EMPLOYEE REFUSAL TO SUBMIT FOR
DRUG AND/OR ALCOHOL TESTING
I understand that MAU requires a drug and alcohol screen under its Substance Abuse
Policy at the time of hire, if I am involved in an on the job accident or injury, or under
circumstances that suggest possible involvement or influence of drugs or alcohol.
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 Substance Abuse Policy,
they will be answered by my immediate supervision and/or Human Resources.
By my signature below, I acknowledge that I have refused to submit to a drug or
alcohol test by furnishing a sample of my urine or hair for analysis as required under
the Substance Abuse Policy of MAU (the Company). I understand and agree that my
refusal to submit to a drug or alcohol test under company policy, or if I otherwise fail
to cooperate with the testing procedures, will result in immediate termination or
rescinding of any offer of employment.
Remember, "involved in an on-the-job accident or injury" means not only the one
who was injured, but also anyone who arguably or potentially contributed to the
accident or injury event in any way, i.e., the person suspected of causing someone
else to get hurt gets tested as well.
Signature of Employee Date
Employee's Name - Printed
Company Representative Date
Form # 116-03/17
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