Employee DIRT Program Form

EMPLOYEE DIRT PROGRAM FORM

Program Overview

The Employee Drug Impairment Recognition Training (DIRT) Program is designed to provide employees with instruction on recognizing signs of impairment, appropriate reporting procedures, and the employer's testing and disciplinary protocols. Participation, acknowledgement, and certain authorizations documented on this form are required for continued access to safety-sensitive duties. Completion of this form does not alter at-will employment status.

Personal Information

Position Information

Reporting Manager:

Employment Start Date:

Employment History (Most Recent)

Education

Graduation Date:

References

Reference 1:

Reference 2:

Reference 3:

DIRT Training Details

Training Date:

Trainer/Instructor:

In-person    Online/Virtual    Self-paced module

Duration: Assessment Score:

Assessment Result: Pass Fail

Legal Notices, Consents and Authorizations

At-Will Employment: I acknowledge that my employment with the employer remains at-will, meaning either the employee or employer may terminate employment at any time, with or without cause or advance notice, subject to applicable law.

Equal Employment Opportunity: The employer is an equal opportunity employer. Decisions related to training, assignment, discipline, or termination will be made without unlawful discrimination.

Confidentiality: Materials, assessments, and incident reports created under the DIRT Program are maintained as employer records. Such records are confidential to the extent permitted by law and are accessible only to authorized personnel.

Consent to Observation and Investigation: I acknowledge and consent that, if reasonable suspicion of impairment arises, I may be subject to observation by trained personnel, an investigation, and documentation in accordance with company policy.

Consent to Testing: I understand that reasonable-suspicion drug and/or alcohol testing may be required under company policy. By checking the box below I provide consent consistent with company testing procedures and acknowledge that refusal to comply may result in disciplinary action up to and including termination.

I consent to reasonable-suspicion drug and alcohol testing as described above.

Authorization for Background and Previous Employer Contact: I authorize the employer to contact prior employers and professional references listed on this form and to obtain background information where permitted by law. I certify that the information I have provided is true and complete to the best of my knowledge.

I authorize contact with previous employers and consent to background checks as allowed by law.

Disciplinary Policy & Accommodations

Employees found to be impaired at work or who refuse required testing are subject to disciplinary action, including reassignment, suspension, or termination consistent with policy and applicable law. Employees with a recognized disability who request accommodation will be considered under the employer's reasonable accommodation procedures.

Employee Certification

I certify that all information on this form is true and complete. I understand the requirements of the DIRT Program and agree to comply with its policies and procedures. I acknowledge that failure to disclose information or comply with program requirements may result in corrective action.

Supervisor Review (for administrative use)

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