Drug Free Workplace Forms And Sample Letters Information
Drug Free Workplace Forms
1. Send 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
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. __________
(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.
(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.
(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.
How To Fill Out The Non-DOT Drug and Alcohol Form
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_______
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
Specimen I.D. #____________________
Soc. Sec. #______________________
_________ ________________ ______________ _________________ ________ _________ ________________ ______________ _________________ ________
_________ ________________ ______________ _________________ ________ _________ ________________ ______________ _________________ ________ _________ ________________ ______________ _________________ ________ _________ ________________ ______________ _________________ ________ _________ ________________ ______________ _________________ ________ _________ ________________ ______________ _________________ ________ _________ ________________ ______________ _________________ ________ _________ ________________ ______________ _________________ ________ _________ ________________ ______________ _________________ ________ _________ ________________ ______________ _________________ ________ _________ ________________ ______________ _________________ ________ _________ ________________ ______________ _________________ ________ _________ ________________ ______________ _________________ ________ _________ ________________ ______________ _________________ ________ _________ ________________ ______________ _________________ ________
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.
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: ___________________________________ ______________________________
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.
Witnessed by: ___________________________________ ___________________________________
(Witness Signature) (Date)
(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.
(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.
(ON COMPANY LETTERHEAD)
ADULTERATION TO SPECIMEN
DATE:______________TO: ___________________________________ The test you took on _________________ has been found to have been adulterated.
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.
(Company Letterhead) (Sample)
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 daysafter 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.
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All forms, policies, information and procedures should be reviewed by your legal counsel before being used in any way.
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