DOE F 470.12 Human Reliability Program (HRP) Alcohol Testing Form (LA

OMB Control No. 1910-5122
Expiration Date: 04/30/2027

DOE F 470.12 (DRAFT) All other versions are obsolete

A. Employee Name:

Print Screening Results Here or Affix with Tamper Evident Tape

US Department of Energy (DOE)
Human Reliability Program (HRP) Alcohol Testing Form
Los Alamos National Laboratory Use Only
STEP 1: TO BE COMPLETED BY ALCOHOL TECHNICIAN
(First, M.I., Last)

B. Employee ID No:
C. Employer Name:

HRP Supervisor:

Phone:

D. Reason for Test:
Random

Reasonable Susp.

Post-Accident

Retun to Duty

Follow Up

Pre-Employment

I certify that I am about to submit to alcohol testing required or permitted by U.S. Department of Energy Regulations
and that the identifying information provided on the form is true and correct:

Signature of Employee:

Date:

STEP 3: TO BE COMPLETED BY ALCOHOL TECHNICIAN
(If the technician conducting the screening test is not the same technician who will be conducting the confirmation test, each technician
must complete their own form). I certify that I have conducted alcohol testing on the above-named individual in accordance with the
procedures established in the U.S. Department of Transportation regulation 49 CFR Part 40, that I am qualified to operate the testing
device(s) identified, and that the results are recorded.
TECHNICIAN:

BAT

DEVICE:

SALIVA

BREATH

15-Minute Wait:

Yes

No

Screening Test: (For BREATH DEVICE* write in the space below only if the testing device is not designed to print.)

Test #

Testing Device
Name

Device Serial # or Lot #
& Exp. Date

Activation Time

Reading Time

Result

Print Screening Results Here or Affix with Tamper Evident Tape

STEP 2: TO BE COMPLETED BY EMPLOYEE

CONFIRMATION TEST: Results MUST be affixed to each copy of this form or printed directly onto the form.

Remarks:

Company Street Address:

Alcohol Technician’s Name:

Company City, State, Zip:
Phone Number:

Signature:

Date:

STEP 4: TO BE COMPLETED BY EMPLOYEE IF TEST RESULT IS 0.02 or HIGHER
I certify that I have submitted to the alcohol test, the results of which are accurately recorded on this form. I understand that I
will be sent home and will not be allowed to perform HRP duties for 24 hours because the results are 0.02 or greater.

Signature of Employee:
650523

Date:
Copy 1 — Employer / Copy 2 —Employee / Copy 3 —Alcohol Technician

Print Screening Results Here or Affix with Tamper Evident Tape

Alcohol Technician’s Company:

OMB Control No. 1910-5122

DOE F 470.12 (DRAFT)

U.S. DEPARTMENT OF ENERGY
HUMAN RELIABILITY PROGRAM (HRP) ALCOHOL TESTING FORM

Expires: 04/30/2027

PREVIOUS EDITIONS ARE OBSOLETE

Instructions
Step 1:

The Breath Alcohol Technician (BAT) completes the information required in this step. The HRP Supervisor is the
person who initially or annually nominates the person for HRP certification.
If the employee refuses to provide an ID number, indicate this in the Remarks field in Step 3.

Step 2:

The employee reads, signs, and dates the certification statement in Step 2.
If the employee refuses to sign the certification statement do not proceed with the alcohol test. Contact the HRP
Supervisor.

Step 3:

The BAT checks the type of device being used (saliva or breath) and conducts the alcohol screening test.
The screening test information may be entered on the form by the technician, or for breath testing devices capable of
printing, the information may be printed directly to the record. Printed information must be affixed to the form on the
spaces provided.
Screening test results are less than 0.02: The BAT completes the remaining information in this step, and signs in the
space provided. The test process is complete.
Screening test results are 0.02 or greater: The BAT must complete a confirmation test in accordance with the
Department of Transportation (DOT) regulations. An evidential breath testing device that is capable of printing must
be used in conducting this test. A 15-minute waiting period should occur before conducting the confirmation test.
Affix the printed information to the form in the space provided, complete the remaining information in this step, and
sign in the space provided.
If the employee has a breath alcohol confirmation test result of 0.02 or higher: Notify the HRP supervisor, and
proceed to Step 4.

Step 4:

If the employee has a breath alcohol confirmation test result of 0.02 or greater, the employee must complete Step 4.
If the employee refuses to sign the certification statement in Step 4, be sure to indicate this in the Remarks field in
Step 3.

Make two copies of the completed form. Forward the original form to the employer. The employee and the BAT each retain
one copy of the completed form.
PRIVACY ACT STATEMENT
Sections 2165 and 2201(I) of title 42 of the United States Code authorize the collection of information by the U.S. Department of Energy (DOE) to regulate
the possession and use of special nuclear material and access to restricted data. DOE will use the information collected on this form to aid in the
determination of an individual’s eligibility for an HRP certification. The information may also be provided to other agencies of the United States government
for investigations that involve protection of the national security, public health and safety, or the environment. Submission of the information requested on
this form is voluntary, but failure to provide the information may result in denial of an HRP certification. If DOE uses the information for purposes other than
those indicated in this statement, it will provide notice of those additional purposes to persons who have submitted information on this form. This statement is
in reference to the relevant System of Records Notice (SORN) per Circular A-108, DOE-50, HRP Records SORN 230104
(https://www.federalregister.gov/documents/2009/01/09/E8-31316/privacy-act-of-1974-publication-of-compilation-of-privacy-act-systems-of-records).
OMB BURDEN DISCLOSURE STATEMENT
This data is being collected to administer an alcohol test. The data you supply will be used for alcohol testing to ensure that individuals who occupy positions
affording access to certain materials, nuclear explosive devices, facilities, and programs meet the highest standards of reliability and physical and mental
suitability. Public reporting burden for this collection of information is estimated to average 6 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Office of the
Chief Information Officer, Enterprise Policy Development & Implementation Office, IM-22, Information Collection Management Program (1910-5122),
U.S. Department of Energy, 1000 Independence Ave., SW, Washington, DC 20585; and to the Office of Management and Budget (OMB), OIRA, Paperwork
Reduction Project (1910-5122), Washington, DC 20503. Notwithstanding any other provision of the law, no person is required to respond to, nor shall any
person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that
collection of information displays a currently valid OMB control number. Submission of this data is mandatory.

DOE F 470.12 (DRAFT)

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