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DRUG AND/OR ALCOHOL TESTING CONSENT FORM <br />EMPLOYEE AGREEMENT AND CONSENT TO <br />DRUG AND/OR ALCOHOL TESTING <br />I hereby agree, upon a request made under the drug/ alcohol testing policy of AMSO (the Company), to <br />submit to a drug or alcohol test and to furnish a sample of my urine, breath, and/or blood for analysis. I <br />understand and agree that if I at any time refuse to submit to a drug or alcohol test under company policy, <br />or if I otherwise fail to cooperate with the testing procedures, I will be subject to immediate termination. I <br />further authorize and give full permission to have the Company and/or its company physician send the <br />specimen or specimens so collected to a laboratory for a screening test for the presence of any prohibited <br />substances under the policy, and for the laboratory or other testing facility to release any and all <br />documentation relating to such test to the Company and/or to any governmental entity involved in a legal <br />proceeding or investigation connected with the test. Finally, I authorize the Company to disclose any <br />documentation relating to such test to any governmental entity involved in a legal proceeding or <br />investigation connected with the test. <br />I will hold harmless the Company, its company physician, and any testing laboratory the Company might <br />use, meaning that I will not sue or hold responsible such parties for any alleged harm to me that might <br />result from such testing, including loss of employment or any other kind of adverse job action that might <br />arise as a result of the drug or alcohol test, even if a Company or laboratory representative makes an <br />error in the administration or analysis of the test or the reporting of the results. I will further hold harmless <br />the Company, its company physician, and any testing laboratory the Company might use for any alleged <br />harm to me that might result from the release or use of information or documentation relating to the drug <br />or alcohol test, as long as the release or use of the information is within the scope of this policy and the <br />procedures as explained in the paragraph above. <br />This policy and authorization have been explained to me in a language I understand and I have been told <br />that if I have any questions about the test or the policy, they will be answered. <br />I UNDERSTAND THAT THE COMPANY WILL REQUIRE A DRUG SCREEN TEST UNDER THIS <br />POLICY WHENEVER I AM INVOLVED IN AN ON-THE-JOB ACCIDENT OR INJURY UNDER <br />CIRCUMSTANCES THAT SUGGEST POSSIBLE INVOLVEMENT OR INFLUENCE OF DRUGS OR <br />ALCOHOL IN THE ACCIDENT OR INJURY EVENT. <br />Signature of Employee Date <br />Employee's Name - Printed <br />Company Representative Date <br />