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<br />. <br /> <br />. <br /> <br />. <br /> <br />CITY OF MOUNDS VIEW <br />EMPLOYEE/JOB APPLICANT <br />DRUG/ALCOHOL TEST CONSENT FORM <br /> <br />I have peen requested to give a (urine) (blood) sample for testing <br />to determine the presence of drugs and alcohol. <br /> <br />I have read and understand the city's policy on drug and alcohol <br />testing. I agree to submit to these tests, and also agree that the <br />testing agency is authorized by me to provide the results of the <br />test to the City of Mounds View. I understand that my alteration <br />of this consent form, refusal to consent or to cooperate fully in <br />the taking of this sample, or my refusal to consent or to cooperate <br />fully in the taking of this sample, or my refusal to authorize <br />release of information to the city of Mounds View may result in <br />disciplinary action up to and including discharge, and for job <br />applicants may be grounds for rejection. <br /> <br />I also understand that a. positive result may be grounds for <br />discipline up to and including discharge, and for applicants may be <br />grounds for rejection. <br /> <br />In order to insure accuracy of this screening, it is necessary to <br />know any and all of the prescription drugs, non-prescription drugs, <br />over-the-counter medications, or any other chemical substance you <br />have taken within the last month. If you are not taking any <br />medication, drugs, or other chemical substances, please write <br />"NONE". <br /> <br />MEDICATION: <br /> <br />DOSAGE AND FREQUENCY: <br /> <br />PRESCRIBED BY: <br /> <br />ANY OTHER INFORMATION RELEVANT TO THE RELIABILITY OF OR EXPLANATION <br />OF A POSITIVE TEST RESULT: <br /> <br />EMPLOYEE/APPLICANT NAME: <br />SIGNATURE: <br /> <br />DATE: <br /> <br />SUPERVISOR'S NAME: <br /> <br />SIGNATURE: <br /> <br />DATE: <br />