EMPLOYMENT BACKGROUND CHECKS
Drug Free Workplace Forms And Sample Letters Information
Drug Free Workplace Forms
Please also note that many drug screening, driving record and state release authorization forms are available in a
PDF file to our Automated Employment Screening Clients.
All of these FCRA compliant release documents may be e-mailed to the applicants and easily completed online.
Our Automated Employment Screening provides an
applicant controlled process that allows FCRA compliant background check
forms, and releases including drug screening Electronic Chain Of custody forms to be completed online by the applicant.
We provide several short videos to easily acquaint you with the system.
This makes the background check process fast and easy.
Call Us now at 800-459-3034 and begin ordering instant driving records and background checks within minutes or:
Employers May Also Be Interested in Our Web Page On:
“How Employees And Job Applicants Beat Drug Tests”
Learn about the legal requirements that can affect drug-free workplace policies and workplace drug testing.
Updated 06/2020
Please note it may be important to have your company drug screening policy in your employee’s handbooks.
You should also address the time limit for taking the drug test at the time you provide the chain of custody forms to the applicant.
A written letter attached to the form saying that the applicant has 24 or 48 hours (Or whatever you choose) to complete the test.
Instructions:
1. To receive work comp insurance drug free workplace credit, send DFWP Credit Application with policy and forms to your Workers’ Compensation Insurance Company.
2. Distribute the “Letter to all Employees” on the company letterhead to all employees.
3. Give a copy of the Drug Free Policy to all employees as well as those offered a position with the company, along with these forms:
a. Consent, Release and Acknowledgement of Understanding
b. Worker’s Compensation Policy Acknowledgement
c. Authorization of Medical Information
4. Make sure all forms are signed and are witnessed where necessary.
5. Keep signed forms in an employee personnel file.
APPLICATION FOR DRUG FREE WORKPLACE PREMIUM CREDIT PROGRAM
Name of Employer: ___________ ___________ ____________
Date Program Implemented: ____________ ___________
Testing: Procedures for drug testing established and/or drug testing conducted in the following areas:
___ Job applications ___ Routine fitness for duty ___ Reasonable suspicion ___Follow-up to Employee Assistance
Notice of Employer’s Drug Testing Policy:
___ Copy to all employees prior to testing ___ Show notice of drug testing on vacancy __Posted on employer’s premises announcements __ Copy to job applicants prior to testing ___Copies available in human resources office or __ General notice given 60 days prior to other suitable locations testing ___ No notice required because the employer had a drug testing program in place prior to this rule’s effective date.
Drug Free Workplace Education And Training
: __ Resource file on providers __ Employee Assistance Programs __ Annual education course
A. Name of Medical Review Officer: XXXXXXXXX, M.D., MRO
B. Name of approved Department of Health and Rehabilitative Service Lab or NIDA lab Quest Diagnostics
C. Phone Number 000-000-0000
D. Address __________ ____________ ____________ __________ _____________
Employer Name Date
Officer/Owner Signature* _________ ___________ ________ Title
* Application must be signed by an officer or owner.
THE ABOVE SIGNED CERTIFIES THAT THIS INFORMATION IS A TRUE AND FACTUAL DEPICTION OF THEIR CURRENT PROGRAM. ____________ ________ _________
____________ ____________ ____________
Notary Public’s Signature
Date Exp. of Commission Form 09-1
(COMPANY)
LETTER TO ALL EMPLOYEES
Date: ____________
Dear Employees:
The use of drugs is a national problem that seriously affects every American. Drug abuse not only affects individual users and their families,
but it also presents new dangers for the workplace. Business and labor must take a leadership role in the nationwide effort to reduce the use of illegal drugs and alcohol.
As you are aware, this company has always been committed to providing a safe work environment and fostering the well-being and health of our employees.
Illegal drug use jeopardizes this commitment and undermines the capability of the company to produce quality products and services.
To address this problem, we have developed a policy regarding the illegal use of drugs and the abuse of alcohol that we believe best serves the interest of all employees.
Our policy formally and clearly states that the illegal use of drugs will not be tolerated. This policy was designed with two basic objectives in mind:
1) Employees deserve a work environment that is free from the effects of drugs, including alcohol, and the problems associated with their use,
2) This company has a responsibility to maintain a healthy and safe workplace. I believe it is important that we all work together to make a drug free workplace and a safe, rewarding place to work.
