted by the Board
of Directors of West Bend Mutual Insurance Company at a meeting duly called and held on the 21st day of December, 1999.
Appoin tment ofAttorney-In -Fact The president or any vice president; or any other officer ofWest Bend Mutual Insurance Company may appoint
by written certificate Attorneys -In -Fact to act on behalf of the company in the execution of and attesting of bonds and undertakings and other
written obligatory instruments of like nature. The signature of any officer authorized hereby and the corporate seal maybe affixed by facsimile
to any such power of attorney or to any certificate relating therefore and any such power of attorney or certificate bearing such facsimile
signatures or facsimile seal shall be valid and binding upon the company, and any such power so executed and certified by facsimile signatures
and facsimile seal shall be valid and binding upon the company in the future with respect to any bond or undertaking or other writing obligatory
in nature to which itis attached. Any such appointment maybe revoked, for cause, or without cause, by any said officer at anytime.
In witness whereof, the West Bend Mutual Insurance Company has caused these presents to be signed by its president undersigned and its
corporate seal to be hereto duly attested by its secretary this 17th day of August, 2021.
GvuS alb ....
Attest...
Christopher C. Z Kart°�TF':�. Kevin A. Steiner
Secretary 'r
SRAi. ? Chief Executive Officer/President
State of Wisconsin .._.....
County of Washington
On the 17th day of August, 2021, before me personally came Kevin A. Steiner, to me known being by duly sworn, did depose and say that he resides
in the County of Washington, State of Wisconsin; that he is the President of West Bend Mutual Insurance Company, the corporation described in and
which executed the above instrument; that he knows the seal of the said corporation; that the seal affixed to said instrument is such corporate seal;
that is was so affixed by order of the board of directors of said corporation and that he signed his name thereto by like order.
Jd+ E. a.
oTA.,+ ' p s
i a' .Z 2
Matthew E. Carlton
_�G ;%2 i
Senior Corporate Attorney
� `w1 op mss°° '
Notary Public, Washington Co., W1
�� „„„„,••+°
My Commission is Permanent
The undersigned, duly elected to the office stated below, now the incumbent in West Bend Mutual Insurance Company, a Wisconsin corporation
authorized to make this certificate, Do Hereby Certify that the foregoing attached Power of Attorney remains in full force effect and has not been
revoked and that the Resolution of the Board of Directors, set forth in the Power of Attorney is now in force.
Signed and sealed at West Bend, Wisconsin this 26th day of October 2021
i'
cARPORaTF.: ..
a�g Heather Dunn
' Vice President — Chief Financial Officer
Notice: Any questions concerning this Power of Attorney may be directed to the Bond Manager at West Bend Mutual Insurance Company.
1900 South 18th Avenue I West Bend, WI 53095 1 Phone: (608) 410-3410 1 Fax: (877) 674-2663 1 www.thesilvedining.com
0��� CONTRACTOR'S BID FOR PUBLIC WORK - FORM 96
State Form 52414 (R2 12-13) / Form 96 (Revised 2013)
•> Prescribed by State Board of Accounts
r ie
PART
(To be completed for all bids. Please type or print)
Date (month, day, year): October 26, 2021
1 Governmental Unit (Owner): City of South Bend
2. County: St. Joseph
3. Bidder (Firm):_ TGB Unlimited, Inc.
Address: 25020 SR 2
City/State/ZlPcode: South Bend, IN 46619
4. Telephone Number: 574-968-2040
5. Agent of Bidder (if applicable): N/A
Pursuant to notices given, the undersigned offers to furnish labor and/or material necessary to complete
the public works project of Traffic Signal Detection Improvements
(Governmental Unit) in accordance with plans and specifications prepared by
Jones Petrie & Rafinski and dated 9-10-2021 for the sum of
Two Hundred Forty Two Thousand Four Hundred Fifty Two Dollars and 001100 $ 242,452.00
The undersigned further agrees to furnish a bond or certified check with this bid for an amount specified in the
notice of the letting. If alternative bids apply, the undersigned submits a proposal for each in accordance with the
notice. Any addendums attached will be specifically referenced at the applicable page.
If additional units of material included in the contract are needed, the cost of units must be the same as
that shown in the original contract if accepted by the governmental unit. If the bid is to be awarded on a unit
basis, the itemization of the units shall be shown on a separate attachment.
The contractor and his subcontractors, if any, shall not discriminate against or intimidate any employee,
or applicant for employment, to be employed in the performance of this contract, with respect to any matter
directly or indirectly related to employment because of race, religion, color, sex, national origin or ancestry.
Breach of this covenant may be regarded as a material breach of the contract.
CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS
(If applicable)
I, the undersigned bidder or agent as a contractor on a public works project, understand my statutory
obligation to use steel products made in the United States (I.C. 5-16-8-2). 1 hereby certify that I and all
subcontractors employed by me for this project will use U.S. steel products on this project if awarded. I
understand that violations hereunder may result in forfeiture of contractual payments.
The above bid is accepted this
following conditions: N/A
Contracting Authority Members:
ACCEPTANCE
26th day of October 2021 , subject to the
PART II
(For projects of $150,000 or more — IC 36-1-12-4)
Governmental Unit: City of South Bend
Bidder (Firm) TGB Unlimited
Date (month, day, year): October 26, 2021
These statements to be submitted under oath by each bidder with and as a part of his bid.
Attach additional pages for each section as needed.
SECTION I EXPERIENCE QUESTIONNAIRE
1. What public works projects has your organization completed for the period of one (1) year prior to the
date of the current bid?
Contract Amount
Class of Work
Completion
Date
Name and Address of Owner
City of Elkhart
80,000.00
Conduit/Lighitng
2021
266,000.00
Conduit/Lighting
2020
City of Elkhart
240,000.00
Conduit/Lighting
2020
INDOT
437,000.00
Airport Lighting
2021
Logansport
2. What public works projects are now in process of construction by your organization?
Expected
Contract Amount
Class of Work
Completion
Name and Address of Owner
Date
50,000.00
Lighting/Condiut
2021
City of Mishawaka
1,700,000.00
Conduit/Fiber Install
2021
St. Joseph County
273,000.00
Airport Lighting
2021
Winamac
94,000.00
Signal Lighting
2021
INDOT
3. Have you ever failed to complete any work awarded to you? No If so, where and why?
4. List references from private firms for which you have performed work.
American Renolit Corporation, Tim Jones, 219-324-6886
City of Mishawaka, Steve Whitfield, 574-258-1639 _
C & E Excavating, Bryan Slott, 574-262-4346
Bob Frame Plumbing, Dave Frame, 574-291-7511
Town of Peru. Nick Parkman. 765-469-2256
SECTION II PLAN AND EQUIPMENT QUESTIONNAIRE
1. Explain your plan or layout for performing proposed work. (Examples could include a narrative of when
you could begin work, complete the project, number of workers, etc. and any other information which you
believe would enable the governmental unit to consider your bid.)
Per Plans and Specifications
2. Please list the names and addresses of all subcontractors (i.e. persons or firms outside your own firm
who have performed part of the work) that you have used on public works projects during the past five (5)
years along with a brief description of the work done by each subcontractor.
N/A
3. If you intend to sublet any portion of the work, state the name and address of each subcontractor,
equipment to be used by the subcontractor, and whether you will require a bond. However, if you are
unable to currently provide a listing, please understand a listing must be provided prior to contract
approval. Until the completion of the proposed project, you are under a continuing obligation to
immediately notify the governmental unit in the event that you subsequently determine that you will use a
subcontractor on the proposed project.
N/A
4. What equipment do you have available to use for the proposed project? Any equipment to be used by
subcontractors may also be required to be listed by the governmental unit.
Ford F700 Dump Truck, T190 Bobcat, 763 Bobcat, XP185 Ingersoll Rand Compressor, Hamm Tandem roller
275 Ring O Matic Vacuum/Excavator, Ford 8000, Kodiak Digger Derrik, Komatsu PC 150, Leeboy 900 Paver
Vermeer 24 x 40 Directional Boring Machine, Vermeer 18 x 22 Directional Boring Machine,Vermeer 36 x 50 Directional Boring Machine
Vermeer RTX450 combination Trencher/Backhoe, Vermeer MX240 Mixing System, Vibration Compactor
John Deer 401 C, Vermeer E900 Vac, Cat 936F, Bobcat 442, Bobcat 335G, New Holland Track Loaders, John Deere 330
5. Have you entered into contracts or received offers for all materials which substantiate the prices used in
preparing your proposal? If not, please explain the rationale used which would corroborate the prices
listed.
Yes
SECTION III CONTRACTOR'S FINANCIAL STATEMENT
Attachment of bidder's financial statement is mandatory. Any bid submitted without said financial
statement as required by statute shall thereby be rendered invalid. The financial statement provided hereunder to
the governing body awarding the contract must be specific enough in detail so that said governing body can make
a proper determination of the bidder's capability for completing the project if awarded.
SECTION IV CONTRACTOR'S NON — COLLUSION AFFIDAVIT
The undersigned bidder or agent, being duly sworn on oath, says that he has not, nor has any other
member, representative, or agent of the firm, company, corporation or partnership represented by him, entered
into any combination, collusion or agreement with any person relative to the price to be bid by anyone at such
letting nor to prevent any person from bidding nor to include anyone to refrain from bidding, and that this bid is
made without reference to any other bid and without any agreement, understanding or combination with any other
person in reference to such bidding.
He further says that no person or persons, firms, or corporation has, have or will receive directly or
indirectly, any rebate, fee, gift, commission or thing of value on account of such sale.
SECTION V OATH AND AFFIRMATION
I HEREBY AFFIRM UNDER THE PENALTIES FOR PERJURY THAT THE FACTS AND INFORMATION
CONTAINED IN THE FOREGOING BID FOR PUBLIC WORKS ARE TRUE AND CORRECT.
Dated at
STATE OF Indiana
COUNTY OF St. Joseph
South Bend this
26th day of _ October 2021
TGB Unlimited
(Name of Organization)
By
Vice President of Operations
(Title of Person Signing)
ACKNOWLEDGEMENT
Before me, a Notary Public, personally appeared the above-named
Gene Mann and
swore that the statements contained in the foregoing document are true and correct.
Subscribed and sworn to before me this 26th day of O 2021
N ryu is
TI
LYNN s ate
Bot Indiai
June 18, 2023 ���PPY•P���' Notery Pubilc,
My Commission Expires: 4�g Laporte County
commission Expires
County of Residence: LaPorte�''No AQP My June 18. 2113
:.
BID/PROPOSAL
CITY OF SOUTH BEND
Project Name: Traffic Signal Detection Improvements
Project Number: 120-M
For Bids Due: October 26, 2021
Contractor Name: TGB Unlimited, Inc. (dba) S/T Bancroft Electric
nivininn 1 • Hicknry Rd at W Catalna Dr
1865
Item No.
Description
Quantity
Unit
Unit Price
Total
Amount
1
Construction Engineering
1
LS
800.00 1
800.00
2
Maintaining Traffic
1
LS
2,500.00
2,500.00
3
Mobilization and Demobilization
1
LS
800.00
800.00
4
Remove FUR Detection
1
LS
500.00
500.00
5
Hemispherical Camera Detection
System
1
LS
34,970.00
34,970.00
6
Remove PED Push Button System
Assembly
4
EA
90.00
360.00
7
PED Push Button Assembly
4
EA
1,831.00
7,324.00
8
Traffic Signal Cable
1
LS
950.00
950.00 71
DIVISION 1 TOTAL 48,204.00
$25,
Version 08/25/2021 Contractor's Bid for Public Works - 7
Project Name:
Project Number:
For Bids Due:
Contractor Name:
BID/PROPOSAL
CITY OF SOUTH BEND
Traffic Signal Detection Improvements`
120-046 r
October 26, 2021
TGB Unlimited, Inc. (dba) SIT Bancroft Electric
rliuiainn 9• Wirnlrnru of Mirncla I n
Item No.
Description
Quantity
Unit
Unit Price
Total
Amount
1
Construction Engineering
1
LS
800.00
800.00
2
Maintaining Traffic
1
LS
2,500.00
2,500.00
3
Mobilization and Demobilization
1
LS
800.00
800.00
4
Remove Service Point
1
LS
1,200.00
1,200.00
5
20' Aluminum Truss Mast Arm
1
LS
3,120.00
3,120.00
6
Hemispherical Camera Detection System
1
LS
34 970.00
34,970.00
7
Remove PED Push Button System
Assembly
1
EA
90.00
1,831.00
90.00
8
PED Push Button Assembly
8
LS
14,648.00
9
Traffic Signal Cable
Service Point — Single Meter, Cabinet &
Foundation
1
LS
950.00
950.00
10
1
EA
9,200.00 9,200.00
I
DIVISION 2 TOTAL 68,278.00
type
Version 08/25/2021 Contractor's Bid for Public Works - 8R1
BIDIPROPOSAL
CITY OF SOUTH BEND
Project Name: Traffic Signal Detection Improvements
Project Number: 120-046
For Bids Due: October 26, 2021
Contractor Name: TGB Unlimited, Inc. (dba) S/T Bancroft Electric
Division 3• S Ironwood Dr at E Calvert St
Item No. Description
Quantity
Unit
Unit Price
Total
Amount
1
Construction Engineering
1
LS
800.00
800.00
2
Maintaining Traffic
1
LS
2,500.00
2,500.00
3
Mobilization and Demobilization
1
LS
80000800.00
4
Remove FUR Detection
1
LS
1,600.00
1,600.00
5
Hemispherical Camera Detection System
1
LS
34,970.00
34,970.00
6
Remove PED Push Button Assembly
8
EA
90.00
720.00
7
PED Push Button Assembly
8
EA
1,831.00
14,648.00
8
Remove 3 -Section Signal Head
2
EA
240.00
480.00
9
4 -Section Signal Head w/Sign
2
EA
1,085.00
2,170.00
10
Traffic Signal Cable
1
LS
950.00
950.00
DIVISION 3 TOTAL 59,638.00
Version 08/25/2021 Contractor's Bid for Public Works - 9
BID/PROPOSAL
CITY OF SOUTH BEND
Project Name: Traffic Signal Detection Improvements
Project Number:
For Bids Due:
120-046
October 26, 2021
Contractor Name: TGB Unlimited. Inc. (dba) S/T Bancroft Electric
Divisinn 4- S Ironwood Dr at Ewino Ave
Item No.
