Pediatric Healthcare Connection - Consent To Drug And Alcohol Testing

I hereby agree, upon a request made under the drug/alcohol testing policy of Pediatric Healthcare Connection Inc., herby after to be referred to as PHC to submit to a drug or alcohol test and to furnish a sample of my urine, breath, and/or blood for analysis. I understand and agree that if I at any time refuse to submit to a drug or alcohol test under PHC policy, or if I otherwise fail to cooperate with the testing procedures, I will be subject to immediate termination. I further authorize and give full permission to have PHC and/or its company physician send the specimen or specimens so collected to a laboratory for a screening test for the presence of any prohibited substances under the policy, and for the laboratory or other testing facility to release any and all documentation relating to such test to PHC and/or to any governmental entity involved in a legal proceeding or investigation connected with the test. Finally, I authorize PHC to disclose any documentation relating to such test to any governmental entity involved in a legal proceeding or investigation connected with the test.

I understand that only duly-authorized PHC officers, employees, and agents will have access to information furnished or obtained in connection with the test; that they will maintain and protect the confidentiality of such information to the greatest extent possible; and that they will share such information only to the extent necessary to make employment decisions and to respond to inquiries or notices from government entities.

I will hold harmless PHC, its company physician, and any testing laboratory PHC might use, meaning that I will not sue or hold responsible such parties for any alleged harm to me that might result from such testing, including loss of employment or any other kind of adverse job action that might arise as a result of the drug or alcohol test, even if a PHC or laboratory representative makes an error in the administration or analysis of the test or the reporting of the results. I will further hold harmless PHC, its company physician, and any testing laboratory PHC might use for any alleged harm to me that might result from the release or use of information or documentation relating to the drug or alcohol test, as long as the release or use of the information is within the scope of this policy and the procedures as explained in the paragraph above.

This policy and authorization have been explained to me in a language I understand, and I have been told that if I have any questions about the test or the policy, they will be answered.

I understand that the PHC will require a drug screen and/or alcohol test under this policy whenever I am involved in an on-the-job accident or injury under circumstances that suggest possible involvement or influence of drugs or alcohol in the accident or injury event, and I agree to submit to any such test.


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