I, (______________________________), have received a copy, read and understand the Drug and Alcohol Testing Program policy and its supporting documents. I consent to submit to the Drug and Alcohol Testing Program as required by the Drug and Alcohol Testing Program policy, its supporting documents, regulations and the law.
I understand that if I violate the Drug and Alcohol Testing Program policy, its supporting document, regulations or the law, I may be subject to discipline up to and including termination or I may be required to successfully participate in a substance abuse evaluation and a substance abuse treatment program, if recommended by the substance abuse professional. If I am required to and fail to or refuse to successfully participate in a substance abuse evaluation or recommended substance abuse treatment program, I understand I will be subject to discipline up to and including termination. I understand that if I violate the Drug and Alcohol Testing Program policy, its supporting documents, regulations or the law, I may be subject to discipline up to and including termination.
I also understand that I must inform my supervisor of any prescription medication I use. I further understand that drug and alcohol testing records about me are confidential and may be released in accordance with this policy, its supporting documents, regulations or the law.
| Signature | __________________________________________ | Date | ________________________________ |