405.06 E2 - Drug and Alcohol Testing Program Acknowledgment Form

I, (____________________), have received a copy, read and understand the Drug and Alcohol
            Name of Employee

Testing Program policy of the South Tama Community School District and its supporting documents.

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

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.

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)

 

 

(June 10, 2019)