Note: each state has different drug and alcohol testing rules. Refer to your state regulations to ensure compliance with state and local requirements

Transcription

1 Note: each state has different drug and alcohol testing rules. Refer to your state regulations to ensure compliance with state and local requirements EMPLOYEE ACKNOWLEDGMENT AND AGREEMENT I,, acknowledge receipt of the Drug and Alcohol Testing Policy of NAME (the Company ). I further acknowledge that I have read the policy and agree to the conditions and rules as stated in the policy. I further state that I am aware of the consequences if I violate the rules set forth in the policy and/or if my test results are confirmed positive, including the possibility of suspension of any and all duties, referral to a substance abuse professional for evaluation, and possible termination of employment should I refuse or fail to complete any counseling or treatment program deemed appropriate under the policy, or should I have a confirmed positive test. I acknowledge that my employment with the Company is contingent upon my consent to the terms and conditions contained within the drug and alcohol policy. I further acknowledge that the Office Manager or HR Consultant are the contacts within the Company for questions about this policy and program. Employee or Job Applicant Signed: Dated:

2 NOTICE OF DRUG AND ALCOHOL TESTING DATE: TO: The Company (the Company ) has determined that there is a basis to ask you to submit to a drug and alcohol test pursuant to the company's drug and alcohol testing program. The reason(s) for this request are: Please contact (designated tester) at a.m. / p.m. for this drug and alcohol test, which shall be conducted at the sole expense of the Company. You will be paid for the time required to participate in the test. A copy of the drug and alcohol testing policy of the Company is attached for your review. Please note: you will have the opportunity to state if you have taken any prescription or nonprescription medication or other substance prior to the drug and alcohol test. You will also be asked to sign a consent form at the time of the test. Please contact the Company if you have any questions regarding the policy or testing procedures. Thank you for your cooperation.

3 CONSENT TO DRUG AND ALCOHOL TESTING I have had the opportunity to read and ask questions about the Drug and Alcohol Testing Policy (the Policy ) of The Company (the Company ). The reasons for this drug and alcohol test have been fully explained to me by an authorized representative of the Company. The consequences of not submitting to drug and alcohol testing have been explained to me by the Company. I,, voluntarily consent to drug and alcohol testing conducted by in accordance with the Policy. Signed: Dated:

4 Date:, 2016 DRUG AND ALCOHOL TESTING NOTICE REGARDING OFFER OF EMPLOYMENT To: : The sample from the drug and alcohol test administered on, 2016 on behalf of Murphy Bros (the Company ) was tested on, 2016 and the results of the test were provided to the Company on, The test results were positive for the following substance(s): A confirmatory test was then conducted on, 2016 and the positive results of the test on the following substance(s) were CONFIRMED: PLEASE TAKE NOTICE: You have a right to request a copy of the test results; You have a right to explain the positive test results within three (3) working days of receipt of this notice. The Company may request that you indicate any over-the-counter or prescription medication or other substance that you are currently taking or have recently taken and any other information that may be relevant to the reliability of, or explanation for, the positive test result; and Within three (3) working days of receipt of this notice, you have a right to request that a confirmatory re-test be conducted, at your own expense, on the original sample used for the test, Please also note that if the test, (or if requested, the re-test) is positive and there is no satisfactory explanation for the positive result, the Company s offer of employment will be immediately withdrawn and you will have no right or claim of any kind or nature whatsoever to continued employment with the Company.

5 DRUG AND ALCOHOL TESTING NOTICE REGARDING OFFER OF EMPLOYMENT Date:, 2016 To: : The sample from the drug and alcohol test administered on, 2016 on behalf of The Company (the Company ) was tested on, 2016 and the results of the test were provided to the Company on, The test results were negative and the Company welcomes you as an employee.

6 DRUG AND ALCOHOL TESTING NOTICE TO EMPLOYEE Date:, 2016 To: : The sample from the drug and alcohol test administered on, 2016 on behalf of The Company (the Company ) was tested on, 2016 and the results of the test were provided to the Company on, The test results were positive for the following substance(s): A confirmatory test was then conducted on, 2016 and the positive results of the test on the following substance(s) were CONFIRMED: PLEASE TAKE NOTICE: You have a right to request a copy of the test results; You have a right to explain the positive test results within three (3) working days of receipt of this notice. The Company may request that you indicate any over-the-counter or prescription medication or other substance that you are currently taking or have recently taken and any other information that may be relevant to the reliability of, or explanation for, the positive test result; and Within three (3) working days of receipt of this notice, you have a right to request that a confirmatory re-test be conducted, at your own expense, on the original sample used for the test,