HomeMy WebLinkAboutD.O.T. STOP Agreement to Provide Services Controlled Substances Testing-1996 10 24r
r
s
,~,
AGREEMENT TO PROVIDE SERVICES
I. AGREEMENT
This agreement is made between D.O.T. STOP, (also referred to as the Provider) and City of tMnter
S rin s, also referred to as the Company).
11. SCOPE OF SERVICES
D.O.T. STOP will provide State of Florida or Federally regulated drug and alcohol testing services as well as
other services listed in Exhibit A to the Company to support the Company's policies for drug and alcohol
testing and related educational services.
The Company acknowledges that a policy for drug and alcohol testing of applicants and/or employees is in
effect and that the Company requires drug and alcohol testing services to be provided by D.O.T. STOP.
Both D.O.T. STOP and the Company recognize that federal, state, and local laws may apply to services
described in this agreement. In particular, DOT drug and breath alcohol testing services must be pertormed
according to rules and regulations established by the Department of Transportation (hereafter referred to
DOT). Both parties agree to assure, to the best of their ability, that services provided are rendered according
to all applicable laws and regulations.
III. SIGNIFICANT CHANGE IN SERVICES PROVIDED.
If during the term of this agreement, there is a significant change in the requirements of the provider as the
result of regulatory changes or other changes mandated by federal or state law, both parties agree to
renegotiate the services and fees provided herein.
The parties below have executed this agreement on this a4 day of October , 1996.
D.O.T. STOP
9484 S. Orange Blossom Trail
Orlando, FL. 32837
Title: Executive Director
COMPANY: City of Winter Sarinas
Address: 1126 East State Road 434
Winter Sgrinras, FL. 32~Q8• ~,~
RONALD W . CL MC~~E "
Title : CITY MANA~FSR _
1
1_
ADDENDUM A:
CONTROLLED SUBSTANCES (DRUG) TESTING PROCEDURES
All controlled substances (Drug) testing conducted as required under 49 CFR Part 382 will comply with 49
CFR Part 40, Procedures for Transportation Workplace Drug and Alcohol Testing Programs. These
procedures require that the controlled substances testing is pertormed by a laboratory certified by the
Substance Abuse and Mental Health Services Administration. (DHHS) Drug testing is limited to testing for
Marijuana (THC), Cocaine, Opiates, Amphetamines and Phencyclidine (PCP). 49 CFR Part 40 specifies the
protocol to be followed for all DOT testing to protect the driver, assure the integrity of the testing, safeguard
the validity of the test results and ensure that those results are attributed to the correct driver.
All controlled substances testing will require the driver to submit a minimum of 45 ml of urine. The Federal
Drug Testing Custody and Control Form will be used to document the collection process. All specimens will
be split at the collection site into two (2) specimen bottles and sealed in the presence of the donor. Both
bottles will be sent to the laboratory.
American Medical Laboratories (AML) is the laboratory contracted by D.O.T. STOP to perform controlled
substance testing required by DOT and FHWA and is certified by the Substance Abuse and Mental Health
Services Administration (SAMHSA) and Department of Health and Human Services (DHHS) to perform
federally regulated testing. In addition, AML is certified by the Agency for Health Care Administration of the
State of Florida as a forensic toxicology laboratory. AML fully meets DOT and FHWA Controlled Substance
Testing Regulations
AML will forward all test results and summary reports to the MRO and the Company in accordance with 49
CFR Part 40.29.
AML shall provide the Company an aggregate (quarterly) statistical summary of urinalysis testing of their
employees. The Summary shall contain the following information:
i. Number of specimens received for testing;
ii. Number of specimens confirmed positive for;
a. Marijuana metabolite;
b. Cocaine metabolite;
c. Opiates;
d. Phencyclidine;
e. Amphetamine;
iii. Number of specimens for which a test was not performed
The report shall be provided to the Company 14 days after the end of the quarter covered by the summary.
2
MEDICAL REVIEW OFFICER (MROj SERVICES
D.O.T. STOP's Medical Review Officer (MRO) is Jock Sneddon, M.D. Dr. Sneddon is a licensed physician
with extensive knowledge of substance abuse disorders and the medical training required to interpret and
evaluate drug test results. The duties of the MRO shall be in compliance with 49 CFR Part 40.33. All results
will be provided by telephone or secure fax as indicated by the Company within 48 hours of verification.
REPORTING
Jock Sneddon, M.D., D.O.T. STOP's Medical Review Officer, will report results to the Company in such a
manner described below to assure that disclosure of information to unauthorized personnel does not occur.
Changes in the reporting protocol made in writing to D.O.T. STOP on the letterhead of the Company will be
implemented as specified upon receipt.
At the Company's request all results, both negative and positive, will be telephoned in a secure manner to the
authorized person(s) designated by the Company to receive such results.
