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Name (print) Social Security Number
The above named employee is to have the following test (check one) _____ Drug _____ Alcohol _____ Both Drug & Alcohol
Type of Test (check one) _____ Random

_____ Post-accident

_____ Follow-up

_____ Pre-employment (drug only)

_____ Reasonable suspicion

_____ Return-to-duty

Time Sent by District School District Contact Person (phone)
Time Arrived at Collection Site Collection Site Person
Time Test was Completed Collection Site Person

I understand I am to go directly to the collection site located at:

I understand a positive drug test result or an alcohol test result of .04 alcohol concentration or greater will result in termination of my employment and that an alcohol test result of greater than .02 but less than .04 alcohol concentration requires me to cease performing a safety‐sensitive function for twenty‐ four hours.

I further understand my drug and alcohol testing results are reported to and maintained by the school district and the Iowa Drug and Alcohol Testing (IDATP) medical review officer for the purpose of completion of reports including, but not limited to, the Annual Summary/MIS reports required under the federal drug and alcohol testing regulations.

Employee’s Signature __________________________________________ Date ________________________________