Form Dss-8218a - Work First Program Substance Use Screening Notice - North Carolina Economic And Family Services

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WORK FIRST PROGRAM SUBSTANCE USE SCREENING NOTICE

(Provide this notice to all applicants/recipients subject to this requirement)

County Name: ____________________ Product Delivery Case Number: __________________________

Adults who apply for or receive Work First cash assistance will be asked to complete a combination of two substance use screening

questionnaires as a requirement to receive cash assistance. The first screening is the Alcohol Use Disorder Identification Test, or AUDIT.

The second screening is the Drug Abuse Screening Test, or DAST-10. These questionnaires are used together to screen for potential

alcohol and substance use disorders.

If an applicant or recipient does not complete either the AUDIT or DAST-10, the applicant or recipient is ineligible for Work First cash

assistance. The applicant or recipient remains in the cash assistance case and is required to participate in work activities, if applicable.

The remaining household members may be eligible to receive Work First.

Per North Carolina State General Statute 108A-29.1, a drug test is required if there is reasonable suspicion of illegal use of controlled

substances by an applicant or recipient. This is an eligibility requirement for receiving Work First program assistance.

Reasonable suspicion is established when the individual meets at least one of the following criteria:



A criminal conviction related to illegal controlled substances within three years of the date of application.



A score on the DAST-10 that meets or exceeds the minimum acceptable score.

The individual will then be referred for substance use testing (urine toxicology).

The applicant/recipient has the right to refuse screening and testing. However, the applicant or recipient is ineligible for Work First cash

assistance. The applicant or recipient remains in the cash assistance case and is required to participate in work activities, if applicable.

The remaining household members may be eligible to receive Work First

If the applicant or recipient has a confirmed positive test result, the individual will be disqualified from Work First, but the remaining

household members may be eligible to receive Work First.

Results of the test are confidential and will not be released to law enforcement.

Each applicant/recipient who is referred for testing will receive a separate notice explaining the test process, and their rights

and responsibilities.

I acknowledge that I have received a copy of this form and that I have read, or had read to me, the information on this form.

Signature of applicant/recipient: ____________________________________

Date: _________________

Printed Name of applicant/recipient:

_______________________________

Date: __________________

County DSS Case Worker’s Signature: _______________________________

Date: __________________

DSS- 8218A (rev. 08-2015)

Economic and Family Services

The North Carolina Division of Social Services does not discriminate against any persons on the basis of race, color, national origin, religion, disability, sex or age in

the admission, treatment or participation in its programs, services and activities or in employment.