Description
Quantity
Unit
Unit Price
Total
Amount
1
Construction Engineering
1
LS
800.00
800.00
2 Maintaining Traffic
1
LS
2,500.00
2,500.00
3
Mobilization and Demobilization
1
LS
800.00
800.00
4
Remove FLIR Detection System
1
LS
1,600.00
1 P600.00
5
Hemispherical Camera Detection System
1
LS
34,970.00
34,970.00
6
Traffic Signal Cable
1
LS
950.00
950.00
DIVISION 4 TOTAL 41.620.00
Version 08/2512021 Contractor's Bid for Public Works - 10
BID/PROPOSAL
CITY OF SOUTH BEND
Project Name: Traffic Signal Detection Improvements
Project Number: 120-046
For Bids Due: October 26, 2021
Contractor Name: TGB Unlimited Inc. dba S/T Bancroft Electric
Division 5: E Ireland Rd at S St. Joseph St
Item No. l
1
Description
Quantity
1
Unit
Unit Price
Total
Amount
Construction Engineering
LS
800.00
800.00
2
Maintaining Traffic
1
LS
2,500.00
2,500.00
3
Mobilization and Demobilization
Replace Roadway Loops, 3 EA & Detector
Housin
1
LS
800.00
800.00
4
1
LS
4,900.00
4,900.00
5
Signal Pedestal on Type "A" Foundation
1
EA
700.00
700.00
6
PED Push Button Assembly
2
EA
1,831.00
3,662.00
7
Traffic Signal Cable
1
LS
950.00
950.00
8
Remove Service Point
Service Point — Single Meter, Cabinet &
Foundation
1
LS
1,200.00
1,200.00
9
1
EA
9,200.00
1 9,200.00
DIVISION 5 TOTAL 24,712.00
Version 08/25/2021 Contractor's Bid for Public Works - 11R1
Project Name:
Project Number:
For Bids Due:
Contractor Name:
BIDIPROPOSAL
CITY OF SOUTH BEND
Traffic Signal Detection Improvements
120-046
October 26, 2021
TGB Unlimited, Inc. (dba) SIT Bancroft Electric
D�wiww4 Cl--- Qii! C..r ~Ami
Location
Base Bid
Division 1:
Hickoy Rd at W Catat a Dr
4820400
Division 2:
Hickory Rd at Miracle Ln
68 278-00
Division 3:
S Ironwood Dr at E Calvert St
59638 00
Division 4:
S Ironwood Dr at Ewing Ave
41,620.00
Division 5:
E Ireland Rd at S St Joseph St
24,7 2.00
Grand Total Base Bid, All Divisions
242 452.00
Bidder (Firm) TGB Unlimited, Inc. (dba) S/T Bancroft Electric
Address 25020 State Road 2
City, State/ Zip South Bend, IN 46619 Telephone Numbe�r-'� ( 55,74 ) 968-2040
By: ,�
(Signature)
Gene Mann
(Printed Name of Person Signing)
This is a divisible bid. Contractors shall be required to bid on all divisions. The City reserves
the right to award any/all divisions.
Version 08/25/2021 Contractor's Bid for Public Works - 12R1
Part of State Form 52414 (R2 / 2-13) / Form 96 (Revised 2013)
1
TGB Unlimited, Inc.
25020 SR 2
(Contractor)
(Address)
South Bend, IN 46619
FOR
PUBLIC WORKS PROJECTS
OF
City of South Bend
Traffic Signal Detection Improvments
9:00 AM
Filed October 26 1 2021
Action taken
CITY OF SOUTH BEND
MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN
FORM MBE -1.0
MBE UTILIZATION PLAN
This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects involving MBE participation. It is
the bidder's sole responsibility to verify whether any listed minority-owned business meets the MBE qualifications.
Project Number:
Bidder:
120-046
Project Name: Traffic Signal Detection Improvements
TGB Unlimited, Inc. (dba) SIT Bancroft Electric Total Bid Amount:
MBE Goal: 1.6%
Page 1 of 1
Primary Contact Person I Scope of Work to be Performed I Dollar Amount of MBE ' TQr—
Name & Address of MBE (Namerrelephone) (Attach scope/schedule if you need additional space) Component ` of oOTot —1
Master Enterprises
4195 Millersville Rd,
Indianapolis, IN 46205
r
Darrin Orr Supply Signal Equipment
Submitted by: Gene Mann
Print Name Signature
Version 08/25/2021 Contractor's Bid for Public Works -13
25,239.60
10-26-2021
Date
10.42%
This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects involving WBE participation. It Is
the bidder's sole responsibility to verify whether any listed woman -owned business meets the WBE qualifications.
Project Number:
Bidder:
120-046 Project Name: Traffic Signal Detection Improvements
TGB Unlimited, Inc. (dba) S!T Bancroft Electric Total Bid Amount:
Name & Address of WBE Primary Contact Person Scope of Work to be Performed
(Namerrelephone) (Attach soope/schedule if you need additional space)
1
State Barricading James Michalski Maintenance of Traffic
24963 US 20 574-287-1744
South Bend, IN 46628
Submitted by:
Gene Mann
Print Name
_4_zz-e tL�L�
Signa e
Version 08/25/2021 Contractor's Bid for Public Works - 14
WBE Goal: 4.5%
Page 1 of 1
Dollar Amount of WBE Percentage
of Total
Component o,,,,o_,,_ ,
$10,902.00
10-26-2021
Date
4.5%
CITY OF SOUTH BEND
MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN
FORM WBE-1.0
WBE UTILIZATION PLAN
This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects involving WBE participation. It Is
the bidder's sole responsibility to verify whether any listed woman -owned business meets the WBE qualifications.
Project Number:
Bidder:
120-046 Project Name: Traffic Signal Detection Improvements
TGB Unlimited, Inc. (dba) S!T Bancroft Electric Total Bid Amount:
Name & Address of WBE Primary Contact Person Scope of Work to be Performed
(Namerrelephone) (Attach soope/schedule if you need additional space)
1
State Barricading James Michalski Maintenance of Traffic
24963 US 20 574-287-1744
South Bend, IN 46628
Submitted by:
Gene Mann
Print Name
_4_zz-e tL�L�
Signa e
Version 08/25/2021 Contractor's Bid for Public Works - 14
WBE Goal: 4.5%
Page 1 of 1
Dollar Amount of WBE Percentage
of Total
Component o,,,,o_,,_ ,
$10,902.00
10-26-2021
Date
4.5%
CITY OF SOUTH BEND
MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN • r
FORM MBE-2.1
MBE CONTACTED
This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects
requiring Good Faith Efforts to contact MBEs. It Is the bidder's sole responsibility to verify whether any listed
minority-owned business meets the MBE qualifications. Attach additional pages if necessary.
PAGE_J_OF 1
Project Number: 120-046 MBE Participation Goal 1.6%
Project Name: Traffic Signal Detection Improvements
Bidder: TGB Unlimited, Inc. dba SIT Bancroft Electric
By: J �L VPO - -
(Signat ) (Title) (Date)
MBE Firm Master Enterprises
Owner or Contact at MBE Firm Darrin Orr
Telephone: 317.720.4146 Fax: Email: dOrr@MasterEnt84.com
TYPE OF WORK SOLICITED FOR THIS PROJECT:
Supply Signal Equipment
RESULTS OF CONTACT WITH THE MBE FIRM:
Quote received.
MBE Finn
Owner or Contact at MBE Firm
Telephone: Fax: Email:
TYPE OF WORK SOLICITED FOR THIS PROJECT:
RESULTS OF CONTACT WITH THE MBE FIRM:
Version 08/25/2021 Contractor's Bid for Public Works -19
CITY OF SOUTH BEND
MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN.
FORM MBE -2.1 -"-
WBE CONTACTED
This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects
requiring Good Faith Efforts to contact WBEs. It is the bidder's sole responsibility to verify whether any listed
woman -owned business meets the WBE qualifications. Attach additional pages If necessary.
PAGE_] OF 1
Project Number: 120-046 WBE Participation Goal 4.5%
Project Name: Traffic Signal Detection Improvements
Bidder: TGB Unlimited, Inc. (dba) SIT Bancroft Electric
By. C_If� Vice President of Operations 10-26-2021
(Sigma re) (Tide) (Date)
WBE Firm State Barricading
Owner or Contact at WBE Firm James Michalski
Telephone: 574-287-1744 Fax: 574-300-772 1 Email: statebarricadel@aol.com
TYPE OF WORK SOLICITED FOR THIS PROJECT:
Traffic Control Signage
RESULTS OF CONTACT WITH THE WBE FIRM:
Quote received.
WBE Firm Traffic Control Specialists
Owner or Contact at WBE Firm Nickolas Fisher
Telephone: (574) 772-7001 Fax: 574 772-7002 Email: nickolas@tcspecialists.net
TYPE OF WORK SOLICITED FOR THIS PROJECT:
Traffic Control Signage
RESULTS OF CONTACT WITH THE WBE FIRM: Quote received.
Version 08/25/2021 Contractor's Bid for Public Works - 20
CITY OF SOUTH BEND, INDIANA
CONTRACTOR'S BID FOR PUBLIC WORK
RESPONSIBLE BIDDER CHECKLIST
Project Name Traffic Signal Detection Improvements
Project No. 120-046
For Bids Due October 26, 2021
Contractor Name: TGB Unlimited, Inc. (dba) SIT Bancroft Electric
The City seeks to enhance its ability to identify responsive and responsible bidders on all City public works
projects by institution of comprehensive submission requirements in compliance with State law. Quality
workmanship, efficient operation, safety, and timely completion of projects requires that all bidders meet
certain minimum requirements to be responsive and responsible bidders.
THIS FORM MUST BE SUBMITTED WITH YOUR BID.
INSTRUCTIONS:
If you are a pre -qualified bidder, complete Section I only.
If you are not a pre -qualified bidder, complete Section II only.
Section II acts as an application for pre -qualification. Submission of Section II will allow the bidder to be
considered for pre -qualification for bids with the City of South Bend Department of Public Works. Pre-
qualified bidders will then be exempt from a portion of the submission requirements outlined in Section 6-
63 of The Responsible Bidding Ordinance No. 10594-18 (hereinafter, "Responsible Bidding Ordinance")
for a period of twelve (12) months.
Thereafter, contractors who are pre -qualified must submit a complete application for continuation of "pre-
qualified" standing, on a form provided by the City ("Responsible Bidder Checklist (1) Pre -Qualified
Bidders") by December 3111 for the upcoming calendar year, or within twelve (12) months of obtaining pre-
qualified standing. If the status of any item changes within the twelve (12) months, it is the responsibility of
the contractor to notify the City. Failure by any pre -qualified contractor to submit its complete application
for continuation of "pre -qualified" standing within the time prescribed above shall result in automatic removal
of the designation, effective January 1 of the following year, or immediately following the twelve (12) months
of pre -qualified standing.
However, the "removed" contractor or subcontractor shall still be permitted to bid on City public works
projects, though the contractor must submit all required documents under 6-63 until "pre -qualified" status
is re-established.
Please Note: The City reserves the right to request supplemental information from the bidder,
additional verification of any information provided by the bidder, and may also conduct random
inquiries of the bidder's current and previous customers regardless of pre -qualified standing.
It is the sole responsibility of the potential bidder to comply with all submission requirements applicable to
the bidder in Section 6-63 of the Responsible Bidding Ordinance no later than the date of the public bid
opening.
Version 08/25/2021 General Conditions - 6
POST BID SUBMISSIONS:
Post -bid submissions must be submitted in accordance with Section 6-64 of the Responsible Bidding
Ordinance. The post -bid submission requirements are as follows:
1. All bidders shall collect, maintain, and provide upon request, a current written list that discloses the
name, address, licensing status, and type of work for any subcontractor from whom the bidder has
accepted a bid and/or intends to hire on any part of the public work project, including individuals
performing work as independent contractors.
2. Each subcontractor, whose portion of the project is estimated to be at least one -hundred fifty
thousand dollars ($150,000.00), shall be required to adhere to the requirements of Section I of the
Responsible Bidder Ordinance as though it were bidding directly to the City, except that the
subcontractor shall submit the required information (including the name, address, and type of work)
to the successful bidder prior to the commencement of work.
3. Failure of a subcontractor to submit the required information shall not disqualify the successful
bidder from performing work on the project and shall not constitute a contractual default and/or
breach by the successful bidder. However, the City may withhold all payment otherwise due for
work performed by a subcontractor, until the subcontractor submits the required information and
the City approves such information.
4. The disclosure of a subcontractor list ("Disclosed Subcontractor(s)") to the City by a bidder shall
not create any rights in the Disclosed Subcontractor(s). Thus, a bidder may substitute another
subcontractor for a Disclosed Subcontractor by giving the City, upon request, written notice of the
name, address, licensing status, and type of work of the substitute subcontractor.
5. The successful bidder and all subcontractors on a public works project are required to submit
certified payroll utilizing the federal form known as WH -347 or a similar form on a bi-weekly basis,
submitted within 10 days after the end of each bi-weekly payroll period. Certified payrolls shall
identify the job title and craft for each employee. Certified payrolls shall be submitted
electronically.
Please Note: Submissions deemed inadequate, incomplete, or untimely by the City may result in
the automatic disqualification of the bid.
The City, after review of complete and timely submissions, shall, in its sole discretion, after taking into
account all information in the submission requirements, determine whether a bidder is responsive and
responsible, and provide a Pre -Qualification Verification Letter. The City specifically reserves the right to
utilize all information provided in the contractor's submission and any information obtained by the City
through its own independent verification of the information provided by the contractor.
Version 08/25/2021 General Conditions - 7
PRE -QUALIFIED BIDDER CHECKLIST
(a) Acknowledgements:
(i) — By checking this box, I hereby acknowledge that I am a pre -qualified bidder with
the City of South Bend and that I have met the pre -qualification requirements within
the last twelve (12) months. A copy of my Pre -Qualification verification letter
Is attached.
_ By checking this box, I hereby acknowledge that the City reserves the right to
request supplemental information, additional verification of any information
provided by me, and may also conduct random inquiries of my current and prior
customers.
(b) Attachments:
(i) _ Indiana Secretary of State's on-line records (ie. Business verification) dated within
sixty (60) days of the submission of said document showing that business is in
existence, current with the Indiana Secretary of State's Business Entity Report,
and eligible for a certificate of good standing. (Not applicable to individuals, sole
proprietors or partnerships).
(ii) _ Statement on staffing capabilities, including labor sources. This statement
indicates and ensures I have sufficient employees on staff to complete the work. It
outlines how I intend to meet the staffing needs of the work.
(iii) _ List of projects of similar size and scope of work performed in all areas, including
the State of Indiana, within the last three (3) years.
(iv) _ For every project, submit evidence of participation in apprenticeship and training
programs, applicable to the work to be performed on the project, which are
approved by and registered with the United States Department of Labor's Office of
Apprenticeship, or its successor organization.
Version 08/25/2021 General Conditions - 8
II. PRE -QUALIFICATION CHECKLIST (FOR BIDDERS THAT ARE NOT PRE -QUALIFIED)
(a) Acknowledgements:
(i) By checking this box, I hereby acknowledge that I am not a pre -qualified bidder
with the City of South Bend.
(ii) A/ By checking this box, I hereby acknowledge that the City reserves the right to
request supplemental information, additional verification of any information
provided, and may also conduct random inquiries of my current and prior
customers. The City reserved the right to utilize all information provided in this
submission and all information obtained in inquiries or requests to determine if a
bidder is responsive and responsible. Additionally, I acknowledge that all
information provided to the City shall be regarded as public records.
(iii) By checking this box, I hereby acknowledge that copies of all Applicable
apprenticeship certificates or standards for training programs applicable to the
work performed on the project may be requested at any time and shall be furnished
upon request.
(iv) By checking this box, I hereby acknowledge and ensure that I and all sub-
contractors, from whom I have accepted a bid and/or intend to hire to perform work
on the public work project, are properly licensed. Furthermore, I acknowledge my
understanding that it is my responsibility to ensure that all sub -contractors have
the necessary licenses to undertake the work called for in this bid. If a sub-
contractor loses their license at any point, it is the responsibility of that sub-
contractor to notify the City.
(b) Attachments:
(i) 14
Indiana Secretary of State's on-line records (ie. Business verification) dated within
sixty (60) days of the submission of said document showing that business is in
existence, current with the Indiana Secretary of State's Business Entity Report,
and eligible for a certificate of good standing. (Not applicable to individuals, sole
proprietors or partnerships).
(ii) !�Z
List identifying all former business names.
(iii) [-
Any determinations by a court or governmental agency any violations of federal
state, or local laws including, but not limited to, violations of contracting or antitrust
laws, tax or licensing laws, environmental laws, Occupational Safety and Health
Act (OSHA), or federal Davis -Bacon and related Acts, within the preceding five (5)
(iv)
years.
Statement about staffing capabilities, including labor sources. This statement
indicates and ensures I have sufficient employees on staff to complete the work I
am bidding on OR outlines how I intend to meet the staffing needs of the work.
(v)
Statement that individuals who will perform work on the public work project on my
behalf will be properly classified as an employee or as an independent contractor
under all applicable state and federal laws and local ordinances.
(vi)
For every project, submit evidence of participation in apprenticeship and training
programs, applicable to the work to be performed on the project, which are
approved by and registered with the United States Department of Labor's Office of
V
Apprenticeship, or its successor organization.
(vii)
Copy of a written plan for employee drug testing that covers all of my employees
who will perform work on the public work project and meets or exceeds the
requirements set forth in IC 4-13-18-5 or IC 4-13-18-6.
(viii) V
Evidence that I am utilizing a surety company which is on the Bureau of Fiscal
Service "Department of Treasury's Listing of Approved Sureties" as required in the
bid specifications or contract.
Version OB/25/2021 General Conditions - 9
(ix) v Written statement of any federal, state or local tax liens or tax delinquencies owed
to any federal, state or local taxing body in the preceding three years,
(i) v List of projects of similar size and scope of work performed in all areas, including
the State of Indiana, within three (3) years prior to the date on which the bid is due.
Date: October 26, 2021
(Sign Hfiio
Gene Mann
(Print Name Here)
TGB Unlimited, Inc. (dba) SIT Bancroft Electric
(Name of Company)
25020 State Road 2
(Address of Company)
South Bend
(City)
Indiana
(State)
574-968-2040
(Telephone Number)
Version 08/25/2021 General Conditions -10
The Bancroft Companies
Foresight.... Insight.... Onsite
TGB Unlimited, Inc.
City of South Bend
Traffic Signal Detection Improvements
10-26-2021
1. SOS Business Entity Print out attached
2. No Former business names
3. No determinations of violations
4. TGB Unlimited is fully staffed if need arises we use RoadTecs to find a TWIC card
holder.
5. Individuals who will perform work on this project will be employees and/or sub-
contractors and classified under all applicable state and federal laws and local
ordinances.
6. Attached Apprenticeship and training Certification and DOL Certification and
Memorandum of Understanding.
7. Drug Plan attached
8. Department of Treasury's Listing of Approved Sureties
9. None
10. List of Projects within past 3 years
a. INDOT R -41066-A; 2021
b. INDOT R -41473-A; 2021
c. INDOT R -39008-A; 2020
d. City of Mishawka, Bremen Hwy & Meijer Dr.; 2020
e. City of South Bend; Lincolnway West; 2019
Business Name: TGB UNLIMITED INC.
Entity Type: Domestic For -Profit Corporation
Creation Date: 06/09/2005
Principal Office Address: 25020 STATE ROAD 2, SOUTH BEND, IN,
46619, USA
Jurisdiction of Formation: Indiana
BUSINESS INFORMATION
HOLLI SULLIVAN
INDIANA SECRETARY OF STATE
10/25/202105:02 PM
Business ID: 2005061300353
Business Status: Active
Inactive Date:
Expiration Date: Perpetual
Business Entity Report Due 06/30/2023
Date:
Years Due:
•erning Peron Information
Title Name Address
President Ty Bancroft 25020 State Road 2, South Bend, IN, 46619, USA
Vice President Scott Bancroft 25020 State Road 2, South Bend, IN, 46619, USA
Vice President of Operations Gene Mann 25020 State Road 2 25020 State Road 2, South Bend, IN, 46619, USA
Name
Title Address
TY BANCROFT Incorporator 2955 E MCKINLEY, SOUTH BEND, IN, 46615, USA
Type: Individual
Name: TY BANCROFT
Address: 25020 STATE ROAD 2, SOUTH BEND, IN, 46619, USA
2 -- NTr4iTl-
Certificate
o ccrec�itation
This document rgresmnts that
ABC of Indiana Apprenticeship gust
]rmirzg mei all fire requirements of the Stajulardi._ed Craft Training process n�s sei tortes by .'VCCEK ;
:ird upon rernrr�nEetzcitztiorz of theBoard of Trustees. is hereby declared am
i.;
s
AccreditedTrainiong .3pomor
with accreditation granted on this
elemxth day ofSeptember. 2014.
Z.
Dmiald E. Whale
President. N+C`tER
�W,
4 BCO
Associated Builders and Contractors
Indiana
entucl
Memorandum of Understanding
9/17/21
Please accept this as verification that TGB Unlimited Inc. is a
member in good standing of Associated Builders & Contractors
of Indiana/Kentucky, Inc.
ABC's Program is certified by the Federal Department of Labor,
Office of Apprenticeship and Training and by the National
Center for Constructions Education and Research (NCCER).
ABC of Indiana uses the NCCER curriculum. TGB Unlimited Inc.
currently has 7 (seven) students enrolled in the apprenticeship
training program
Feel free to call me with any questions regarding our
apprenticeship program.
Regards,
B r a*U,1& Fee4
Brianne Feeks
Elkhart Apprenticeship Coordinator
2701 Industrial Dr. Ste. 190—Elkhart, Indiana 46516— 574-218-0340
brianne@abcindianakentucky.org
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ASSOCIATED BUILDERS & CONTRACTORS OF INDIANA
INDIANAPOLIS, INDIANA
FOR THE OCCUPATIONS OF: BRICKLAYER (0052), CARPENTER (0067), CEMENT MASON (0075), ELECTRICIAN (0159), OPERATING ENGINEER (0365), PAINTER (0379),
PIPE FITTER (0414), PIPE FITTER -SPRINKLER SYSTEMS (0404A), PLUMBER (0432), ROOFER (0480), SHEET METAL WORKER (0510), HVAC (0637), CONSTRUCTION
CRAFT LABORER (0661), ASSEMBLER -METAL BUILDING (0377), INSULATION WORKER (0909), GLAZIER (0221)
, eyisferreoras parf of fje �afional�fpprenfices rp 54-oyram
in accor�ance cvift4'h6e basic sfanorardS 0fapprenfices-4ip
esfa� 6 Xis. t6eoWy 1,6e c5ecrelary of P--) aor
REGISTERED MARCH 211982
REVISED JANUARY 69 2006
IN030060001
.�eyislralion xo.
PHONE: (816) 235-3700.
UNDERWRITING LIMITATION b/: $6,537,000.
SURETY LICENSES c.f/: AL, AK, AZ, AR, CA, CO, CT, DE, DC, FL, GA, HI, ID, IL, IN, IA, KS, KY, LA, ME, MD, MA, MI, MN, MS, MO, MT,
NE, NV, NH, NJ, NM, NY, NC, ND, OH, OK, OR, PA, PR, RI, SC, SD, TN, TX, UT, VT, VA, WA, WV, WI, WY.
INCORPORATED IN: New Hampshire.
West American Insurance Company
(MAIC #44393)
BUSINESS ADDRESS: 175 Berkeley Street, Boston, MA 02116.
PHONE: (617) 357-9500 x1420.
UNDERWRITING LIMITATION b/: $4,866,000.
SURETY LICENSES c,f/: AL, AK, AZ, AR, CA, CO, CT, DE, DC, FL, GA, ID, IL, IN, IA, KS, KY, LA, ME, MD, MA, MI, MN, MS, MO, MT, NE,
NV, NH, NJ, NM, NY, NC, ND, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VT, VA, WA, WV, WI, WY.
INCORPORATED IN: Indiana.
WEST BEND MUTUAL INSURAh!rE COMPANY
(MAIC #15350)
BUSINESS ADDRESS: 1900 South 18th Avenue, West Bend, WI 53095.
PHONE: (262) 334-5571.
I ; NDERWRITING LIMITATION b/: $ 140,552,000.
5 JRETY LICENSES c,f/: AL, AK, AZ, AR, CA, CO, CT, DE, DC, FL, GA, HI, ID, IL, IN, IA, KS, KY, LA, ME, MD, MA, MI, MN, MS, MO, MT,
N. E, NV, NH, NJ, NM, NY, NC, ND, OH, OK, OR, PA, Rl, SC, SD, TN, TX, UT, VT, VA, WA, WV, WI, WY.
INCORPORATED IN: Wisconsin.
Transla�
FISEL LAUER & JOHNSON
CERTIFIED PUBLIC ACCOUNTANTS
196E 1125
VALPARAISO, IN 46383
123 N MAIN STREW
HEBRON. IN 46341
(219) 996-3500 / JOHN@FUCPA.COM
Independent Accountant's Review Report
March 30, 2021
To the Stockholders
TGB Unlimited, Inc.
dba S/T Bancroft Electric
South Bend, Indiana
We have reviewed the accompanying financial statements of TGB Unlimited, Inc. DBA S/T
Bancroft Electric, (an S Corporation) which comprise of the balance sheets as of December 31,
2020 and 2019, and the related statements of income, retained earnings, & cash flows for the
years then ended, and the related notes to the financial statements. A review includes primarily
applying analytical procedures to management's financial data and making inquiries of company
management. A review is substantially less in scope than an audit, the objective of which is the
expression of an opinion regarding the financial statements as a whole. Accordingly, we do not
express such an opinion.
Management's Responsibility for the Financial Statements
Management is responsible for the preparation and fair presentation of these financial
statements in accordance with accounting principles generally accepted in the United States of
America; this includes the design, implementation, and maintenance of internal control relevant
to the preparation and fair presentation of financial statements that are free from material
misstatement whether due to fraud or error.
Accountant's Responsibility
Our responsibility is to conduct the review engagement in accordance with Statements on
Standards for Accounting and Review Services promulgated by the Accounting and Review
Services Committee of the AICPA. Those standards require us to perform procedures to obtain
limited assurance as a basis for reporting whether we are aware of any material modifications
that should be made to the financial statements for them to be in accordance with accounting
principles generally accepted in the United States of America. We believe that the results of our
procedures provide a reasonable basis for our conclusion.
Accountant's Conclusion
Based on our review, we are not aware of any material modifications that should be made to the
accompanying financial statements for them to be in accordance with accounting principles
generally accepted in the United States of America.
