407.5E4 Drug and Alcohol Testing Program Referral to Substance Abuse Professional Acknowledgment Form

I, _________________________________________, understand that I 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 with the district, 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 the complete the substance abuse evaluation my 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 recommended substance abuse treatment program, if any, to the school district and I understand that my failure to release these records my subject me to discipline up to and including termination.

Signature of Employee: ____________________________________Date____________

------------------------------------------------------------------------------------------------------------