UHRS 4/2009
FORM 3
EMPLOYEE REFUSAL TO SUBMIT TO SUBSTANCE ABUSE TESTING
I have been informed by my supervisor of behaviors that constitute a reasonable suspicion that I am currently under the inuence
of alcohol or drugs. I have been further informed that university policy requires me to submit to a substance abuse testing of my
blood and/or urine under such circumstances.
I understand that my refusal to submit to substance abuse testing may in and of itself be grounds for corrective action, up
to and including termination of my employment.
I hereby refuse to authorize or submit to any substance abuse testing of my blood and/or urine for alcohol and/or drugs.
Employee – Print Name
Employee – Signature Date
Supervisor – Print Name
Supervisor – Signature Date
Witness/Union Representative – Print Name
Witness/Union Representative – Signature Date
Note to Supervisor: If employee refuses to sign either the Consent to Drug and/or Alcohol Testing Form or this refusal to test form, please
complete the following Statement of Refusal.
Statement Of Employee Refusal
I, the supervisor whose signature appears below, arm that I explained to the information
that appears above and informed the employee that refusal to submit to substance abuse testing based upon reasonable suspi-
cion was grounds for termination of employment. The employee refused to sign either the consent or the refusal.
Signature Print Name
Title Date
