Jerome School District #261

SUBSTANCE ABUSE POLICY 5320‐F

ACKNOWLEDGEMENT OF RECEIPT OF DRUG TESTING PROGRAM AND AGREEMENT TO ABIDE BY THE PROGRAM

I, ___________________________________________________________________, hereby acknowledge that I

have received a copy of the Drug Testing Program.

In conjunction with my receiving a copy of the Jerome School District’s Drug Testing Program, I further

acknowledge the following:

I have read the program and fully understand the terms contained therein, and the consequences for violating any

terms of the program.

I understand that my compliance with all terms of the program is a condition of my employment with the Jerome

School District to abide by all terms of the program.

I authorize the lab and/or Medical Review Officer retained by the district to release test result information to the

Jerome School District.

___________________________________________________________/________________________

Employee’s Signature Date

Witnessed by: Jerome Public Schools #261

By: _____________________________________________/___________________________________

Witness’s Signature Witness’s Printed Name

Date: ____________________________________

Policy History:

Adopted on: 09/27/11

Revised on: