DRUG/ALCOHOL TESTING CONSENT FORM

I, ___________________________________, hereby give my consent to authorize my employer known
as ___________________________________ and the testing laboratory designated to conduct
analytical tests deemed necessary, on an ongoing basis, to determine the absence or the presence of
☐ - Alcohol ☐ - Class A Drugs (heroin, cocaine, etc.) ☐ - Class B Drugs (cannabis, amphetamines, etc.)
in my body through the use of urine, hair, blood, breath or any sample as specified by statute and
regulation.
I give my consent to release the results of the test(s) and other medical information from the laboratory to
my employer pursuant to statute or regulation with the condition that the results may not be used in any
criminal proceeding.
My employer may request proof that I am taking a controlled substance as directed pursuant to a lawful
prescription issued in my name. If requested, I agree to provide such proof within 72 hours.
I have the right to request a re-test of the initial specimen at a licensed laboratory of my choice if and
when I have a positive test for drugs. All requests for a re-test of the sample must be made within ten
(10) working days of the receipt of the original positive test result. The results of the samples must be
forwarded to me by the appointing authority of the licensed laboratory.
I further understand that a positive test, refusal to authorize this form, refusal to take the test, or failure to
produce a specimen, may result in disciplinary action up to and including dismissal in accordance with
any local, State, or Federal statute, regulation, and policy.

Employee Signature ____________________________ Print ____________________________

Date ____________________________

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