Drug & Alcohol Program Self-Assessment Form - Minnesota ... [PDF]

Dec 21, 2016 - Note: Small Operators (50 or fewer covered employees) are required to keep this information (MIS. Report)

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MINNESOTA DEPARTMENT OF PUBLIC SAFETY Office of Pipeline Safety 445 Minnesota Street, Suite 147, St. Paul, Minnesota 55101-5147 Phone: 651/201-7230 FAX: 651/296-9641 TTY: 651/282-6555 http://ops.dps.mn.gov

December 21, 2016 Alcohol and Gambling Enforcement Bureau of Criminal Apprehension Driver and Vehicle Services Emergency Communication Networks Homeland Security and Emergency Management Minnesota State Patrol Office of Communications

Subject: 2016 Drug & Alcohol Program Self-Assessment Form Drug & Alcohol Program Administrator: PHMSA is requiring MNOPS to resume Headquarters Drug & Alcohol (HQ D&A) inspections again. This will be done on a multi-year cycle. In 2016 MNOPS finished a Comprehensive D&A Inspection of all Intrastate operators, which included a visit to your collection site facility/clinic. The Minnesota Office of Pipeline Safety is continuing with the Intrastate Self-Assessment Program for 49 CFR Parts 199 and 40. Please send MNOPS a copy of:  2016 Drug and Alcohol Self-Assessment Form  2016 PHMSA MIS Report.  2016 Contractor(s) PHMSA MIS Report(s)

Office of Justice Programs Office of Pipeline Safety Office of Traffic Safety State Fire Marshal

If you have any questions please call Pat Donovan Office - (651) 201-7232 Email - [email protected]. MIS reporting instructions: http://phmsa.dot.gov/pipeline/regs/drug then click on (MIS Reporting Guidance)

Note: Small Operators (50 or fewer covered employees) are required to keep this information (MIS Report) and upon request from PHMSA, small operators are required to send this information (MIS Report) per 49CFR Part 199.119 and 199.229.

EQUAL OPPORTUNITY EMPLOYER

Office of Pipeline Safety 445 Minnesota Street, Suite 147, St. Paul, Minnesota 55101-5147 Phone: 651/201-7230 FAX: 651/296-9641 TTY: 651/282-6555 http://ops.dps.mn.gov

INTRASTATE ANTI-DRUG and ALCOHOL MISUSE PREVENTION SELF-ASSESSMENT FORM – 2016 Instructions: Enter applicable information into the fields below using Adobe Reader. The electronic form can be submitted directly to MNOPS for collection of information. Please click print to save a copy of this information for your records.

General Information Operator’s Name: Contact Name:

Operator IOCS ID:

Inspection Unit IOCS ID:

(Entered by MNOPS)

(Entered by MNOPS)

Contact Title:

Address: e-mail address:

Telephone#:

Facility Type: Gas Transmission

Gas Distribution

Hazardous Liquid

Liquefied Natural Gas

Anti-Drug and Alcohol Misuse Plan/Policy Developed by: Anti-Drug and Alcohol Misuse Testing Program Administered by: Contractor’s Records Maintained by: Specimen Collection Conducted by: Breath Alcohol Test Conducted by:

I, the undersigned, certify that the information provided on this Minnesota Office of Pipeline Safety, Anti-Drug and Alcohol Misuse Prevention Self-Assessment Form is, to the best of my knowledge and belief, true, correct, and complete.

Signature

Date of Signature

Title

( ) Phone Number

NOTE: If any question on the following self-assessment form is answered by other than a “YES” response, please identify the question and explain in the “COMMENTS” area at the bottom of the page, or attach an additional sheet. Drug & Alcohol Self-Assessment Form Page 2 of 4 2016

Office of Pipeline Safety 445 Minnesota Street, Suite 147, St. Paul, Minnesota 55101-5147 Phone: 651/201-7230 FAX: 651/296-9641 TTY: 651/282-6555 http://ops.dps.mn.gov

§§199.1, 199.200 and §40.1 1. Is your company continuing to comply with the drug and alcohol testing regulations as required under 49 CFR Parts 199 and 40?

COMPLIANCE  YES  NO  N/A

§§199.101 and 199.202 1. Is your company continuing to maintain written anti-drug and alcohol misuse prevention plans? 2. Have there been any significant changes to the policy/plans? Please provide MNOPS with a copy of any changes.

COMPLIANCE  YES  NO  N/A  YES  NO  N/A

PLEASE PROVIDE THE NAME, ADDRESS AND PHONE NUMBER OF THE FOLLOWING: USE AN ADDITIONAL SHEET OF PAPER IF NECESSARY.

§§199.101 and §40.121 Name: Address:

MEDICAL REVIEW OFFICER(s) Phone Number: ( )

§199.101 Name: Address:

SUBSTANCE ABUSE PROFESSIONAL(s) Phone Number: ( )

§199.101 Name: Address:

DRUG TESTING LABORATORY(s) Phone Number: ( )

§§199.113 and 199.243 Name: Address:

EMPLOYEE ASSISTANCE PROGRAM(s) Phone Number: ( )

COMMENTS:

Drug & Alcohol Self-Assessment Form

Page 3 of 4

2016

Office of Pipeline Safety 445 Minnesota Street, Suite 147, St. Paul, Minnesota 55101-5147 Phone: 651/201-7230 FAX: 651/296-9641 TTY: 651/282-6555 http://ops.dps.mn.gov

§§199.115 and 199.245 1. Does your company monitor those contractors and subcontractors who perform functions covered by the drug/alcohol plan? 2. Has the method of contractor monitoring changed? If so, please specify what changes were made.

COMPLIANCE  YES  NO  N/A

§§ 199.227 1. Are records maintained in a secure location? 2. By Whom: Operator/Service Provider/Contractor Name:

COMPLIANCE  YES  NO  N/A

 YES  NO  N/A

Phone Number: (

)

§§199.119 and 199.229 COMPLIANCE 1. Has your company maintained the necessary MIS data sheets?  YES  NO  N/A 2. Who maintains the data? Name: Phone Number: ( ) §§40.33 and 40.213 1. Who supplies your company’s trained Breath Alcohol Technicians and Screening Test Technicians? (Use an additional sheet of paper if necessary.) Service Provider’s: Name: Phone Number: ( ) §§40.229 COMPLIANCE 1. Does your company only use devices listed on the Conforming  YES  NO  N/A Products List? 2. Please provide the name, model and serial number of the device(s) used. Name: Model: Serial No.: COMMENTS:

SECTION INITIALLY LEFT BLANK FOR UPDATES CHANGES IN CODES

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Drug & Alcohol Self-Assessment Form

Page 4 of 4

2016

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