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FORM C DOT/CDL Employees Certificate of Receipt Acknowledgement of receiving materials required by 49 CFR Part 382. 601 Employee Name SS or ID Employer State of Indiana This is to certify that I have been provided educational materials that explain the requirements of 382. 601 and my employer s policies and procedures with respect to meeting the requirements. This includes all items checked* The designated person to answer questions about the material The categories of drivers subject to Part 382. Sufficient information about the safety-sensitive functions and periods of the workday that compliance is required* Specific information concerning prohibited driver conduct. Circumstances under which a driver will be tested* Test procedures driver protection and integrity of the testing processes and safeguarding the validity of the test. The requirements that tests are administered in accordance with Part 382. An explanation of what will be considered a refusal to submit to a test and the consequences. from safety-sensitive functions and 382. 605 procedures. 002 or greater but less than 0. 04. Information on the affects of alcohol and controlled substances use on an individual s health work personal life signs and symptoms of a problem and available methods of intervening when a problem is suspected* A copy of my employer s substance abuse policy. 601 Employee Name SS or ID Employer State of Indiana This is to certify that I have been provided educational materials that explain the requirements of 382. 601 and my employer s policies and procedures with respect to meeting the requirements. This includes all items checked* The designated person to answer questions about the material The categories of drivers subject to Part 382. 601 and my employer s policies and procedures with respect to meeting the requirements. This includes all items checked* The designated person to answer questions about the material The categories of drivers subject to Part 382. Sufficient information about the safety-sensitive functions and periods of the workday that compliance is required* Specific information concerning prohibited driver conduct. Sufficient information about the safety-sensitive functions and periods of the workday that compliance is required* Specific information concerning prohibited driver conduct. Circumstances under which a driver will be tested* Test procedures driver protection and integrity of the testing processes and safeguarding the validity of the test. Circumstances under which a driver will be tested* Test procedures driver protection and integrity of the testing processes and safeguarding the validity of the test. The requirements that tests are administered in accordance with Part 382. An explanation of what will be considered a refusal to submit to a test and the consequences. The requirements that tests are administered in accordance with Part 382. An explanation of what will be considered a refusal to submit to a test and the consequences. from safety-sensitive functions and 382. 605 procedures. 002 or greater but less than 0. 04. Information on the affects of alcohol and controlled substances use on an individual s health work personal life signs and symptoms of a problem and available methods of intervening when a problem is suspected* A copy of my employer s substance abuse policy.

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