CCP 06-12-2000 - Laserfiche WebLink

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CITY OF ARDEN HILLS e NOTIFICATION FORM AND CONSENT FOR DRUG AND ALCOHOL TESTING * * * I acknowledge that I have seen aJ1d read the City of Arden Hills Policy Implementing ilie Federal Onmibus Transportation Employee Testing Act aJ1d Related Regulations. I hereby consent to undergo drug and/or alcohol testing purStiaJ1t to said policy, aJ1d I auiliorize a collection of a urine, blood aJ1d/or breath sample from me for those purposes, I understaJ1d iliat the procedure employed in this process will ensure the integrity of ilie sample aJ1d is designed to comply wiili medical-legal requirements. I understaJ1d iliat ilie results of this drug aJ1d/or alcohol testing may be discussed wiili aJ1d/or made available to my employer, ilie City of Arden Hills. I further understaJ1d iliat the results of this testing may affect my employment status, as described in ilie policy. I am currently taking, or have recenfly (wiiliin the last month) taken, ilie following over-ilie-counter or prescription medications (if none, write "none"): . Oilier information relevaJ1t to ilie reliability of, or explanation for, a positive test result (if none, write "none"): Signature Date Witness Date I hereby refuse to submit to a drug or alcohol test. I have seen a copy of ilie Policy Implementing the Federal Omnibus Transportation Employee Testing Act aJ1d Related Regulations aJ1d understaJ1d iliat a refusal to submit to testing may subject me to discipline including, but not limited to, discharge. Signature Date Witness Date DATA PRIVACY NOTICE The information collected pursuant to this Policy is to be used to determine your eligibility for employment and the performance of certain safety sensitive functions. You are not required to provide the information and submit to the tests, but your failure to do so will result in the City withdrawing a conditional job offer or that you may be discharged from employment, whichever may apply. The results of the tests performed will be private data and will not be released to other employers, governmental agencies, or persons without the written A consent of the employee tested, except as provided by regulation and law or pursuant to a court order. Only those individuals with a .. necessity to perform their functions under this Policy will have access to the test results.