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Please complete this Acknowledgment of receipt and understanding of the University Drug and Alcohol policy, Consent to Test, and Authorization to Release Test Results. This form is required for all Safety Sensitive and Covered positions as per University policy, or in other applicable cases i.e., random screening, reasonable suspicion screening, and post-accident screening.
Are you a Candidate for Employment or a Current Employee?
Current Employee
Candidate for Employment
Candidate/Employee Information.
First Name
Last Name
e-Mail Address
Phone Number
Department Applied/Employed
Hiring Manager/Supervisor Name
Clayton State University (CSU) has a vital interest in providing a safe environment for its students, employees, faculty, and visitors. Drug and alcohol abuse is a serious health problem, which can endanger University operations and the safety of those who work and learn at the University or seek its services. It is the intent and goal of this policy to provide a supportive process for intervention and rehabilitation while also protecting the working and learning environment. It is the policy of Clayton State University that illicit drug use, including their manufacture, sale, distribution, dispensation, possession, or use is prohibited in the workplace, on the campus, or as part of any University activities.
Drug and Alcohol Testing
: The policy authorizes pre-placement drug screening of applicants selected to fill positions designated as safety-sensitive, and drug or alcohol screening of University personnel performing in such positions when there is reason to be concerned for drug or alcohol i.e., random screening, reasonable suspicion screening, and post-accident screening. Human Resources is primarily responsible for appropriate posting or circulation of this policy. This policy applies only to high risk or safety-sensitive positions. The University administratively reviews position functions and responsibilities and identifies covered positions involving a substantial risk of injury in the performance of job duties, such as in connection with police and security duties, maintenance of hazardous facilities such as boilers, HVAC, or elevators, and operation of CSU vehicles or equipment that must be used with caution (golf carts, lawnmowers, etc.). Covered positions shall be determined by Human Resources.
Penalties for Violation of University Policy
: University policy prohibits the unlawful possession, use, or distribution of illicit drugs and alcohol on the campus and at University-sponsored events held off campus and is intended to protect and support the employees and students of Clayton State University. Any employee admitting to or convicted of the unlawful possession, use, or distribution of illicit drugs and/or alcohol on the campus or at University-sponsored events held off campus will be subject to disciplinary action (up to and including suspension, suspension without pay, and/or termination), may be referred for prosecution, and may be required to satisfactorily participate in a drug and alcohol assistance or rehabilitation program as agreed upon between the employee and the Department of Human Resources.
Please type "
I Understand and Acknowledge
," below.
You may view the Drug and Alcohol Screening Policy in the
Employee Handbook
located here.
Please type "
I Understand and Acknowledge
," below.
Instructions for Screening:
1. Report to the designated testing location as ordered.
2. Please be prepared to present valid picture identification.
3. Please be sure to retain any receipts or confirmations of screening completion provided to you by the designated screening location for your records.
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I Understand and Acknowledge
," below.
YOU ARE ADVISED THAT IF:
a) you expressly decline to submit to an alcohol or drug screening;
b) you fail to appear at the testing location by or within the specified time;
c) you engage in conduct that obstructs the screening process;
d) you fail to provide adequate urine (normally 45 ml.), or breath for alcohol testing, or other samples for screening without an acceptable medical reason;
e) you leave the screening site before providing an adequate sample in the allotted time (up to 3 hours if necessary);
f) the temperature of your specimen is outside the acceptable range;
g) the laboratory or the medical review officer (MRO) determines that your sample has been adulterated or substituted, or,
h) the screening indicates the use of an illegal drug(s) without a legitimate medical explanation;
It will be considered a refusal, and the actions described below will be taken:
1. The offer of employment will be rescinded, and you will be ineligible for employment by any State entity for two years.
2. Appropriate discipline will be enacted, which may include (without limitation) reassignment, suspension with or without pay pending professional counseling, treatment, and evaluation, or discharge , for current EMPLOYEES.
Please type "
I Understand and Acknowledge
," below.
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