MISSOURI STATE UNIVERSITY-WEST PLAINS
ASSOCIATE OF SCIENCE IN NURSING DEGREE PROGRAM
INFORMED CONSENT AND RELEASE OF LIABILITY
DRUG AND ALCOHOL TESTING
I understand that as a student in Missouri State University-West Plains Associate of
Science in Nursing Program, a drug/alcohol test will be a condition of admission,
readmission or transfer to the program, and may be requested at any time throughout
the progression of the program. I understand that I may be responsible for the cost of
the screening. I understand that the presence of certain drugs, alcohol, or controlled
substances is grounds for immediate dismissal from the program. I further understand
that I am not obligated to comply with this screening; however, refusal to consent or to
pay for the screening will result in dismissal.
I hereby consent to have my urine tested for drugs and alcohol. I consent to a breath
test for alcohol if required by policy.
I hereby release Missouri State University-West Plains and the Associate of Science in
Nursing Degree Program from any liability from and against any claims, actions, or losses
that arise out of the testing. I agree to the release of the test results to the Associate of
Science in Nursing Degree Program of Missouri State University-West Plains.
I authorize Missouri State University-West Plains Associate of Science in Nursing Program
to release drug test results to clinical agencies as needed to ensure my participation in
clinical experiences.
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Date
Student signature
Date
ORIGINAL ADOPTION DATE: 05/04
REVISED:
03/15
REVIEWED: 03/15