THE YMCA OF THE TRIANGLE AREA SUBSTANCE ABUSE PREVENTION POLICY
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1 THE YMCA OF THE TRIANGLE AREA SUBSTANCE ABUSE PREVENTION POLICY The Young Men s Christian Association of the Triangle Area (the YMCA ) intends to maintain a substance abuse free workplace. Alcohol and illegal drugs may not be brought onto YMCA premises or used by an employee during work hours. As used in this policy, the term illegal drugs means substances listed as controlled substances in Schedules I through V of Section 202 of the Controlled Substances Act (21 U.S.C. 812) which have not been legally prescribed to the employee by a properly licensed physician. As used in this policy, the term drug test and controlled substance test(s) mean a urinalysis screen for the presence of marijuana, cocaine, opiates, amphetamines, and phencyclidine (PCP), or a metabolite of those substances. Alcohol test means a breath test for the intoxicating agent in beverage alcohol, ethyl alcohol, or other low molecular weight alcohol. This policy is to be construed in accordance with the Americans with Disabilities Act and the North Carolina Handicapped Persons Protection Act. This policy is a not a contract of employment, and should not be interpreted as creating any contractual rights. Nothing herein should be construed as altering employees employment at will status. The YMCA reserves the right to revise or alter this policy at its sole discretion at any time and to interpret the policy as it deems in the best interest of the YMCA. I. WORK RULES A. It is a violation of YMCA policy to possess, consume, or be under the influence of alcohol or illegal drugs in a company vehicle, on company premises or during working hours, or to report to work under the influence of alcohol or illegal drugs. No driver may be on duty or operate a vehicle while the driver is in possession of alcohol. No driver may use alcohol in the four hours before performing any safety sensitive functions. B. Any employee who is convicted of a crime related to illegal drugs must report such conviction to their Branch Director and the Human Resources Vice President or Human Resources Manager within 5 days. Any employee whose job involves driving a vehicle or operating heavy machinery must report a conviction of driving while impaired or driving under the influence to their Branch Director and the Human Resources Vice President or Human Resources Manager within 5 days. C. Employees will and applicants may be required as a condition of employment to submit a breath and urinalysis screen for determining use of alcohol and/or illegal drugs, as described in this policy. D. Each employee, as a condition of employment, will be required to sign the Acknowledgement of Policy that is reprinted as the last page of this policy. E. Each employee, as a condition of employment, is required to comply with all the terms and conditions of this Substance Abuse Prevention Policy. F. Prescription Drug Policy Any employee who is taking prescription medication must inquire of their physician whether such medication could affect their ability to safely perform their job. If so, the employee must notify their Branch Director and Human Resources Vice President or Human Resources Manager that they will be taking a prescription medication, describe the Rev. 08/2003
2 potential impairment, and the duration of the impairment. Employees are prohibited from working when they are unable to safely perform their job functions. Employees need not reveal the nature of the condition requiring medication or the kind of medication prescribed unless such information is specifically job related. II. SUBSTANCE ABUSE PREVENTION TESTING No employee will be subjected to alcohol or drug testing without their consent. However, since testing is a condition of continued employment, refusal to submit to or to report for such testing or improperly tampering with such testing will subject the employee to termination. A. Driver Testing. All applicants and employees required to maintain commercial drivers licenses in order to fulfill their job responsibilities are subject to all kinds of testing described in this policy. All such employees are hereafter refereed to as DOT drivers. In addition, employees and applicants who operate YMCA vans, motor vehicles or heavy equipment, either as a regular or intermittent part of their work, are required to submit to all kinds of testing described in this policy. All such employees are hereafter referred to as vehicle operators. The term drivers includes DOT and vehicle operators. B. Coast Guard Testing. Applicants and employees required to be tested under Coast Guard regulations are subject to testing as provided in those regulations. C. General Employee Testing. All other employees are subject to random, reasonable suspicion, and post-accident testing under this policy. The YMCA reserves the right to expand its testing