Written reports titled "D.O.T. MRO DETERMINATION /VERIFICATION REPORT" will be sent by U.S. Mail,
in an envelope stamped "CONFIDENTIAL". This report will be mailed the same day as the final interpretation
of the test is complete.
The report will include the following:
• A statement that the controlled substances test being reported was in accordance with 49 CFR Part 40.
• The name of the individual for whom the test results are being reported.
The type of test indicated on the custody and control form (random, pre-employment, etc.)
• The date and location of the test collection.
• The identification of the persons or entities performing the collection and analysis of the specimens, and
serving as MRO for the specific test.
• The verified results of the controlled substances test (positive or negative) and if positive, the identity of
the controlled substance(s) for which the test was verified positive.
• That the MRO has made every reasonable attempt to contact the driver.
3
EMPLOYEE NOTIFICATION
Prior to verifying a "positive" report, the MRO shall make every reasonable effort to contact the driver
(confidentially) and afforcJ him/her the opportunity to discuss the test result. If after making all reasonable
efforts and documenting them, the MRO is unable to reach the driver directly, the MRO shall contact the
designated management official, who shall direct the driver to contact the MRO as soon as possible (within 24
hours). The MRO will document any information presented by applicant to explain or dispute the test result.
Under the "split-sample" collection procedures, the driver has 72 hours following notification of a positive
result to request the secondary sample be analyzed. In the event asplit-sample was not taken, or was of
inadequate quantity, the original test would be voided (canceled) and the driver would not be subject to a
retest.
While the primary sample is tested at specific thresholds for each controlled substance, the secondary (split)
sample is analyzed only for the presence of controlled substances. !f a negative result is reached on the
secondary test, the original test results are disregarded and the MRO shall notify the employee, the Company
and the Department of Transportation.
MRO RECORDKEEPING
FIVE (5) YEARS
The MRO shall maintain all dated records and notifications for verified positive controlled substance test
results, identified by individual for a period of five years.
ONE (1) YEAR
The MRO shall maintain all dated records and notifications for negative and canceled controlled substance
test results, identified by individual, for a period of one year.
The MRO shall not release the individual controlled substance test results of any driver to any person without
a specific, written authorization from the tested driver. However, this shall not prohibit the MRO from releasing
results to the employer or Federal, State, or local officials with regulatory authority over the controlled
substance testing program.
4
PROVIDER AND COMPANY RESPONSIBILITIES FOR BREATH ALCOHOL TESTING
I. PROVIDER RESPONSIBILITIES
1-A. TESTING DEVICES, PERSONNEL, AND FACILITIES
Breath Alcohol tests performed by D.O.T. STOP personnel will use Evidential Breath Testing (EBT) devices
approved by the National Highway Traffic Safety Administration (NHTSA) and listed in the NHTSA
Conforming Products List (CPL) for both screening and confirmation of breath alcohol content.
Breath Alcohol Technicians (BATs) shall be trained and certified by D.O.T. STOP and the EBT manufacturer
to perform such testing. Breath Alcohol Tests shall be performed in accordance with the regulatory
requirements of the Department of Transportation as specified in 49 CFR Part 40. D.O.T. STOP will maintain
facilities and personnel adequate to pertorm the services agreed to be provided to the company. In particular,
D.O.T. STOP will maintain aural and visual privacy during the pertormance of the test.
I-B. RECORDKEEPING
D.O.T. STOP will maintain, in a secure location with controlled access, all dated records, information and
documents in which D.O.T. STOP BAT personnel are acting as the agent of the employer for the purpose of
maintaining records for the company as required by DOT breath alcohol testing regulations, 49 CFR Part
40.83.
The schedule for maintenance of specific information and minimum time periods will be as follows:
FIVE (5) YEARS:
1. Records pertaining to the calibration of each EBT used in alcohol testing under the 49 CFR Part 40
Procedures.
2. Records of the results of the external calibration checks of each EBT.
TWO (2) YEARS:
1. Records of the inspection and maintenance of each EBT used in employee testing.
2. Documentation of the employer's compliance with the Quality Assurance Plan (QAP) for each EBT
used for alcohol testing under the procedures of 49 CFR Part 40.
3. Records of the training, proficiency testing, and certification of each BAT used in employee testing.
5
49 CFR Part 40 does not specify the amount of time that the BAT copy (copy 3) of the employee's alcohol
test results of the U.S. Department of Transportation (DOT) Breath Alcohol Testing Form is maintained.
D.O.T. STOP will maintain these records for a minimum period of two years unless notified by the employer
in writing to extend this time period. Disclosure of testing information to unauthorized persons is not
permitted.
The employee, upon written request to obtain copies of any records pertaining to his/her alcohol test, is
entitled to such records. Nothing in this agreement shall prohibit the provider from releasing to the employer,
it's agents or to officials of the DOT or DOT operating agency or any State or local officials with regulatory
authority over the testing program, individual test results, or from releasing individual test results or related
information to comply with requests from a legal action, including by not limited to unemployment hearings,
workers' compensation hearings or other legal hearing, initiated by the tested individual.
