Fill and Sign the Consent Drug Screening Form

Consent Form to Pre-Employment Drug Screening To: _______________________________________________________________________ (Company) ___________________________________________ ( Street Address or Post Office Box __________________________________________________ (City, state, and zip code) Name of Applicant: ___________________________________________________ Social Security Number : __________________________________ Telephone Number: _____________________________________ Alternate Phone Number (if available): ____________________________________ Applicant: Please read entire document prior to signing. _______________________________________________________ (Applicant’s Signature) Type of Test: Job Applicant/Pre-Employment (drugs only) Request: I have been requested to provide a urine specimen for analysis for controlled substances . I understand that this analysis may indicate the presence of controlled substances in my system. Collection Site: I have been instructed to go to a collection site within _____ (number of days) business days after accepting an offer of employment. If I am unable to go to a testing site within _____ (number of days) business days following the acceptance of my offer, I will need to obtain approval from the individual who sent the offer of employment letter to me. Extending the time frame for testing will not be guaranteed. I understand that __________________________ _______________________________ (Company) will make a reasonable attempt to accommodate me. Laboratory: _________________________________________________________ (Name of laboratory) is the organization that will be testing the sample. Refusal: I understand that I have the right to refuse to undergo testing for controlled substances. If I refuse, I understand that my conditional offer of employment will be withdrawn if I am a job applicant. Consent: I consent to the urine sample collection as specified above. I also consent to testing for controlled substance by the laboratory referred to above and the release of the laboratory test results to a medical review officer and then to ________________________________________ _____________________. (Company) Consequences: I understand that a positive test result for controlled substances will result in the withdrawal of any job offer that has been made to me if I am an applicant. I UNDERSTAND THE ABOVE CONDITIONS AND I AGREE TO COMPLY WITH THEM. Witness my signature this the ______ day of ______________________, 20_____. ____________________________________ APPLICANT _______________________________________ Witness