Free FAA Form 8060-12 - Federal

Form Approved: OMB No. 2120-0607 08/31/2010 AUTHORIZATION FOR RELEASE OF DOT DRUG AND ALCOHOL TESTING RECORDS UNDER PRIA AND MAINTAINED UNDER TITLE 49 CODE OF FEDERAL REGULATIONS (49 CFR) PART 40 Pilot Records Improvement Act Of 1996 (PRIA) Title 49 U.S.C. § 44703(h), RECORDS OF EMPLOYMENT OF PILOT APPLICANTS, as amended
Part I: To be completed by the new employer, signed by the applicant/employee, and transmitted to the previous employer. TO:
(Previous Employer Name ­ Printed)

___________________________________ ________
(Street Address)

,
(City)

__________,

_________,
(State)

__________
(Zip)

I, ______________________________________________ SSN: ________________________ have applied for employment
(Applicant/Employee Name ­ Printed) (OPTIONAL ­ See the attached Privacy Act statement)

with ____________________________________________________, _______________________, and hereby authorize the
(Hiring Air Carrier Name ­ Printed) (Air Carrier Certificate Number)

release of records from Department of Transportation-regulated drug and alcohol testing of me by my previous employer, to ______________________ __________________________________ FAX Number:__________________________
(Of the hiring Air Carrier) (Printed name of the Designated Employer Representative (DER) authorized to receive the released records)

I understand that this release of 5 years of records by my previous employer satisfies the requirements of DOT Code of Federal Regulations 49 CFR § 40.25(a)-(i) and 49 CFR § 40.333, and is limited to the following DOT-regulated testing records: 1. 2. 3. 4. 5. 6. 7. 8. Confirmed alcohol test results indicating an alcohol concentration of 0.04 or greater; Verified positive drug test results; Documentation of refusals to take required alcohol and/or drug tests (including substituted or adulterated test results); Documentation of other violations of DOT agency drug and alcohol testing regulations; Substance Abuse Professional (SAP) reports; All follow-up test results and schedules for follow-up tests, including documentation of each return-to-duty test; Information obtained from previous employers under 49 CFR § 40.25 concerning drug and/or alcohol violations; Records of negative and cancelled drug test results, and confirmed alcohol test results with an alcohol concentration of less than 0.039. Date: ________________________

Applicant/Employee Signature: _____________________________________________

A reproduction of this authorization shall be deemed effective and valid as an original. Part II: To be completed by the previous employer (DER) and transmitted by mail or fax to the new employer. In the five year period, prior to the date of the employee's signature in Part I, for DOT regulated testing: 1. Did the employee have any confirmed alcohol tests with a concentration of 0.04 or higher? 2. Did the employee have any verified positive drug tests? 3. Did the employee refuse to be tested? 4. Did the employee have other violations of DOT agency drug and/or alcohol testing regulations? 5. Did a previous employer report a drug and/or alcohol rule violation to you? 6. If you answered `yes' to any of the above items, did the employee complete the `return-to-duty' process? YES_____ NO_____ YES_____ NO_____ YES_____ NO_____ YES_____ NO_____ YES_____ NO_____ N/A_____ YES_____ NO_____

If you answered `yes' to item 6, please provide the appropriate return-to-duty documentation (SAP reports and follow-up testing). 49 U.S.C. § 44703(h)(1)(B) requires `records' to be furnished. This includes records of positive as well as negative results. Name of the Designated Employer Representative (DER) providing the records:_______________________________________ Phone Number:_______________________Email or FAX Number:_____________________________ Date:_______________ PREVIOUS EMPLOYER: If the individual named in Part I above has requested a copy of their records pursuant to a PRIA records request on FAA Form 8060-11A, AIRMAN NOTICE AND RIGHT TO RECEIVE COPY -- AIR CARRIER AND OTHER RECORDS (PRIA), copies of the Drug and Alcohol records must be provided to the individual (Title 49 U.S.C. § 44703(h)(6)). Forward copies of the Drug and Alcohol records to the address provided by the individual on FAA Form 8060-11A.

