Clearinghouse Database Violation Reporting

$45.00

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Type of Employer Report*
Employer Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
USDOT #
Phone*
Email*
Driver Name*
First Last
Driver Date of Birth*
CDL #*
State of Issue*
Country of Issue*
Date of Alcohol Test
Reason For Test
Test Result

Breath alcohol concentration level
Date of Test
Test Type
Reason For Test
Documentation of the Refusal
Accepted file types: pdf, docx, Max. file size: 512 MB.
Upload Documentation
Test Type
Specimen ID #
Date of Test
Reason For Test
Test Result
Date of Verified Result*
Date Drivers Follow up Plan has Been Successfully Completed
Date Employer Obtained Actual Knowledge: (date field)
Description of the violation:
Witnesses to the violation, include any contact information
Accepted file types: pdf, docx, Max. file size: 512 MB.
Evidence supporting each fact alleged in the description of the violation
Max. file size: 512 MB.
Evidence supporting each fact alleged in the description of the violation, which may include, but is not limited to, affidavits, photographs, video or audio recordings, employee statements (other than admissions pursuant to § 382.121), correspondence, or other documentation.
A certificate of service or other evidence showing that the employer provided the employee with all information reported.
Accepted file types: pdf, docx, Max. file size: 512 MB.
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