SRS Drug & Alcohol Testing Consent Form

1. User ID (If known):

2. First Name: *This question is required.

3. Middle Initial: *This question is required.

4. Last Name: *This question is required.

5. Suffix

CUI//SP-PRVCY

I the undersigned, hereby knowingly and voluntarily authorize and consent to the collection and testing of specimens of my urine and breath alcohol by a collection facility and laboratory to be designated by Savannah River Nuclear Solutions, LLC for the purpose of drug testing. I authorize the collection facility, laboratory, and Medical Review Officer (MRO) to disclose the results of my drug tests to Savannah River Nuclear Solutions, LLC. I acknowledge that the drug test results will be shared with and utilized by the applicable contractor to determine my eligibility for employment therewith, but does not guarantee employment or continued employment. Such testing is required to determine fitness for duty and to meet applicable United States Department of Energy requirements.

I acknowledge that, should I test positive for alcohol, an illegal substance, or a legal substance without a valid prescription on or after my first day of employment with the applicable contractor, I may be subject to workplace counseling through the applicable contractor’s Recovery and Abstinence/Employee Assistance Program and/or discipline, up to and including termination as well as being denied access to the site. I acknowledge that at the time of collection, a refusal to authorize the collection of my breath alcohol and/or the collection and testing of my urine by the collection facility and laboratory, or a refusal to authorize the above disclosure of the test results will be treated as a positive drug test. I further acknowledge that a positive drug test may result in denial of employment or access to the site if a subcontractor employee .

I acknowledge that it is against the law to defraud drug testing. If an observed collection test is necessary, due to possible indicators of a suspected adulterated or substituted specimen (examples: specimen temperature is out of range, observed signs of intent to adulterate (devices, etc.) or, specimen quality issues: unusual odor, color, foaming, foreign object in specimen), the Collector will be required to perform an immediate directly observed collection. If I decline to allow a directly observed collection, it will be considered refusal to test and will be considered a POSITIVE test which could lead to disciplinary actions up to and including termination.

In addition, I hereby knowingly and voluntarily release Savannah River Nuclear Solutions, LLC, the applicable contractor, the collection facility, the testing laboratory and their respective officers, directors, employees and agents from any and all claims, damages, losses, liabilities, costs and expenses, including attorney fees, arising from or relating to such collection and testing and any disclosure of the results thereof, including without limitation, the disclosure of any inaccurate or incomplete results, to the fullest extent permitted by law. I acknowledge that I have the right to receive a copy of this authorization.

CONTROLLED BY: SRS Medical Operations, NonLocalTestReq@srs.gov

6. Required *This question is required.

I have read and understood the above Authorization & Consent in its entirety, and I agree that a copy of this document is as valid as the original. I agree that an electronic signature is acceptable in completing the execution of this agreement.