City of Hickory
PO Box 398
Hickory, NC 28603
Phone: (828) 323-7421
Fax: (828) 323-7550
Human Resources Department
2019-2020 Certification Regarding Nicotine Use
Employee Name (Print): _______________________________________________
Department: _______________________
Non-Nicotine User
I certify that I am eligible for the Non-Nicotine User Premium, by checking this box and returning this
form to Human Resources to be placed in my personnel file. For the purposes of this certification,
nicotine products include tobacco in all forms, as well as nicotine gum, lozenges, patches and e-
cigarettes in any form containing nicotine.
• I certify that this information is true & correct to the best of my knowledge.
• I understand that by certifying that I am a non-nicotine user, my name will be placed in a random drawing for nicotine testing.
• I understand that by certifying that I am a non-nicotine user, I agree to undergo nicotine (cotinine) testing should my name be
randomly drawn to do so.
• I understand that refusal to submit to a required random test will be considered a positive test result.
o I acknowledge & understand that the following conditions apply should my random cotinine test return a positive result:
1.
I will be required to pay back the premium, dated back to July 1 of the current fiscal year.
2.
I will also be required to pay the nicotine user premium for the remainder of the current fiscal year.
3.
I will be disciplined for making a fraudulent statement certifying my nicotine use. The disciplinary action will be at least a
one-day (1) suspension without pay and possibly up to & including dismissal
o I acknowledge & understand that if my nicotine user status changes and I do not immediately change
my status with Human Resources, & I test positive on a random test, all three of the above stated
conditions apply.
Nicotine User
I acknowledge that I will pay the Nicotine User premium by checking this box.
• I declare that I use nicotine in some form or that I choose not to disclose my status as it relates to nicotine use.
• I understand that by using nicotine, I am choosing to pay the nicotine user premium.
• I understand that if I cease to use nicotine, I may request to fill out another certification & that I will then declare myself a non-
nicotine user subject to nicotine testing as outlined in the Non-Nicotine User section above.
• I understand that I may change my nicotine-user status to “non-nicotine user” anytime during the fiscal year by notifying
Human Resources & completing a new Certification form. Any premiums collected will not be refunded.
Refusal to sign this form will place the coworker in the Nicotine User category.
Employee Signature Date
Human Resources Date
If you have questions, please call Human Resources at 828.323.7421
05/13/2019
