COUNTY ROAD COMMISSION DRUG AND ALCOHOL TESTING AUTHORIZATION FORM

I,	 	,	as	an	employee/applicant	of
the   	   Road   Commission (the “Road   Commission”), hereby acknowledge that I have received and read the Road Commission’s Drug-Free Workplace Policy and that the Drug-Free Workplace Policy requires me to be subject to drug and/or alcohol testing. Drug testing will occur by urinalysis unless a disability recognized under federal and/or State law necessitates that I be tested by an alternative method. Alcohol testing may include breath, saliva, or blood testing.

I further understand that the purpose of this analysis is to determine or rule out the presence of drugs and/or alcohol.

I hereby freely and voluntarily consent to this request for a drug and/or alcohol test and agree to participate in the testing program.

I hereby release the Road Commission, its employees, agents, and contractors from any and all liability whatsoever arising from this request for testing, from the actual testing procedures, and from decisions made concerning my application for or continuation of employment based on the results of the analysis.

I agree to cooperate in all aspects of the testing program and understand that refusal to participate in required testing may result in denial of employment or disciplinary action up to and including termination of employment.

I hereby authorize the release of my drug and/or alcohol test results to the Road Commission’s Medical Review Officer (MRO) as provided by the Road Commission’s policy.

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Employee Signature								Date

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Employee Printed Name