1-C. REPORTING OF RESULTS
D.O.T. STOP will report results to the Company in such a manner described below in Exhibit "A" below to
assure that disclosure of information to unauthorized personnel does not occur. Changes in the reporting
protocol/Company information made in writing to D.O.T. STOP on the letterhead of the employer will be
implemented as specified upon receipt.
D.O.T. STOP BATs will make all reasonable attempts to immediately notify the employer's authorized
representative of breath alcohol test results at or above 0.02.
"COPY 1 -ORIGINAL -FORWARD TO THE EMPLOYER" of the U.S. Department of Transportation (DOT)
Breath Alcohol Testing Form will be faxed and then mailed via first class U.S. Mail on the next business day.
Overnight carrier service can be arranged; the employer will be responsible for arranging payment of the
charges.
6
II. COMPANY/ EMPLOYER RESPONSIBILITIES
II-A. MAINTAINING ACCURACY OF EMPLOYER INFORMATION
The company acknowledges that the information provided in and EXHIBIT A will be updated as necessary to
assure that test results and other information remain secure and confidential.
II-B. PROCEDURE FOR REQUESTING BREATH ALCOHOL TESTS
The company acknowledges that the pertormance of necessary verification procedures may be dependent
upon cooperation by the company representatives and/or the individuals to be tested. The subject to be tested
must provide a photo identification or be personally identified by a company representative.
In order to assure the accuracy of information pertaining to the test and the subject, the company will provide
a written request fora breath alcohol test stating the reason for the test (Random, Reasonable
Suspicion/Cause, Post-accident, Return to Duty, Follow-up.) The testing facility must have this information
before the pertormance of the breath test. The company may provide a facsimile transmission (fax) of the
request to the testing location or have the testing subject bring the request to the testing location.
II-C. SPECIAL REQUIREMENTS FOR REASONABLE SUSPICION/ CAUSE AND POST- ACCIDENT
TESTING.
The company agrees to provide a company representative to be present at the testing location whenever a
Reasonable Suspicion/Cause or Post-Accident Breath Alcohol Test is requested. The company representative
will remain at the testing location until the testing procedure is complete. If the Breath Alcohol Test confirms
at or above 0.02, the company representative will be responsible for informing the testing subject of company
policy and assuring the safety of the public.
II-D. DESIGNATION OF AUTHORIZED REPRESENTATIVES
The company will designate a representative and an alternate to whom D.O.T. STOP will report test results
and discuss or report other information. Changes of designated representatives and the effective date of the
changes will be made in writing to D.O.T. STOP on the letterhead of the company.
7
CONTROLLED SUBSTANCES (DRUG) AND ALCOHOL POLICY FOR DRIVERS
D.O.T. STOP shalt provide the Company a Policy and Procedures Manual For Drivers on the misuse of
alcohol and use of controlled substances. The policy provides the required content as stated in 49 CFR
382.601 and the Company's policies and procedures with respect to meeting these requirements. It is the
Company's responsibility to provide a copy of this policy along with educational information to each driver
prior to the start of alcohol and controlled substances testing and to each driver subsequently hired or
transferred into a position that requires driving a commercial motor vehicle. A detailed step by step action
plan and a computer disk containing required documents are included in the manual.
The policy includes detailed discussion of the following:
1. The Company representative designated to answer questions about the policy.
2. The categories of drivers subject to the provisions of 49 CFR 382.601.
3. Information for drivers regarding pertorming safety sensitive functions
4. Prohibited conduct.
5. Circumstances under which a driver will be tested for Alcohol and/or Controlled
Substances
6. Controlled substances and alcohol testing procedures.
7. Consequences to drivers engaging in Conduct prohibited by the Federal Highway
Administration's (FHWA) drug use and alcohol misuse rules.
8. Consequences for drivers found to have an alcohol concentration of .02 or greater but less than .04.
9. Confidentiality.
10. Authorization for the release of alcohol and controlled substances test information by previous
employers
11. Information concerning the effects of alcohol and controlled substances; signs and
symptoms of an alcohol or controlled substance problem; intervention, confrontation and referral to
management.
In addition, D.O.T. STOP will provide the Company with the following materials:
1. Certificate of Receipt
2. Authorization for the release of alcohol and controlled substance test information by previous
employers.
3. Drug and Alcohol Educational Materials.
4. Documentation of reasonable suspicion of alcohol or drug use while pertorming DOT safety sensitive
duties.
5. Documentation forms for use when alcohol or drug tests are not administered within the time
required.
6. A copy of Federal Highway Administration rule 49 CFR Part 382.
It is the responsibility of the Company to add or revise disciplinary actions based on company policy and
have the policy reviewed by legal counsel. Furthermore, it is the responsibility of the Company to maintain a
file of all "Certificates of Receipts" verifying that each driver has received a copy of the policy and related
educational materials.
