Authorization To Disclose The Result Of Drug Testing & Request Lab
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Office of Enrollment Services
Authorization to Disclose the Result of Drug Testing & Request Lab Forms
Student ID#: A00_________ First Name: ________________Last Name:_______________________
Program/Major:________________________ If Joint Program, Affiliate Name:______________________
Clinical Site: ______________________________ Dates of expected rotation: ____________________
__________________________
SHRP Program Director / Clinical Coordinator:_______________
:________________________
Please indicate the lab you will be attending (LABCORP OR Quest)
Please call the labs for closest location. LABCORP 1-800-833-3984 Quest 1-800-877-7484
Please send the Lab form to:
My Mailing Address
My Program
I will pickup at Enrollment Services
Some University-affiliated clinical facilities require students to undergo drug testing prior
to placement at the site. Consequently, in order to complete your educational program at
UMDNJ, the performance of a drug test (or drug tests) may be required; UMDNJ engages
the services of a consumer reporting agency to conduct drug testing through a diagnostic
testing laboratory. Clinical facilities may require disclosure of a student's drug test by the
University prior to permitting the student to participate in the educational program at the
facility.
Please read and sign the following authorization statement:
I hereby authorize UMDNJ to disclose the results of drug test(s) that may be required by
a clinical facility(ies) to satisfy the requirements for placement prior to the start of,
or during, my educational program at such facilities. I release UMDNJ, its affiliated entities,
employees and agents from all liability for disclosing the information related to the drug test(s)
and for acting based on such information and/or reports.
Signature: ________________________________________ Date: ____________________________________
The results of the tests will be forwarded to Enrollment Services then a copy will be sent
directly to the student & Program Director/Clinical Coordinator.
For any questions, please contact Enrollment Services at (973) 972-5454.
Program Director/Clinical Coordinator Name (Please print):_______________________________
Program Director/Clinical Coordinator Signature:_______________________________ Date:_______________
ENROLLMENT SERVICES USE ONLY
Enrollment Services Signature______________________________________________ Date _____________________________________________
School of Health Related Professions
65 Bergen Street, Room 149 • PO Box 1709, Newark, NJ 07107 - 1709
973-972-5454 • Fax: 973-972-7463
Web Site:
The University is an affirmative action/equal opportunity employer
Revised 08/09
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Parent category: Legal