Sample Alcohol And Substance Abuse Policy Template (Page 2 of 5) in pdf

Sample Alcohol And Substance Abuse Policy Template Page 2

EMPLOYEE CONSENT FORM

(APPENDIX A)

I hereby acknowledge receipt of (company name), Drug-Free Workplace Policy regarding drugs and

alcohol. I have read and understand this policy. I understand that the refusal to submit to any drug

testing required by this policy or a positive test result is grounds for disciplinary action up to and

including termination. Furthermore, I authorize the release of the test results to my employer, and/or

on post-accident tests, the Company’s workers compensation insurance carrier and understand that

refusal to release these results is grounds for disciplinary action up to and including termination. I

understand that if I test positive for alcohol or drugs including, but not limited to, inactive components

or metabolites associated with the use of such drugs following an on the job accident, I may be ineligible

for workers compensation benefits or have benefits reduced by 50 percent as allowed by Missouri law.

I recognize that the Company’s policy on drugs and alcohol does not constitute an expressed or implied

contract of employment.

As a condition of continued employment, employees must sign the attached consent form and comply

with the policy.

I have read and understand this policy and will abide by it as a condition of my employment.

EMPLOYEE NAME: ________________________________________________________

SOCIAL SECURITY NUMBER: _________________________________________________

EMPLOYEE SIGNATURE: __________________________ DATE: _____________________

WITNESS SIGNATURE: ___________________________ DATE: _____________________

Sample Alcohol And Substance Abuse Policy Template Page 2