8
DOT REQUIRED SUPERVISOR TRAINING
D.O.T. STOP will provide Supervisor Training to the Company's supervisors who are designated to determine
whether reasonable suspicion exists and require a driver to undergo testing under 382.607. In accordance
with 49 CFR 382.603, it is the responsibility of the Company that these supervisors receive at least 60
minutes of training on alcohol misuse and 60 minutes of training on controlled substances use. D.O.T.
STOP's Supervisor Training covers physical, behavioral, speech and performance indicators of probable
alcohol misuse and use of controlled substances.
Drug and Alcohol testing procedures are discussed and demonstrated. Prohibitions, consequences, types of
testing required and recordkeeping are explained in detail. With each revision or amendment of 49 CFR Part
382, the class curriculum is updated to provide the most current guidance.
Supervisors will receive a training manual and certificate of participation. It is the responsibility of the
Company to maintain a file of the certificate(s) to document the training of each supervisor for as long as the
trained individual is designated to supervise drivers.
Regularly scheduled Supervisor of Drivers Drug and Alcohol Training classes are held at D.O.T. STOP. The
schedule is published in the monthly client newsletter "D.O.T. STOP/ SHOP". It is recommended that the
company call to schedule supervisors for the class since class size is limited. If a company has a large
number of supervisors to be trained, on-site classes can be arranged.
9
RANDOM TESTING CONSORTIUM FOR ALCOHOL AND CONTROLLED SUBSTANCES
D.O.T. STOP will administer a Random testing program for Controlled Substances and Alcohol at percentage
rates specified by the Federal Highway Administration for the current calendar year. The 1996 Random
Controlled Substances testing rate will be 50% and the 1996 Random Alcohol testing rate will be 25%.
All drivers will be included in the random Consortium testing pool for each testing cycle. The random testing
selection process used by D.O.T. STOP is a scientifically valid, computer-based random number generator.
Under this process, each driver has an equal chance of being tested each time a selection is made. At the
request of the Company, D.O.T. STOP will establish an individual testing pool if the number or drivers is
adequate to maintain. Company's with more than 40 drivers will be considered for separate pools.
D.O.T. STOP will manage the random testing program for the Company. The names, Social Security
numbers and location/department of current employees of the Company required to have a Commercial
Drivers License (CDL) must be submitted by mailing or faxing a current driver list to D.O.T. STOP on the first
working day of each month. D.O.T. STOP will update the Company's random pool as received.
D.O.T. STOP will coordinate with the Company's Drug Program Administrator the frequency of the random
selections if the Company has its own Company Pool. D.O.T. STOP will determine the dates for the
Consortium Pool testing cycles which will be spread throughout the calendar year. Each time a random
selection is make, D.O.T. STOP will send to the authorized Company representative a "Notification of
Random Selection" form via U.S. Mail . This form will include a list composed of the driver's name, SS #
and location or department if provided and will indicate if the driver had been selected for random drug and/or
alcohol testing.
Attached to the master D.O.T. STOP will attach an individual "Notice of DOT Required Random Drug /Alcohol
test" and collection site instructions for each driver selected. The designated company official must note the
time and date the driver was given notice to proceed immediately to the collection site, The driver must bring
this individual notice to the collection site.
Testing for alcohol must be done prior to, during or immediately after the performance of a safety sensitive
function.
It is the responsibility of the Company to keep the list of selected drivers confidential. Once the driver has
been notified that he/she has been selected for testing, the driver must proceed immediately to the testing
location. Furthermore, it is the responsibility of the Company to notify D.O.T. STOP that the required testing
for each selected driver has been performed. The completed form may be faxed or mailed to D.O.T. STOP.
10
EXHIBIT A
REPORTING PROTOCOLS and FEES
The company represents that the means of obtaining results from the Provider will assure that the results and
other information remain secure and confidential.
The company designates the following procedure for reporting drug and alcohol results to the designated
representative indicated by the marked box below:
[ ]Telephone all results (both positive and negative) of drug and alcohol tests, then mail original via U.S.
Mail first class.
[ ]Telephone only positive results, then mail original via U.S. Mail first class. Mail original negative results
via U.S. Mail first class.
For REPORTING Purposes:
Company name: Citv of Winter Sprincs
Authorized company representatives:
(1) Marv Wilson
(2) John Ketterincham
Mailing Address: 1126 East State Road 434
City, State, Zip: Winter Savings, FL. 32708
Telephone: (4071327-1800
FEE SCHEDULE
For BILLING Purposes:
Company Name: City of Winter Sprincs.
