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April 20, 2009 (Regular Meeting) Page 1329 FORM A CABARRUS COUNTY GOVERNMENT ACKNOWLEDGMENT OF RECEIPT OF DRUG FREE WORK PLACE POLICY I have been given a copy of and have read the Drug Free Workplace Policy (the "Policy") adopted by CABARRUS COUNTY GOVERNMENT as well as post-accident information, procedures, and instructions to enable me to comply with my obligations under the Policy and information concerning the effects of controlled substances use and alcohol abuse on an individual's health, work, and personal life; signs and symptoms of a controlled substances or alcohol problem (mine or a coworker's); and available methods of intervening when a controlled substances or alcohol problem is suspected. I hereby acknowledge that I understand, accept, and agree to be bound by the conditions specified in the Policy and these materials. I further understand and agree that: To be retained as an employee, the following will apply: • As a condition of employment and continued employment with CABARRUS COUNTY GOVERNMENT, I may be required to provide blood, urine, saliva, breath, or other accepted scientific samples for drug and alcohol testing under the circumstances described in the Policy, and I hereby consent to such testing. • 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 FORM B CABARRUS COUNTY GOVERNMENT DRUG TESTING AUTHORIZATION HR reviewed 9/20/2009 STEP 1: To Be Completed By Employee's Supervisor Please complete and sign this collection sites. Designate Advise donor to bring picture information to collector. Applicant / Employee Name: IS TO REPORT IMMEDIATELY FOR TESTING TO: Employee Health Center, 895 Church Street, Concord, NC DATE: 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). form. Send it with Applicant/Employee to the reason for testing, the time and date. identification (ID). Do not give medical TYPE OF TEST TEST REASON