DRUG AND ALCOHOL SCREEN EXAM CONSENT FORM Sample Clauses

DRUG AND ALCOHOL SCREEN EXAM CONSENT FORM. Employee Name Social Security No. Date of Birth / / M F Date / / Time am/pm Name of Supervisor/Agent Requesting Exam Name of Appointing Authority or Designee Authorizing Testing I consent to an examination and the collection of blood and urine specimens by and the release of the test results by laboratory as requested by the (Appointing Authority) to determine the presence of alcohol and/or drugs, if any.
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Related to DRUG AND ALCOHOL SCREEN EXAM CONSENT FORM

  • Drug and Alcohol Policy 67.1 The Parties agree to apply the Drug and Alcohol Management Program (as amended from time to time) contained in Appendix G. 67.2 The Employer may refer an Employee affected by drugs or alcohol to the services provided by Incolink.

  • Drug-Free Workplace Certification As required by Executive Order No. 90-5 dated April 12, 1990, issued by the Governor of Indiana, the Company hereby covenants and agrees to make a good faith effort to provide and maintain a drug-free workplace at the Project Location. The Company will give written notice to the IEDC within ten (10) days after receiving actual notice that the Company, or an employee of the Company in the State of Indiana, has been convicted of a criminal drug violation occurring in the workplace. False certification or violation of this certification may result in sanctions including, but not limited to, suspension of payments under the Agreement, termination of the Agreement and/or debarment of contracting opportunities with the State for up to three (3) years. In addition to the provisions of the above paragraph, if the total amount set forth in the Agreement is in excess of $25,000.00, the Company agrees that it will provide a drug-free workplace by: A. Publishing and providing to all of its employees a statement notifying them that the unlawful manufacture, distribution, dispensing, possession or use of a controlled substance is prohibited in the Company’s workplace, and specifying the actions that will be taken against employees for violations of such prohibition;

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