TPA Questionnaire Step 1 of 7 14% Your name First Last Contact Email Company Section BreakI. Regulatory Issues 1. Has your organization or any of the following services provided by your organization ever been subject to a Notice of Proposed Exclusion (NOPE) or Public Interest Exclusion (PIE) issued by the U.S. DOT per 49 CFR Part 40 Subpart R?1a. Third Party Administrator (TPA)*YesNo1b. Medical Review Officer (MRO)*YesNo1c. Collections*YesNo1d. Substance Abuse Professional (SAP)*YesNo2. Have any of your clients ever been the subject of a DOT audit?*YesNoIf YES: What assistance did you provide? Select All Pre-Audit Guidance Production of Records MIS Reports Random Testing Records (Testing Pools, Selections, Tests) 3. Do you subscribe to the List Serve on the ODAPC website?*YesNo4. If you provide TPA services in multiple states, how do you stay apprised of changing state laws? II. Breath Alcohol Testing and Procedures1. Do you provide/arrange Breath Alcohol Testing (BAT/STT) services?*YesNoIf NO: Skip to Section IIIIf YES- 1a. Are the BATs employees or contracted?EmployeesContracted2. Do you require or request documentation the BATs have received DOT required training?YesNoIf Contracted: Skip to Section III3. Do you maintain copies of the BAT’s qualification documents, including proficiency demonstrations on an evidential breath testing device (EBT)?YesNoThird Choice4. Do you maintain copies of the BAT calibration/calibration check logs?YesNoN/A5. Do you maintain a copy of the QAP (Quality Assurance Plan) for each device used?YesNoN/A6. Are calibration checks performed according to the QAP for each device?YesNoN/A III. Random Testing and Consortium Services1. Do you provide DOT random program management and/or consortium services?YesNoIf Consortia Services: 1a. Which DOT agency(ies)? Select All FMCSA FAA FRA USCG FTA PHMSA 1b. Do you have a notification process in place for random selections for your consortia?YesNoN/A1c. Do you have a system in place to monitor compliance and address non-compliance with your consortia members?YesNoN/A1d. Are you prepared to present all consortia compliance related documents in the event of an audit or compliance review?YesNoN/A2. Do you have a scientifically valid process in place for making random selections?YesNo3. Do you provide non-DOT Random Program management services?YesNoIf YES: 3a. Are you aware of and comply with any state-specific requirements regarding random drug and alcohol testing?YesNo3b. Are you prepared to present all compliance related documents in the event of an audit?YesNo IV. Training, Development and Leadership1. Do you participate as an active member in good standing with any industry associations?*YesNoIf YES: 1a. Which association(s) are you a current member of:NDASASAPAADATIASHRMNAPBSOther2. Does your company and/or any of your employees have any industry related credentials or training certifications?YesNoIf YES: 2a. Which credential(s) and/or certification(s):3. How long have you been performing TPA services?YEARS MONTHS 4. How and where do you receive industry updates to remain current on relevant information?5. Are you licensed to perform business operations according to the city, county, state where your business(es) is/are located?YesNo6. Do you provide specimen collector training?YesNo7. Do you provide training for BATs or STTs?YesNo8. Do you provide training for DERs?YesNo9. Do you provide reasonable suspicion training for supervisors?YesNo10. Do you provide employee drug and alcohol awareness training?YesNo11. Have you ever encountered an uncooperative or problematic collection site?YesNoIf YES: Describe what you have done to help bring that site into compliance (attach description)12. When a collection site has a fatal flaw, do(es) you or your MRO have a system to track the completion of error correction training within the required 30 days?YesNo V. Services and Product Offerings 1. Do you have a written agreement to provide/arrange drug and alcohol collection services?YesNo(if yes, add Collection Site Agreement information regarding qualifications)2. Do you audit a percentage of your third party collection sites annually?YesNoIf YES: Percentage 3. Do you use your own personnel to provide for on-site drug or alcohol collections at a customer location using a vehicle owned/leased by your organization?YesNoN/AIf YES: Please provide a certificate of insurance showing auto liability coverage4. Do you provide/arrange Medical Review Officer (MRO) services?YesNoIf YES: 4a. Is the MRO a direct employee of your firm?Direct EmployeeContractor4b. How is your MRO notified of individual client requirements for reporting non-standard situations?5. Do you provide/arrange Substance Abuse Professional (SAP) services or referrals?YesNoIf YES: Is the SAP a direct employee of your firm?Direct EmployeeContractor6. Do you provide/arrange Employee Assistance