Employee Drug Testing Consent

Employee Drug Testing Consent

Personal Information

Position Information

Start Date:    Salary/Rate: $

Consent to Drug and Alcohol Testing

I, the undersigned employee, hereby voluntarily consent to undergo drug and alcohol testing as a condition of employment and/or continued employment with the Employer. I understand that testing may be conducted under the Employer's drug-free workplace program and may include initial screening and confirmatory tests performed by certified laboratories and reviewed by a Medical Review Officer (MRO).

I authorize the release of test results to the Employer and to the Employer's designated representatives, including human resources personnel, the MRO, and testing facility staff, for purposes related to employment decisions and compliance with applicable workplace policies.

Reason for Test (check all that apply)

Pre-employment screening    Random testing    Post-accident/injury testing

Reasonable suspicion/cause    Return-to-duty    Follow-up testing

Specimen Type

Specimen(s) to be collected (check as applicable):
Urine    Breath    Blood
Saliva (oral fluid)    Hair    Other:

Procedures and Acknowledgements

I acknowledge that specimen collection will be conducted in accordance with established chain-of-custody procedures. I understand that an initial positive screening result will be confirmed by a different, more specific confirmatory test. I have the right to notify the MRO of any legitimate medical use of prescription medication, and to request that any confirmatory positive result be reviewed in light of such information.

I understand that a confirmed positive result, a verified refusal to provide a specimen, an adulterated or substituted specimen, or other violations of the testing protocol may result in disciplinary action up to and including termination, consistent with Employer policy and applicable law.

Release and Authorization

By signing below I expressly authorize any physician, laboratory, medical facility, MRO, or health care provider who has information relating to my drug/alcohol testing to release such information to the Employer and the Employer's designated representatives for purposes of evaluating compliance with workplace policies and determining employment status.

I also authorize the Employer to disclose testing results and related information to third parties where required by law or necessary for job-related safety determinations.

Employment History (most recent first)

Dates Employed:

Dates Employed:

Education

Graduation Date:

Professional References

Legal Disclosures

At-Will Employment: I understand that, unless otherwise set forth in a written agreement signed by an authorized representative of the Employer, my employment is at-will and may be terminated by either the Employer or me at any time, with or without cause or notice.

Equal Opportunity: The Employer provides equal employment opportunities to all employees and applicants without regard to legally protected characteristics. This testing program is applied consistent with applicable nondiscrimination requirements.

Acknowledgement of At-Will Employment: I acknowledge the at-will employment statement.     Acknowledgement of Equal Opportunity: I acknowledge the equal opportunity statement.

Authorization for Background and Reference Checks

I authorize the Employer to contact my former employers, listed references, and any other parties necessary to verify information provided herein or to obtain information relevant to my employment. I further authorize the Employer to conduct background checks and to obtain criminal history information to the extent permitted by law.

Consent to Background Check: I consent to background and reference checks as described above.

Employee Certification and Consent

I certify that the information I have provided in this document is true and complete to the best of my knowledge. I understand that falsification, omission, or misrepresentation of facts may result in denial of employment or disciplinary action, up to and including termination.

By signing below, I knowingly and voluntarily consent to the collection and testing of biological specimens for drugs and alcohol under the Employer's testing program. I understand my rights to explanation of results, to discuss positive findings with the MRO, and to provide documentation of legitimate medical prescriptions. I understand that refusal to cooperate with testing procedures is treated as a refusal to test and may result in disciplinary action, up to and including termination.

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