Billing contact: John Ketterincham
Billing Address: 1126 East State Road 434
City, State, Zip: Winter Savings. FL. 32708
Telephone: (4071327-1800
The Company agrees to pay D.O.T. STOP/ Centra Care within 30 days of receipt of invoice for services:
Breath Alcohol Testing (by/at DOT STOPor Cenra Care*") $25.00
(Includes screening and confirmation testing)
Controlled Substance Test (collected at D.O.T.STOP)
(Includes collection, testing & MRO services)
Controlled Substance Test
(Includes MRO & testing)
Ceuta Care Drug test Collection Fee•"
855 S. US Highway 17-92 Longwood, FL 32750
DOT Drug & Alcohol Policy
DOT Required Supervisor Training
CDL Driver DOT/FHWA Policy and Procedure
Education and Training
Random Drug 8 Alcohol Testing Consortium
Annual Membership Fee
Additions and/or Deletions to Random Pool
$35.00
$25.00
$20.00
$100.00 W/P Program:
$40.00 per person
$100.00 per session
$75.00
$1.00 per name
Random Pull Charge $1.00 per name
After Hours Fee (at D.O.T. STOP) $60.00
Emergency services available 24 hours a day, seven days a week.
** Centra Care Services will be billed by Centra Care
11
..t,'
.,..<'
."
AGREEMENT TO PROVIDE SERVICES
I. AGREEMENT'
This agreement is made between D.O.T, STOP, (also referred to as the Provider) and City of Winter
Sorinas. Fire & Police Deoartments and Drua Free Workolace, also referred to as the Employer).
II. SCOPE OF SERVICES .
D.O.T. STOP will provide State of Florida or Federally regulated drug and alcohol testing services as well as
other services listed in Exhibit A to the Employer to support the Employer's pOlicies for drug and alcohol
testing and related educational services.
The Employer aCknowledges that a policy for drug and alcohol testing of applicants and/or employees is in
effect and that the Employer requires drug and alcohol testing selVices to be provided by D.O.T. STOP.
Both D.O.T. STOP and the Employer recognize that federal, state, and local laws may apply to services
described in this agreement. In particular, State of Florida Worker's Compensation Statutes 440.1 01 and
440.102 and the drug and alcohol testing rules established by the Florida Agency for Health Care
Administration (AHCA 59A-24) must be followed for all Drug Free Workplace testing. Both parties agree to
assure, to the best of their ability, that selVices provided are rendered according to all applicable laws and
regulations.
III. SIGNIFICANT CHANGE IN SERVICES PROVIDED.
If during the term of this agreement, there is a significant change in the requirements of the provider as the
result of regulatory changes or other changes mandated by federal or state law, both parties agree to
renegotiate the services and fees provided herein.
The parties below have executed this agreement on this 24 day of October ,1996.
D.O.T, STOP EMPLOYER: City of Winter Sorinas
9484 S. Orange Blossom Trail Address: 1126 East SR 434
Orlando, FL 32837 . Winter Sorinas. FL 32708
By: ~nA 0 ~'?r ;. ~ -- By: ~~ M. -rr)~
, Rona W. McLem~re
Title: Executive Director Title: . City Manager
1
~'
~,
.
SCOPE OF SERVICES
1. AHCA DRUG and ALCOHOL TESTING FOR DRUG FREE WORKPLACE
A. DRUG and ALCOHOL TESTING PROCEDURES
All Drug and Alcohol testing will be conducted as required following the procedures of Florida Drug Free
Workplace Statues 440.101 and 440.102 and will comply with Agency for Heath Care Administration
(AHCA) Chapter 59A-24 Drug-Free Workplace Standards.
These procedures require that drug and alcohol testing be performed by a laboratory licensed by the State
of Florida. Drug testing under 59A-24 limited to testing for Alcohol, Amphetamines, Cannabinoids,
Cocaine, Phencyclidine, Methaqualone, Opiates, Barbiturates, Benzodiazepines, Methadone, and
Propoxyphene. AHCA specifies the protocol to be followed for all testing to protect the employee, assure
the integrity of the testing, safeguard the validity of the test results and ensure that those results are
attributed to the correct employee.
All drug testing ~i11 require the employee/applicant to submit a minimum of 30 ml of urine. The HRS Form
.1806 "Drug Testing Chain of Custody Form" or replacement forms authorized or specified by the Agency for
Heath Care Administration will be used to document the collection process. All specimens will be identified
by'a Specimen Identification number matching the Specimen Identification number on the Chain. of Custody
Form and which is placed on the specimen bottle, initialed and dated by the Collector and the donor. The
specimen bottle will be sealed with tamper evident tape in the presence of the donor, secured in a shipping
container and sent to the laboratory for testing.
Blood alcohol tests will be collected, sealed and secured as specified I::lY AHCA rule 59A-24 using HRS
Form 1806 Chain of Custody form (or replacement forms authorized or specified by AHCA).
