DRUG TESTING CONSENT FORM (Example) - …

1 Corporate Healthcare 9718-A Sam Furr Rd., Huntersville, NC drug TESTING REQUISITION form _____ is committed to providing a safe, efficient, and productive work environment and is in compliance with North Carolina Department of Labor laws pertaining to substance abuse TESTING of employees or potential employees. Being under the influence of drugs or alcohol on the job poses a serious safety and health risks to the employee and others. To help ensure a safe and healthful working environment, job applicants and employees may be asked to provide body substance samples (such as urine, hair or blood) to determine the illicit or illegal use of drugs and alcohol. I (the employee) understand the substance abuse test I am taking today will evaluate the presence of specific drug groups or their components/metabolites in my urine, saliva or blood. Employees who refuse to test, test positive for substance abuse or admit to substance abuse may be subject to disciplinary actions up to and including termination.

2 Adulteration (intentional contamination) of body substance samples will be considered a refusal to test. I also understand that I am responsible for informing my employer of any medical treatment or medications that may impact my job performance or the safety of my work place. In addition to abused substances, I give permission to Corporate Healthcare to reveal any legally prescribed medications to my employer discovered during this substance abuse test that might impact safety in the work place. In accordance with state labor laws, this notice explains your rights and responsibilities under the CSERA and associated administrative rules. (1) You may refuse this test; however, your job or employment opportunity may be in jeopardy. (2) Applicants may be screened by means of a Quick Test ; (3) Current employees cannot be screened by means of a Quick Test. (4) Any positive results must be confirmed by an approved lab using gas chromatography with mass spectrometry (GS/MS) or equivalent scientifically accepted method before hiring decisions are made.

3 (5) You can request a retest of any positive sample. Retests must be of the same sample and must be paid for by the employee. (6) You can file a complaint with the Department of Labor, (919) 807-2796 or 1-800-LABOR-NC or appropriate state department of labor, if you believe procedural requirements of the CSERA were violated. The department has no jurisdiction regarding an employer s requirement for controlled substance TESTING or it decisions regarding results of controlled substance TESTING . Employee Printed Name Employee Signature Employee Number/SSN Date Test is for (circle one): Random For Cause New Hire Test(s) to be performed (circle): 6 panel urine// 10 panel panel urine / Hair / Saliva / Alcohol (urine) / NASCAR Test / DOT (See our web site for what is tested on each test) TESTING Authorized by: Designated Employer Representative (DER) Printed Name Designated Employer Representative Signature Date DER Telephone Number Send Results to (address/e-mail/fax/call to telephone number):_____ _____ Identity of Employee Verified By: DL Photo Company ID Other: Test Results: Negative _____ Positive (will be sent for GC/MC Confirmation) _____ Refused To Test _____ Remarks _____ Test Performed By: Corporate Healthcare of Lake Norman Date.

4 Results Verified By Medical Staff _____ THIS form SHOULD BE FAXED TO CORPORATE HEALTHCARE (Fax 704 987-8221) PRIOR TO THE EMPLOYEE ARRIVING FOR TESTING Date/Time Employee Notified Date/Time Employee Tested Corporate Healthcare 9718-A Sam Furr Rd., Huntersville, NC Tel. 704 987-7970 Fax. 704 987-8221 Web Site: Payment Authorization form If your company does not have a contract with a billing agreement on file with Family Healthcare of Lake Norman, PC dba Corporate Healthcare, payment will need to be made before tests can be performed. Corporate Healthcare will maintain no credit card information and the credit card information on this document will be obliterated after your account has been charged. A receipt will be sent with your test results. Please fax this credit card information to our secure fax along with the drug Test Requisition form to 704 987-8221. Company Name:_____ Employee(s) Name:_____ Payment Method: Contract on file or credit/debit card or employee will pay at time of service Credit Card Info: VISA / MC Exp.

5 Date _____ Name on Card _____ Signature_____ Address _____ City/Zip _____ Name/Telephone number for questions if different from Designated Employee Representative _____ Amount Authorized _____