SUBSTANCE ABUSE POLICY
Employee Notification of Random Substance Abuse Test
Employee Name: _______________________ SSN (last four digits): _____________________
Department: _______________________ Supervisor’s Name: _____________________
Notification Date: _______________________ Time of Notification: _________________am/pm
Part A-Manager or Supervisor Reads to the Employee:
You have been selected for random substance abuse testing today.
In accordance with the City’s Substance Abuse Policy, you must report to the Occupational Health Clinic located on the
1
st
floor of Retreat Hospital (located at 2621 Grove Avenue, Richmond, VA 23220. Telephone 804-254-5467) no later
than forty-five (45) minutes from the time of this notification.
You must present photo identification to the staff at the Occupational Health Clinic at Retreat Hospital. If you do not
have photo identification, a supervisor will accompany you to the Occupational Health Clinic at Retreat Hospital.
If you do not have transportation, The City of Richmond will provide you with transportation to the Occupational Health
Clinic at Retreat Hospital and will return you to your work site.
If you refuse to comply with these directions, you will be disciplined in accordance with the City’s Substance Abuse
Policy.
Manager or Supervisor’s Signature: ___________________________ Date/Time _________________
Part B-Employee Acknowledgement
Acknowledge being notified to appear for Substance Abuse Testing, and have been notified to report to the drug-testing
station with picture identification at the Occupational Health Clinic at Retreat Hospital.
Acknowledge that once notified for random testing, I will be tested at the Occupational Health Clinic at Retreat Hospital
(located at 2621 Grove Avenue, Richmond, VA 23220. Telephone 804-254-5467). I will have a total of forty-five (45)
minutes to report to the Occupational Health Clinic at Retreat Hospital testing site from the time of notification.
There are no exceptions.
Acknowledge that if I fail to submit to a random drug test within forty-five (45) minutes of such notification, my failure
to submit to the drug testing shall be considered as a refusal, and shall be the basis for the imposition of discipline, in
accordance with the Substance Abuse Policy.
Acknowledge that if I refuse, I will not be forced to have a test administered, but I will not be allowed to return to duty,
and I will be immediately placed on Leave Without Pay (LWOP) and sent or transported home.
Acknowledge that if I test positive for prohibited substance or alcohol use, I will be disciplined in accordance with the
provisions of the Substance Abuse Policy.
Employee Signature: _____________________________________ Date/Time ________________
Employee and Supervisor are to sign and date the form as requested. Forward the completed form to the Department’s Substance Abuse
Coordinator accompanied with the Confirmation of Test form.
SAP Form (revised 09-13-2006)
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