Employment Drug Test Notification

EMPLOYMENT DRUG TEST NOTIFICATION

Employee Personal Information

Employee Name:

Position Information

Reporting Manager:

Proposed Start Date: Salary (if applicable): $

Employment History (Most Recent)

Dates Employed: From To

Employment History (Previous)

Dates Employed: From To

Education

Graduation Date:

Professional References

Phone: Email:

Phone: Email:

Phone: Email:

Drug Test Notification Details

Reason for Test: Pre-Employment Random Post-Accident Reasonable Suspicion Return-to-Duty Follow-Up Other

Scheduled Test Date: Time:

Specimen Type: Urine Saliva Hair Breath Blood

Preparation Instructions: Do not consume food, alcohol, or illicit substances and avoid smoking or chewing gum for hours prior to collection. Bring valid photo identification and this notification.

I acknowledge that a government-issued photo ID will be presented at collection.

Legal Notices, Consent, and Acknowledgments

Purpose and Scope: The above-named employee is required to undergo the drug and/or alcohol screening identified above. The test will be administered in accordance with the employer's written drug-testing policy and applicable law. This notification constitutes formal notice and an opportunity to consent or object as described herein.

Medical Review and Prescription Disclosure: If the test result is confirmed positive, the result will be referred to a Medical Review Officer (MRO) for review. You may provide information to the MRO regarding lawful prescription or over-the-counter medications prior to or at the time of collection. You are encouraged to disclose current prescription medications in writing below.

Confidentiality: Test results and related medical information will be maintained in a confidential medical file and released only to those persons designated by employer policy or as required by law. By signing, you authorize release of results to the employer's designated representatives and the MRO for purposes of employment determination.

Refusal and Adverse Consequences: Refusal to submit to the test, failure to appear at the scheduled time, or tampering with a specimen will be treated as a positive result and may subject you to disciplinary action up to and including termination, or withdrawal of a conditional offer of employment, consistent with employer policy and applicable law.

Split Specimen & Retest: You have the right, where applicable by policy or law, to request that a split specimen be preserved and tested upon written request to the MRO within the required timeframe. Costs for split specimen testing will be assessed as set forth in employer policy.

Background Checks and Reference Contact Authorization: By signing this form you also authorize the employer to contact prior employers and references provided in this document to verify employment history and related information and to conduct lawful background checks to the extent permitted by law.

I authorize release of test results and related medical information to employer representatives and the Medical Review Officer as necessary for employment determination.

I authorize the employer to contact previous employers and conduct background checks as described above.

Applicant Certification

I certify under penalty of perjury that all information provided on this form is true and complete to the best of my knowledge. I understand the testing process, my rights to disclose lawful medication use to the Medical Review Officer, and the potential consequences of a positive result or refusal to test. I further certify that I have received this notification and opportunity to ask questions prior to testing.

By checking the box below and signing, I give my informed consent to the specified drug and/or alcohol testing described in this notification and to the release of results as indicated.

I certify that the statements above are accurate and I consent to testing and release of results.

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