American Medical Laboratories (AML) is the laboratory contracted by D.O.T. STOP to perform drug and'
alcohol testing as specified in Florida Statute 4~0.101 and 440.102 and is licensed by the Agency for Health
Care Administration of the State of Florida, as a forensic toxicology laboratory,
AML will forward all test results to the MRO in accordance with AHCA Rule S'9A-24.
B. MEDICAL REVIEW OFFICER (MRO) SERVICES
2
.
,
, '
REPORTING
Jock Sneddon, M.D., D.O.T. STOP's Medical Review Officer, is a Certified Medical Review Officer (June
28, 1992) accredited by the American Association of Medical Review Officers (AAMRO). A copy of Dr.
Sneddon's Certification is attached. Dr. Sneddon will report results to the Employer in such a manner
described below to assure that disclosure of information to unauthorized personnel does not occur.
Changes in the reporting protocol made in writing to D.O.T. STOP on the letterhead of the Employer will
be implemented as specified upon receipt.
At the Employer's request all results, both, negative and positive, will be telephoned in a secure manner to
the authorized person(s) designated by the Employer to receive such results.
Written reports titled "AHCA/WORKERS' COMPENSATION MRO DETERMINATION / VERIFICATION
REPORT" will be sent by U.S. Mail, in an envelope stamped"CONFIDENTIAL". This report will be mailed
the same day as the final interpretation of the test is complete. A sample of this form is attached.
The report will include the following:
. A statement that the controlled substances test being reported was in accordance with applicable
screening and confirmation cut-off levels established by the State of Florida AHCA drug testing rules 59A-24
and the Florida Workers' Compensation Statutes 440.101 and 440.102
. . The Specimen Identification Number
. The name of the individual for whom the test results are being reported.
. The type of test indicated on the chain of custody form Gob-applicant, random, reasonable suspicion,
etc.)
. The date and location of the test collection.
. The identification of the persons or entities performing the collection and analysis of the specimens, and
serving as MRO for the specific test.
. The verified results of the drug/ alcohol test (positive or negative) and if positive for drug (s), the identity
of the drug(s) for which the test was verified positive.
EMPLOYEE NOTIFICATION
Prior to verifying a "positive" report, the MRO shall make every reasonable effort to contact the employee
(confidentially) and afford him/her the opportunity ~o discuss the test result. If the MRO is unable to reach
the employee directly within 3 days of receipt of the results from the. laboratory, the MRO shall contact the
designated management official, who shall direct the employee to contact the MRO as soon as possible. If
the MRO has not been contacted within 2 working days from the request, the MRO shall verify the report as
positive to the employer.
3
.
t.
Within 5 days of notification to the donor of the positive test result, the employee/applicant will be
responsible for providing to the MRO all necessary documentation to verify prescription or over the counter
medications which may have caused a positive test .result. The MRO will document any information
presented by employee to explain or dispute the test result.
If the MRO determines that there is a legitimate medical explanation for the positive test result, based on
the medical judgment of the MRO and accepted standards of practice, the MRO shall report a negative test
result to the employer.
MRO RECORDKEEPING
TWO (2) YEARS:
The MRO shall maintain all dated records and notifications for verified positive drug and / or alcohol test
results, identified by individual for a. period of two years.
ONE (1) YEAR:
The MRO shall maintain all dated records and notifications for negative and canceled drug and / or alcohol
test results, identified by individual, for a period of one year. .
The MRO shall not release the individual test results of any employer to any person without a specific,
written authorization from the tested employee. However, this shall not prohibit the MRO from releasing
results to the employer or Federal, State, or local officials with regulatory authority over the drug and alcohol
testing program.
The employee, upon written request to obtain copies of any records pertaining to his/her alcohol test, is
entitled to such records. Nothing in this agreement shall prohibit the provider from releasing to the
employ~r, it's agents or to officials of any State or local officials with regulatory authority over the testing
program, individual test results, or from releasing individual test results or related information to comply with
requests from a legal action, including by not limited to unemployment hearings, workers' compensation
hearings or other legal hearing, initia~ed by the tested individual.
REPORTING OF RESULTS
D.O.T. STOP will report results to the EfTlployer in such a manner described in Exhibit "An to assure that
disclosure of information to unauthorized personnE~1 does not occur. Changes in the reporting protocol /
Employer information made in writing to D.O.T. STOP on the letterhead of the employer will be
implemented' as specified upon receipt.
4
~
l
EMPLOYER! EMPLOYER RESPONSIBiliTIES
A. MAINTAINING ACCURACY OF EMPLOYER INFORMATION
. '.
The employer acknowledges that the information provided in and EXHIBIT A will be updated as necessary
to assure that test results and other information remain secure and confidential.
B. PROCEDURE FOR REQUESTING DRUG AND ALCOHOL TESTS
The employer acknowledges that the performance of necessary verification procedures may be dependent
upon cooperation by the employer representatives and/or the individuals to be tested. The subject to be
tested must provide a photo identification or be personally identified by a employer representative.
