DEPARTMENT OF HOMELAND SECURITY OMB No. 1625-0040 U.S. Coast Guard Exp. Date 03/31/2021 DOT/USCG PERIODIC DRUG TESTING FORM OPTIONAL CG-719P Who must submit this form INSTRUCTIONS This form MAY be used to satisfy the requirements for Periodic Testing Requirements in accordance with Title 46 CFR 16. Please print This specimen is verified POSITIVE for The test was CANCELLED because insert reason verified test result is in accordance with Title 49 CFR 40 Subpart G. MEDICAL REVIEW OFFICER CONTACT INFORMATION Phone CG-719P 04/17 Signature MRO signature stamp is authorized for negative results only Name of MRO Qualifying Organization Registration Number Issued by Qualifying Organization Reset Page 1 of 2 A drug test is required for all transactions EXCEPT endorsements documents of continuity duplicates and STCW certificates. 220. If you participate in a USCG random or pre-employment drug test program this form may not be necessary. See page 2 for details. NOTE The cost of the drug test is the sole responsibility of the applicant not the Coast Guard. Section I Applicant Consent I certify that I am the described applicant and that I have provided the specimen s described below in accordance with Department of Transportation procedures given in 49 CFR 40. I also understand that making in any way a false or fraudulent statement entry or evidence is a violation of the U*S* Criminal Code at Title 18 U*S*C. 1001 which subjects the violator to federal prosecution and possible incarceration fine or both. Name Last First Middle Reference Number if applicable Social Security Number Date MM/DD/YYYY Signature of Applicant Required 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 Specimen Analyzed For Drugs identified by 49 CFR 40. 85 including Marijuana metabolite Cocaine metabolites Amphetamines Opiate metabolites Phencyclidine PCP NEGATIVE CANCELLED or Positive and/or refusal to test because of adulteration or substitution* Please complete the next block for all non-negative results FOR POSITIVE/ADULTERATED/CANCELLED DRUG TESTS ONLY To be reported to the nearest USCG Sector or Unit. 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 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 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.
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Welcome to the National Maritime Center webinar regarding how to apply for a merchant mariner credential the first step to applying for a merchant mariner credential or MMC is to obtain an application packet from our website or from our customer service center our website can be accessed at WWE MAL /n MC and our customer service center can be reached at one eight eight eight I asked an MC each application packet contains a merchant mariner credential application acceptance checklist this is a list of forms which must accompany the application in order for the National Maritime Center to evaluate your qualifications to hold an MMC next determine whether you need to apply for a transportation workers identification credential or TWIC from the Transportation Safety Administration Coast Guard policy letter 11-15 explains this in detail complete the application for a merchant mariner credential there is a video titled cg — 7 1 9 b on our website which will help with completing the application pay any applicable fees via pay gov print your receipt and add a copy of it to the application package there is an instructional video called how to use pay gov available on the fees portion of our website foreign nationals applying for rating endorsements must show proof that they are lawfully admitted to the United States for permanent residence please prey photocopy of the front and back of your alien registration card form i-551 all applicants must disclose all convictions not previously reported to the Coast Guard a conviction is a guilty or no contest plea deferred adjudication required class attendance contributions of time or money a requirement to receive treatment placement under supervision or on probation or a decision to forgo appeal of a court's conviction physical form cg7 19k is to be used for all original renewal and rays of grade officer and qualified reading endorsement applications physical form CG 719 KE is to be used for entry-level applications for example ordinary seaman wiper steward Department or food handler please note that a food handler endorsement with a 719 KE requires a statement from your position stating that you are free of communicable diseases be sure that your medical practitioner completes all parts of the form including signature and that it is dated within 12 months of your application unless you are applying for a raise of grade raise of grade transactions require that the form be dated within 36 months of the application a chemical testing report also known as a drug screen is required for all original and renewal transactions as well as any officer endorsement raise of grade and any time you apply for your first qualified rating endorsement the report must be dated within six months of your application a letter from your marine employer on company letterhead or a letter from a chemical testing consortium group may be used in lieu of this form in addition to the Coast Guard forms a complete application package.
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