REFUSAL OF POST-ACCIDENT DRUG TEST

REFUSAL OF POST-ACCIDENT DRUG TEST
Strategic Focus Clear Vision Defined Strategy. Proven Results.

3540 E. Broad St. Store 6870 #126 Mansfield, Tx 76063
Email: claims@stratfocusllc.com

Email the completed forms to claims@stratfocusllc.com or Fax to: 1 214 833 7257

ACKNOWLEDGEMENT OF REFUSAL TO SUBMIT TO

POST-ACCIDENT DRUG TEST

I_______, acknowledge that I have refused to submit to a post-accident drug

test as required by my employer. I understand that refusing to submit to a post-

accident drug test may lead to disciplinary action up to and including termination and

may result in a loss of workers' compensation and/or unemployment compensation

benefits.
Acknowledger Name
EMPLOYEE NAME
EMPLOYEE SIGNATURE

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DATE

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EMPLOYER SIGNATURE

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DATE

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