Supplementary Information
The supplementary information included in the Schedules of Cost of Revenues is presented for
purposes of additional analysis and is not a required part of the basic financial statements. Such
information is the responsibility of management and was derived from, and relates directly to,
the underlying accounting and other records used to prepare the financial statements. The
supplementary information has been subjected to the review procedures applied in our review of
the basic financial statements. We are not aware of any material modifications that should be
made to the supplementary information. We have not audited the supplementary information
and do not express an opinion on such information.
J n M. Lauer, CPA, MST
Partner
Fisel, Lauer & Johnson
TGB Unlimited, Inc.
DBA SIT Bancroft Electric
NOTES TO FINANCIAL STATEMENTS
DECEMBER 31, 2020 and 2019
(See Independent Accountant's Review Report)
DESCRIPTION OF BUSINESS —TGB Unlimited, Inc., DBA SIT Bancroft Electric (The Company)
operates as an electrical contractor engaged in the installation of electrical components.
Contracts are primarily with industries, as well as state and local government agencies.
Substantially all customers are located in northern Indiana.
NOTE 1 —SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES—This summary of
significant accounting policies is presented to assist in understanding the Company's financial
statements. The financial statements and notes are representation of the Company's
management, who is responsible for their integrity and objectivity. These accounting policies
conform to generally accepted accounting principles and have been consistently applied in the
preparation of financial statements.
Following is a summary of the significant accounting policies of the Company:
Revenue and Cost Recognition —The Company recognizes revenues from construction
contracts on the percentage -of -completion method, measured by the percentage of actual cost
incurred to date to estimated cost for each contract. This method is used since management
considers total cost to the be the best available measure of progress on the projects. Provision
for estimated losses on uncompleted contracts is made in the period in which such losses are
determined. When changes in job performance, job conditions and estimated profitability occur,
including those arising from contract penalty provision and final contract settlements, these
changes may result in revisions to the final estimated revenue. Costs and income are
recognized in the period in which the revisions are determined.
Contract costs include all direct labor, labor burden, material, subcontract and equipment costs
and those indirect costs related to contract performance, such as indirect labor, supplies and
tools. General and administrative expense are charged to expense as incurred. Claims for
additional contract revenue are recognized when the realization of the claim is assured, and the
amount can be reasonably estimated. The asset, "Cost and Earnings in Excess of Billings"
represents revenues recognized in excess of amounts billed. The liability, "Billings in Excess of
Costs and Earnings", represents billings in excess of revenues recognized.
The Company's total revenues do not include sales tax, as the Company is a pass-through
conduit for collection and remitting sales tax.
The Bancroft Companies
Foresight.... Insight.... Onsite
owl
TGB Unlimited, Inc.
25020 STATE ROAD 2
South Bend, IN. 46619
PH. 574-968-2040
FX.574-968-2045
DRUG FREE WORK PLACE POLICY
EFFECTIVE
JULY 24, 2015
TGB Unlimited, Inc.
25020 State Road 2
South Bend, IN 46619
574-968-2040
Table of Contents
Tableof Contents........................................................................................................................... 1
A. Forward................................................................................................................................... 3
B.
Purpose...................................................................................................................................3
C.
Applicability............................................................................................................................. 3
D.
Terms & Definitions.....................................................................................................................3
E.
Legal Drugs................................................................................................................................... 4
F.
Prohibited Substances..................................................................................................................4
G.
Prohibited Conduct..................................................................................................................5
H. Compliance with Testing Requirements..................................................................................5
I. Testing Procedures..................................................................................................................6
DrugTests.................................................................................................................................... 6
Safeguards for Controlled Substance Testing............................................................................8
Direct Observation Collection is Mandatory in the Following Circumstances .........................8
ShyBladder Procedure................................................................................................................9
BreathAlcohol Test ...................................... :............................................................................. 9
ShyBreath Procedure............................................................................................................... 10
Safeguards for Alcohol Testing................................................................................................ 11
J. Positive Test Results.............................................................................................................11
K. Compliance with the Treatment Program Requirements and Employee Assistance Program
for Non -DOT Circumstances..................................................................................................11
L. Types of Testing.........................................................................................................................
12
Random Drugand Alcohol Testing....................................................................................................
12
Reasonable Suspicion Testing.....................................................................................................................
12
Post -Accident Testing Under TGB UNLIMITED, INC..................................................................................13
DBA S/T BANCROFT ELECTRIC's Authority..................................................................................................13
Return -to -Duty Testing.....................................................................................................................
15
Follow -Up Testing............................................................................................................................15
M. Confidential ResuitRecord Keeping..................................................................................16
N. Supervisor Training...........................................................................................................16
0. Employee Training ..............................
16
P. Employee Contract for Policy Violations..................................................................................16
Q. Employer Contacts..................................................................................................................17
Addendum A: Terms & Definitions............................................................................................... 17
Addendum B: Effects of Alcohol and Controlled Substance Use........................................................17
2
A. Forward
Among TGB UNLIMITED, INC. DBA S/7- BANCROFT ELECTRIC most vital concerns are the safety,
health, and well-being of its employees and all people who come into contact with its workforce,
property, and/or its products, and services. It is our goal to provide a healthy, satisfying work
environment that promotes personal opportunities for growth. Furthermore, our employees have
the right to work with persons free from the effects of alcohol and/ordrugs.
TGB UNLIMITED, INC. DBA SIT BANCROFT ELECTRIC does not intend to intrude into the private
lives of its employees and recognizes the employees' off -the -job as well as on -the -job -
involvement with illegal drugs can have a negative impact on the workplace, fellow employees
and customers. Employees are expected to report for work with no illegal drugs in their bodies
and free of all adverse effects of alcohol misuse. TGB UNLIMITED, INC. DBA S/T BANCROFT
ELECTRIC encourages employees to seek professional assistance any time for personal problems,
including alcohol or drug dependency that adversely affects their ability to perform their assigned
duties.
Supervisors of TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC are dedicated to the fair and
equitable application of this policy. They are required to apply all aspects of this policy and to use
it in an unbiased and impartial manner.
B. Purpose
The purpose of this Policy is to assure employee fitness for duty and to protect fellow employees,
customers and the public from risks posed by the abuse of illegal drugs and the misuse of alcohol.
This policy is intended to comply with all Federal, State, and Local regulations and/or laws that
apply to governing drug-free workplace programs.
C. Applicability
Thispolicyappliesto TGB UNLIMITED, INC. DBA SIT BANCROFT ELECTRIC employee, eitherfull or
part-time, of TGB Unlimited, Inc. DBA S/T Bancroft Electric when they are on company propertyor
when performing anywork forTGB Unlimited, Inc. DBA S/T Bancroft Electric.
Officers and clerical staff are exempt from this policy.
Performing work for the company means any time an employee is ready to work, begins work,
and until the employee is relieved from all responsibility for performing work.
D. Terms & Definitions
Definitions as used under this Policy are set forth in Addendum A.
3
E. Legal Drugs
For a drug to be legally prescribed the employee must have a prescription or other written
approval in his/hernamefrom a licensed physician for the use ofthe drug in the course of medical
treatment. The prescription or written document must also contain the name of the substance,
the quantity/amount to be taken, and the period of authorized use. Any abuse or misuse of legal
drugs while performing work for TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRICis prohibited.
The appropriate use of legally prescribed drugs and non-prescription medications is not
prohibited by TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC. However, the use of any
substance, which carries a warning label that indicates that motor skills, mental functioning, or
judgment may be affected, the employee must report thisto supervisory personnel immediately.
If an employee undergoes prescribed medical treatment with a drug or controlled substance, the
employee is required to report this treatment to the Designated Employer Representative (DER)
prior to performing their job function. An employee must obtain a written release from the
prescribing licensed medical practitioner that the medication(s) will not affect the employee's
ability to perform theirjob functions safely.
TGB U NLI M ITED, INC. DBA S/T BANCROFT ELECTRIC reserves the right to obtain an independent
medical opinion regarding the potential effects of a prescription or over-the-counter drug on an
employee's ability to perform their job functions.
Further, TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC reserves the right to place any
employee taking medication(s) on a non -paid leave of absence pending a decision as to whether
the employee may continue to perform regular job duties while taking the medication(s).
F. Prohibited Substances
Any substance or illegal drug identified in the Controlled Substance Act (21 U.S.C. 812) is
prohibited at all times. This includes, but not limited to, marijuana (THC), amphetamines (AMP),
opiates (OPI,) phencyclidine (PCP), and cocaine (COC), as well as any drug not approved for
medical use by the U.S. Drug Enforcement Administration or the U.S. Food and Drug
Administration. Illegal use includes, but not limited to, any illegal drug use, misuse of legally
prescribed drugs, and the use of illegally obtained prescription drugs.
TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC's policy does not authorize "medical
marijuana" under a state law to be a valid medical explanation for an employee's positive drug
test result.
Marijuana remains a drug listed in Schedule I of the Controlled Substances Act. It remains
unacceptable for any employee subject to drug testing under TGB UNLIMITED, INC. DBA S/T
BANCROFT ELECTRIC's policy to use marijuana.
CI
The consumption of beverages containing alcohol or substances in which alcohol is present
(including any medication, mouthwash, food, candy) or any other substance in which alcohol is
present while performingjob functions for TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC is
prohibited.
G. Prohibited Conduct
No employee shall report for duty or remain on duty while having an alcohol concentration of
0.04 or greater.
No employee shall use alcohol while performing their job functions.
No employee shall perform their job functions within four (4) hours after using alcohol.
No employee required to take a post -accident alcohol test shall use alcohol for eight (8) hours
following the accident or until he/she undergoes a post -accident alcohol test, whichever
occurs first.
No employee shall report for duty or remain on duty when the employee uses any controlled
substance, except when the use is pursuant to the instructions of a licensed medical practitioner
who advised the employee that the substance will not adversely affect the employee's ability to
perform their job duties.
No employee shall report for duty or remain on duty, if the employee tests positive for
controlled substances or has adulterated or substituted a test specimen.
UnderTGB UNLIMITED, INC. DBA S/T BANCRO FT ELECTRIC independent authority, engaging in
unlawful manufacture, distribution, dispensing, possession, or use of prohibited substances is
prohibited by any employee of TGB UNLIMITED, INC. DBA SrTBANCROFT ELECTRC. Employees
who violate this provision will beterminated.
Employees who violate any of these provisions will be terminated.
All employees of TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC are required to notifytheir
supervisor within five (5) days of any criminal drug statute conviction. Failure to comply with
this provision shall result in termination.
H. Compliance with Testing Requirements
All employees of TGB UNLIMITED, INC. DBA S'T BANCROFT ELECTRIC will be subject to urine drug
testing and breath alcohol testing. A refusal to test is considered a violation of TGB UNLIMITED,
INC. DBA S/T BANCROFT ELECTRIC policy and will lead to immediate removal from duty and
termination of employment.
The following items constitute a refusal to test:
(i) Failureto appear or remain at the test site.
(ii) Failure to provide urine specimen when required.
(iii) Failure to permit direct observation or monitored collection when required.
(iv) Declines to take a second test when directed.
(v) Failure to provide sufficient urine or breath without a valid medical explanation.
(vi) Failure to undergo a medical evaluation.
(vii) Failure to cooperate with thetesting process.
(viii) Attempt to dilute, substitute, or tamper with a specimen.
(ix) Failure to sign the Custody Control Form or Breath Alcohol Form
(x) Admits to the collector that he or she adulterated or substituted their specimen.
(xi) Fails to follow the observer's instructions to raise and lower their clothing and to turn
around to permit the observer to determine if the employee has a prosthetic or other
device that could be used to interfere with the process.
(xii) If MRO reports that there is a verified adulterated or substituted test result.
(xiii) During the MRO interview the employee admits to adulterating or substituting.
I. Testing Procedures
Drug and/or alcohol testing shall be conducted at afacility designated byTGB Unlimited, Inc. dba
S/T Bancroft Electric. Drugand/or alcohol collection, analysis and reporting shall be conducted in
accordance with the procedures outlined in this Policy and are consistent with the Federal
regulations enumerated in 49 CFR Part 40 and all applicable state laws. Required analytical urine
drug testing and breath alcohol testing shall be conducted when circumstances warrant or as
outlined in th is policy. TGB U NLI M ITED, INC. DBA S/T BANCROFT ELECTRIC affirms the need to
protect individual dignity, privacy, and confidentiality throughout the testing process. If at any
time the integrity of the testing procedures or the validity of the tests results are compromised,
the test will be cancelled.
Drug Tests
The drugs that will be tested for include marijuana (THC), cocaine (COC), opiates (OPI),
amphetamines (AMP), and phencyclidine (PCP). Urine specimens will be conducted using the
split specimen sample method as described in 49 CFR Part 40. Each specimen will be
accompanied by a Chain of Custody or Custody and Control Form (CCF) and identified using a
unique identification number that attributes the specimen to the correct individual.
The specimen will be sent to a laboratory where a validity test will be performed to ensure that it
is non -adulterated human urine. Then an initial drug screen test will be conducted on the primary
specimen. For the primary specimen that is not negative, a confirmatory Gas
Chromatography/Mass Spectrometry (GC/MS) test will be performed. The primary test will be
considered positive if the amounts present are above the minimum thresholds established in 49
CFR Part40.
3
All test results from the laboratory will be reported to a Medical Review Officer (MRO). The
MRO is a licensed physician with detailed knowledge of substance abuse disorders and drug
testing. The MRO is knowledgeable of MRO guidelines and 49 CFR Part 49 operating
administration regulations. The MRO must obtain the appropriate qualification training,
satisfactorily complete an examination, and annually complete twelve (12) hours of professional
development related to MRO functions as mandated in 49 CFR Part 40.
The MRO will review all test results to ensure the scientific validity of the test and to determine
whether there is a legitimate medical explanation for a confirmed positive test result. The MRO
will contact the employee, notify him/her of the positive laboratory result, and provide the
employee with an opportunity to explain the confirmed test result. The MRO will subsequently
review the employee's medical history/records to determine whether there is a legitimate
medical explanation for the positive test result. If no legitimate medical explanation is found, the
test will be verified positive and reported to TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC's
Designated Employee Representative(DER). If a legitimate medical explanation isfound, the MRO
will report the test as negative.
If the MRO indicates that a recollection under direction observation is required because of
creatinine concentration of the specimen was equal to or greater than 2mg/dL but less than or
equal to 5 mg1dL, TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC must immediately instruct
the employee to undergo a recollection under direct observation. Procedures for Transportation
Workplace Drug and Alcohol Testing Programs, 49 CFR Part 40, rules out the possibility that
employers do not receive a report indicating a substituted specimen for donors who may naturally
produce low creatinine levels.
If the creatinine concentration of the dilute specimen is greater than 5 mg/dL but less than or
equal to 20 mg/dL, TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC will direct the employee
to take another test immediately. Such collections will be unobserved, unless there is another
basis for use of direct observation (i.e. 49 CFR Part 40.67(b)). A refusal to submit to the second
test will be deemed a refusal to test and a violation of DOT regulations. The result of the second
test will be the result of record. If the second testis also dilute negative, TGB UNLIMITED, INC.
DBA S/T BANCROFT ELECTRIC will not make the employee take a third test, unless the MRO directs
a recollection under direct observation.
The split specimen sample will be stored at the initial laboratory until the analysis of the primary
specimen is complete. If the primary specimen is negative, the split sample will be discarded.
However, if the primary specimen is positive, the split sample specimen will be retained by the
initial laboratory for testing if so requested by the employee through the MRO within 72 hours of
being notified. The split sample specimen, if requested to be tested, will be sent to an alternate
certified laboratory for testing, at the expense of the employee or applicant.
7
Safeguards for Controlled Substance Testing
o The Collector must complete mandated qualification training as defined in 49 CFR Part 40
to be able to perform collections.
o The Collector must obtain photo identification from the employee or be identified by an
TGBUNLIMITED, INC. DBA SIT BANCROFTELECTRIC representativepriortoadministering
the test.
o The Collector will ask the employee to display the contents of their pockets prior to the
test being taken.
o The Collector will ask the employee to wash their hands only with water or a moist
towelette.
o The Collector and employee will check the identification numbers of the seals with the
number on the CCF.
o The Collector will ask the employee to sign the CCF signifying the correctness of the data
for testreporting.
o The Collector will unwrap and wrap the specimen containers in the presence of the
employee.
o After the specimen is collected, the Collector will inspect the specimen for sufficient
volume, temperature and signs of tampering .
o The specimen sample containers are placed in a shipping container, sealed with tamper
proof seals in the presence of the employee . The employee will be asked to initial the
seals on the specimen sample containers.
o The Laboratory will check the seals on the specimen bottles upon receipt to ensure they
are not broken, if they are broken, the Laboratory will report the test as cancelled.
o The Laboratory will report the results to the MRO by electronic communication.
Direct Observation Collection is Mandatory in the Following Circumstances
o The Laboratory reports an invalid specimen / invalid result and the MRO reports there
was not an adequate medical explanation for the results.
o The test results are reported as positive adulterated or substituted cancelled with no split
specimen sample available.
o The Collector observed materials brought to the collection site orthe employee's conduct
clearly indicated an attempt to tamper with the specimen.
o The Collector notes that the temperature of the specimen was out of range or the
specimen appeared to have been tampered with. Note: The Collector is NOT required to
take the employee's body temperature. The DER from TGB UNLIMITED, INC. DBA SIT
BANCROFT ELECTRIC will be notified of the out of temperature specimen after the direct
observation test is completed.
o The MRO reports a negative -dilute result with a creatinine concentration greater than or
equal to 2 mg/dL, but less than or equal to 5 mg/dl.
The observer must physically watch the donor urinate into the collection container. The
observer must be the same gender as the employee. If someone else is to observe the
collection other than the collector in order to ensure a same gender observer, the observer must
verbally instruct that person to follow procedures noted below.
The observer must request the employee to raise his or her shirt, blouse, or dress/skirt, as
appropriate, above the waist; and lower clothing and underpants to show you, byturning around,
that they do not have a prosthetic device. After the observer has determined that the employee
does not have such a device, you may permit the employee to return clothing to its proper
position for observed urination.
The observer must watch the employee urinate into the collection container. Specifically, they
are to watch the urine go from the employee's body into the collection container.
The observer but not the collector, must not take the collection container from the employee, but
must observe the specimen as the employee takesit to the collector.
The collector, when someone else has acted as the observer, must include the observer's name
in the "Remarks" line of the CCF (Step2).
If the employee declines to allow a directly observed collection required or permitted under this
section to occur, this is a refusal to test.
Shy Bladder Procedure
If the employee cannot provide a specimen at the initial attempt, the employee will be urged to
drink up to 40 oz. of water. The amount of water is to be spaced out over a three hour period.
The employee is not required to drink the water by49 CFR Part 40 regulations.
If the employee refuses to make the attempt to provide a new urine specimen or leaves the
collection site before the collection process is complete, the collection is discontinued, and the
Collectorshall note thefact on the "Remarks" line of the CCF(Step 2), and immediately notifythe
DER. This is a refusal to test and is considered a violation of the DOT regulations.
If the employee has not provided a sufficient specimen within three hours of the first unsuccessful
attempt to provide the specimen, the collection will be discontinued, noted on the "Remarks" line
of the CCF (Step 2), and the DER will be contacted immediately bythe collection site.
The DER will, after consulting with the MRO, direct the employee to obtain, within five days, an
evaluation from a licensed physician, acceptable to the MRO, who has expertise in the medical
issues raised bythe employee's failure to provide a sufficient specimen. (The MRO may perform
this evaluation if the MRO has appropriate expertise.)
If there is a valid medical reason, the test result will be changed by the MRO to "Cancelled." If
there is not an adequate basisfor determining that a medical condition has, or with a high degree
of probability could have, precluded the employee from providing a sufficient amount of urine,
the MRO, will issue a "Refusal to Test".
Breath Alcohol Test
All tests for breath alcohol will be conducted using a National Highway Traffic Safety
Administration (NHTSA) approved Evidential Breath Testing (EBT) device. The device must be
9;
operated by certified Breath Alcohol Technician (BAT). The certification training must meet the
qualification as defined in 49 CFR Part 40.
An air blank test will be administered prior to the screening test and the confirmation test, if
required. This indicates the EBT chamber is clear. A screening breath test will be given. If the
results are less than a concentration of 0.020, the test results is negative.
If the results of the test are between 0.020-0.039; the employee must be removed from the job
function for at least 24 hours.
If the result is 0.040 or higher, the Collection Site shall contact the DER immediately. The DER
shall remove the employee from his/her job function, and refer the employee to the company's
Employee Assistance Program (EAP).
Further. an employee who tests between 0.020 and 0.039 on a second occasion at any time
during employmentwithTGBUNLIMITED,INC.DBAS/TBANCROFTELECTRICwill,UnderTGB
UNLIMITED. INC. DBA S/T BANCROFT ELECTRIC's independent authority, beterminated from
employment.
Shy Breath Procedure
If an employee does not provide a sufficient amount of breath to permit a valid breath test, the
BAT instructs the employee to attempt again to provide a sufficient amount of breath. If the
employee refuses to make the attempt, the BAT must discontinue the test, note the fact on the
"Remarks"line of the ATF, and immediately notify the DER. This is a refusal to test.
If the employee again attempts and fails to provide a sufficient amount of breath, the BAT may
provide another opportunity if there is a strong likelihood that it could result in providing a
sufficient amount of breath. When the employee has failed to produce a sufficient amount of
breath, the BAT must note the fact on the "Remarks" line of the ATF and immediately notify the
DER.
If an EBT that has the capability of operating manually is being used, the BAT may attempt to
conduct the test in manual mode.
As the employer, when the BAT informs you that the employee has not provided a sufficient
amount of breath, the employer must direct the employee to obtain, within five days, an
evaluation from a licensed physician acceptable to the employer and who has expertise in the
medical issues raised by the employee's failure to provide a sufficient specimen.
The physician will provide a written statement of their conclusions to the DER directly. Upon
receipt of the report from the examining physician, the DER must immediately inform the
employee and take appropriate action based upon TGB UNLIMITED, INC. DBA SIT BANCROFT
ELECTRIC policy.
10
Safeguards for Alcohol Testing
o The BAT will request photo identification from the employee or be identified by a TGB
UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC representative prior to administering the
test.
o The Employee will select an individually sealed mouthpiece and it will be opened by the
BAT while in the presence of the employee for the initial test.
c The EBT used for the test will be approved by the National Highway Traffic Safety
Administration.
o Calibration checks will be frequently performed to insure the EBT is working efficiently.
The employee may ask to see the last calibration.
o For a confirmation breath test, the BAT will allow the employee to select an individually
sealed mouthpiece.
o The sealed mouthpiece will beopened bythe BATwhile in the presence of the employee
for the confirmation test.
.1. Positive Test Results
Any employee of TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC that has a confirmed
positive drug or alcohol test will be removed from his/her position, informed of the educational
and rehabilitation programs available, and referred to the company's EAP Provider for
assessment. No employee will be allowed to return to duty of their job functions without the
approval of the EAP and theemployer.
K. Compliance with the Treatment Program Requirements and
Employee Assistance Program for Non -DOT Circumstances
Early recognition and treatment of drug dependency are essential to successful rehabilitation.
Those employees recognizing a substance abuse problem should seek assistancefrom the DER.
Referrals are held in strict confidence but supervisors and appointing authorities who need to
know will be kept abreast of the employee's treatment, leave needs, and prognosis on a case-
by-case basis. Employees who are referred to the EAP Coordinator, Alcohol & Addictions
Resource Center, by their supervisor, or who, as a condition of continued employment,
participate in an alcohol/substance abuse rehabilitation program are subject to the Return -to -
Duty and Follow -Up tests, as specified in this policy.
11
L. Types ofTesting
Random Drug and Alcohol Testing
All employees of TGB UNLIMITED, INC. OBA S/r BANCROFT ELECTRIC will be subjectto random
unannounced testing. The selection of these employees for random testing of drug and alcohol
will be made using a scientifically valid method that ensures each d employee will have an equal
chance of being selected each time selections are made. Thus, an employee might be selected
more than once during a year. Each employee selected for random testing shall be tested during
the selection period.
The percentage of the number of employees in the random program is established by TGB
UNLIMITED, INC. OBA S/r BANCROFT ELECTRIC on an annual basis. At the effective date of this
policy, the minimum annual percentage are ten [10%] percent of the average number of
employees for alcohol testing, and twenty five [25%] percent of the average number of employees
for drug testing.
o Random tests will be unannounced.
o The dates for random tests will be spread throughout the year.
o An employee who is selected for random testing will be required to report to the
collection site immediately upon notification from TGB UNLIMITED, INC. OBA S/r
BANCROFT ELECTRIC's DER. The employee will be in a duty status from the time they
leave to go to the collection site until the time they return/leave the collection site.
o A random test for alcohol shall be scheduled to occur only just prior to, during, or just
after the employee performs their job function, or at any time that the employee is in
readiness to perform their jobfunction.
o A random test for controlled substances can be scheduled at any time the employee is on
duty, and is not related to when the employee is performing their job function.
o TGB UNLIMITED, INC. OBA S/T BANCROFT ELECTRIC will maintain participation in a
qualified consortium for its random selection process.
Reasonable Suspicion Testing
Reasonable Suspicion referral testing will be made on the basis of documented objective facts
and circumstances, which are consistent with the chronic and withdrawal effects of controlled
substances. Such employee conduct must be witnessed and documented by at least one
supervisor that has been trained in Reasonable Suspicion detection.
The required observationsfor alcohol and/orcontrol led su bsta nces Reasonable Suspicion Testing
shall be made by a supervisor or company official who istrained in accordance with 49 CFR Part
382.603. The training must include ways to determine the signs and symptoms of drug and alcohol
use. Should the supervisor observe such symptoms or reactions, the employee must submit to
testing. The supervisor must conclude that the employee is impaired in his/her work performance.
Documentation asto the physical appearance, behavior, performance indicators speech and body
odors of the employee must be completed prior to the test result being received.
12
Observation and testingfor Reasonable Suspicion for controlled substances can occur at anytime
the employee is on duty. An employee who is suspected of controlled substance use must be
immediately removed from their position and is required to undergo testing.
Observation and testing for Reasonable Suspicion for alcohol can occur only before, during, or
just after the employee's job function, or at any time that the employee is in readiness to perform
a job function. An employee who is suspected of alcohol misuse must be immediately removed
from their job function and is required to undergo testing. A company official will escort the
employee to the collection site.
The employee cannot return to duty until an alcohol test has been conducted with a BAC less than
0.020.
If an alcohol test is not conducted within two (2) hours, the reasons the test was not conducted
must be documented. If an alcohol test is not conducted within eight (8) hours, any attempts to
conduct an alcohol test will cease and the supervisor/DER shall document the reasons for not
conducting the t est. If no alcohol test is conducted, the employee cannot perform their job
function until twenty-four (24) hours have elapsed following the original determination of
Reasonable Suspicion of alcohol use.
An employee who is tested for controlled substances under this Reasonable Suspicion will be
compensated if the test results are negative and will not be compensated for time missed from
work if the test result is positive, adulterated or substituted.
Examples of Reasonable Suspicion include, but are not limited to, the following:
Physical signs and symptoms consistent with prohibited substance use or alcohol misuse.
Evidence of the manufacture, distribution, dispensing, possession, or use of controlled
substances, drugs, alcohol, or other prohibited substances.
Occurrence of a serious or potentially serious accident that may have been caused by prohibited
substance abuse or alcohol misuse.
Physical contact (meaning fights), assaults, and flagrant disregard or violations of established
safety, security, or other operating procedures.
Post - Accident Testing Under TGB UNLIMITED, INC.
OBA S/T BANCROFT ELECTRIC's Authority
All employees of TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC are required to undergo
urine drug testing and breath alcohol testing, if they are involved in an accident with a vehicle
owned or leased by TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC, and if one or all of the
following conditions are met:
The accident resulted in a human fatality
13
(ii) TheemployeeofTGBUNLIMITED,INC.DBAS/T BANCROFT ELECTRIC was issueda
citation and a vehicle was towed from the scene of the accident.
(iii) The employee of TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC was issued a
citation and an individual involved in the accident received bodily injury requiring
immediate medical treatment away from the scene of the accident.
The employee(s) must be tested for controlled substances within (32) hours following the
accident. If a drug test is not administered within (32) hours following the accident, TGB
UNLIMITED, INC. DBA S/TBANCROFT ELECTRIC shall cease attempts to administer the test, and
prepare and maintain on file a record stating the reasons the test was not promptly administered.
An alcohol test should be administered within two (2) hours of the accident. If this has not been
done, TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC will document the reason the test was
not completed within two (2) hours of the accident and will continue to attempt to obtain a test
and document their attempts within the eight (8) hour period. At the end of the eight (8) hours,
TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC will cease the attemptto administer the test
and document whythe test was not completed.
Any employee of TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC involved in an accident
must refrain from alcohol use for eight (8) hours following the accident or until he/she has
completed an alcohol test or released from duty.
The employee must remain readily available for testing, until they are released from the scene of
the accident. Any employee of TGB UNLIMITED, INC. DBA S/TBANCROFT ELECTRIC who
voluntarily leaves the scene of an accident priorto submission to drug and alcohol testing will be
considered to have refused to test and the employee will be terminated.
If the employee is required to leave the scene under the authority of medical or police personnel,
they must notify TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC as to their whereabouts
If TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC is unable to perform a urine drug test and
a breath alcohol test, (i.e., employee is unconscious, employee is detained by a police agency),
TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC may use drug and alcohol post-accident test
results administered by the State and/or Local law enforcement officials if they were completed.
TGB UNLIMIT ED, INC. DBA S/T BANCROFT ELECTRIC will obtain the results in conformance with
State and Local law.
TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC requires an employee to submit to drug and
alcohol tests following a motor vehicle accident or property damage accident involving injury to
any individual involved in the accident requiring immediate medical treatment away from the
scene, serious damage to any motor vehicle or equipment involved in the accident, a workplace
fatality, or serious property damage even if the employee did not receive a citat ion. Any
14
employee having a physical injury that requires immediate medical attention away from the work
site will be required to submit to drug and alcohol tests.
The drug test for a Post -Accident incident will be composed of a five panel urine test. The drugs
that will be tested for under Non -DOT include marijuana (THC), cocaine (COC), opiates (OPI),
amphetamines (AMP), and phencyclidine (PCP.)
Return -to -Duty Testing
Under TGB UNLIMITED, INC. OBA SIT BANCROFT ELECTRIC's policy, before an employee is
considered for reinstatement after having engaged in prohibited conduct (Section H) which
constitutes a violation of TGB UNLIMITED, INC. OBA S/T BANCROFT ELECTRIC's policy, the
employee must provide a negative Retum-to-Duty drug and/or alcohol t est.
This test must be completed after an assessment by the company's EAP Provider.
The Return -to -Duty test is not limited to a specific substance (i.e. the drug for which the
employee tested positive). Additionally, a drug test may be performed in conjunction with an
alcohol test
depending on the EAP Provider's assessmen.t The result of the alcohol test must be less than
0.02.
If an employee refuses to submit to a Return -to -Duty test orfails to appear at the collection site
within a reasonable time, as determined by TGB UNLIMITED, INC. OBA S/T BANCROFT ELECTRIC
and after being directed to do so bythe DER, this is considered a "Refusal to Test". The employee
will not be permitted to return to their position.
The cost of a Ret urn -t o -Duty test shall be paid by the employee.
Follow -Up Testing
Under TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC's policy, before an employee is
considered for reinstatement after having engaged in prohibited conduct (Section H) which
constitutes a violation of TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC's policy, the
employee must be assessed by the company's EAP Provider and undergo frequent unannounced
Follow-up urine and/or breath testing following their Return -to -Duty Test. The employee will
remain in the random testing program. The company's EAP Provider & the employer will
determine the frequency and duration of the follow-up tests.
The employer or their Third Party Administrator (TPA) will schedule the test dates and ensure
that the appropriate tests are conducted.
Tests may be for both controlled substances and/or alcohol regardless of whether the prohibit
ion violation concerned either specific substance. There is no limit to the number and
frequency of the follow-up tests.
The cost of Follow-up testing requirements shall be paid by the employee
15
M. Confidential Result Record Keeping
The results of all drug and alcohol testing results will be maintained in a secure confidential
manner bythe employer, laboratory, collection site, MRO, SAP, and the Consortium/Third Party
Administrator (C/TPA). Information can only be released in the following circumstances and
with the employee being notified in writing of the release
(i) To a third party only as directed by written instructions of the employee.
(ii) To the decision -maker in a lawsuit, grievance, or other proceeding initiated by or on
behalf of the employed tested.
(iii) To the employee upon written request.
N. Supervisor Training
Supervisors of TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC who are designated to
determine whether or not Reasonable Suspicion exists and who then order an employee to
undergo testing underTGB UNLIMITED, INC. DBAS/TBANCROFT ELECTRIC's policy, shall receive
a minimum of 60 minutes of training on recognizing alcohol misuse; and receive at least an
additional 60 minutes of training on recognizing controlled substance use. The training shall
include the signs and symptoms of alcohol misuse and use of drugs including the effects and
consequences of drug use on personal health, safety, and the work environment. The training
must include manifestations and behavioral cuesthat may indicate prohibited drug use or alcohol
misuse.
0. Employee Training
Each employee shall be provided with a copy of drug abuse and alcohol misuse educational
materials when hired. TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC shall ensure thateach
employee signs a statement certifying that he/she has received a copy of the educational
materials, maintain a copy of the signed statement and may provide a copy to the employee.
P. Employee Contract forPolicy Violations
Undercertain circumstances, employees of TGB UNLIMITED, INC. DBA S/TBANCROFT ELECTRIC
who re-enter the workforce after a violation of the prohibitions (Section H) must agree to a re-
entry contract. The contract may include, but is not limited, to the following items:
(i) A release to return to work statement from the EAP Provider.
(ii) A negative Return -to-Duty test result for drugs and/or alcohol.
(iii) A statement of expected work-related behaviors of theemployee.
(iv) An agreement to follow specified after care requirements with the understanding that a
violation of the re-entry contract is grounds for termination.
16
Q. Employer Contacts
Designated Employer Representative:
Name: Scott Bancroft
Telephone: 574-876-9444 (Cell)
Fax: 574-968-2045
This policy was adopted by TGB UNLIMITED, INC. DBA S/T BANCROFT ELECTRIC on 1-11-2019.
Vice President
(Signature) (Title)
Scott Bancroft
(Print Name)
Addendum A: Terms & Definitions
The definitions contained in Addendum A apply when interpreting or implementing the procedures
required byTGBUNLIMITED, INC. DBAS/TBANCROFT ELECTRIC's controlled substance testing
regulations.
Addendum B: Effects of Alcohol and Controlled Substance Use
Employees may be provided with training material discussing the effects of alcohol and controlled
substance use on an individual's health, work, and personal life. Addendum B is intended to help
individuals understand the personal consequences of substanceabuse.
17
Addendum A: Terms & Definitions
Terms
Definitions
Accident
An occurrence involving a commercial motor vehicle operating on a highway in interstate
or intrastate commerce which results in: (1) A fatality; (2) Bodily injury to a person who, as
a result of the injury, immediately receives medical treatment away from the scene of the
accident; or (3) One or more motor vehicles incurring disabling damage as a result of the
accident, requiring the motor vehicle(s) to be transported away from the scene by a tow
truck or other motor vehicle.
Adulterated
A specimen that contains a substance that is not expected to be present in human urine,
Specimen
or contains a substance expected to be present but is at a concentration so high that it is
not consistent with human urine.
Affidavit
A form that must be signed by the collector to correct a problem on the original Chain of
Custody form. For example, if the date was missing, incorrect, or the collector's signature
was missing.
Affiliate
Persons are affiliates of one another if, directly or indirectly, one controls or has the power
to control the other or a third party controls or has the power to control both. Indicators
of control include, but are not limited to: interlocking management or ownership; shared
interest among family members; shared facilities or equipment; or common use of
employees. Following the issuance of a public interest exclusion, an organization having
the same or similar management, ownership, or principal employees as the service agent
concerning whom a public interest exclusion is in effect is regarded as an affiliate. This
definition is used in connection with the public interest exclusion procedures of Subpart R
of this part.
Air Blank
In evidential breath testing devices (EBTs) using gas chromatography technology, a reading
of the device's internal standard. In all other EBTs, a reading of ambient air containing no
alcohol.
Alcohol
The intoxicating agent in beverage alcohol, ethyl alcohol or other low molecular weight
alcohols, including methyl or isopropyl alcohol.
Alcohol
The alcohol in a volume of breath expressed in terms of grams of alcohol per 210 liters of
Concentration
breath as indicated by a breath test under this part.
Alcohol
A subsequent test using an EBT, following a screening test with a result of 0.02 or greater,
Confirmation
that provides quantitative data about the alcohol concentration.
Test
Alcohol Screening
A breath or saliva device, other than an EBT, that is approved by the National Highway
Device
Traffic Safety Administration (NHTSA) and placed on a conforming products list (CPL) for
such devices.
Alcohol Screening
An analytic procedure to determine whether an employee may have a prohibited
Test
concentration of alcohol in a breath or saliva specimen.
Alcohol Testing
A place selected by the employer where employees present themselves for the purpose of
Site
providing breath or saliva for an alcohol test.
Alcohol Use
The drinking or swallowing of any beverage, liquid mixture or preparation (including any
medication), containing alcohol.
Terms
Definitions
Blind Specimen
Blind specimen or blind performance test specimen. A specimen submitted to a
or Blind
laboratory for quality control testing purposes, with a fictitious identifier, so that the
Performance Test
laboratory cannot distinguish it from an employee specimen.
Specimen
Breath Alcohol
A person who instructs and assists employees in the alcohol testing process and operates
Technician
an evidential breath testing device.
Canceled Test
A drug or alcohol test that has a problem identified that cannot be or has not been
corrected, or which this part otherwise requires to be cancelled by the Medical Review
Officer. A cancelled test is neither a positive nor a negative test.
Chain of Custody
The procedure used to document the handling of the urine specimen from the time the
employee gives the specimen to the collector until the specimen is destroyed. This
procedure uses the Federal Drug Testing Custody and Control Form (CCF).
Clinic
A medical facility that can be used as a collection site.
Collection
A container into which the employee urinates to provide the specimen fora drug test.
Container
Collection Site
A place selected by the employer where employees present themselves for the purpose of
providing a urine specimen for a drug test and breath sample for an alcohol test. This site
must possess all necessary personnel, materials, equipment, facilities and supervision to
provide for the collection, security, shipment of urine samples to a laboratory and an
evidential breath tester for confirmation breath testing.
Collector
A person who instructs and assists employees at a collection site, who receives and makes
an initial inspection of the specimen provided by those employees, and who initiates and
completes the CCF.
Confirmation
A second analytical procedure performed on a urine specimen to identify and quantify the
Drug Test
presence of a specific drug or drug metabolite.
Confirmation
A second test performed on a urine specimen to further support a validity test result.
Validity Test
Confirmed Drug
A confirmation test result received by an MRO from a laboratory.
Test
Consortium/Third
A service agent that provides or coordinates the provision of a variety of drug and alcohol
Party
testing services to employers. C/TPAs typically perform administrative tasks concerning
Administrator
the operation of the employers' drug and alcohol testing programs. This term includes,
but is not limited to, groups of employers who join together to administer, as a single
entity, the DOT drug and alcohol testing programs of its members.
Continuing
Training for medical review officers (MROs) and substance abuse professionals (SAPS) who
Education
have completed qualification training and are performing MRO or SAP functions, designed
to keep MROs and SAPS current on changes and developments in the DOT drug and
alcohol testing program.
Designated
An employee authorized by the employer to take immediate action(s) to remove
Employer
employees from safety -sensitive duties, or cause employees to be removed from these
Representative
covered duties, and to make required decisions in the testing and evaluation
processes. The DER also receives test results and other communications for the employer,
consistent with the requirements of 49 CFR Parts 40 and 382. Service agents cannot act as
DERs.
Dilute Specimen
A specimen with creatinine and specific gravity values lower than expected for human
urine.
Terms
Definitions
Direct
An observer of the same gender physically watches the donor urinate into the collection
Observation
container. The observer must be the same gender as the donor --there are no exceptions
Procedure
to this regulation. If someone else is to observe the collection other than the collector in
order to ensure a same gender observer, the observer must verbally instruct that person
to follow procedures noted below.
The observer must request the driver to raise his or her shirt, blouse, or dress/skirt, as
appropriate, above the waist; and lower clothing and underpants to show you, by turning
around, that they do not have a prosthetic device. After the observer has determined that
the driver does not have such a device, you may permit the driver to return clothing to its
proper position for observed urination.
The observer must watch the driver urinate into the collection container. Specifically, they
are to watch the urine go from the driver's body into the collection container.
