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Name: Elizabeth Smith
SS#: 663-10-6984
STORE #: 0241
DRUG AND ALCOHOL POLICY STATEMENT
AND
STATEMENT OF UNDERSTANDING AND AGREEMENT REGARDING DRUG AND ALCOHOL
TESTING
I UNDERSTAND THAT THE COMPANY FORBIDS USE OF OR BEING UNDER THE INFLUENCE OF ALCOHOL, ILLEGAL
DRUGS, PRESCRIPTION DRUGS OR OVER THE COUNTER DRUGS NOT USED ACCORDING TO PROFESSIONAL
INSTRUCTIONS, OR OTHER INTOXICANTS OR PROHIBITED SUBSTANCES WHILE ON COMPANY PREMISES OR WHILE
ON DUTY OR CONDUCTING COMPANY BUSINESS.
I UNDERSTAND THAT COMPANY POLICY ALSO PROHIBITS POSESSION, SALE, PURCHASE, SOLICITATION OF
PURCHASE OR SALE, RECEIPT, TRANSPORT, OR DISTRIBUTION OF ANY OF THESE SUBSTANCES ON COMPANY
PREMISES, WHILE ON DUTY, OR WHILE CONDUCTING COMPANY BUSINESS.
AS A PREREQUISITE TO MY EMPLOYMENT OR AS A CONDITION OF MY EMPLOYMENT, I UNDERSTAND THAT AT
SUCH TIME OR TIMES AS THE COMPANY SHALL REQUIRE, I MAY BE REQUESTED TO UNDERGO BLOOD TESTS,
URINALYSIS, OR OTHER FORMS OF TESTING FOR THE PRESENCE OF ALCOHOL, ILLEGAL DRUGS, PRESCRIPTION
DRUGS OR OVER THE COUNTER DRUGS NOT USED ACCORDING TO PROFESSIONAL INSTRUCTIONS, OR OTHER
INTOXICANTS OR PROHIBITED SUBSTANCES. I UNDERSTAND THAT I MAY BE RANDOMLY SELECTED FOR TESTING;
SELECTED FOR TESTING BASED ON REASONABLE SUSPICION OF POLICY VIOLATION, SELECTED FOR TESTING
UPON THE OCCURRENCE OF A WORK-RELATED INJURY OR ILLNESS; OR, SELECTED FOR TESTING BASED ON
OTHER REASONABLE CAUSE. I UNDERSTAND THAT I MUST COMPLY WITH THESE TESTING REQUESTS
REGARDLESS OF THE BASIS.
I FURTHER UNDERSTAND THAT AT THE TIME OF EACH SUCH EXAMINATION OR TEST, I WILL BE REQUIRED TO
EXECUTE ALL FORMS OF CONSENT AND RELEASES OF LIABILITY AS ARE USUALLY AND REASONABLY ATTENDANT
TO EACH SUCH EXAMINATION. I UNDERSTAND THAT THE RESULTS OF ANY SUCH EXAMINATIONS SHALL BE MADE
AVAILABLE TO SELECTED PERSONNEL OF AGENCIES, LAW ENFORCEMENT, OR TO OTHERS WHERE PROVIDED BY
LAW. I ALSO UNDERSTAND THAT A POSITIVE TEST RESULT, REFUSAL TO PROMPTLY COOPERATE IN THE TESTING
PROCESS, OR OTHER VIOLATION OF THIS POLICY STATEMENT CONSTITUTES GROUNDS FOR IMMEDIATE
DISCHARGE.
I UNDERSTAND THAT THE COMPANY RESERVES THE RIGHT TO SEARCH OR INSPECT MY PERSON AND MY VEHICLE
AND PERSONAL PROPERTY WHICH I BRING ONTO COMPANY PREMISES. I UNDERSTAND THAT REFUSAL OF A
REQUEST TO COOPERATE IN A SEARCH IS GROUNDS FOR IMMEDIATE TERMINATION OF EMPLOYMENT.
THE UNDERSIGNED FURTHER STATES THAT HE OR SHE HAS READ THE STATEMENT ABOVE; HAS RECEIVED A
COPY OF THE COMPANY’S DRUG AND ALCOHOL POLICY STATEMENT AND UNDERSTANDS THE CONTENTS
THEREOF; AND AGREES WITH ALL ASPECTS OF THIS STATEMENT AND THE TESTING OBLIGATIONS DESCRIBED
ABOVE.
REFUSAL TO SIGN THE CONSENT FORM WILL RESULT IN TERMINATION OF EMPLOYMENT.
ASSOCIATE SIGNATURE:
Elizabeth Smith - 02/24/2022 - 8:15:13 - 173.217.75.205
PARENTS’ SIGNATURE OR LEGAL GUARDIAN (if under age 18)
STORE MANAGER INITIALS: