Fillable SUBSTANCE ABUSE REASONABLE SUSPICION POST TEST TRANSPORTATION REFUSAL

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SUBSTANCE ABUSE REASONABLE SUSPICION POST TEST TRANSPORTATION REFUSAL

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SUBSTANCE ABUSE REASONABLE SUSPICION
POST TEST TRANSPORTATION REFUSAL FORM
Employee Name:
Department:
Position:
Date of Observation:
Time:
By signing below, I acknowledge my understanding of the following:
1. I understand that MAU recommends that I not operate a vehicle and that MAU has agreed to
provide transportation to my home at MAU’s expense.
2. I understand that I also have the option of contacting a friend or family member for transport.
3. I understand that by refusing transport per MAU recommendations and leaving by driving my
vehicle:
a. I agree to hold MAU harmless for any injuries, damages or liabilities of any kind
resulting from my decision to refuse MAU’s transportation offer
b. I understand that MAU will immediately contact local law enforcement.
I HAVE REFUSED THE OFFER OF TRANSPORTATION MADE TO ME BY MAU.
Employee Signature
Date
Supervisors Signature
Signature Date
Supervisors Printed Name
SUMMARY:
Additional Witness (Optional)
Witness Signature
Signature Date
Witness Printed Name
Form 421-3/17
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SUBSTANCE ABUSE REASONABLE SUSPICION POST TEST TRANSPORTATION REFUSAL

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Completed 7 April 2021

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