policy at a later date. III. KINDS OF TESTS A. Pre-Employment Test A pre-employment test is a drug test triggered by an offer of employment. All offers of employment to drivers are conditional upon negative drug test(s). A positive result from a drug test will cause the contingent job offer to be withdrawn. B. Reasonable Suspicion Test This test will occur when there is reasonable cause to believe that an employee is under the influence of alcohol or illegal drugs at work or on company property, based upon the impaired appearance of the employee, behavior, speech or body movements indicative of alcohol use or illegal drug use, or suspicious appearances at a work site or in part of a work site. Employees may also be tested if there are reliable indicators of drug or alcohol use in violation of this policy, including the report of an individual known to the YMCA who reports admission of, or observation of drug or alcohol use in violation of this policy by an employee. Employees who are asked to take a reasonable suspicion test will not be allowed to continue working. The individual to be tested is to be sent to a professional testing facility as soon as possible. In the event such an employee refuses to be tested, he/she will be immediately removed from YMCA premises and sent home. Reasonable effort will be made to secure safe passage home via relative, cab, escort, etc. Rev. 08/2003 2
3 DOT regulations allow reasonable suspicion testing just before, during, or just after the DOT driver is performing safety-sensitive functions. In addition, observation supporting an alcohol reasonable suspicion test must be based on conduct or appearances occurring just before, during, or just after the DOT driver is performing safety sensitive functions. Safety-sensitive functions include any of the following: (1) All time at a YMCA facility or other property, or on any public property, waiting to be dispatched, unless the driver has been relieved from duty by the YMCA; (2) All time inspecting equipment or otherwise inspecting, servicing, or conditioning any commercial motor vehicle at any time; (3) All driving time ; (4) All time, other than driving time, in or upon any commercial motor vehicle except time spent resting in a sleeper berth; (5) All time loading or unloading a vehicle, supervising or assisting in the loading or unloading, attending a vehicle being loaded or unloaded, remaining in readiness to operate the vehicle, or in giving or receiving receipts for shipments loaded or unloaded; (6) All time spent performing the driver requirements of sections and relating to accidents; and (7) All time repairing, obtaining assistance, or remaining in attendance upon a disabled vehicle. However, under the authority of this policy, any employee, including DOT drivers, may be asked to take a reasonable suspicion test at any time during their working hours when there is reasonable cause to believe that the individual is under the influence of alcohol or illegal drugs. Supervisors will receive training on factors which can indicate substance abuse. These include, among others, the following: (1) Observable phenomena, such as direct observation of alcohol or drug use or possession and/or the physical symptoms of being under the influence of alcohol or illegal drugs; (2) A pattern of abnormal conduct or erratic behavior, which suggests alcohol/drug abuse or use of alcohol or illegal drugs on the job; (3) Arrest or conviction for a drug-related offense, or the identification of an employee as the focus of a criminal investigation into illegal drug possession, use or trafficking (the term trafficking shall also mean distribution ); (4) Newly discovered evidence that the employee tampered with a previous drug or alcohol test. Reasonable suspicion drug testing will most often be based on specific contemporaneous, articulable observations concerning the appearance, behavior, speech, or body odors of the driver, and may include indications of the chronic and withdrawal effects of drug abuse. Observations supporting a reasonable suspicion test should be made by at least one supervisor or company official trained to detect substance abuse, and must be documented within 24 hours or before release of the results, whichever is sooner. If factors other than direct observation of Rev. 08/2003 3