The observer but not the collector, must not take the collection container from the driver,
but must observe the specimen as the driver takes it to the collector.
The collector, when someone else has acted as the observer, must include the observer's
name in the "Remarks" line of the CCF (Step 2).
If the driver declines to allow a directly observed collection required or permitted under
this section to occur, this is a refusal to test.
Drug Metabolites
A chemical that is released from the ingesting process. This is what is checked for in a drug
screen. Particular substances produce particular metabolites.
Drugs
The drugs for which tests are required under this part and DOT agency regulations are
marijuana, cocaine, amphetamines, phencyclidine (PCP), and opiates.
Employee
Any person who is designated in a DOT agency regulation as subject to drug testing and/or
alcohol testing. The term includes individuals currently performing safety -sensitive
functions designated in DOT agency regulations and applicants for employment subject to
pre-employment testing. For purposes of drug testing under this part, the term employee
has the same meaning as the term "donor" as found on CCF and related guidance
materials produced by the Department of Health and Human Services.
Employer
A person or entity employing one or more employees (including an individual who is self-
employed). The term includes an employer's officers, representatives, and management
personnel. Service agents are not employers for the purposes of this part.
Error Correction
Training provided to BATs, collectors, and screening test technicians (STTs) following an
Training
error that resulted in the cancellation of a drug or alcohol test. Error correction training
must be provided in person or by a means that provides real-time observation and
interaction between the instructor and trainee.
Evidential Breath
A device approved by NHTSA for the evidential testing of breath at the .02 and .04 alcohol
Testing Device
concentrations, placed on NHTSA's Conforming Products List (CPL) for "Evidential Breath
Measurement Devices" and identified on the CPL as conforming with the model
specifications available from NHTSA's Traffic Safety Program.
Terms
Definitions
HHS
The Department of Health and Human Services or any designee of the Secretary,
Department of Health and Human Services.
Initial Drug Test
The test used to differentiate a negative specimen from one that requires further testing
for drugs or drug metabolites.
Invalid Drug Test
The result of a drug test for a urine specimen that contains an unidentified adulterant or
an unidentified interfering substance, has abnormal physical characteristics, or has an
endogenous substance at an abnormal concentration that prevents the laboratory from
completing or obtaining a valid drug test result.
Laboratory
Any U.S. laboratory certified by HHS under the National Laboratory Certification Program
as meeting the minimum standards of Subpart C of the HHS Mandatory Guidelines for
Federal Workplace Drug Testing Programs; or, in the case of foreign laboratories, a
laboratory approved for participation by DOT under this part. (The HHS Mandatory
Guidelines for Federal Workplace Drug Testing Programs are available on the internet at
http://www.health.org/workpi.htm or from the Division of Workplace Programs, 1 Choke
Cherry Road, Room 2-1035, Rockville, MD 20857.)
Medical Review
A person who is a licensed physician and who is responsible for receiving and reviewing
Officer
laboratory results generated by an employer's drug testing program and evaluating
medical explanations for certain drug test results.
Negative Dilute
A drug test result which is negative for the five drugs/drug metabolites, but has a specific
gravity value lower than expected for human urine.
Negative Result
A result that indicates that the specimen did not exceed certain levels of drug
metabolites. The average turnaround time for a negative result is 24 hours from the time
the laboratory receives the specimen, though this could vary.
Non -negative
A urine specimen that is reported as adulterated, substitute, invalid, or positive for
Specimen
drug/drug metabolites.
Positive Dilute
A urine drug test result which is positive for the five drugs/drug metabolites, but has a
specific gravity value lowerthan expected for human urine.
Positive Result
For a drug test means a verified presence of the identified drug or its metabolite at or
above the minimum levels specified in 49 CFR Part 40, as amended. The confirmed result
is sent to the MRO for review. A positive alcohol test result means a confirmed alcohol
concentration of 0.04 BAC or greater.
Primary
In drug testing, the urine specimen bottle 'A' that is opened and tested by a' first'
Specimen
laboratory to determine whether the employee has a drug or drug metabolite in his or her
system; and for the purpose of validity testing. The primary specimen is distinguished
from the split specimen, defined in this section. A 'second' laboratory may test bottle 'B'
should the donor not agree with the results from bottle W.
Qualification
The training required in order for a collector, BAT, MRO, SAP, or STT to be qualified to
Training
perform their functions in the DOT drug and alcohol testing program. Qualification
training may be provided by any appropriate means (e.g., classroom instruction, internet
application, CD—ROM, video).
Refresher
The training required periodically for qualified collectors, BATS, and STTs to review basic
Training
requirements and provide instruction concerning changes in technology (e.g., new testing
methods that may be authorized) and amendments, interpretations, guidance, and issues
concerning this part and DOT agency drug and alcohol testing regulations. Refresher
training can be provided by any appropriate means (e.g., classroom instruction, internet
application, CD—ROM, video).
Terms
Definitions
Refusal to Test
The following are considered a refusal to test if the employee:
0 Fails to appear for any test (excluding pre-employment) within a reasonable time, as
determined by the employer, after being directed to do so by the employer.
o Fails to remain at the testing site until the testing process is complete.
o Fails to provide a urine or breath specimen for any drug or alcohol test required by the
company's policy.
0 In the case of a directly observed or monitored collection in a drug test, fails to permit
the observation or monitoring of his/her provision of a specimen.
0 Fails to provide a sufficient amount of urine or breath when directed, and it has been
determined, through a required medical evaluation, that there was no adequate medical
explanation for the failure.
o Fails or declines to take a second test the employer or collector has directed the
employee to take.
o Fails to undergo a medical examination or evaluation, as directed by the MRO as part of
the verification process, or as directed by the DER as part of the "shy bladder" or "shy
lung" procedures.
0 Fails to cooperate with any part of the testing process (e.g., refuse to empty pockets
when so directed by the collector, behave in a confrontational way that disrupts the
collection process).
0 If the MRO reports that there is verified adulterated or substituted test result.
o Failure or refusal to sign Step 2 of the alcohol testing form.
Security-Sensitive
A position in which the normal or periodic job responsibilities of the employee entail, at
Position
some point and to some degree, access to cash, securities, bonds, or other negotiable
Non-DOT
instruments, and/or precious and/or valuable commodities; involve the use of, or access
to, firearms and/or other weapons and/or armaments; involve protection of property,
valuables, and/or individuals; relate to matters of national security, military, or law
enforcement; and/or entail access to assets and/or information vital to, sensitive for,
and/or with high proprietary interest to the Company [and for whom the illicit use of drugs
and/or misuse of alcohol by the employee in that position could compromise the interests
of the Company and/or any individual or entity affiliated to, or in contact with, the
Company]. Associated with a Non-DOT Drug Free Workplace.
Service Agent
Any person or entity, other than an employee of the employer, who provides services
specified under this part to employers and/or employees in connection with DOT drug and
alcohol testing requirements. This includes, but is not limited to, collectors, BATS and
STI's, laboratories, MROs, substance abuse professionals, and C/TPAs. To act as service
agents, persons and organizations must meet the qualifications set forth in applicable
sections of this part. Service agents are not employers for purposes of this part.
Shipping
A container that is used for transporting and protecting urine specimen bottles and
Container
associated documents from the collection site to the laboratory.
Shy Bladder
If the driver cannot provide a specimen at the initial attempt, the driver will be urged to
drink up to 40 oz. of water. The amount of water is to be spaced out over a three hour
period. The driver is not required to drink the water by 49 CFR Part 40 regulations.
If the driver does not provide a specimen, or refuses to provide a specimen, the test will
Terms
Definitions
be marked as a "Refusal to Test" and considered a violation of the DOT regulations. The
driver will be sent to a physician with expertise in the field, within five (5) days for an
evaluation as to why the individual was not able to provide a specimen. If there is a valid
medical reason, the test result will be changed to "Cancelled."
Shy Breath
If a driver does not provide a sufficient amount of breath to permit a valid breath test, the
BAT instructs the driver to attempt again to provide a sufficient amount of breath. If the
driver refuses to make the attempt, the BAT must discontinue the test, note the fact on
the "Remarks" line of the ATF, and immediately notify the DER. This is a refusal to test.
If the driver again attempts and fails to provide a sufficient amount of breath, the BAT may
provide another opportunity if there is a strong likelihood that it could result in providing a
sufficient amount of breath. When the driver has failed to produce a sufficient amount of
breath, the BAT must note the fact on the "Remarks" line of the ATF and immediately
notify the DER.
If an EBT that has the capability of operating manually is being used, the BAT may attempt
to conduct the test in manual mode.
As the employer, when the BAT informs you that the driver has not provided a sufficient
amount of breath, the employer must direct the driver to obtain, within five days, an
evaluation from a licensed physician selected by the employer and who has expertise in
the medical issues raised by the driver's failure to provide a sufficient specimen.
The physician will provide a written statement of their conclusions to the DER directly.
Upon receipt of the report from the examining physician, the DER must immediately
inform the driver and take appropriate action based upon the DOT agency regulations.
Specimen Bottle
The bottle that, after being sealed and labeled according to the procedures in this part, is
used to hold the urine specimen during transportation to the laboratory.
Split Specimen
In drug testing, a part of the urine specimen that is sent to a first laboratory and retained
unopened, and which is transported to a second laboratory in the event that the employee
requests that it be tested following a verified positive test of the primary specimen or a
verified adulterated or substituted test result.
Stand -Down
The practice of temporarily removing an employee from the performance of their job
functions based only on a report from a laboratory to the MRO of a confirmed positive test
for a drug or drug metabolite, an adulterated test, or a substituted test, before the MRO
has completed verification of the test result. Employers are prohibited from standing
employees down.
Substance Abuse
A person who evaluates employees who have violated a DOT drug and alcohol regulation
Professional
and makes recommendations concerning education, treatment, follow-up testing, and
aftercare.
Substituted
A specimen with creatinine and specific gravity values that are so diminished that they are
Specimen
not consistent with human urine.
Temperature
A strip on the collection container that determines whether or not the urine is in the 90 -
Strip
100 degree range. This helps to ensure that tampering has not occurred.
Validity Test
An evaluation of the specimen to determine if it is consistent with normal human urine.
Validity testing determines whether certain adulterants or foreign substances were added
to the urine, if the urine was diluted, or if the specimen was substituted.
Terms
Definitions
Verified Test
A drug test result or validity testing result from an HHS-certified laboratory that has
undergone review and final determination by the MRO.
Addendum B: Effects of Alcohol and Controlled Substance Use
The following information provides a general overview of the effects of alcohol and controlled
substances use on an individual's health, work, and personal life; signs and symptoms of an alcohol or a
controlled substances problem (the driver's or a co-worker's); and available methods of intervening
when an alcohol or a controlled substances problem is suspected, including confrontation, referral to
any employee assistance program and/or referral to management.
This information combined with your Company's substance abuse policy complies with all Federal, State,
and Local regulations and/or laws that apply to governing drug-free workplace programs. If you have
any questions regarding your Employers' policy, please contact the Designated Employer
Representative(s) (DERs) named in your Company's Drug -Free Workplace Policy.
Please note that alcohol use, drug abuse, and controlled substance are interchangeable throughout this
information.
Effects of Alcohol
In American society, alcohol is a legal drug. Nonetheless, it is a depressant and is the leading drug of
abuse. Alcohol abuse is responsible for about half of all auto collisions in this country. It is also the most
widely used drug. It is a contributing factor to problems in the workplace including diminished
productivity and increased absenteeism.
FACT., A 5 ounce glass of wine, a 12 ounce can of beer, and a 1-1/2 ounce shot of hard liquor all
contain the same amount of alcohol. Each one-half ounce of alcohol takes the average body
about one hour to process. Cold showers, exercise, and coffee do not quicken the sobriety.
A central nervous system depressant, alcohol first acts on those parts of the brain that affect self-control
and other learned behaviors. It impairs alertness, judgment, coordination, and reaction time. It lowers
inhibitions and a person's inability to divide attention. If taken in large amounts alcohol can cause
damage to the liver and heart, and can cause permanent brain damage. Heavy drinkers shorten their
lives in half.
Signs and Symptoms of Abuse:
Dulled mental processes
— Lack of coordination
— Slowed reaction time
— Poorjudgment
— Reduced inhibitions
Health Effects:
Decreased sexual functioning
— Liver disease
— Increased cancers of the mouth,
tongue, pharynx, esophagus,
rectum, breast, and skin
— Kidney disease
Ulcers
— Elevated blood pressure
— Weakens muscles
Workplace Issues - Job Performance
— Inconsistent work quality
— Poor concentration and lack of focus
— Lowered productivity or erratic work patterns
— Increased absenteeism or on the job "presenteeism"
— Unexplained disappearances from the jobsite
— Carelessness, mistakes or errors in judgment
— Needless risk taking
— Disregard for safety for self and others- on the job and off the job accidents
— Extended lunch periods and early departures
Workplace Behavior
— Frequent financial problems
— Avoidance of friends and colleagues
— Blaming others for own problems and shortcomings
— Complaints about problems at home
— Deterioration in personal appearance or personal hygiene
— Complaints, excuses and time off for vaguely defined illnesses or family problems
Effects of Drugs
Mariivana
Tetrahydrocannabinol (THC) is the active ingredient in marijuana. Whether this drug is
smoked or ingested it produces an initial euphoria, followed by a sense of relaxation,
dreaminess, and auditory and visual enhancement. A user will feel increased appetite
and lowered inhibitions. It is considered an "Enhancer" which means it enhances the
effects of any other sedative it is used with. It's also a "Gateway Drug". Increased THC
potency in modern marijuana dramatically compounds the side effects. Combining
alcohol or other depressant drugs with marijuana increases the impairing effects of
both.
