Code No. 403.6E2

DRUG & ALCOHOL PROGRAM AND PRE-EMPLOYMENT TESTING 
ACKNOWLEDGMENT FORM

I,   (  Name of Employee   ), have received a copy, read and understand the Drug and Alcohol Testing Program policy of the ________________________ School District and its supporting documents.  
	            	        
I understand that if I violate the Drug and Alcohol Testing Program policy, its supporting documents or the law, I may be subject to discipline up to and including termination.

I also understand that I must inform my supervisor of any prescription medication I use.  
 
In addition, I have received a copy of the U.S. DOT publication, “What Employees Need to Know about DOT Drug & Alcohol Testing,” and have read and understand its contents.

Furthermore, I know and understand that I am required to submit to a controlled substance (drug) test, the results of which must be received by this employer before being employed by the school district and before being allowed to perform a safety-sensitive function.  I also understand that if the results of the pre-employment test are positive, that I will not be considered further for employment with the school district. 

I further understand that drug and alcohol testing records and information about me are confidential, and may be released at my request or in accordance with the district’s drug and alcohol testing program policy, its supporting documents or the law.
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(Signature of Employee)                                                                            (Date)