Substance Abuse Screening

Substance abuse screening
Hello {firstName}
Please review and complete the form on the following page. Then, complete and sign the consent and release forms that follow so that we may process your substance abuse screening. These forms include the WSI Enterprises substance abuse screening release, the DISA Global Solutions substance abuse screening release, and the DISA membership application.

Click "Next" below to begin.
Estimated time to complete: 5 minutes

Substance abuse screening
Employee information
Name*
Other names you have used
Phone*
Email*
Location*
Position*
Start date*

MonthDayYear
Street address*
Apartment or unit
City*
State*
Zip code*
Social security number*
Date of birth*

MonthDayYear
Driver's license number*
Driver's license state*
Driver's license expiration date*

MonthDayYear

Substance abuse screening
Screening consent and release
I, the undersigned, an applicant for employment with, or an existing employee employed by WSI Enterprises Inc., hereby voluntarily consent to the observed taking of specimens for substance abuse screening as a condition of my initial and/or continued employment with WSI Enterprises Inc. I authorize the release of all results of such screening to WSI Enterprises Inc.

I release WSI Enterprises Inc., the test laboratory, its physicians, nurses, technicians, and any other employees or agents involved with my tests from any and all liabilities, claims, or causes of action relating to such substance abuse screening including, without limitation, those that may result from administering such tests and/or the disclosure of test results.

I understand and voluntarily agree that if WSI Enterprises Inc. asks me to, I will submit to substance abuse screening. I understand that either refusal to submit to the substance abuse screen or a positive result may result in revocation of a conditional offer of employment, or termination of my employment, as applicable.

In the case of a breath alcohol test, I understand and agree that if the breath alcohol test level as determined by the test reflects an illegal level of intoxication, I will be unable to operate a motor vehicle and must use an alternate form of transportation operated by someone other than myself. If I refuse alternative transportation, I understand and agree that law enforcement officials will be notified.

The various forms of substance abuse testing are as follows:

Post accident testing
Testing of an employee who is involved in an on-the-job accident (vehicular or otherwise) which may have involved human error and may have caused a fatality, serious injury, or significant property damage.

Pre-employment testing
A candidate for employment must pass the drug and/or alcohol test as a condition of employment. Testing can be performed as part of the application process (1) before an offer of employment is made, or (2) as a part of the hiring process after an offer of employment is made but before the employee commences work.

Random testing
The testing of employees who are chosen on a "neutral selection" basis without advance notice. True random testing is conducted by pooling a selected amount of numbers determined by the client from the total number of qualified participants' numbers in the random pool.

Return to duty testing
Employees returning from a leave of absence for sickness or injury exceeding a given number of days can be required to submit and successfully pass a drug and/or alcohol test as a condition of reinstatement.

Reasonable suspicion or cause testing
The "cause" required is an objective, factual, individualized basis for testing, such as when an employee's observed behavior or physical appearance suggests drug and/or alcohol use or possession of drugs and/or alcohol.
I have read and agree to the above. I hereby consent to the substance abuse testing as outlined. *
Date*

MonthDayYear
Signature*

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Substance abuse screening
DISA Global Solutions release
I understand and agree that:
1. In connection with my application for employment, I understand that a consumer report or an investigative consumer report may be requested from DISA Global Solutions, Inc. (hereinafter referred to as DISA) that may include information as to my character, general reputation, personal characteristics, mode of living, and credit standing.
2. I understand that as directed by company policy and consistent with the job described, that information such as but not limited to criminal and warrant records, social security number verification, credit and financial information, education, driving history, employment history, personal references, certifications and professional licenses, drug testing results, address history, and workers' compensation records may be obtained.
3. I understand that such information may be obtained by direct or indirect contact from former employers, schools, courts, public agencies, or any other agency or institution and through personal interviews with neighbors, friends, associates, acquaintances, or other persons who have such knowledge.
4. Medical and workers' compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) and/or any other applicable state laws. According to the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained by my prospective employer from a consumer reporting agency. If so, I will be notified and given the name and address of the agency or the source which provided the information.
5. I acknowledge that a telephonic facsimile (fax) or photographic copy shall be as valid as the original. This release is valid for most federal, state, and county agencies.
The information requested here is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purposes.

By signing this form I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference, insurance company, or any other source contacted by DISA or its agent, to furnish the information described in Section 1. I hereby release the employer and agents and all persons, agencies, and entities providing information or reports about me from any and all liability arising out of the requests for or release of any of the above-mentioned information or reports. I acknowledge that I have read and understood the Employee Screening Release Authorization form. I understand that if hired my consent will apply throughout the term of my employment.
I have read and agree to the above. I hereby consent to the terms of the DISA employee screening release. *
Date*

MonthDayYear
Signature*

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Substance abuse screening for {name}
For internal use only
Employee information
Name
Address
Phone
Email
Social security number
Date of birth
Location
Position
Title
Start date
Substance abuse screening
YesNo
Date of review

MonthDayYear

Substance abuse screening
DISA membership application
I have received and reviewed a copy of the applicable DISA Contractor’s Consortium Substance Abuse Program Policy or Policies (“DCC”) and/or North American Substance Abuse Program Policy (“NASAP”).
View the substance abuse program policy
I am applying for membership into the applicable DISA Contractor Consortium Program or Programs (“DCC”), and/or North American Substance Abuse Program (“NASAP”) under the sponsorship of the Company Member indicated above. I agree, upon acceptance to:
- Abide by all program requirements for the DCC and/or NASAP programs to include applicable testing policies, rules, and regulations.
- Authorize the DCC to release my drug and/or alcohol test results to the Company Member for which I worked at the time I was tested and/or the Company Member which required me to take a post-offer of employment drug and/or alcohol test.
- Authorize the DCC to release information about my status in the DCC programs and policies to those Companies on the premises for which I seek to work, enter, or am currently working.
- Authorize the release of my DCC and/or NASAP status, test results, and other program activity to the North American Contractors Safety Council through NASAP with the understanding that this status may be shared with those companies participating in the NASAP program.
- Acknowledge and agree that this Membership Application represents a consent form and application for membership and in no way is a contract for services or products between me, DISA, and/or NASAP. I also agree that I am not a consumer of any product or services provided by DISA or NASAP to my employer or potential employer and that any product or services provided by DISA under the DCC and NASAP policies and programs are limited to DISA’s third-party administration of drug testing programs for and on behalf of my employer or potential employer.
- Acknowledge and understand that any “Inactive” status I may have in the applicable DCC program and/or NASAP program does not expire and I will remain on an “Inactive” status until such time that I complete the required Substance Abuse Professional (SAP) rehabilitation program and/or testing requirements of the applicable policy.
- Understand that I have a right to receive a copy of this authorization and application for membership in DCC and NASAP programs.
- You cannot amend any portions of this application through verbal promises and/or exceptions.
- It is the responsibility of your employer or potential employer to provide you with copies of or access to the relevant DCC and NASAP policies. You may ask your employer or potential employer for copies of or access to the relevant policies.
- The DCC and NASAP policies may be revised from time-to-time. You may ask your employer or potential employer for any updated policies and it is the responsibility of your employer to provide you copies of or access to the relevant policies.
I have read and agree to the above. I hereby consent to the conditions of the DISA membership application. *
Date*

MonthDayYear
Signature*

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