Drug testing will begin for current employees 60 days from this date. __________
Sincerely,
(COMPANY) DRUG TESTING CONSENT, RELEASE AND ACKNOWLEDGEMENT OF UNDERSTANDING
I hereby consent to submit to urinalysis and/or other tests as shall be determined thereof by the company as a condition of employment and for the purpose of determining specific drug content.
I agree that a D.H.H.S. and (state where required) certified lab may collect these specimens for these tests and may use them or forward them to a testing laboratory designated by the Company for analysis.
I further agree to have these results reviewed by a Medical Review Officer.
I hereby release to the company, the results of the test(s) to which I have consented. I further authorize the company to discuss the results with medical/personnel collecting the Specimen, the testing facility, it’s directors, officers, agents, and employees responsible for administering the aforementioned test(s)
or evaluating the results thereof and any of them herein and to use the test results in conjunction with employment actions, professional licensing procedures, and as a defense to any legal action to which I am party.
I release any testing facility or any physicians who have tested me from any liability arising from a release of any and all results, written reports, medical records, and data concerning my test(s) to the appropriate company officials or government agencies.
I agree that a reproduced copy of this form shall have the same effect as the original.
I understand the company’s Drug Abuse and Drug Testing Policy and consent to the terms set forth in the policy.
I further acknowledge that the policy has been posted in an appropriate place on the company’s premises and copies are available for inspection during regular business hours.
I acknowledge that I have read this policy and fully understand that the company can establish other work rules related to possession, use, sale or solicitation of drugs, including policies concerning arrests or convictions for drug or alcohol-related offenses, and can suspend, or terminate, or deny employment for such conduct.
I have carefully read the foregoing and fully understand its contents. I agree that my signing of this Consent, Release and Acknowledgement of Understanding form is voluntary and that I have not been coerced into signing this document.
Signature ________ ___________ __________ _________ Date _________ _________ _______ Printed name ______ _________ _____________ ________ _________ __________ _________
(COMPANY) WORKERS’ COMPENSATION POLICY ACKNOWLEDGEMENT FORM
This form acknowledges the receipt and understanding of the State of ________ Worker’s Compensation policy. Our company is a drug-free workplace for the benefit of all employees, customers and the business entity. State law provides for the possible denial of workers’ compensation benefits for employees’ who are injured while working and subsequently test positive.
The use of illegal drugs will not be tolerated or subsidized.
The following drugs are among those tested for under our company policy:
Cannabis Cocaine Amphetamines PCP Opiates There are multiple sub-families of individual drugs under the D.H.H.S. requirements.
These are known by many names.
As adults we all know it is ill-advised for anyone to take pills or medication that have not been prescribed by a physician.
Improper use of prescription medication can place you in a position of forfeiting your job, workers’ compensation benefits and unemployment benefits as well.
Do not misuse prescribed, non-prescribed or over-the-counter medication; do not use illegal drugs or misuse alcohol. The Company has a written policy on drug abuse.
It is posted and available to you to read, understand and follow. It is your responsibility to know the provisions of this policy.
SUMMARY STATEMENT: The State workers’ compensation laws and administrative rules are published and are available in public libraries.
Employees can write to the State Department of Labor & Employment Security, Division of Workers’ Compensation for detailed information.
EMPLOYEE ____________ ____________ _________ DATE _________ ________ _____
(COMPANY) AUTHORIZATION FOR LIMITED — — USE OR DISCLOSURE OF MEDICAL INFORMATION
EXPLANATION: This authorization for use or disclosure of medical information is requested of you to ensure the accuracy, confidentiality, and prompt availability of said information.
AUTHORIZATION: I hereby authorize the Medical Review Officer, any counselor or treatment facility I may be referred to and the testing laboratories to furnish the company, with results of all tests run.
I further authorize any doctor who has written a prescription which I may be using to disclose the purpose of the prescription, the conditions under which it is to be taken, and any other pertinent information to the Medical Review Officer to assist in the MRO’s determination of my fitness for duty.
