Employment Drug Statement

EMPLOYMENT DRUG STATEMENT

Personal Information

Position Information

Employment History (Most Recent)

Education

References (Professional)

Legal Disclosures and Policy Acknowledgment

At-Will Employment: I understand that employment, if offered, is at-will and may be terminated by the employer or me at any time, with or without cause and with or without notice, unless otherwise agreed in a signed written contract. This statement does not alter the at-will employment relationship unless a written agreement signed by an authorized representative specifically states otherwise.

Equal Opportunity: The employer provides equal employment opportunity and does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, genetic information, or other protected characteristics as required by applicable law.

Drug and Alcohol Testing Consent

I acknowledge that the employer maintains a drug- and alcohol-free workplace policy. I understand and agree that as a condition of employment or continued employment I may be required to submit to testing for drugs and alcohol under the circumstances described below. I further understand that compliance with testing requirements is a condition of employment and refusal to submit to testing or a confirmed positive result may result in disciplinary action up to and including termination.

Circumstances under which testing may be required (check all that apply):

Specimen types that may be collected for testing (check all methods you consent to):

Medical and Confidentiality Consents

Medical Review: I authorize laboratory personnel and the employer's designated Medical Review Officer (MRO) to review test results and to discuss medically relevant information necessary to evaluate test results. I understand that the MRO will give me an opportunity to discuss any legitimate medical explanation for a confirmed positive test result prior to reporting to the employer.

Confidentiality: Test results and related medical records will be maintained in confidential files and disclosed only as permitted by law or as required for employment decisions, safety investigations, or treatment and rehabilitation referrals.

Prescription Medication Disclosure and Medical Conditions

If you are currently taking any prescription medications or over-the-counter medications that may affect test results or job performance, you must disclose them below. Disclosure does not imply exemption from testing; it allows the MRO to evaluate legitimate medical use.

If applicable, describe any medical condition that the MRO or treating physician should be aware of in relation to drug or alcohol testing:

Prior Test History and Explanations

Have you ever had a prior confirmed positive drug or alcohol test with any employer or testing program?     Yes    No

Authorization and Applicant Certification

By signing below, I certify under penalty of perjury that the information provided on this document is true and complete to the best of my knowledge. I authorize the employer, its agents, and service providers to obtain and release drug and alcohol test results and related medical information to each other, to the Medical Review Officer, to a treating physician as necessary, and to any other representative of the employer with a legitimate need to know for employment decisions.

I consent to the collection of samples, analysis, and disclosure described above and I authorize release of my prior drug and alcohol testing records to the employer and its agents for the purpose of determining eligibility for employment or continued employment. I understand that refusal to consent to testing, tampering with a specimen, or a confirmed positive result may result in discipline up to and including termination.

I further authorize the employer to contact my prior employers and references to verify employment history and inquire about past drug/alcohol testing results where permitted by law. I release all prior employers and references from liability for furnishing such information.

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