Physical, behavioral, speech and performance indicators of marijuana use include:
uncharacteristically relaxed inhibitions, increased appetite, odor of marijuana or burning
rope or grass, red eyes, dry mouth, difficulty concentrating, short attention span, poor
concentration and coordination, and errors in judgment.
Signs and Symptoms of Abuse:
— Reddened eyes due to
increased blood pressure
— Lackadaisical attitude
— Difficulty comprehending
complex ideas
Slowed speech
— Distinctive odor on clothing
— Chronic sore throat
— Chronic fatigue and lack of
motivation
— Irritating cough
— Lack of body coordination
Workplace Issues
Health Effects:
Emphysema -like symptoms
— Lung Cancer
Cell abnormalities
— Respiratory tract and sinus
infections
Lowered immune system
response
— Impotency and infertility;
changes to reproductive
system
Loss of interests and
motivation
This drug alters a users sense of time and reduces the ability to perform tasks requiring
concentration; and thus reduces significantly productivity in the workplace.
FACT., One or two joints will stay in the user's system for two or three days. If
marijuana use occurs three or four times a week, the metabolite stays in the
system for about two weeks. Daily use of marijuana will stay in the system
anywhere from three to six weeks.
Cocaine
Cocaine is a powerful stimulant that is very addicting leading to physical and
psychological dependence. It is commonly sniffed, injected, and or snorted in a powder
form.
Free -base cocaine is also known as "crack" or "rock" and is smoked. Cocaine creates an
initial surge of excitement followed by a sense of increased energy, alertness, and
inflated sense of self-esteem. Chronic nasal problems, recurrent sinusitis, sleep, and
anxiety disorders are just a few of the physical, behavioral, speech, and performance
indications of cocaine use.
Signs and Symptoms of Abuse:
— Dilated pupils
— Increased pulse rate
— Elevated blood pressure
Insomnia
— Loss of appetite
— Tactile hallucinations
— Paranoia
— Seizures
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— Anxiety and agitation
— Periods of increased activity
followed by fatigue and
depression
— Wide mood swings
— Difficulty concentrating
Health Effects:
— Cardiac arrest or
respiratory failure
— Ulcerated mucous
membrane of the nose
HIV/Hepatitis/AIDS
— Increase tolerance and
craving for the drug
FACT: Crack is often considered the "safer' form of cocaine. This is NOT
correct. Crack cocaine is the most addictive and dangerous drug today. Crack
causes vomiting, tremors, convulsions, and rapid heartbeat. High doses depress
brain functioning, which may lead to death. Cocaine remains in a users system
for about two to four days.
Workplace Issues
— Extreme mood and energy swings create instability. Sudden noise causes a
violent reaction.
— Lapses in attention and ignoring warning signals increases probability of
accidents.
— High cost frequently leads to theft and/or dealing.
— Paranoia and withdrawal may create unpredictable or violent behavior.
— Performance is characterized by forgetfulness, absenteeism, tardiness, and
missing assignments.
Amphetamines
Amphetamines stimulate the central nervous system promoting a feeling of alertness
and an increase in speech and general activity. Depending on the dosage and quality,
they may also bring auditory, visual, or tactile hallucinations. Frequent users often suffer
from measles like acne, have trouble with their teeth, gums, and nails, and have dry
hair.
A derivative of from amphetamines is methamphetamines. It has become more popular
in recent years, and can be manufactured from common household products. It has
similar effects on the central nervous system, but enters the system much faster. It is
highly addictive, and comes in several forms: white powder, pills, and crystal -like rock. It
can be swallowed, injected, inhaled, or smoked. Names can vary depending on form,
geographical location, and the local drug culture. Also known as crank
Signs and Symptoms of Abuse:
Mood changes
— Restlessness
— Dilated pupils
— Increased heart rate and
blood pressure
— Decreased appetite
— Impaired concentration
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— Impaired mental
functioning
Swings between apathy and
alertness
Health Effects:
Increased heart and
respiratory rates
— Elevated blood pressure
— Sweating
— Headaches
Workplace Issues
— Blurred vision
— Dizziness
— Sleeplessness and anxiety
— Poor coordination
— Physical collapse
— Since the drug alleviates the sensation of fatigue, it may be abused to increase
alertness during periods of overtime or failure to get rest.
— With heavy use or increasing fatigue, the short-term mental or physical
enhancement reverses and becomes impairment.
FACT., Frequent users become dependent on using amphetamines and
methamphetamines to avoid the "down" mood that they experience when the
high wears off. They can be detected in a user's body for about two to three days
after use.
Opiates
Opiates are pain relievers that cause drowsiness and respiratory depression along with
euphoria. Common opiates are opium, morphine, codeine, synthetic narcotics (Vicodin,
Darvon, Demerol and methadone), and heroin. Most medical problems associated with
opiates are caused by the uncertain dosage levels, use of non-sterile needles,
contamination of the drug, and or the combination of a narcotic with other drugs.
Common street names are: smack, junk, dope, brown sugar, morpho, and coties. Many
abusers are also taking prescription drugs containing codeine or morphine.
Signs and Symptoms of Abuse: Initially produces a feeling of euphoria that is
followed by:
— Drowsiness
— Nausea and vomiting
Constricted pupils
— Watery eyes and itching
— Low and shallow breathing
Clammy skin
— Impaired respiration
— Convulsions
— Coma
— Death
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Health Effects:
Tolerance develops rapidly
— Addiction
HIV/AIDS/Hepatitis
— Premature, stillborn or
addicted infants
Workplace Issues
Effects on Mental Performance
— Depression and apathy
— Wide mood swings
— Slowed movement and reflexes
In addition the high physical and psychological dependence level of opiates compounds
the impaired functioning.
Effects on Driver Performance
The apathy caused by opiates can translate into an "I don't really care" attitude towards
performance. The physical effects as well as the depression, fatigue, and slowed reflexes
impede the reaction time of the driver, raising the potential for accidents. Although opiates
have a legitimate medical use in alleviating pain, workplace use may cause impairment of
physical and mental functions.
— Premature death/fatal accidents
— Injuries/accident rates
— Absenteeism/extra sick leave, and
— Loss of production.
FACT., Heroin accounts for 90% of the narcotic abuse in this country. When
injected it reaches the brain in 15 to 30 seconds and the effect lasts three to five
hours. Opiates can be detected in a users system one to two days after use.
PCP (phencyclidine)
PCP is often referred to as 'angel dust', 'rocket fuel', or 'killer weed'. It is a
hallucinogenic drug that is smoked, swallowed, snorted, or injected. This drug distorts
the senses and often produces hallucinations. PCP interrupts the function of the
neurocortex, the section of the brain that controls the intellect and keeps instincts in
check as it blocks pain receptors. Violent PCP episodes may result in self-inflicted
injuries.
Signs and Symptoms of Abuse:
— Impaired concentration
— Confusion and agitation
— Muscle rigidity
— Profuse sweating
— Repetitive speech patterns
— Blank stares
— Impaired driving ability
2
Health Effects:
— Memory problems
— Speech difficulties
— Depression
— Anxiety
— Violent behavior
— Paranoia
— Hallucinations
— Convulsions
— Coma
Workplace Issues
Employees who fall under Federal guidelines such as the Department of
Transportation's testing regulations are prohibited from using PCP.
Use causes severe disorientation.
FACT: PCP has a direct effect on the brain's internal stimuli. Users deal with their
environment in a manner that is not characteristic of their normal behavior.
More deaths occur from erratic behavior on the users part than on the actual
drug use itself. This drug remains in the user's body for up to eight days after
use.
Over the Counter (OTC) Drugs
Over-the-counter (OTC) drugs, especially cough and cold medications are becoming popular as
recreational drugs, especially for young people. Hospitals have reported dozens of overdoses in
the past two years, including deaths. Antihistamines, decongestants, cough syrups, pain
relievers, mouthwashes, reducing aids, sleeping aids, stimulants, alcohol, caffeine, lookalikes,
act-alikes.
Combinations:
Cold and cough preparations with codeine and/or alcohol, with antihistamines and
decongestants or with phenylpropanolamine (PPA). Mouthwash with alcohol. Aspirin with
caffeine and/or acetaminophen. Amphetamine (speed) look -a -like with caffeine, PPA,
ephedrine. Quaalude (lude) look -a -like with acetaminophen or aspirin. Cocaine (coke) look-a-
like with caffeine, PPA, ephedrine and benzocaine, lidocaine, procaine or tetracaine.
Dextromethorphan (DXM) is found in over 120 non-prescription cough and cold
medications. It is a synthetic drug similar to morphine, and has been added to cough syrups and
some cold medications since the 1970's. Sleep aids like Tylenol PM, Excedrin PM, and Sominex
can exert a stimulant effect that disrupts the regular sleep pattern.
Some Popular OTC Drugs:
Dextromethorphan (DXM)
— Coricidin HBP Cough & Cold Medicine
— Robitussin DM (2 milligram per milliter)
— Nyquil
— Vicks Formula 44
— Dramamine taken in high doses (one entire package or more) can cause
hallucinations.
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What It Feels Like:
Varies from mild drug effects to extreme combination drug effect. Alertness, anxiety,
restlessness, confusion, dizziness, numbness, lightheadedness, mild euphoria, drowsiness,
relaxation, nausea, headache, hostility, delirium, excitement, body tension. Look -a -like
amphetamine: agitation, hallucination. Look -a -like cocaine: rush of euphoria, anxiety.
Health Effects:
To Your Mind: Stimulates or depresses central nervous system, especially
respiratory center.
To Your Body: Alters heart rate, blood pressure, and breathing, interferes with
control of body movements and reflex actions.
Hypertension. Inability to sleep. Changes in blood pressure and heart functions. Respiratory
depression, individual allergic or psychotic reactions, kidney and liver damage. Coma, vomiting,
tremors, ulcers, colitis. Needle related infections and AIDS.
Special Characteristics:
Depressant effect is intensified if antihistamines, alcohol, tranquilizers, and like drugs
are combined. Nose sprays effect "nasal rebound effect" and addiction. Cold pills combined with
cough syrups can double dose and side effects of all drugs. Small children are strongly affected
by alcohol based drugs. Aspirin should be avoided before surgery. It interacts with various
prescription drugs and can cause internal bleeding when combined with alcohol. Aspirin use for
children under age 16 with chicken pox or flu can bring on Reye Syndrome. Aspirin is the most
common cause of accidental poisoning in children. Ibuprofen may have side effects for those
allergic to aspirin. PPA can cause heart palpitations. Indocin and PPA can raise blood pressure to
life-threatening levels.
When to Get Help?
— Do you take more medication than is prescribed?
Is your work or school performance affected by your drug use?
— Are you having problems with family and friends?
— Are you spending more on drugs than you can afford?
— Do you use a variety of drugs?
One "yes" and your common sense tell you it's time to get smart about drugs and the rest of
your life.
0
What should I do if I have a drug or alcohol abuse problem?
Seek help. Your work is a vital part of everyday life. Yet, by abusing drugs or alcohol, you risk
your own life, your co-workers lives and the lives of the public.
Most every community in the country has resources available to confidentially assist you
through the evaluation and treatment of your problem. If you would like to find a treatment
facility close to you, check with your local yellow pages, local health department or visit the U.S.
Department of Health and Human Services treatment facility locator at
http://findtreatment.samhsa.gov. This site provides contact information for substance abuse
treatment programs by state, city and U.S. Territory.
Also, many workplace programs are in place to assist employees and family members with
substance abuse, mental health and other problems that affect their job performance. While
they may vary by industry, here is an overview of programs that may be available to you:
Employee Assistance Programs (EAPs)
EAPs may be available to employees as a matter of company policy. EAPs are generally provided
by employers or unions.
Note: Many employees believe they only need to contact an EAP counselor if they have a
positive drug and/or alcohol test. Not true! EAP programs vary considerably in design and
scope. Some focus only on substance abuse problems; others undertake a broad brush approach
to a range of employee and family problems. Some include prevention, health and wellness
activities. Some are linked to the employee health benefit structures. These programs offer
nearly full privacy and confidentiality, unless someone's life is in danger. Do you know what
programs are available at your job? Be sure to ask your employer!
Voluntary Referral Programs
Often sponsored by employers or unions, referral programs provide an opportunity to self-
report to your employer a substance abuse problem before you violate testing rules. This gives
you an opportunity for evaluation and treatment, while at times guaranteeing your job. Be sure
to check your company to see if there is a voluntary referral program.
Remember: Self -reporting just after being notified of a test does not release you from your
responsibility of taking the test, and it also does not qualify as a voluntary referral.
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Where to Go For Help
Listed below are some numbers and addresses for national sources of help and information. For local
assistance please refer to your community phone book and those resources noted below.
National Toll -Free Numbers and Informative Websites
Substance Abuse Treatment Locator
(800) 662- HELP/
www. find treatment. samhsa. g0v
At -Anon (For Families of Alcoholics)
(800) 356-9996/ www.aa.org
Nar-Anon (For Families of Drug Addicts)
(800) 477-6291 / www.nar-anon.org
American Council on Alcoholism
(800) 527-5344 / www.aca-uso.org
National Council on Alcoholism and Drug
Dependence Hope line
(800) NCA -CALL / www.ncodd.org
Focus on Recovery Helpline
(800)134-0410/www.focushealthcare.com
Marijuana Anonymous
(800) 766-6779
Drug Abuse Information and Treatment
Referral Hotline
(NIDA HOTLINE)
The Partnership for a Drug -Free America
www.Drug-Free.org
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The National Institute on Drug Abuse
www.NIDA.NIH.gov
Do Something
www.dosomething.org
Turn to Help Now
www.tumtohelpnow.com
Substance Abuse and Mental Health Services
Administration (SAMHSA)
www.somhsa.gov
Department of Health and Human Services
(800) 661 -HELP
Local Mental Health Centers
(Check Phone Directory)
Alcoholics Anonymous
(Consult your local directory