4 behavior indicative of being under the influence are the trigger for the test (e.g., arrest, evidence of prior test tampering, information from a reliable source indicating substance abuse, etc.), those factors should also be documented within 24 hours of the test. Supervisors must request permission to conduct a reasonable suspicion test from the Human Resources Vice President, and may not require such a test without such approval. If an alcohol test for DOT purposes is not administered within two hours following the determination to request such test, the employer shall prepare and maintain on file a record stating why the alcohol test was not administered within two hours. If the test is not administered within eight hours, the testing effort shall stop and a record shall be prepared stating why the test was not conducted. C. Post-Accident Testing (1) Drivers. When a driver is involved in an accident while driving a vehicle or operating heavy equipment in the course and scope of his/her employment which (1) requires medical attention away from the site of the accident, (2) results in a fatality, or (3) involves property damage of at least $1, or requires a vehicle to be towed from the site AND the driver receives a citation for a moving traffic violation, the driver must take an alcohol and controlled substance test. Additionally, in any accident, which results in fatality, the driver must take an alcohol and drug test. (2) Employees. When any employee is involved in a work-related accident which (1) requires medical attention away from the site of the accident, (2) results in a fatality, or (3) involves property damage of at least $1,000.00, the employee must take an alcohol and drug test. It is the employee s responsibility to notify the Branch Director and the Vice President of Risk Management that an accident has occurred so that a test can be arranged. Such notice should be given as soon as feasible, so the test can be conducted within as short a time as possible. If the employee cannot provide consent due to incapacity following the accident, he/she is required to provide consent for review of medical records which may indicated the absence or presence of alcohol or illegal drugs in their system at the time of the accident. If an alcohol test for DOT purposes is not administered within two hours following the determination to request such test, the employer shall prepare and maintain on file a record stating why the alcohol test was not administered within two hours. If the test is not administered within eight hours, the testing effort shall stop and a record shall be prepared stating the reasons why the test was not conducted. If a controlled substance test under this section is not administered within 32 hours after the accident, the YMCA shall cease efforts to administer the test, and prepare a written record stating why such test was not administered. D. Random. Those selected will be notified and must proceed to the lab immediately after notification to provide samples for the testing. (1) Drivers. At various times, the YMCA will select vehicle operators, DOT drivers, and other employees for random alcohol and drug testing by a neutral method. Annually, 50% of the Rev. 08/2003 4
5 DOT drivers and vehicle operators will be tested for drug use and 25% for alcohol use. DOT regulations allow random testing only just before, during, and just after the performance of safety-sensitive functions. However, under the authority of this policy, all drivers can be randomly tested at any time during their working hours. (2) Shop, Grounds, Maintenance. Employees whose jobs involve working in the shop, maintaining equipment, building or grounds, and those who operate industrial and/or heavy machinery will be subject to random testing for drugs at a 25% annual rate. This means that the YMCA will test that number of employees equal to one-fourth of the average annual number of employees holding jobs in this category. (3) Other employees. All full-time employees not described in paragraphs (1) and (2) above will be subject to random drug testing at a 10% annual rate. This means that the YMCA will test that number of employees equal to one-tenth of the average annual number of employees exclusive of employees in paragraphs (1) and (2) above. E. New Employee Testing. All new full-time employees will be subject to drug testing on the first random testing following their employment. F. Return to Duty Testing. Any driver who uses alcohol in violation of this policy or fails an alcohol test must take an alcohol test and obtain a result less than.02 prior to performing any safety-sensitive functions. A driver who uses drugs in violation of this policy must take a drug test and obtain a negative result before performing any safety-sensitive functions. G. Follow-Up Testing. In the event that an employee who has failed a drug or alcohol test and has been sent for referral to a substance abuse counselor returns to work, that employee must agree to follow-up alcohol and/or drug tests during the first 12 months following return to work. The tests will be administered in accordance with the recommendation of a substance abuse professional. DOT regulations allow follow-up testing just before, during, or just after performance of safety-sensitive functions. However, under the authority of this policy (see Second Chance Program), follow-up testing may be done at any time during working hours. IV. MEDICAL REVIEW OFFICER The YMCA has retained the services of a physician to serve as the Medical Review Officer (MRO). The MRO will receive the results of all positive controlled substance tests and will contact any applicant or employee (including drivers) whose test is positive to discuss the test result and determine its validity. Any employee who receives a message to call the MRO must do so before operating any motor vehicle, heavy equipment or machinery which could cause injury, and in any event, within two business days. Failure to promptly respond to a message to call the MRO is grounds for immediate suspension and/or termination. V. PRIOR EMPLOYMENT TEST REVIEW Each applicant for a driver position must provide specific written authorization to the YMCA to obtain information from prior employers about that driver s alcohol tests with a result greater than 0.04, positive controlled substance tests, and refusals to test for the two years preceding employment Rev. 08/2003 5
6 with the YMCA. Failure to provide such authorization will result in disqualification from employment. This information must be received no later than 14 days after the driver begins performing safety-sensitive functions. VI. DISCIPLINARY POLICY A. Violation of this policy, including but not limited to (1) possessing alcohol or illegal drugs in a YMCA vehicle or at the work site, (2) reporting to or being at work under the influence of drugs or alcohol or (3) using/consuming alcohol or illegal drugs during work hours, will be grounds for termination of employment. B. Any applicant or employee who refuses to take or tampers with an alcohol or controlled substance test will be immediately suspended and subject to termination. C. Any employee who is asked to have a reasonable suspicion test will be placed on leave until results are known. If the test is negative, the employee will be recalled to work. D. Positive results of a drug test will result in an automatic presumption that the applicant or employee has reported to work significantly impaired by illegal drugs in violation of this policy and employment may be terminated. Employees tested under the New Employee Testing (described in Paragraph E of Section III) who have positive results (e.g., fail the test) will be terminated. All applicants and employees have the right to obtain a second controlled substance test, at their own expense, on the retained portion of the sample which produces a positive result. DOT drivers must make this request to the MRO within 72 hours of being notified of a positive result. All other employees must make such request in writing directly to the lab, which conducted the test, and shall also notify the YMCA in writing within 72 hours of receiving notice that the YMCA test is positive. The applicant or employee will be place on leave of absence until the results of the second test are received. The YMCA reserves full discretion to (1) terminate any applicant or employee based upon the results of the first test, (2) to determine whether a negative result on the employee-procured test cancels the positive result of the company s test, and (3) to decide the extent of appropriate discipline in any second-test situation. If the split sample test is negative, or if the sample is insufficient or otherwise unusable/unavailable for the second test, the entire testing process is cancelled for DOT purposes. However, the company may nonetheless terminate employment based on the initial positive result. E. Positive results of an alcohol test will result in an automatic presumption that the applicant or employee has reported to work significantly impaired by alcohol in violation of this policy and employment may be terminated. An alcohol test will be considered positive when the result shows 0.04 or more grams of alcohol per 210 liters of breath. Although not considered a positive test, an alcohol test result of Rev. 08/2003 6
7 greater than 0.02 but less than 0.04 grams of alcohol per 210 liters of breath will result in the driver or employee being placed on administrative suspension for 24 hours. F. Any employee who intentionally fails to report an accident, which would have subjected him/her to testing under this policy, is subject to termination. G. Any employee who has a positive drug or alcohol result shall be provided with names, addresses, and phone numbers of substance abuse professionals, counseling, and treatment centers. VII. SECOND CHANCE PROGRAM An employee who has been employed for 95 days in a full-time position prior to taking a drug or alcohol test may avoid termination of employment following a positive test result when all of the following conditions are met: A. The YMCA determines that the employee should be offered a Second Chance. This decision will be entirely within the YMCA s discretion, based upon the circumstances surrounding the failed test and other relevant factors, including, but not limited to, employment history and performance. B. The employee must go to a health care professional who is experienced in