Program (EAP) services or or are those services contracted?NoProvided In-HouseContracted7. Do you currently perform instant testing or Point-of-Collection (POCT) testing for your clients?YesNoIf YES: 7a. Are you aware of states where the use of such devices is prohibited?YesNo7b. Do you provide training for those who will conduct collections with such devices (typically provided by the device manufacturer)?YesNo7c. Do you regularly audit your internal inventory for device expiration date(s), if applicable?YesNo7d. Do you confirm quality control in accordance with the manufacturer on the devices you use to ensure accuracy?YesNo8. Do you provide state and/or federal compliance advice, consulting, legal services or other formalized compliance service for your customers?YesNoIf YES: How do you provide these services? Retain Legal Representative Internal Counsel Regulatory Compliance Officer Other (please specify): 9. Do you provide policy development and/or review services?YesNoIf YES: Who reviews policy/services?Internal EmployeeContracted Representative10. Do you provide FMCSA Clearinghouse Database services?YesNo11. Do you provide previous drug and alcohol checks as required in 49 CFR Part 40.25 for DOT regulated clients?YesNoIf YES: Do you provide these services internally or do you contract them to a third party provider?Internal EmployeeThird Party Provider12. Do you provide Driver Qualification File (DQF) management services?YesNoIf YES: Does your program comply with the regulations found in 49 CFR Part 391?YesNo13. Do you offer Background Check services?YesNo14. Are you functioning as a Designated Employer Representative (DER)?YesNoIf YES, please explain: VI. Ethical Standards, Integrity and Confidentiality1. Do you store internally or electronically any Personally Identifiable Information (PII) (such as social security numbers, date of births, etc.)?YesNoIf YES: 1a. Do you have security measures in place to protect any sensitive information (PII, test results, health reports, etc.)?YesNoIf NO: 1b. Does your outside vendor who stores sensitive information, (PII, test results, health reports, etc.), have security measures in place to protect the information?YesNo2. Do you provide online access for your customers to order services, manage accounts, view test results, etc.?YesNoIf YES: 2a. Do you comply with state and federal record retention requirements?YesNo3. Does your organization currently maintain general liability insurance?YesNoIf YES: Please provide a certificate of coverage4. Does your organization currently maintain errors and omissions coverage (professional liability) insurance?YesNoIf YES: Please provide a certificate of coverage5. Are your employees required to sign a confidentiality or a non-disclosure agreement to protect client information?YesNo6. Does your organization maintain a Drug-Free Workplace policy prohibiting drug and alcohol use for all employees?YesNo Quick Quiz: 1. Identify the appropriate regulation number to the corresponding DOT Agency.FTA FAA FMCSA FRA USCG PHMSA 2. Which regulation determines who is tested and which regulation determines how testing is conducted?Part 40DOT Agency3.What are the current annual random drug and alcohol testing rates for each DOT Agency?FRA Drugs Alcohol FAA Drugs Alcohol FTA Drugs Alcohol USCG Drugs Alcohol FMCSA Drugs Alcohol PHMSA Drugs Alcohol 4. When can the C/TPA act as a DER on behalf of the employer? In the case of an owner-operator truck driver When the employer does not want to appoint a DER If the employer wants the C/TPA to act as the DER None of the above All of the above 5. What happens if one employer in a Consortium does not complete their random drug and alcohol testing as required and the annual percentage rate is not met? Nothing since all other employers have complied The entire consortium is out of compliance The MRO is out of compliance None of the above All of the above 6. Who is responsible for reporting verified drug test results to the employer and/or the TPA? Collector Laboratory MRO SAP DER 7. For FMCSA, how many hours of reasonable suspicion training are required for DOT supervisors? Drugs Alcohol 8. What reason(s) for testing requires a negative drug test result? Pre-employment, Random & Return-to-Duty Pre-employment & Random Pre-employment, Return-to-Duty and Follow-up Return-to-Duty, Random & Follow-up Post-accident & Reasonable Suspicion 9. What reason(s) for testing per DOT always require collections performed under direct observation? Pre-employment & Random Return-to-Duty & Follow-up Random & Reasonable Suspicion Follow-up & Post-Accident Post-accident & Reasonable Suspicion 10. How long does an employee have to report to a collection site after notification of a DOT random test? 24 hours 48 hours 2 hours 1 hour Employees must proceed immediately to the collection FileMax. file size: 256 MB.CAPTCHA Δ
