‘I [insert name] am a test supervisor under the provisions of the Passenger Transport (Drug & Alcohol Testing) Regulation, 2010. You are now required to submit to a [insert test type] in accordance with the regulation and State Transit’s Drug and Alcohol Procedure. Failure to undergo testing is considered a breach of the regulation and State Transit’s Procedure and could lead to prosecution and disciplinary action.’

OR

‘I [insert name] am a test supervisor and ask that you participate in a [insert test type]. Refusal to participate in this test could lead to prosecution and disciplinary action.’

(Circle test type below as appropriate)

 Random                   Incident                   Reasonable Cause                        Targeted

Choose one of the following scripts and read it aloud to the worker when commencing the testing process.

‘I [insert name] am a test supervisor under the provisions of the Passenger Transport (Drug & Alcohol Testing) Regulation, 2010. You are now required to submit to a [insert test type] in accordance with the regulation and State Transit’s Drug and Alcohol Procedure. Failure to undergo testing is considered a breach of the regulation and State Transit’s Procedure and could lead to prosecution and disciplinary action.’

OR

 ‘I [insert name] am a test supervisor and ask that you participate in a [insert test type]. Refusal to participate in this test could lead to prosecution and disciplinary action.’

 Worker Name Employee Number / Contractor Company
 Worker Position Depot/Site
 Employee DOB Driver Authority Card #
 Employee Signature

 

Date & Time:  Location of test: Tester (Name): Tester Signature:
Declaration of Drugs and/or Alcohol: Includes: prescription/non-prescription medication
Test Type (Circle):

Drug        Alcohol

 Test Type (Circle):

Saliva     Urine     Blood     Breath

 Result (Circle, document detail):

Positive              Negative

 
Refusal / Inability to provide (please detail)
Comments (This section may include exchanged dialogue between the tester and worker):

NB: If positive, notify Worker’s Manager and Safety Professional, Safety Programs.

 

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