FAA Form 8060-12 (10-05)

INSTRUCTIONS
FAA FORM 8060-12, AUTHORIZATION FOR RELEASE OF DOT DRUG AND ALCOHOL TESTING RECORDS UNDER PRIA AND MAINTAINED UNDER TITLE 49 CODE OF FEDERAL REGULATIONS (49 CFR) PART 40

Pilot Records Improvement Act Of 1996 (PRIA) Title 49 U.S.C. § 44703(h), RECORDS OF EMPLOYMENT OF PILOT APPLICANTS, as amended

Air Carriers should use this form to request the appropriate records from current and/or past employers as contemplated under 49 U.S.C. § 44703(h), Records of Employment of Pilot Applicants, As Amended. NOTICE: This request is for the 5-year period preceding the date of the employee's signature in Part I of this form. This request will not be deemed valid unless Parts I and II are completed as specified. Pursuant to 49 U.S.C. § 44703(h)(5), a person who receives a request for records under 49 U.S.C. § 44703(h)(1) shall furnish a copy of all such requested records maintained by the person not later than 30 days after receiving the request. An additional copy must be furnished to the subject of this request only if that person has so indicated on the attached FAA Form 8060-11A, by checking the `YES' block. See the note to the previous employer at the bottom of FAA Form 8060-12. This form may be photocopied for use, or is available on the Internet at http://www.faa.gov/pilots/lic_cert/pria/ or http://forms.faa.gov/ This form is to be used as an attachment to FAA Forms 8060-11 and 8060-11A. A separate form must be used for each airman whose records are requested. Do not use with FAA Forms 8060-10 or 8060-10A. Part I: To be completed by the new employer and signed by the applicant/employee. All entries must be completed legibly with black or dark blue ink. 1. TO ­ enter the name and address of the applicant/employee's previous employer. 2. Enter the name and SSN of the applicant/employee. (SSN is optional ­ see Privacy Act statement below) 3. Enter the name and air carrier certificate number of the requesting employer. 4. Enter the name of the Designated Employer Representative authorized to receive the released records. 5. Signature ­ signature of the applicant/employee. 6. Date ­ enter the date of the request Part II: To be completed by the previous employer (DER). DER is assigned IAW 49 CFR Part 40. All entries must be completed legibly with black or dark blue ink. 1. DER answers questions 1 through 6, and prepares copies of the required supporting documents. 2. Enter the name of the Designated Employer Representative authorized to release the requested records. 3. Enter the phone / Email address / FAX numbers of the person (DER) providing the requested records. 4. Enter the date that the requested records have been prepared and forwarded to the new employer.
PAPERWORK REDUCTION ACT STATEMENT
Title 49 United States Code (49 U.S.C.) §44703(h), Records of Employment of Pilot Applicants, as amended, requires all air carriers to request FAA records and Air Carrier and Other Records concerning an individual before allowing that individual to begin service as a pilot. 49 U.S.C. § 44703 (h)(8) requires the FAA Administrator to promulgate standard forms to request records.The information entered on the standard forms will be used to facilitate the search and retrieval of the required records. It is estimated that the average burden per respondent associated with this collection of Air Carrier and Other Records is 30 minutes. The requirement to collect and evaluate background information on the pilot, before beginning service, is mandatory;however, the use of this form is not, although it is highly recommended. An agency may not conduct or sponsor, and a person is not required to respond to, this request for information unless a current and valid OMB control number is prominently displayed. The OMB control number assigned to this collection is 2120-0607. Comments concerning the accuracy of this burden and suggestions for reducing the burden should be directed to the FAA at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, ABA-20.

PRIVACY ACT STATEMENT The information on the accompanying form is solicited under authority of Title 49 U.S.C. § 44703(h), Records of Employment of Pilot Applicants, as amended, and maintained under Title 49 Code of Federal Regulations (49 CFR) Part 40. The purpose of this data is to be used to determine the suitability of a pilot applicant being considered by an air carrier for employment. The routine use of this information, after the request has been completed, allows a hiring air carrier to evaluate the professional competence and suitability of a pilot applicant, before extending a firm offer of employment to that pilot. Submission of the SSN is voluntary; however, disclosure of the SSN could facilitate the retrieval of the appropriate records which are usually maintained in alphabetical order and/or cross-referenced with the airman certificate number and/or SSN. Failure to disclose the SSN could result in a delayed, incorrect, or negative response to this request, caused by the possible misidentification of the records, or the failure to identify the appropriate records of the person who is the subject of this request. FAA Form 8060-12 (10-05)