Form UC-843 Drug and Alcohol Testing Questionnaire

Form UC-843 Drug and Alcohol Testing Questionnaire

State of Connecticut Department of Labor, Employment Securing Adjudications

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Form UC-843 Drug and Alcohol Testing Questionnaire >

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Claimant Name

First NameLast Name
Claimant's Social Security Number
Enter the 9 digits of the claimant's Social Security Number (SSN).
Dear Employer:

The above named individual has indicated that his/her unemployment resulted from the failure of a drug/alcohol test.

Certain information regarding the test is required in order to determine the individual’s eligibility for unemployment benefits and the extent of your account’s liability for any benefits which may be paid. The following release authorizes you to disclose the information requested below for the purpose of determining the claimant’s eligibility for unemployment benefits.
Employer Name

First NameLast Name
Employer Registration Number
Claimant's Signature
Date

MonthDayYear
When was the drug/alcohol test administered?

MonthDayYear
What type of test was administered?
e.g., urinalysis test; breath alcohol test, etc.
What was the nature of the test?

Reasonable suspicionPre-employmentRandom
If the nature of the test was reasonable suspicion, please use the space below to (1) explain in detail why the individual was referred for the test and (2) specify what kind of behavior was observed and by whom.
Enter your response in the space above.
Was the test required by law?

YesNo
If the test was not mandated by federal law, please use the space below to explain.
Enter your response in the space above.
Was the claimant legally disqualified under state or federal law from performing the job for which s/he was hired as a result of the failure of the test?

YesNo
If the claimant was not legally disqualified under state or federal law from performing the job for which s/he was hired as a result of the failure of the test, please use the space below to explain.
Enter your response in the space above.
Please attach the following: (1) a copy of the Federal Drug Testing Custody and Control Form, if applicable, (2) a copy of the Medical Review Officer’s certification of the test result, if applicable, (3) a copy of the Breath Alcohol Testing Form with test results affixed, if applicable, and (4) in all cases, a copy of the applicable portion of the employer’s drug/alcohol testing policy.

If you are submitting a paper version of this form, please attach to this form physical copies of the documents requested above.
Cancelof
Rebuttal to information provided by the claimant is requested.

Yes, copy attachedN/A
Please be advised that if your response to this questionnaire is not received by [INSERT TIME] ON [INSERT DATE], a decision will be issued based on the information available.
Employer Representative Name

First NameLast Name
Employer Representative Title
Employer Representative Phone Number

Area CodePhone Number
Date

MonthDayYear
Should be Empty: