HR Drug Testing Commitment Form

HR DRUG TESTING COMMITMENT FORM

Employer:    Employee:

Personal Information

Position Information

Expected Start Date:

Employment History (Most Recent First)

Dates Employed: to

Dates Employed: to

Education

Graduation Date:

References (Professional)

Drug Testing Acknowledgment and Consent

I, the undersigned employee/applicant, understand and agree that as a condition of employment and continued employment I may be required to submit to drug and alcohol testing in accordance with company policy. Testing may include pre-employment, random, reasonable suspicion, post-accident, return-to-duty and follow-up testing. I acknowledge that refusal to submit to required testing or tampering with a specimen is grounds for disciplinary action up to and including termination.

I consent to the collection and analysis of specimens, including urine, breath, saliva, hair, or blood as designated by the employer or its authorized testing provider. I authorize release of test results to the employer, the Medical Review Officer (MRO), and other designated company representatives for the purposes of evaluating fitness for duty and administering personnel actions.

Specimen types consented to (check all that apply):

Urine   Breath (alcohol)   Saliva   Hair   Blood

I understand that positive test results will be reviewed by a qualified MRO who will contact me to verify legitimate, lawful use of prescription medication when appropriate. I understand my right to request analysis of a split specimen in accordance with procedures established by the employer and the testing laboratory, and that any such request must be made to the MRO within the timeframe specified by testing procedures.

I authorize the employer and the MRO to release findings and related information to the employer's designated representatives for the purposes of personnel decisions and any required reporting. I further authorize the release of information to any substance abuse professional involved in evaluation, treatment, return-to-duty, or follow-up testing.

I authorize the employer to conduct background checks and to contact prior employers for verification of employment, including prior drug and alcohol testing records where permitted by law.

Policy, Confidentiality and Consequences

The employer's drug and alcohol policy sets forth prohibited substances, testing procedures, and disciplinary consequences for violations. Test results and related medical information will be treated as confidential medical records and disclosed only to those with a legitimate business need to know. However, disclosure may be required to supervisors in order to effect safety-sensitive reassignments or to comply with applicable law.

Consequences for a confirmed positive test, refusal to test, or tampering include removal from safety-sensitive duties, mandatory evaluation by a substance abuse professional, suspension, or termination. Reinstatement after a confirmed positive test may be conditioned on successful completion of a treatment and monitoring program and a negative return-to-duty test.

At-Will Employment & Equal Opportunity

Employment with the employer is at-will unless expressly provided otherwise in a signed written agreement. Either the employee or the employer may terminate the employment relationship at any time, for any lawful reason, with or without cause or notice.

The employer is an equal opportunity employer. Decisions related to testing, discipline, and reasonable accommodations will be made in accordance with applicable law and the employer's policies.

Applicant / Employee Certification

I certify that the information I have provided on this form is true and complete to the best of my knowledge. I understand that any falsification, omission, or misrepresentation may result in denial of employment or disciplinary action, including termination. I have read and understand the drug testing policy summary above and agree to comply with the policy and testing procedures.

I acknowledge receipt of the employer's Drug and Alcohol Testing Policy and consent to the terms set forth in this Drug Testing Commitment Form.

I understand that I may be required to provide medical documentation if I assert that a positive test was caused by legally prescribed medication. I further understand that any such documentation will be reviewed by the MRO and the employer in accordance with applicable procedures.

Acknowledgments (Initials)

Initial to acknowledge each statement:

Safety-sensitive duties:    Random testing possible:    Refusal = consequences:

Authorization to Contact Prior Employers

By checking the box below I authorize the release of my prior employment drug and alcohol testing records, if any, to the employer for purposes of evaluating my qualifications and compliance with applicable safety standards.

I authorize prior employers to release drug and alcohol testing records as permitted by law.

Medical or Disability Information

If you have a medical condition or are taking prescription medication that may affect test results or the collection process, please list medications or explain below. The employer will consider requests for reasonable accommodation in accordance with applicable law.

Employee Acknowledgment

By signing below I attest that I have read, understand, and agree to comply with this Drug Testing Commitment Form and the employer's drug and alcohol testing policy. I consent to testing and to the release of results as described above.

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