PERSONNEL
403.6E04 - DRUG/ALCOHOL TEST NOTIFICATION FORM
Date
Name (print)
Social Security Number
The above named employee is to have the following test:
Drug
Alcohol
Both Drug and Alcohol
Type of Test
Random
Pre-employment (drug only)
Post-accident
Reasonable suspicion
Time Sent by District
School District Contact Person (Phone)
Time Arrived at Collection Site
Collection Site Person
Time Test Was Completed
Collection Site Person
I understand I am to go directly to the collection site located at:
(address of collection site)
I understand a positive drug test result or an alcohol test result of .04 alcohol concentration or greater will result in termination of my employment and that an alcohol test result of greater than .02 but less than .04 alcohol concentration requires me to cease performing a safety-sensitive function for twenty-four hours.
I further understand my drug and alcohol testing results are reported to and maintained by the school district and the Iowa Drug and Alcohol Testing (IDATP) medical review officer for the purpose of completion of reports including, but not limited to, the Annual Summary/MIS reports required under the federal drug and alcohol testing regulations.
Employee's Signature
Date