Code No.: 403.7E2
DRUG & ALCOHOL PROGRAM AND PRE-EMPLOYMENT TESTING
I, ( ), have received a copy, read and understand the Drug and
Alcohol Testing Program policy of the Anamosa Community School District and its supporting
I understand that if I violate the Drug and Alcohol Testing Program policy, its supporting documents or
the law, I may be subject to discipline up to and including termination.
I also understand that I must inform a District Nurse of any prescription medication I use.
In addition, I have received a copy of the U.S. DOT publication, “What Employees Need to Know about
DOT Drug & Alcohol Testing,” and have read and understand its contents.
Furthermore, I know and understand that I am required to submit to a controlled substance (drug) test, the
results of which must be received by this employer before being employed by the school district and
before being allowed to perform a safety-sensitive function. I also understand that if the results of the
pre-employment test are positive, that I will not be considered further for employment with the school
I further understand that drug and alcohol testing records and information about me are confidential, and
may be released at my request or in accordance with the district’s drug and alcohol testing program
policy, its supporting documents or the law.
(Signature of Employee) (Date)