— — USES: The Company may use the medical information authorized only for the following purpose: To determine my ability to do my job or my qualifications for employment or continued employment and to defend in any legal proceedings in which my employment or actions are at issue.
DURATION: This authorization shall become effective immediately and shall remain in effect throughout the duration of my employment with the company and any post-employment legal matters or proceedings, unless rescinded by me in writing.
RESTRICTIONS:
I understand that the Drug Free Workplace Administrator may not further use or disclose the medical information unless further authorization is given by me or in case of post accident testing or disclosure is required or permitted by law or licensing authority.
ADDITIONAL COPY:
(1) I further understand that I have a right to receive a copy of this authorization on my request.
(2) I further agree that a reproduced copy of this form shall have the same force and effect as the original.
DRUG SCREEN SPECIMEN VERIFICATION:
I hereby authorize the hospital, clinic, or laboratory, its physicians and technicians, specified by the Company, to obtain a sample of my urine, blood, or breath to be analyzed for the presence of controlled substances.
SIGNATURE __________ ___________ _______ DATE ________ _________
How To Fill Out The Non-DOT Drug and Alcohol Form
Drug Test:
Use a Custody & Control form (all copies attached)
1.Step 1 “C.” print Social Security # of employee.
2. Step 1 “D” check Reason for Test: ex: Pre-Employment_______ Random _______
Alcohol Test:
1. If it is a Blood Alcohol test, use a separate Custody & Control form, and in Step 1, –
“E” Test to be performed: print Blood Alcohol Test. (In Florida).
2. If it is a Saliva or Breath Alcohol Test use that specific form
3. Complete the Company Log for tracking and billing information.
4. Give the entire Custody & Control form (all copies attached) and/or Alcohol form to employee.
5. Give directions to collection site and instruct employee to take a photo ID.
DRUG TESTING LOG
Date Sent _________ _________ _______
Specimen I.D. # ______ _______ _______
Name _______ __________ ___________
Soc. Sec. # ______ ________ ________
Reported
_________ ________________ ______________ _________________ ________ _________ ________________ ______________
_________ ________________ ______________ _________________ ________ _________ ________________ ______________
_________ ________________ ______________ _________________ ________ _________ ________________ ______________
_________ ________________ ______________ _________________ ________ _________ ________________ ______________
_________ ________________ ______________ _________________ ________ _________ ________________ ______________
_________ ________________ ______________ _________________ ________ _________ ________________ ______________
_________ ________________ ______________ _________________ ________ _________ ________________ ______________
Procedure for Prescription Medications
If an employee is taking any prescription medication that may interfere with their ability to perform their assigned duties they must present to their supervisor a note from the prescribing physician stating:
(1) that they cannot perform those duties;
(2) what they can do;
(3) when they will be able to return to their usual duties.
(COMPANY)
AFFIDAVIT OF APPEARANCE FOR TESTING
___________ ____________ ______________ _____________ (Donor’s name) Collection site and address: ___________ __________ _________ _____________ _________ ________ ___________ __________ _________
Date sent: _________ ___________ __________ Time sent: ________ __________ ____________
Signature of Collector: ____________ ___________ __________ _________ ________ _________ _________ __________ (Date) ________(Time) _________
REFUSAL OF INJURY TREATMENT FORM
I, _______ _________ ________ _______, refuse treatment for my injury and/or drug testing.
(Print Name) _________ __________ __________ ________ ________ __________ __________ __________ _________ (Signature) (Date)
WITNESSED BY: ___________ ________ __________ ______ _____________ __________ _______
(Witness Signature) _________ ________ __________ _____________ (Date) _______ __________ _______
REFUSAL OF DRUG TESTING FORM
I, ________ _________ _______ _______, refuse drug testing.
(Print Name) ___________ __________ _________ _______ _________ ___________ _________ _______ (Signature) (Date) __________
Witnessed By: _________ ____________ _______ ___________ ___________ _______ (Witness Signature)
REFUSAL OF ALCOHOL TESTING FORM
I, _________ _____________ _______ ________, refuse alcohol testing.
