Belte r r a Cor p or at ion S afety M an ual D oc I D C H S M BE L 2 0 1 7 Pa g e 4 85 of 53 8 POST I N C I D EN T D R U G A N D A L C OH OL T EST I N G R EF ER R A L F OR M Doc u m e n t Identif icat ion F R M 027 P age Nu m b e r 1 of 1 Doc u m e n t C r e ation Dat e J a nua r y 1 2013 Im p le m e n tat ion Dat e J a nua r y 1 2013 I n c ident De s c riptio n This i nc ident r e sult e d in or c ould have re sult e d in Ye s No F a talit y S e rious pe rsona l i njur y to an indivi dua l Environme ntal spi ll with sig nific a nt i mpl ica ti ons S ig nific a nt l oss or da ma ge to prope rt y e quipm e nt or ve hicle s Ne a r miss incide nt t ha t h a d the pote nti a l t o c a use sig nific a nt inj ur y or d a m a ge Othe r e x plain be low F ull na me of Empl o y e e r e fe r re d fo r te st B a sis for d e c isi on to con duc t t e st not a utom a ti c de c isi on to t e st must be re a sona bl e g round s P rovide re leva nt d e tails da tes tim e s loca ti ons na mes of witnesse s i f a n y a nd de sc riptio n of e ve nt s or pa tt e rns of be h a vior just if y in g a t e st P lea se a tt a c h R e a sona ble Ca use a nd P ost I nc id e nt Dr u g a nd Alc ohol Te sti ng R e f e rr a l C he c kli st plus a n y e x tra pa ge s if ne c e ssa r y F irst R e view i n g P e rson S e c ond R e view in g P e rso n F ull Na me F ull Na me S ig n S ig n Da te Da te Note C ompl e ted f orm to be se nt t o de sig n a ted hu man r e sourc e s re p re se nta ti ve