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<br /> ~ I <br /> ARDEN HILLS EMPLOYEE OR JOB APPLICANT . .' <br /> DRUG OR ALCOHOL TEST CONSENT FORM -- I <br /> I have been ordered to give a urine sample for testing to determine presence of drugs or alcohol. I <br /> I have read and understand the City's policy on drug and alcohol testing. I agree to submit to I <br /> these tests, and also agree that the testing agency is authorized by me to provide the results of the <br /> test to the City of Arden Hills. I understand that my alteration of this consent form, refusal to <br /> consent, or to cooperate fully in the taking of a urine sample, or my refusal to authorize release of I <br /> information to the City of Arden Hills constitutes insubordination which may result in <br /> disciplinary action up to and including discharge and for applicants may be grounds for rejection. <br /> I also understand that a positive result may be grounds for discipline up to and including I <br /> discharge and for applicants may be grounds for rejection. <br /> In order to insure accuracy of this screening, it is necessary to know any and all of the I <br /> prescription drugs, non-prescription drugs, over-the-counter medications, or any other chemical <br /> substance you have taken within the last month. If you are not taking any medication, drugs, or I <br /> other chemical substances, please write "NONE". <br /> MEDICATION: -, <br /> DOSAGE AND FREQUENCY: <br /> PRESCRIBED BY: <br /> ANY OTHER INFORMATION RELEVANT TO THE RELIABILITY OF OR I <br /> EXPLANATION OF A POSITIVE TEST RESULT: <br /> I <br /> EMPLOYEE NAME: <br /> SIGNED: I <br /> DATED: I <br /> SUPERVISOR NAME: I <br /> SIGNED: <br /> WITNESS: I <br /> DATED: I <br /> -. <br /> I <br />