California State University / Alliant Insurance Services
OCIP Safety Program
Campus/Project Name:
Drug Test Consent
Resulting from the safety sensitive nature of construction, in order to maintain a safe, healthy and efficient work
environment, and to minimize absenteeism and tardiness, all employees shall be subject to this Substance Abuse
Prevention Policy that includes drug screening and testing as described below.
Periodic oral swab drug screening will be used to determine if there is reasonable suspicion to proceed to a urine drug test. All
(100% of) employees of the prime contractor and all subcontractors on the project site on selected days, periodically during
the course of the project, shall be required to submit to drug screening with oral swabs. Your employer will assemble a roll
sheet of all people on-site the day of the drug screening. Workers on the roll sheet, and not present at the drug screening,
shall be drug screened before their return to work.
A negative screening result indicates neither drugs nor alcohol were detected. The employee may remain on the jobsite and
is subject to future drug screening. For non-negative screening results (positive or inconclusive) the employee may not
return to the jobsite until a confirming lab-based urine test, reviewed by a Medical Review Officer, has confirmed a negative
result. The employee may submit to a urine test prior to leaving the site which will be sent to a certified lab for
confirmation. If the test is confirmed positive the employee shall not return to the site.
If there is reasonable cause to suspect that there is drug or alcohol use by an employee, and/or when an employee is
involved in any type of incident requiring a medical visit and/or resulting in property damage in excess of $500, a urine test
will be performed.
Employees governed by this policy may possess a prescription medication in its original container and prescribed for
current use of the person in possession by an authorized medical practitioner provided that the employee taking the
prescription medicine performs no duties which may affect the employee’s work ability (particularly their alertness and
coordination), safety and the safety of others. Because marijuana remains illegal under Federal Law, medical marijuana
cards or prescriptions permitting their use will not be allowed by workers on this project.
Employees that refuse to sign this drug test consent form shall not be allowed to work on the project.
Contractor / Subcontractor:
Employee’s Name:
Date of Birth:
/
/
Last, First
MM/DD/YYYY
Address
City, State, Zip
Local Home Address:
Soc. Sec. #:
-
-
Position / Craft:
I hereby consent and agree to give specimens of my saliva and/or urine to the facility designated by my employer as
described above. These specimens shall be used to detect the presence of drugs and / or alcohol in my biological
system. I further consent and agree that the results of the screening and tests may be furnished to my employer by
the testing facility, and my employer may forward the test results to the general contractor, and any Union hiring hall
which may have referred me.
My signature below acknowledges that I have read, understood, and agree to the content in this consent to drug
screening and testing as described herein.
Employee Signature
Date
Witness Signature
Date
Distribution: Original to Employer
Copy to Employee
Revised February, 2013
The California State University
Owner Controlled Insurance Program