Drug/Alcohol Consent Form

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									This Drug/Alcohol Consent Form is given to employees to consent to drug/alcohol
testing. It describes the testing procedures and explains that a positive test may result
in denial or termination of employment. This document contains standard provisions
commonly included in a drug/alcohol consent form, and may be customized to include
the specific policy of the company. This form should be used by a company or
employer that implements drug/alcohol testing.
                                   DRUG/ALCOHOL CONSENT FORM

I have read and understand the substance abuse and drug and alcohol testing policy of Company. I understand
that if the sample I provide does not test negative, I will be subject to denial of employment or termination of
employment, to the extent permitted by applicable law.

I understand that the testing to be performed will include, but may not be limited to the following: Alcohol,
Amphetamines, Barbiturates, Cocaine, Opiates, Phencyclidine, Marijuana, Benzodiazepines, Methadone,
Propoxyphene, Urine Ethanol, Oxycodone, and Meperidine.

To avoid false positive results, I am advised to avoid foods with poppy seeds within 72 hours prior to testing. I
am advised to refrain from drinking more than 40 ounces of liquid within 3 hours prior to providing the blood or
urine sample for testing. I understand the recommendations listed above, and I am aware that a sample reported
as “diluted,” constitutes a positive result. A positive result will be confirmed as follows (or as otherwise required
by applicable law):
         a.          A positive finding of drugs by preliminary screening procedures will be subsequently
                     confirmed by gas chromatography-mass spectrometry or other scientific testing technique
                     which has been or may be approved by the appropriate state or other governmental office; and
         b.          A positive finding of alcohol by preliminary screening procedures will be subsequently
                     confirmed by either:
                      i. Gas chromatography with a flame ionization detector or other scientific testing technique
                          which has been or may be approved by the appropriate state or other governmental office;
                          or
                      ii. A breath-testing device operated by a breath-testing-device operator.

Furthermore, I understand that in the event a sample is reported as “diluted,” I may re-test within 48 hours, at my
own cost. If the resulting sample tests negative, I understand that Company will reimburse me for the cost of the
test.

I understand that if I desire, I may request, at my expense, that a blood sample be taken at the same time as the
urine sample for additional testing. I understand that I may request a copy of the Department of Transportation’s
drug testing procedures for reference.

I realize that the results of this testing will be shared to the extent required or permitted by applicable law, which
disclosure may include, but is not limited to, me, and such officers, agents or employees of Company who need to
know the information for reasons connected with their employment.

My signature below signifies my consent to provide blood and/or urine samples for testing to determine the
presence of drugs or alcohol in my body, as well as my consent to have the results of such results disclosed as
described above, and my release of Company, its directors, officers, employees, agents, successors and assigns,
and my agreement to hold each of them harmless from, any and all liabilities, claims, losses, costs and expenses
whatsoever (including attorney’s fees and court costs) arising out of or resulting from any such testing or
disclosure.


_________________________________                                ______________________________
Employee Name (please print)                                     Employee Signature

_________________________________                                ______________________________
Social Security Number                                           Date


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