(Print Name) _________ ____________ _________ ___________ __________ _______ _________ __________ (Signature) (Date)
Witnessed By: ______ ________ _________ _________ ________ ______ __________ ___________ ______ (Witness) (Date)
REFUSAL TO SIGN THE REFUSAL FORM
_________ __________ ________ _______ refused to sign the refusal of alcohol testing form.
(Print Name)
Witnessed by: ________ _________ _________ _________ ___________ __________ _______ _______
(Witness Signature) (Date) ________ ________ __________ _________ ___________ _________ _________ ______
(ON COMPANY LETTERHEAD)
NOTICE OF TEST RESULTS: POSITIVE
DATE: _____ ______ _______TO: _______ _________ ________ ___________ The test you took on ______ ______ has been determined to be positive.
The test was confirmed POSITIVE in accordance with Department of Health and Human Services standards. The Medical Review Officer has confirmed the positive test.
Nonetheless, you have five working days to contest the test results to ______ __________ ________ at the company.
In accordance with our company policy you are hereby terminated (or discipline, as stated in policy). Because you tested POSITIVE you may forfeit medical and indemnity benefits in accordance with State Workers’ Compensation Act.
You may appeal this decision or challenge it legally or administratively, at your expense. Also, in accordance with the administrative provisions, you may have the sample in question re-tested at your own expense at another qualified laboratory.
Signed ______ _________ ________ __________
(On Company Letterhead)
NOTICE OF PRE-EMPLOYMENT TEST RESULTS: POSITIVE
DATE: ______ ______ ________TO: ______ _______ ________ The test you took on _____ _____ ______ has been determined to be positive.
The test was confirmed POSITIVE in accordance with D.H.H.S. standards. The Medical Review Officer has confirmed the positive test.
Nonetheless, you have five working days to contest the test results to _____ ______ _______ _______ _____ ____ at the Company. In accordance with our company policy you are hereby disqualified from employment at this company.
You may appeal this decision or challenge it legally or administratively, at your expense.
Also, in accordance with the administrative provisions, you may have the sample in question re-tested at your own expense at another qualified laboratory.
Signed ______ ______ _______ ______ ________
(ON COMPANY LETTERHEAD)
ADULTERATION TO SPECIMEN
DATE: ____ ______ ____TO: _______ ________ ______ ________ ______ The test you took on _____ _____ ____ ___ has been found to have been adulterated.
(Date)
As stated in our policy, adulterations to a test constitute a refusal to test and subsequently result in immediate termination.
Because of this you may forfeit medical and indemnity benefits in accordance with State Workers’ Compensation Act and will forfeit any unemployment compensation.
You may appeal this decision or challenge it legally or administratively, at your expense. Also, in accordance with the administrative provisions you may have the sample in question re-tested at your own expense at another qualified laboratory.
Signed ______ ________ ______ ________ _____
(Company Letterhead) (Sample)
TERMINATION LETTER
Date: ______ _____ ____ ____ Name Address: ______ _______ _____ _______ ________ ________ ________ ______ _____
Dear: Pursuant to the Drug-Free Workplace policy of this Company, it has been determined that you have a positive confirmed drug test result.
As a consequence of this positive drug test, you are being terminated from employment, effective immediately.
Enclosed is a copy of the Consent and Release form that you originally signed which explained your rights, duties and obligations under this companies drug-free workplace program.
You have the right to contest the result of the test within five (5) working days after you receive this letter notifying you of the test result.
Your contest must be in writing and should state why the test results do not constitute a violation of this company’s drug-free workplace program.
If you intend to contest the results of this drug test, you must notify the testing laboratory of any administrative or civil action brought and advise the laboratory of the need to retain any sample taken. The name, address and telephone number of the testing laboratory is as follows:
Quest diagnostics (City) _______ _____ _______ _____ _____ ______ State ______ _____ ____ _____ _____
Zip ____ ____ _______ Phone Number _______ _______ _______ _______
You have the right to consult this testing laboratory for technical information regarding prescription and non-prescription medications or other relevant information.
You have a right to the copy of the drug test results. The re-testing must be done at an HRS licensed or H.H.S. approved laboratory and at your expense.
The second laboratory test must test at equal or greater sensitivity for the drug in question as the first laboratory.
If you intend to have the specimen sample re-tested at your cost, please advise so that the sample can be forwarded to the laboratory.
According to State Rules you may also be denied any Unemployment or Workers Compensation.
Sincerely,