IMPORTANT NOTICE TO ALL ASSOCIATES
In compliance with the federal Drug-Free Workplace Act, all Company associates are hereby notified that the unlawful manufacture, transportation, promotion, distribution, dispensation, possession, purchase, use or sale of illegal drugs or alcoholic beverages by anyone while on Company business or premises is absolutely prohibited. This prohibition also covers illegal or prescription drugs which impair an associates’ ability to perform his/her job safely or properly. Any associate who violates this policy will be subject to disciplinary action, up to and including discharge, and will be reported to law enforcement agencies for possible criminal law action.
As a condition of employment an associate must:
- abide by the terms of this policy; and
- notify the Company of any conviction for a violation of a criminal drug statute occurring in the workplace no later than five (5) days after such conviction. Upon receiving such notice the Company will notify the appropriate federal authority.
The Company has established an Alcohol and Drug-Free Workplace Awareness Program to inform associates of:
- the dangers of drug and alcohol abuse in the workplace;
- the Company’s policy of maintaining a drug and alcohol-free workplace;
- any available drug and alcohol counseling, rehabilitation and associate assistance programs; and
- the penalties that may be imposed for drug or alcohol abuse violation.
Any associate convicted of violating a criminal drug statute in the workplace will be subject to disciplinary action or satisfactory participation in a drug abuse assistance program, as determined by the Company.
Please contact the Human Resources Department if you have any questions about our policy or this very important program. The Company wants to help anyone who needs assistance in this area.
ALL ASSOCIATES ARE ASKED TO ACKNOWLEDGE THAT THEY HAVE READ THE ABOVE POLICY AND AGREE TO ABIDE BY IT.
I have read, understand, and agree to comply with the Company’s Drug and Alcohol Policy.
(OVER) APPLICANT CONSENT FORM
I, _____________________________ voluntarily, do hereby give my consent to the company or a selected Laboratory to collect a urine or blood sample from me. If the Company collects the sample, I further give my consent to the Company to forward the sample to the Laboratory for its performance of appropriate tests thereon to identify the presence of drugs. I furthermore give the Laboratory my permission to release the results of such tests to the Company. I understand that any positive result or refusal to submit to testing may preclude my employment.
I realize my signature is necessary for me to be considered for employment with the Company. I understand that the test results and other medical information will be released only to authorized Company personnel for appropriate consideration.
I am currently taking prescription medicine or have taken prescription medicine with the last seven days. YES __________ NO __________
If yes, please identify the name(s) of the drug(s) and the length of time the drug(s) has been taken.
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List below any non-prescription medication, such as aspirin, antacids, or other over-the-counter medicines taken in the last seven days.
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Name (Please Print – First, Middle, Last) Date
Signature Employee Number (if known)