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Authorization For Release Of DOT Drug And Alcohol Testing Records Form. This is a Official Federal Forms form and can be use in Federal Aviation Administration (FAA).
Tags: Authorization For Release Of DOT Drug And Alcohol Testing Records, FAA 8060-12, Official Federal Forms Federal Aviation Administration (FAA),
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. SEE PRIVACY ACT STATEMENT BELOW American LegalNet, Inc. www.FormsWorkFlow.com PRIVACY ACT STATEMENT: This statement is provided pursuant to the Privacy Act of 1974, 5 USC § 552a: The authority for collecting this information is contained in 49 U.S.C. §§ 40113, 44702, 44703, 44709. The principal purpose for which the information is intended to be used is to identify and evaluate your qualifications and eligibility for the issuance of an airman certificate and/or rating. Submission of the data is mandatory, except for the Social Security Number, which is voluntary. Failure to provide all required information will result in our being unable to issue you a certificate and/or rating. The information collected on this form will be included in a Privacy Act System of Records known as DOT/FAA 847, titled "Aviation Records on Individuals" and will be subject to the routine uses published in the System of Records Notice (SORN) for DOT/FAA 847 (see www.dot.gov/privacy/privacyactnotices), including: (a) Providing basic airmen certification and qualification information to the public upon request; examples of basic information include: · The type of certificates and ratings held, limitations, date of issuance and certificate number; · The status of the airman's certificate (i.e., whether it is current or has been amended, modified, suspended or revoked for any reason); · The airman's home address, unless requested by the airman to be withheld from public disclosure per 49 U.S.C. 44703(c); · Information relating to an airman's physical status or condition used to determine statistically the validity of FAA medical standards; and the date, class, and restrictions of the latest physical · Information relating to an individual's eligibility for medical certification, requests for exemption from medical requirements, and requests for review of certificate denials. (b) Using contact information to inform airmen of meetings and seminars conducted by the FAA regarding aviation safety. (c) Disclosing information to the National Transportation Safety Board (NTSB) in connection with its investigation responsibilities. (d) Providing information about airmen to Federal, State, local and tribal law enforcement agencies when engaged in an official investigation in which an airman is involved. (e) Providing information about enforcement actions, or orders issued thereunder, to Federal agencies, the aviation industry, and the public upon request. (f) Making records of delinquent civil penalties owed to the FAA available to the U.S. Department of the Treasury and the U.S. Department of Justice (DOJ) for collection pursuant to 31 U.S.C. 3711(g). (g) Making record