Procedure No. 5.1 – Supplement 1
DRUG-FREE WORKPLACE STATEMENT
I (name) _______________________________________ agree that as a condition of
employment with Atlantic Cape Community College. I will abide by the terms of this statement.
“I hereby acknowledge receipt of my employer’s policy of maintaining a drug-free workplace.
I hereby agree to notify my employer of any criminal drug-statute convictions for any violation
occurring in the workplace no later than five (5) days after any conviction.
I hereby acknowledge that in the event of any conviction for possession, manufacture,
distribution, dispensation or use of a controlled substance in the workplace I will lose any
privacy rights once the conviction is final, and I hereby waive all privacy rights that I have to this
information.
I hereby further authorize my employer to release any information concerning any violations by
me under the Drug-Free Workplace Act in any unemployment compensation hearings, union
arbitration, workers compensation, federal or state actions involving the terms of my
employment, or internal college grievance or disciplinary procedures.”
I have read the above, acknowledge its receipt and agree to abide by the terms thereof.
___________________________________________
Print Name College ID#
___________________________________________
Employee’s signature Date
___________________________________________
Supervisor’s signature Date
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