I agree to abstain completely from mood-changing chemicals except as prescribed by my primary provider, to notify my designated worksite monitor of such prescriptions, and to provide such documentation as may be required to verify a prescription.

I agree to provide a urine/blood sample* for drug screen, to be obtained in the presence of a qualified witness if the employer has documented reason to believe that I may be unfit for duty. The cost of the laboratory test shall be the responsibility of the employer. Positive urines will be cause for immediate assessment by my supervisor, Director of Nursing and myself. Relapse may or may not result in termination.

I will comply with PAP drug screening requirements at my expense.

*Note: During the course of this agreement, it is understood by the principals that no poppy seed products or herbal supplements will be ingested.

I agree to execute consent forms and/or medical authorization forms required for designated worksite monitor, treatment center, and/or SPAN to obtain information and records needed to monitor my compliance with this agreement.

I understand that my continued employment depends not only on meeting the terms of this agreement but also on satisfactory performance of my job. My employer will monitor my job performance and an unsatisfactory performance evaluation may be grounds for my termination consistent with the general employment criteria for all employees.

I understand the responsibilities of my job and am capable of meeting those responsibilities. I agree to notify my designated worksite monitor if at any time I believe I am not capable of performing any of my required job functions.