SAMPLE RETURN TO WORK AGREEMENT FOR DOT SAFETY SENSITIVE EMPLOYEES

Date of violation:  ______________________________

Violation: _____________________________________

Employee Name: _______________________________

I, _______________________________ agree to complete the rehabilitation, education and or treatment plan as prescribed by the SAP.

Upon successful completion of the SAP’s plan and a release to duty from the SAP to Essex Westford School District, I agree to and understand the following are conditions of employment with Essex Westford School District and are consistent with DOT regulations following a positive drug and or alcohol test.  

Return to Duty testing - drug and or alcohol testing (as directed by the SAP)

Return to duty drug test must be negative and breath alcohol test results must be less than 0.02.

Follow-up testing - drug and or alcohol testing program as prescribed by the SAP.

DOT requires a minimum of six (6) follow-up tests performed in the first year. I acknowledge that follow-up testing may continue for up to sixty (60) months and is at the discretion of the SAP.

All follow-up tests will be unannounced and in conjunction with random drug and alcohol testing. Once notified of the follow-up test you will be escorted to the collection site by Essex Westford School District representative.

Directly Observed collections are required for all Return to duty and Follow-up testing drug testing.

I further acknowledge that by signing this agreement I agree to the conditions and requirements set forth here and that acts of insubordination included but not limited to those described in the Essex Westford School District Drug & Alcohol Testing: Transportation Employees policy may result in disciplinary action including termination of my employment with Essex Westford School District.

POSITIVE TEST RESULTS – Any subsequent positive drug and or alcohol test given for any reason will result in immediate termination.

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Safety-Sensitive Employee Printed Name                         Employee Signature Date

_____________________________________________ _____________________________________   __________

Employer Representative Printed Name                       Employer Signature        Date

EMPLOYEE ACKNOWLEDGEMENT OF RECEIPT OF PROGRAM MATERIALS

Drug & Alcohol Testing: Transportation Employees

I, ________________________________ hereby acknowledge receipt of (employee’s printed name)

Essex Westford School District Drug & Alcohol Testing: Transportation Employees program materials and understand my rights and responsibilities under statutes provided by the Department of Transportation and Federal Motor Carriers Safety Administration.

_____________________________________________ _____________________________________   __________

Safety-Sensitive Employee Printed Name                         Employee Signature Date

_____________________________________________ _____________________________________   __________

Employer Representative Printed Name                       Employer Signature        Date