11-17-2021 Council Packet - Laserfiche WebLink

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79 CITY OF LITTLE CANADA CITY EMPLOYEE AND APPLICANT** NOTIFICATION AND DRUG SCREENING CONSENT FORM I acknowledge that I have received and understand the City’s Controlled Substance and Alcohol Testing for Commercial Drivers (DOT) Policy. I agree to comply with the City’s policy on controlled substance and/or alcohol and understand failure to comply is grounds for disciplinary action, up to and including termination. If I am an applicant, I understand my conditional job offer will be withdrawn if I refuse to test or test positive for a controlled substance. I hereby consent to undergo controlled substance and/or alcohol testing pursuant to said policy, and I authorize collection of a urine and/or breath sample from me for these purposes. I understand that the procedure employed in this process will insure the integrity of the sample and is designed to comply with medical and legal requirements. I consent to the release of the controlled substance and/or alcohol test results in accordance with the City’s Controlled Substance and Alcohol Testing (DOT) Policy to the selected Medical Review Officer (MRO), and within the City on a need-to-know basis, and to additional parties in accordance with written authorization or as otherwise required by applicable or state law. I further understand that the results of this testing may affect my employment status, as described in the policy as well as federal law updates, as applicable. In the event of a post-accident test, the drug and/or alcohol test result(s) may also be provided to the workers’ compensation insurance carrier. I understand that if I am an applicant, the City will conduct a “full query” of the Federal Motor Carrier Safety Administration’s Clearinghouse to determine whether a record exists for me. In addition, I understand that if I become or am an employee, the City will, at least once a year, conduct a limited query of the Clearinghouse to determine whether a record exists for me. Therefore, I hereby consent to the City conducting limited queries of the FMCSA Commercial Driver’s License Drug and Alcohol Clearinghouse (Clearinghouse) to determine whether drug or alcohol violation information about me exists in the Clearinghouse for purposes of my candidacy and throughout the duration of my employment, as applicable. I also understand that if the limited query conducted by the City indicates that drug or alcohol violation information about me exists in the Clearinghouse, FMCSA will not disclose that information to the City without first obtaining additional specific consent from me. I further understand that if I refuse to provide consent for the City to conduct a limited query of the Clearinghouse, the City must prohibit me from performing safety-sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations.