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CITY OF MOUNDS VIEW <br /> EMPLOYEE/JOB APPLICANT <br /> DRUG/ALCOHOL TEST CONSENT FORM <br /> I have been requested to give a (urine) (blood) sample for testing <br /> to determine the presence of drugs and alcohol. <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 /> 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 /> 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 /> MEDICATION: <br /> DOSAGE AND FREQUENCY: <br /> PRESCRIBED BY: <br /> ANY OTHER INFORMATION RELEVANT TO THE RELIABILITY OF OR EXPLANATION <br /> OF A POSITIVE TEST RESULT: <br /> EMPLOYEE/APPLICANT NAME: <br /> SIGNATURE: <br /> DATE: <br /> SUPERVISOR'S NAME: <br /> SIGNATURE: <br /> DATE: <br />