403.6E2 Drug and Alcohol Testing Program Acknowledgment Form

Code No. 403.6E2

DRUG & ALCOHOL TESTING PROGRAM ACKNOWLEDGMENT FORM

I, _______________________, have received a copy, read and understand the Drug and Alcohol Testing Program policy of the Grinnell-Newburg School District and its supporting documents.

I understand that if I violate the Drug and Alcohol Testing Program policy, its supporting documents or the law, I may be subject to discipline up to and including termination or I may be required to successfully participate in a substance abuse evaluation and a substance abuse treatment program, if recommended by the substance abuse professional.  If I am required to and fail to or refuse to successfully participate in a substance abuse evaluation or recommended substance abuse treatment program, I understand I may be subject to discipline up to and including termination.

I also understand that I must inform my supervisor of any prescription medication I use.

In addition, I have received a copy of the U.S. DOT publication, “What Employees Need to Know about DOT Drug & Alcohol Testing,” and have read and understand its contents.

Furthermore, I know and understand that I am required to submit to a controlled substance (drug) test, the results of which must be received by this employer before being employed by the school district and before being allowed to perform a safety-sensitive function. I also understand that if the results of the pre-employment test are positive, that I will not be considered further for employment with the school district.

I further understand that drug and alcohol testing records and information about me are confidential, and may be released at my request or in accordance with the district’s drug and alcohol testing program policy, its supporting documents or the law.

__________________________________________________ ________________________
(Signature of Employee)                     (Date)

POLICY NOTE: Under federal regulations, school districts may require their drivers to notify them of any prescription medications they are using.

Approved 9/23/2015

Reviewed 1/25/2023