treating substance abuse ( substance abuse professional ) for an evaluation, and must follow all recommendations of that substance abuse professional, including, without limitation, rehabilitation, counseling, or participating in therapy. The YMCA will pay for the cost of the employee s initial visit with the substance abuse professional, but all subsequent charges and expenses are the employee s responsibility, if not covered by the employee s insurance. A leave of absence in accordance with YMCA policies may be granted for reasonable periods when an employee is unable to work due to treatment for substance abuse (alcohol or drugs) C. The employee must consent to the substance abuse professional advising the YMCA concerning the employee s compliance with the recommendations made by that substance abuse professional, on a weekly basis. D. The substance abuse professional must certify to the YMCA that the employee can return to work within a reasonable period of time. The YMCA will make reasonable efforts to return the employee to his/her job prior to the drug test, but cannot make any guarantees, and reserves full discretion to assign the employee to a different job, at the commensurate, regular pay for that job. If the employee s job involved operation of a motor vehicle or heavy machinery, the YMCA may decline to return the employee to that position until it has adequate assurance that the likelihood of drug or alcohol abuse on the job is negligible. An employee who is absent under the Family and Medical Leave Act ( FMLA ) leave policy will be returned to work in the same or a similar position. E. The employee must agree to follow-up drug and alcohol testing on randomly selected dates at least six times in the year following his/her return to work. These follow-up tests are in addition to any other test authorized under this policy. A positive result on any drug Rev. 08/2003 7
8 or alcohol test following return to work will result in termination. The Second Chance program may only be used once by an employee. VIII. TRAINING All drivers and their supervisors are required to attend annual training designed to assist drivers and their supervisors in understanding the dangers of alcohol and drug use. Supervisors and company officials designated to determine whether reasonable suspicion exists will receive one hour of training on controlled substance misuse and one hour of training on alcohol misuse, which shall include the physical, behavioral, speech, and performance indicators of substance abuse. The driver program includes training on the following topics: (1) The identity of the person designated by the company to answer driver questions about the testing program and training materials; (2) Description of the procedures that will be used to test for the presence of alcohol and controlled substances, protect the driver and the integrity of the testing processes, safeguard the validity of the test results, and ensure that those results are attributed to the correct driver; (3) A copy of this policy; and (4) Information concerning the efforts of alcohol and controlled substances use on an individual s health, work, and personal life; signs and symptoms of an alcohol or a controlled substances problem (the driver s or a coworker s); and available methods of intervening when an alcohol on controlled substances problem is suspected, including confrontation, referral to any employee assistance program and/or referral to management. All drivers will be required to acknowledge receipt of training in writing. IX. RECORDS A. The following records will be maintained: 1. Records relating to the collection process: a) Collection logbooks, if used; b) Documents relating to the random selection process; c) Calibration documentation for evidential breath testing devices; d) Documentation of breath alcohol technical training; e) Documents generated in connection with decisions to administer reasonable suspicion alcohol or controlled substances tests; f) Documents gathered in connection with decisions on post-accident tests; Rev. 08/2003 8
9 g) Documents verifying existence of a medical explanation of the inability of an applicant, employee, or driver to provide adequate breath or to provide a urine specimen for testing; h) Consolidating annual calendar year summaries as required by Section ; These documents should be maintained for two years. 