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406.4-E3 Drug and Alcohol Testing Program Acknowledgement Form

EXHIBIT
 
Series 400 - Staff Personnel
 
Drug and Alcohol Testing Program Acknowledgment Form     Code No. 406.4-E3
 
I, (                                       ) ,  have received a copy, read and understand the Drug
   (Name of Employee)   and Alcohol Testing
     
Program policy and its supporting documents.  I consent to submit to the drug and alcohol testing program as required by the Drug and Alcohol Testing Program policy, its supporting documents and the law.
 
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.
 
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 about me are confidential and may be released in accordance with this policy, its supporting documents or the law.
 
 
_________________________________                       _____________
     (Signature of employee)                                                        (Date)