Policy 3-2A APPENDIX A

CITY OF LAWTON

Drug and/or Alcohol Testing Consent Form

Employee/Applicant Name:_____________________________________Date:______________

Department:_____________________________Department Head:________________________

Name of City Representative Requesting Test:________________________________________

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Medical Consent: The undersigned hereby consents to a drug screen/alcohol test to be administered by St. Anthony Hospital, as requested by the City.

Authorization To Release Test Results As Positive or Negative, To the City: I authorize the AM PM clinic and/or St. Anthony Hospital to release the results of the alcohol test and/or drug screen, as being positive or negative, to the City Human Resources Director or his/her designate.

( ) Applicant: I understand that refusal to consent to a drug screen and/or alcohol test shall be sufficient reason for the refusal to hire. I understand that upon a drug screen and/or alcohol test result of positive, my application for employment with the City shall be deemed withdrawn.

( ) Employee: I understand that refusal to consent to a drug screen and/or alcohol test shall be ground for discipline. I further understand that a drug screen and/or alcohol test result of positive shall be grounds for discipline, which may include termination.

( ) I give my consent to the drug screen and/or alcohol test with the understanding that the result of a drug screen test shall be reported to the City Human Resources Department as positive or negative and the results of the test(s) shall remain and be kept confidential unless I direct otherwise.

EMPLOYEE/APPLICANT SIGNATURE:__________________________DATE:___________

CITY REPRESENTAITIVE:_____________________________________DATE:___________