Employee Testing Release

EMPLOYEE TESTING RELEASE

Personal Information

Full Legal Name:

Date of Birth:   Employee ID:

Position Information

Employment History (Most Recent)

Education

Graduation Date:

References (Professional)

Testing Authorization & Consent

I hereby authorize Employer and its authorized representatives, medical review officers, laboratories, specimen collectors, licensed health care providers and testing facilities to collect biological specimens and to perform tests as indicated below. I understand that test results will be used for employment-related decisions, including discipline or termination where allowed by company policy and applicable law.

I authorize release of test results and related medical information to Employer and its designated representatives for the purposes described above. I understand that test data will be treated as confidential medical information but may be disclosed to supervisory personnel, designated safety or human resources staff, insurers, or as required by law or regulation.

I understand that refusal to submit to testing, failure to provide a specimen as instructed, adulteration or substitution of a specimen, or a confirmed positive result may result in employment actions up to and including termination, in accordance with employer policy and applicable law. Such actions may be taken independent of any criminal or civil proceedings.

Authorization to Obtain/Release Records

I hereby authorize any health care provider, previous employer, laboratory, and testing facility to release to the Employer any records or information relating to prior drug/alcohol testing, treatment for substance use or incidental medical records necessary to interpret test results. This release includes records retained by third parties and applies to information created prior to and after the date of this authorization for the duration indicated below.

Legal Disclosures and Statements

At-Will Employment: I understand that, unless otherwise agreed in a written contract signed by an authorized company representative, my employment is at-will, which means the Employer may terminate employment at any time for any lawful reason and I may resign at any time.

Equal Opportunity: The Employer is an equal opportunity employer. Decisions regarding testing, discipline, hiring, promotion, or termination are made without unlawful discrimination and in accordance with company policy and applicable law.

Authorization to Contact Prior Employers and Background Checks

By checking the box below and signing this form, I authorize the Employer to contact my previous employers and references, and to conduct background checks (including criminal history checks) to the extent permitted by law and as reasonably related to my position.

Employee Certification and Release

I certify that all information provided on this form is true and complete. I voluntarily consent to the testing and authorizations described above. I release and hold harmless the Employer, its officers, employees, agents, laboratories, medical review officers, and testing facilities from any claims, demands, liabilities, losses or damages arising from the collection, testing, reporting, or use of test results, except to the extent such claims arise from willful misconduct or gross negligence.

Additional Acknowledgments

I acknowledge that I have had the opportunity to ask questions about the testing process and consequences, and that I will follow any specimen collection instructions. I understand that this authorization remains effective until the date specified in the Duration of Authorization above or until revoked in writing; however, revocation will not apply to tests or disclosures already performed.

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