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<br />It <br /> <br />e <br /> <br />NOTICE OF LEGAL DRUG USE <br /> <br />In accordance with the City's Drug and Alcohol Abuse Policy, <br />please be advised that I am currently taking and possessing <br />at work the following prescription drug which has been <br />prescribed for a valid medical purpose: <br /> <br />Name of drug: <br /> <br />Prescription number: Prescription date: <br /> <br />Prescribing physician's name: <br /> <br />Prescribing physician's phone number: <br /> <br />This drug produces the following side effects: <br /> <br />[] Dizziness <br /> <br />[] Drowsiness <br /> <br />[] Nausea <br /> <br />Other: <br /> <br />My use of this drug is: <br /> <br />temporary and is expected to end on or about <br /> <br />[ ] <br />[ ] <br /> <br />indefinite <br /> <br />[ ] permanent <br /> <br />I hereby give my consent for the above named prescribing <br />physician to answer questions about my use of this drug. <br /> <br />(Individual Name) <br /> <br />(Individual Signature) <br /> <br />(Date) <br />