Employment Drug Test Release

EMPLOYMENT DRUG TEST RELEASE

Employer Name:   Location/Site:

Personal Information

Date of Birth:    Identification Provided:

Position Information

Anticipated Start Date:    Hourly Salary/Rate or Annual Salary:

Employment History (Most Recent Two)

Education

Professional References

Legal Statements and Disclosures

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

Equal Opportunity: The employer does not discriminate on the basis of protected characteristics and considers all qualified applicants for employment without regard to race, color, religion, sex, national origin, age, disability, or other protected status in accordance with applicable law.

Authorization and Consent to Drug/Alcohol Testing

I voluntarily consent to submit to specimen collection and testing for alcohol and controlled substances and authorize the release of test results to the employer, the employer's designated Medical Review Officer (MRO), and other designated representatives for purposes related to my application for employment or continued employment. This consent includes initial screening and any confirmatory testing deemed necessary by the MRO.

I authorize any laboratory, medical professional, or testing facility to release test results and related reports to the employer for employment determination. I understand that a confirmed positive test result or refusal to provide a specimen as required may disqualify me from hire or may result in disciplinary action up to and including termination.

I acknowledge that specimen collection will follow accepted chain-of-custody procedures, and that I may be afforded the opportunity for a split-specimen test where applicable. I understand that I may provide information to the MRO to explain a positive result, and that the MRO will review laboratory findings prior to release of confirmed results.

I release the employer, the testing facility, its agents, and the MRO from liability for release of test results consistent with this authorization. I understand that the employer will maintain confidentiality of test results to the extent required by applicable policy and law.

Authorization to Contact Previous Employers and Background Checks

I authorize the employer and its agents to contact my previous employers, references, education institutions, and other named parties to investigate my background and fitness for duty, including verification of employment dates and performance. I further authorize release of information related to substance abuse treatment or testing history to the extent permitted by law for employment evaluation.

Consent to Background Check: I consent to the employer conducting background checks, including drug and alcohol testing history reviews where permitted.

Applicant Certification and Acknowledgement

I certify that all information provided on this form is true and complete to the best of my knowledge. I understand that falsification, omission, or failure to provide required information may result in denial of employment or termination. I understand that this release is effective for purposes of the testing events identified above and remains in effect while I am an applicant or employee of the employer, as applicable.

I acknowledge that I have received notice that testing may include collection of urine, breath, saliva, hair, or blood specimens as required by employer policy or specific testing protocols. I understand procedures will be performed in a manner intended to protect my privacy and dignity consistent with accepted practices.

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