Background Screen & Drug Test Consent Form
I authorize Vet-1-1 to conduct a background check that will include a criminal background investigation, and also verification of my job qualifications, employment history, academic credentials, licenses, professional designations. I understand that employment is contingent upon a satisfactory background check. In addition, misrepresentations and/or omission of any facts on the Employment Application and/or resume are sufficient cause for summary dismissal when it is discovered.
In exchange for Vet-1-1's consideration of my employment application, I agree not to file or pursue any complaints, claims, or legal actions of any kind against any organization or individual that provides work-related information about me to Vet-1-1 or its agents in accordance with the terms and intent of this release. I also agree not to file or pursue any complaints, claims, or legal actions against Vet-1-1 or any of its employees, representatives, affiliates, or agents arising out of their efforts to obtain work-related information about me.
I have applied for employment with Vet-1-1. In order for my application being considered, I understand and agree to undergo substance testing upon employment offer. I understand that if my test results are positive, I shall not be considered for employment with Vet-1-1. I understand that if I receive a dilute drug test result, I will be required to take a second drug test within 24 hours of receipt of the dilute result. A hair follicle test will not be offered. If I refuse the blood test or do not stay within the required timeline for having the tests administered, I shall not be considered for employment with Vet-1-1.
I hereby authorize any physician, laboratory, hospital or medical professional retained by Vet-1-1 for testing purposes to conduct such testing and to provide the results to Vet-1-1 and I release Vet-1-1 and any person affiliated with Vet-1-1 and any such institution or person conducting the testing, from liability.
Testing may include but is not limited to the following substances:
COC AMP mAMP THC MTD TCA OPI PCP BAR BZO:
Marijuana - THC
Cocaine - COC
Amphetamine - AMP
Methamphetamine - mAMP
Phencyclidine - PCP
Benzodiazepines - BZO
Methadone - MTD
Opiate - OPI
Barbiturates - BAR
Tricyclic Antidepressants - TCA
I will hold harmless Vet-1-1, its company physician, and any testing laboratory Vet-1-1 might use, meaning that I will not sue or hold responsible such parties for any alleged harm to me that might result from such testing; this may include loss of employment or any other kind of adverse job action that might arise as a result of the drug or alcohol test, even if Vet-1-1 or laboratory representative makes an error in the administration or analysis of the test or the reporting of the results. I will further hold harmless Vet-1-1, its company physician, and any testing laboratory Vet-1-1 might use for any alleged harm to me that might result from the release or use of information or documentation relating to the drug or alcohol test, as long as the release or use of the information is within the scope of this policy and the procedures. This policy and authorization have been explained to me in a language I understand, and I have been told that if I have any questions about the test or the policy, they will be answered.
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Vet-1-1 is an Equal Opportunity Employer, and does not discriminate on the basis of Sex, Race, Religion, Age (40 and over), Handicap or National Origin. Remember, "involved in an on-the-job accident or injury" means not only the one who was injured, but also anyone who arguably or potentially contributed to the accident or injury event in any way, i.e., the person suspected of causing someone else to get hurt gets tested as well. Testing only accident or injury victims can, in the eyes of some, appear to be a way of discouraging workers from filing workers' compensation claims, and that in turn can have a very unfavorable effect on workers' compensation retaliatory discharge lawsuits. Drugs that are tested are subject to change.
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