2. Records relating to the applicant s/employee s/driver s test results: a) The employer s copy of the alcohol test form, including the results of the test; b) The employer s copy of the controlled substances test chain of custody and control form; c) Documents sent by the Medical Review Officer to the employee, including those required by Section (a); d) Documents relating to the refusal of any applicant/employee/driver to submit to an alcohol or controlled substances test required by this part; and e) Documents presented by any applicant/employee/driver to dispute the result of an alcohol or controlled substances test administered under this part. 3. Records relating to other violations of 49 CFR Part Records relating to the evaluation: a) Records pertaining to a determination by a substance abuse professional concerning a driver s need for assistance; b) Records concerning a driver s compliance with recommendations of the substance abuse professional 5. Records relating to education and training: a) Documentation of training provided to supervisors for the purpose of qualifying the supervisors to make a determination concerning the need for alcohol and/or controlled substances testing based on reasonable suspicion; and b) Certification that any training conducted under this part complies with the requirements for such training. 6. Records relating to drug testing: a) Agreements with collection site facilities, laboratories, Medical Review Officers, and consortia; Rev. 08/2003 9
10 b) Names and positions of officials and their role in the employer s alcohol and controlled substances testing program(s); c) Monthly laboratory statistical summaries of urinalysis required by Section 40.29(g)(6); and d) The employer s drug testing policy and procedures. These documents identified in paragraphs 2-6 shall be retained for a period of five (5) years. 7. In addition, an annual summary of DOT testing shall be created, which includes the following: a) Number of drivers subject to part 382; b) Number of drivers subject to testing under the alcohol misuse or controlled substances use rules of more than one DOT agency, identified by each agency; c) Number of urine specimens collected by type of test (e.g., pre-employment, random, reasonable suspicion, post-accident) d) Number of positives verified by a MRO by type of test, and type of controlled substance; e) Number of negative controlled substance tests verified by a MRO by type of test; f) Number of persons denied a position as a driver following a pre-employment verified positive controlled substances test and/or a pre-employment alcohol test that indicates an alcohol concentration of 0.04 or greater; g) Number of drivers with tests verified positive by a MRO for multiple controlled substances; h) Number of drivers who refused to submit to an alcohol or controlled substances test required under this subpart; i) Number of supervisors who have received required alcohol training and controlled substances training during the reporting period; j) Number of screening alcohol tests and number of confirmation alcohol tests, by type of test; k) Number of confirmation alcohol tests indicating an alcohol concentration of 0.02 or greater but less than 0.04, by type of test; l) Number of confirmation alcohol tests indicating an alcohol concentration of 0.04 or greater, by type of test; Rev. 08/
11 m) Number of drivers who were returned to duty (having complied with the recommendations of a substance abuse professional as described in Sections and ), in this reporting period, who previously (i) had a verified positive controlled substance test result, or (ii) engaged in prohibited alcohol misuse under the provisions of this part; n) Number of drivers who were administered alcohol and drug tests at the same time, with both a verified positive drug test result and an alcohol test result indicating an alcohol concentration of 0.04 or greater; and o) Number of drivers who were found to have violated any non-testing prohibitions of subpart B of this part (i.e., Section (b)), and any action taken in response to the violation B. INFORMATION ON DRUG AND/OR ALCOHOL TESTING MAY BE RELEASED TO THE DEPARTMENT OF TRANSPORTATION, THE YMCA s WORKERS COMPENSATOIN INSURANCE CARRIER, THE INDUSTRIAL COMMISSION, AND THE EMPLOYMENT SECURITY COMMISSION OR IN THE DEFENSE OF ANY LAWSUIT BY THE EMPLOYEE. REQUESTS TO RELEASE THIS INFORMATION TO OTHER INDIVIDUALS OR ENTITIES MUST BE SUPPPORTED BY THE EMPLOYEE S WRITTEN AUTHORIZATION. C. A driver is entitled to obtain copies of all records maintained by the YMCA relating to that employee s use of alcohol or drugs, including test results, upon written request to their Branch Director and the Human Resources Vice President or Human Resources Manager. D. The YMCA shall release a driver s records of drug and/or alcohol testing to individuals specified by the driver in a written authorization directing the release of such information. Rev. 08/
12 Employee Acknowledgement of The YMCA of the Triangle Area Substance Abuse Prevention Policy I have been provided a written copy of The YMCA of the Triangle Area s Substance Abuse Prevention Policy. I have read and fully understand the policy and consent to all the provisions of that policy, including, if applicable, alcohol and/or controlled substance test(s). I fully understand and agree that a violation of this policy will result in my termination from employment. I also understand and agree that the YMCA may revise the policy from time to time, and that my continued employment after the effective date of any revisions constitutes my consent to the policy as amended. I further acknowledge that the YMCA has provided me with the opportunity to ask further questions related to its alcohol and controlled substance testing program and that all my questions have been answered. Print Employee Legal Name Branch Employee Signature Parent/Guardian Signature (if under 18 years of age) EMPLOYEE COPY 1 of 2 Rev. 08/
