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<br />e <br /> <br />e <br /> <br />TEST CONSENT FOR NON-EMPLOYEES; <br /> <br />PART I. NOTICE TO SPECIMEN DONOR <br /> <br />City policy states that employees, contractors, <br />subcontractors, vendors, and other non-employees working on <br />City premises may be asked in certain situations to provide <br />urine or blood specimens for drug testing purposes. At this <br />time you are being asked to provide a urine or blood <br />specimen relating to the situation checked below: <br /> <br />[] Accident <br />[] Random <br />[] Other <br />PART II. ACKNOWLEDGMENT AND CONSENT OF SPECIMEN DONOR <br /> <br />[] Cause Based on Reasonable Belief <br />[] Return to Employment <br /> <br />In the past 30 days, I have taken medications that treat: <br /> <br />[] Pain [] Muscle spasms [] Allergies [] Nervousness <br />[] Nausea, vomiting, diarrhea [] Asthma, wheezing <br />[] Coughing, sneezing, congestion [] Heart problems <br />[] Weight problems [] Sleeping problems [] Depression <br />[] Other <br /> <br />My employment status is: [] Contractor [] Subcontractor <br /> <br />[ ] Vendor <br /> <br />[] Other <br /> <br />I am employed by <br /> <br />I understand the City is now asking me to provide a specimen <br />of my urine or blood for drug testing. I hereby agree and <br />also authorize the specimen collecting and testing agencies <br />to furnish the results of the test to the City and to my <br />employer. <br /> <br />(Signature of Specimen Donor) <br /> <br />(Signature of Witness) <br /> <br />(Printed Name of Donor) <br /> <br />(Date) <br />