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<br />CITY OF ARDEN HILLS <br /> <br />. <br /> <br />EMPLOYEE OR JOB APPLICANT <br />DRUG OR ALCOHOL TEST CONSENT FORM <br />TRANSPORTATION EMPLOYEE DRUG AND ALCOHOL MODEL POLICY <br />UNDER THE OMNIBUS TRANSPORTATION EMPLOYEE TESTING ACT <br /> <br />I have been ordered to give a urine sample for testing to determine presence of drugs or alcohol. <br /> <br />I have read aJ1d understood the City's policy on drug ood alcohol testing. I agree to submit to <br />these tests, aJ1d also agree f11at f11e testing agency is auf110rized by me to provide f11e results of f11e <br />test to the City of Arden Hills. I understood f11at my alteration of f11is consent form, refusal to <br />consent, or to cooperate fully in the taking of a urine smnple, or my refusal to auf110rize release of <br />information to the City of Arden Hills, constitutes insubordination that may result in disciplinary <br />action up to ood including discharge aJ1d for applicoots may be grounds for rejection. <br /> <br />I also understand that a positive result may be grounds for discipline up to ood including <br />discharge aJ1d for applicoots may be grounds for rejection. <br /> <br />In order to insure accuracy of this screening, it is necessary to know aJ1Y ood all of the <br />prescription drugs, non-prescription drugs, over-f11e-counter medications, or ooy of11er chemical <br />substance you have taken within f11e last month. If you are not taking ooy medication, drugs, or <br />other chemical substances, please write "NONE". . <br /> <br />MEDICATION: <br /> <br />DOSAGE AND FREQUENCY: <br /> <br />PRESCRIBED BY: <br /> <br />ANY OTHER INFORMATION RELEVANT TO THE RELIABILITY OF OR <br />EXPLANATION OF A POSITIVE TEST RESULT: <br /> <br />EMPLOYEE NAME: <br /> <br />SIGNED: <br /> <br />DATED: <br /> <br />SUPERVISOR NAME: <br /> <br />SIGNED: <br /> <br />DATED: <br /> <br />WITNESS: <br /> <br />DATED: <br /> <br />. <br /> <br />14 <br />