Code No. 4O3.10E9
DRUG AND ALCOHOL TESTING PROGRAM REFERRAL TO SUBSTANCE ABUSE PROFESSIONAL ACKNOWLEDGMENT FORM
I, ___________________________________understand 1 have violated the Drug and Alcohol Testing Program policy, its supporting administrative regulations and the law by having a _________Positive drug test result, _________Alcohol test result of 0.04 alcohol breath concentration or greater.
I understand in order to continue my employment, I must be evaluated by a substance abuse professional who shall determine what assistance, if any, I need in resolving problems associated with drug use and/or alcohol misuse. I consent to submit to an evaluation by a substance abuse professional and I understand that my failure to cooperate with and complete the substance abuse evaluation may subject me to discipline up to and including termination.
I also understand that in order to continue my employment, I must successfully complete the substance abuse professional's recommended substance abuse treatment program if any. I consent to successfully complete any recommended substance abuse treatment program, and I understand that my failure to successfully participate and complete the recommended substance abuse treatment program, if any, may subject me to discipline up to and including termination.
I further understand that in order to continue my employment, I must authorize the release to the school district any records related to my substance abuse evaluation and recommended substance abuse treatment program in the possession of or accessible by the substance abuse professional. I consent to authorize the release of the substance abuse professional's records related to my substance abuse evaluation and I recommended substance abuse treatment program, if any, to the school district and I understand that my failure to release these records may subject me to discipline up to and including termination.
Signature of Employee: __________________________________________
Date: _______________________________________________
Revised 7-17-2023