Employee Substance Background Form

EMPLOYEE SUBSTANCE BACKGROUND FORM

PERSONAL INFORMATION

Employee Name:

Date of Birth:    Phone:

POSITION INFORMATION

Reporting Manager:    Start Date:

EMPLOYMENT HISTORY (MOST RECENT FIRST)

Title:    Dates Employed:

Title:    Dates Employed:

EDUCATION

REFERENCES (PROFESSIONAL)

Phone:    Email:    Relationship:

Phone:    Email:    Relationship:

Phone:    Email:    Relationship:

SUBSTANCE-RELATED DISCLOSURES

Have you ever been convicted of a drug- or alcohol-related offense, or had a professional license restricted, suspended, or revoked due to substance use? Yes No

Have you previously participated in substance use treatment, counseling, or an employee assistance program for drug or alcohol use? Yes No

CONSENT FOR DRUG AND ALCOHOL TESTING AND RECORDS RELEASE

I hereby authorize the employer, its designated testing agents, and any medical review officer to collect, test, retain, and disclose specimens and test results as required by applicable company policy. I understand that testing may include urine, blood, breath, saliva, hair, or other scientifically accepted specimen types and may be conducted under any of the following circumstances:

Pre-employment testing
Random testing
Reasonable suspicion testing
Post-accident/safety-sensitive incident testing
Return-to-duty and follow-up testing

I authorize any health care provider, treatment program, employer, or other entity to release my substance use treatment records, testing records, and related medical information to the employer, its agents, and the medical review officer for purposes of employment screening, fitness-for-duty determinations, compliance with company policy, or return-to-duty evaluation. I release such entities from liability for releasing the information in accordance with this authorization.

PRIVACY, MRO, AND TESTING PROCEDURES

Test specimens will be handled and stored in a manner designed to protect confidentiality. Positive, adulterated, substituted, or invalid test results will be reviewed by a medical review officer (MRO) who will contact the employee to discuss legitimate medical explanations prior to reporting a confirmed positive result to the employer. I understand that my consent to testing is a condition of employment or continued employment in safety-sensitive positions or as required by company policy.

LEGAL DISCLOSURES

At-Will Employment: Nothing in this form or in any prior representation shall constitute a contract of employment for any specified period. Employment remains at-will and may be terminated by either party at any time, with or without cause, unless otherwise expressly agreed in writing by an authorized representative of the employer.

Equal Opportunity: The employer provides equal employment opportunity to all applicants and employees without regard to race, color, religion, sex, national origin, age, disability, genetic information, or any other characteristic protected by law. Decisions regarding testing and discipline pursuant to confirmed substance misuse will be applied consistently and in accordance with applicable law and company policy.

APPLICANT CERTIFICATION AND AUTHORIZATIONS

I certify under penalty of perjury that the information provided on this form is true, complete, and correct to the best of my knowledge. I understand that knowingly providing false information or omitting material facts may result in denial of employment or disciplinary action, up to and including termination. I further authorize the employer and its agents to contact the previous employers and references listed on this form, to obtain and verify all information concerning my prior employment, education, and substance-related history, and to conduct background and records checks as permitted by applicable law.

I authorize contact with prior employers and listed references for purposes of verification and investigation.

Release: To the extent permitted by law, I release from liability any person or entity providing information in good faith concerning my suitability for employment, substance history, or fitness for duty.

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