13 PRE-TEST CONSENT FORM I FULLY UNDERSTAND THE CONSEQUENCES OF, AND AGREE TO SUBMIT TO ALCOHOL AND/OR DRUG TEST(S) UNDER THE SUBSTANCE ABUSE PREVENTION POLICY OF THE YMCA OF THE TRIANGLE AREA ( THE YMCA ). I GIVE THIS CONSENT OF MY OWN FREE WILL. I UNDERSTAND THAT THIS TEST IS GIVEN PURSUANT TO DEPARTMENT OF TRANSPORATION REGULATIONS AS WELL AS THE YMCA SUBSTANCE ABUSE PREVENTION POLICY. I hereby authorize the YMCA designated physician, lab technician, or company representative to obtain urine, breath, or blood sample(s) from me, and to release those samples to a laboratory for analysis. I also authorize that laboratory to release to the YMCA designated physician and the YMCA representative any test results, reports, or information that may be requested regarding those samples. I further authorize the YMCA designated physician to release the test results to the YMCA and authorize the YMCA to provide them to its Workers Compensation insurance carrier, to the Industrial Commission, to the Employment Security Commission, and to use the results in defense of any lawsuit against the YMCA. I release the YMCA, its officers, agents, employees, and contractors from any and all claims or causes of action based on or arising from 1) the YMCA s request that I take a drug and/or alcohol test(s), 2) the dissemination of results to the individual s and entities described above, and 3) any employment decision based on those results. Print Employee Legal Name Branch Employee Signature Parent/Guardian Signature (if under 18 years of age) Please provide to the laboratory or MRO the names of any medication you are taking or have taken in the past thirty (30) days. EMPLOYEE COPY 2 of 2 Rev. 08/
14 Employee Acknowledgement of The YMCA of the Triangle Area Substance Abuse Prevention Policy I have been provided a written copy of The YMCA of the Triangle Area s Substance Abuse Prevention Policy. I have read and fully understand the policy and consent to all the provisions of that policy, including, if applicable, alcohol and/or controlled substance test(s). I fully understand and agree that a violation of this policy will result in my termination from employment. I also understand and agree that the YMCA may revise the policy from time to time, and that my continued employment after the effective date of any revisions constitutes my consent to the policy as amended. I further acknowledge that the YMCA has provided me with the opportunity to ask further questions related to its alcohol and controlled substance testing program and that all my questions have been answered. Print Employee Legal Name Branch Employee Signature Parent/Guardian Signature (if under 18 years of age) OFFICE COPY 1 of 2 Rev. 08/
15 PRE-TEST CONSENT FORM I FULLY UNDERSTAND THE CONSEQUENCES OF, AND AGREE TO SUBMIT TO ALCOHOL AND/OR DRUG TEST(S) UNDER THE SUBSTANCE ABUSE PREVENTION POLICY OF THE YMCA OF THE TRIANGLE AREA ( THE YMCA ). I GIVE THIS CONSENT OF MY OWN FREE WILL. I UNDERSTAND THAT THIS TEST IS GIVEN PURSUANT TO DEPARTMENT OF TRANSPORATION REGULATIONS AS WELL AS THE YMCA SUBSTANCE ABUSE PREVENTION POLICY. I hereby authorize the YMCA designated physician, lab technician, or company representative to obtain urine, breath, or blood sample(s) from me, and to release those samples to a laboratory for analysis. I also authorize that laboratory to release to the YMCA designated physician and the YMCA representative any test results, reports, or information that may be requested regarding those samples. I further authorize the YMCA designated physician to release the test results to the YMCA and authorize the YMCA to provide them to its Workers Compensation insurance carrier, to the Industrial Commission, to the Employment Security Commission, and to use the results in defense of any lawsuit against the YMCA. I release the YMCA, its officers, agents, employees, and contractors from any and all claims or causes of action based on or arising from 1) the YMCA s request that I take a drug and/or alcohol test(s), 2) the dissemination of results to the individual s and entities described above, and 3) any employment decision based on those results. Print Employee Legal Name Branch Employee Signature Parent/Guardian Signature (if under 18 years of age) Please provide to the laboratory or MRO the names of any medication you are taking or have taken in the past thirty (30) days. OFFICE COPY 2 of 2 Rev. 08/
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