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April 18, 2011 (Regular Meeting) Page 390 • Failure of a drug or alcohol test, my refusal to submit to drug or alcohol tests under the circumstances set forth in the Policy, violation of the items listed in the "PROHIBITED ACTS" section of the Policy and other provisions of the Policy, and certain other occurrences described in the Policy may result in disciplinary action, up to and including dismissal, as described in the Policy. • The Policy may be modified at any time and in any way at the discretion of CABARRUS COUNTY GOVERNMENT and will become effective immediately upon posting of a notice indicating to me the changes made therein. • The Policy is not a contract of employment with CABARRUS COUNTY GOVERNMENT but compliance with its terms and conditions is a condition to my employment and continued employment with CABARRUS COUNTY GOVERNMENT. Printed Name Signature HR reviewed 4/20/2009 Date: FORM B CABARRUS COUNTY GOVERNMENT DRUG TESTING AUTHORIZATION STEP 1: To Be Completed By Employee's Supervisor Please complete and sign this form. Send it with Applicant /Employee to collection sites. Designate the reason for testing, the time and date. Advise donor to bring picture identification (ID). Do not give medical information to collector. Applicant / Employee Name: IS TO REPORT IMMEDIATELY FOR TESTING TO: Employee Health Center, 845 Church Street, Concord, NC DATE: TIME: Collection Site Staff: This is your authorization to perform the specified Drug and /or Alcohol Testing on the identified applicant /employee. If you have any questions, please call: (Supervisor) at (phone number). TYPE OF TEST Non -Dot ❑ DOT ❑ Emergency Room) TEST REASON to CMC -NE STEP 2: To Be Completed by Collection Site Staff (Please return to Employee) Donor Arrived at Collection Site: Date: Time: Identity Verified: [ ] yes [ ] no Specimen Collected: [ ] Collector's Signature: AM /PM yes [ ] no STEP 3: To Be Completed by Cabarrus County Supervisor (After Employee Returns from Collection /Testing Site) Returned to: Date: Time: AM /PM Supervisor's Name RETURN COMPLETED FORM TO HUMAN RESOURCES Revised 11/29/00; 8/1/07; 4/20/09 FORM C CABARRUS COUNTY GOVERNMENT DRUG TESTING AUTHORIZATION (Out of Town) Random ❑ Reasonable Suspicion Post Accident ❑ After P^„ (Report Other (please specify) STEP 1: To Be Completed By Employee's Supervisor Please complete and sign this form. Send it with Employee to collection site. Designate the reason for testing, the time and date. Advise donor to bring picture identification (ID).