In order to assure the accuracy of information pertaining to the test and the subject, the employer will
provide a written request for the test stating the reason for the test (Job Applicant, Random, Reasonable
Suspicion/Cause, Routine fitness for duty, Return to Duty, Follow-up, Other.) The collection facility must
hav~, this information before the performance of the test. The employer may provide a facsimile
transmission (fax) of the request to the collection location or have the testing subject bring the request to the
testing location.
C. SPECIAL REQUIREMENTS FOR REASONABLE SUSPICION / CAUSE AND POST-ACCIDENT
. TESTING.
The employer agrees to provide a represelltative to be present at the testing location whenever a
Reasonable Suspicion/Cause is requested. The employer representative will remain at the collection
location until the collection procedure is complete,
D. DESIGNATION OF AUTHORIZED REPRESENTATIVES
The employer will designate a representative and an alternate to whom D.O.T. STOP/ MRO Jock Sneddon,
MD will report test results and discuss or report other information. Changes of designated representatives
and the effective date of the changes will be made in writing to D.O.T. STOP on the letterhead of the
employer.
S
.
2. ANNUAL TESTING PROGRAM FOR SPECIAL RISK AND SAFETY SENSITIVE
. FIRE AND POLICE EMPLOYEES
10 PANEL AHCA DRUG TEST COLLECTED AT TIME OF SCHEDULED ANNUAL FITNESS FOR DUTY
PHYSICAL EXAMINATION
OPTION 1
Whenever specimens are collected at a medical facility designated by the city, D.O.T. STOP will assure the
facility has the proper chain of custody form, specimen kits and personnel trained to collect the urine
specimens according to the procedures specified by the Agency for Health Care Administration (AHCA).
Testingwill be performed at American Medical Laboratories as specified above. D.O.T. STOP's Jock
Sneddon, MD will perform Medical Review Officer services as specified above.
OPTION 2
As an alternative to the "scheduled" drug testing described above, the City may assign D.O.T. STOP to
administer an Annual unannounced drug testing program for the City of Winter Springs, Special Risk and
Safety Sensitive employees. This option provides additional deterrence to substance abuse.
A computer based random number generator program will be used to maintain separate pools for the Fire
Department and for the Police Department. The initial data for entry into these pools will be supplied by the
employer' and will include the employee's name, social security number, department, division and other
identifying information which will assist in locating the individual for notification of testing.
Additional updated information regarding employees hired, transferred or removed from Special Risk or
Safety Sensitive positions must be routinely submitted to D.O.T, STOP. This information must be written on
city letterhead and mailed or faxed to D.O.T. STOP. Upon receipt of the information, the pool(s) will be
updated by D.O.T. STOP.
Scheduling for unannounced annual testing will be coordinated between D.O.T. STOP and the City.
Confidentiality of the selected employees for any testing cycle will be maintained by D.O.T. STOP and
communication with the city regardinOg the identities of the selected employees will be strictly guarded,
Each calendar year and before the initiating of the random pull the city will verify the personnel data of the
pool(s). The random number generated program will be programmed to randomly select 20 percent of each
pool (containing all Special Risk and Safety Sensitive employees) for the first testing cycle,
D.O.T. STOP and the designated city coordinator will verify the completion of testing for the selected
employees two weeks Clfter providing the list to the city. Once this verification is made a new testing pool for
each departme~t w~llbe made: containing those employees who have not'yet been tested. Employees
selected but ~.o~ \ested within the two week time-framed will go back into the pool.
6
~.
. .
The second testing cycle will select 25 percent of the untested employees in each pool. Following the
described verification of completed testing, tested individuals will be removed from the pool. The thirc:l
testing cycle will select 35 percent for each department of employees who have not yet been tested. The
fourth testing cycle will select 50 percent of the employees not yet tested. The fifth testing cycle will include
all Special Risk and Safety Sensitive employees who have not yet been tested during that calendar year.
Verification of completed testing and removal of individuals tested from the pool will be completed for each
testing cycle as described above.
It will be the responsibility of the city to maintain confidentiality of selected employees prior to notification to
proceed to the testing site. O.O.T. STOP will notify in writing the identity of selected individuals for each
testing cycle based on the information provided by the city. This notification will be an actual timed and
dated print-out generated by the computer random program for each testing cycle. Prior to running each
random selection, a printout of the "untested" pool(s) will also be printed and provided to the city.
3. UNANNOUNCED RANDOM TESTING OF GENERAL SERVICE EMPLOYEES
In orc:ler to achieve maximum deterrence of substance abuse in the workplace, fairness to employees and
cost-effectiveness of drug testing, the City may designate O.O.T. STOP to administer a scientifically valid
random testing program.
If the city elects this option, O.O.T. STOP will manage the random testing program of all General Service
employees. All general service employees (except for those enrolled in the DOT Random Program for COL
holders) will be entered into a separate random testing pool and the selection process maintained to include
all covered employees for each testing cycle. Each employee will be have a reasonable expectation each
working day that they may be tested that day.
