Cg 719P Form – Fill Out and Use This PDF

DEPARTMENT OF HOMELAND SECURITY

OMB No. 1625-0040

U.S. Coast Guard

Exp. Date: 03/31/2021

Name Last

First

Middle

Reference Number (if applicable)

Social Security Number

Signature of Applicant (Required)

Date (MM/DD/YYYY)

x

Section II: Name of SAMHSA Accredited Laboratory

Name

Street Address

City

State

Zip Code

SECTION III: Medical Review Officer

Date Specimen Collected (MM/DD/YYYY)

The laboratory report has been reviewed in accordance with procedures given in 49 CFR Part

40, Subpart G, and the verified test results are: (CHECK ONE)

NEGATIVE

Specimen Analyzed For (Drugs identified by 49 CFR 40.85),

including:

CANCELLED or

•

Marijuana metabolite

•

Cocaine metabolites

Positive, and/or refusal to test because of adulteration or

•

Amphetamines

substitution.

•

Opiate metabolites

(Please complete the next block for all non-negative results)

•

Phencyclidine (PCP)

MEDICAL REVIEW OFFICER CONTACT INFORMATION

MEDICAL REVIEW OFFICER AUTHORITY

Name Last

First

Middle

Name Last

First

Middle

Street Address

Signature (MRO signature stamp is authorized for negative results only)

City

State

Zip Code

Name of MRO Qualifying Organization

Phone:

Registration Number Issued

by Qualifying Organization:

CG-719P (04/17)

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• A drug test is required for all transactions EXCEPT endorsements, documents of

REQUIREMENTS

continuity, duplicates, and STCW certificates.

• Only a chemical test meeting the requirements of 49 CFR Part 40 will be accepted.

• A DOT Chemical test conducted within the past 185 days by a laboratory accredited

by Substance Abuse and Mental Health Services Administration (SAMHSA),

Department of Health and Human Services.

• COLLECTION of a sample may be conducted by an independent medical facility,

OPTION I

private physician or at an employer-designated site as long as the collection agent

meets the qualification requirements to be a collection agent given in Title 49 CFR

PERIODIC TESTING PROGRAM

Part 40 Subpart C. It is CRITICAL that the sample is sent to an accredited SAMHSA

laboratory for ANALYSIS or the drug test is invalid.

• The ORIGINAL results are required. A FACSIMILE is acceptable, if it is originated

from the Medical Review Officer (MRO) or the Service Agent assisting the mariner,

and sent directly from the office. The drug test result must be signed and dated by the

MRO.

EXAMPLE (From Mariner Employers): APPLICANT'S NAME/SSN has been subject to a

random testing program meeting the criteria of Title 46 CFR 16.230 for at least 60 days

OPTION II

during the previous 185 days and has not failed nor refused to participate in a chemical

test for dangerous drugs.

RANDOM TESTING

EXAMPLE (Active Duty Military/Military Sealift Command/N.O.A.A./Army Corps of

Engineers): APPLICANT'S NAME/SSN has been subject to a random testing program

with no subsequent positive drug test results during the remainder of the six month period.

• An ORIGINAL DATED letter on mariner employer stationary signed by a company

OPTION III

official, stating that they hold evidence that mariner either passed a chemical test for

dangerous drugs within the past 185 days or has been subject to a random testing

program.

PRE-EMPLOYMENT TESTING

EXAMPLE: APPLICANT'S NAME/SSN passed a chemical test for dangerous drugs,

required under Title 46 CFR 16.210 within the previous six months of the date of this letter

with no subsequent positive drug test results during the remainder of the six month period.

CG-719P (04/17)

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