SUBSTANCE ABUSE POLICY
Employee Notification of Reasonable Suspicion Test Form
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 Reasonable Suspicion Substance Abuse Testing today.
In accordance with the City’s Substance Abuse Policy, you will be escorted 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.
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; or if necessary, arrange transportation to your home.
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 Reasonable Suspicion Substance Abuse Testing, and have been notified that I
will be transported to the drug-testing station at the Occupational Health Clinic at Retreat Hospital.
Acknowledge that I must present photo identification to the staff at the Occupational Health Clinic at Retreat Hospital.
Acknowledge that once notified for Reasonable Suspicion Substance Abuse 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 Reasonable Suspicion Substance Abuse 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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