The random testing selection process used by O.O.T. STOP is a scientifically valid, computer-based random
number generator. Under this process, each employee has an equal chance of being tested each time a
selection is made.
The names, Social Security numbers and location/department of employees must be submitted by mailing
or faxing a current list of additions and / or deletions to O.O.T. STOP. O.O.T. STOP will update the
Employer's random pool as received.
O.O.T. STOP will coorc:linate with the Employer's Drug Program Administrator the frequency of the random
selections. Each time a random selection is made, D.O.T. STOP will send to the authorized Employer
representative' a "Notification of Random Selection" form via U.S, Mail. It will be the responsibility of the city
to keep the list of selected employees confidential until the time and date of the testing. Notification of
employees should not be made until the supervisor can direct the employee to immediately proceed to the
testing location.
7
-'
~
The minimum annualized random rate for testing of these individuals will be 50%. The selection of testing
dates will be at-random throughout each calendar year and will be coordinated with the city.
4. Job Applicant, Reasonable Suspicion (including post-accident), Routine Fitness
for Duty, Follow-up Testing.
Whenever specimen collections for drug testing are conducted at a medical facility designated by the city,
D.O.T. STOP will assure the facility has the proper chain of custody form, specimen kits and personnel
trained to collect the urine specimens aCCOrding to the procedures specified by the Agency for Health Care
Administration (AHCA). Testing will be performed at American Medical Laboratories as specified above.
D.O.T. STOP's Jock Sneddon, MD will perform Medical Review Officer services as specified above.
8
.'
4.
EXHIBIT A
REPORTING PROTOCOLS
The employer represents that the means of obtaining results from the Provider will assure that the results
and other information remain secure and. confidential.
The employer designates the following procedure for reporting drug and alcohol results to the designated
representative indicated by the marked box below:
[ ] Telephone all results (both positive and negative) of drug and alcohol tests, then mail original via U.S.
Mail first class.
[ ] Telephone only positive results, then mail original via U.S. Mall first class. Mail original negative results
via U.S. Mail first class.
For REPORTING Purposes: For BILLING Purposes:
Employer name: Employer Name:
Authorized employer representatives: Billing contact:
(1) Billing Address:
(2) City, State, Zip:
(3)
Mailing Address: Telephone:
City, State, Zip:
Telephone:
9
-
- . .
\ .. .
, ,
...t'l
..
FEE SCHEDULE
The Employer agrees to pay D.O.T. STOP withIn 30 days of receipt of invoice for services rendered:
AHCA Blood Alcohol Testing $30.00
(Includes Collection, MRO, Blood alcohol test)
AHCA Blood Alcohol Testing (NOT collected by D.O.T.STOP $20.00
(Includes MRO + Blood alcohol test) ,
5 Panel- AHCA Drug Test! MRO services $35.00
(Includes Collection, MRO, drug test)
. -Amphetamines, Cannabinoids, Cocaine, Phencyclidine, Opiates
5 Panel- AHCA Drug Test! MRO services . $25.00
(Includes MRO + drug test / not collected by D.O.T. STOP)
** Amphetamines, Cannabinoids,Cocaine,Phencyclidine, Opiates
8 Panel** AHCA Drug Test! MRO services $38.00
(Includes Collection, MRO, drug test)
-Amphetamines, Cannabinoids, Cocaine, Phencyclidine,
Methaqualone,Opiates,Barbiturates, Benzodiazepines.
8 Panel- AHCA Drug Test! MRO services $28.00
(Includes MRO + drug test /-not collected by D.O.T. STOP)
** Amphetamiries, Cannabinoids, Cocaine ,Phencyclidine,
Methaqualone,Opiates,Barbiturates, Benzodiazepines.
10 Panel- AHCA Drug Test! MRO services $40.00
(Includes Collection, MRO, drug test) ,
** Amphetamines, Cannabinoids, Cocaine;Phencyclidine,
. Methaqualone,Opiates,Barbiturates, Benzodiazepines,
Methadone, Propoxyphene.
10 Panel** AHCA Drug Test! MRO services $30.00
(Includes MRO + drug test / not collected by D.O.T. STOP)
** Amphetamines, Cannabinoids, Cocaine, Phencyclidine,
Methaqualone, Opiates, Barbiturates, Benzodiazepines,
Methadone, Propoxyphene.
Substance Abuse Educational Program $100.00 per o'1e hour session
Unannounced Annual Drug Testing for Fire, Police, and Safety- $75,00
Sensitive Employees-- Random Selection Pool and / or
General Services Random Pool Annual'Membership
Initial entry/additions/deletions to random P901 $ 1,00 per name
Random pull charge $1,00 per name
After-hours fee ( at D.O.T. STOP) $60.00
**Emergency services available 24 hours a day, seven days a week.
10