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• ST. ANTHONY EMPLOYEE OR JOB APPLICANT <br /> DRUG OR ALCOHOL TEST CONSENT FORM <br /> I have been ordered to give a urine sample for testing to determine <br /> presence of drugs or 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 St. Anthony. I understand that my alteration <br /> of this consent form, refusal to consent, or to cooperate fully in <br /> the taking of a urine sample, or my refusal to authorize release of <br /> information to the City of St. Anthony constitutes insubordination <br /> which may result in disciplinary action up to and including <br /> discharge and for 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 NAME: <br /> SIGNED: <br /> DATED: <br /> SUPERVISOR NAME: <br /> SIGNED: <br /> WITNESS: <br /> DATED: <br /> • 6 <br />