2014/05/21 Council Agenda Packet

15 Section 17 Consent for Sampling and Release of Information Form CONSENT/RELEASE Subject to my rights under Article 38 of the Collective Bargaining Agreement between Local 46 of the IAFF and the City of Everett, I consent to the collection of a urine/blood, and/or breath sample by and its analysis by for alcohol and those drugs specified in the Collective Bargaining Agreement. Laboratory test results will be allowed to be released to the City only after the results have been reviewed and interpreted by the Medical Review Officer. Information provided to the employer shall be only whether the tests were confirmed positive or were negative and not any other results of the test without my written consent. The laboratory is not authorized to release the results of this test to any other person or entity other than the City without my written consent. I understand I have the right to my complete test results and that the laboratory will preserve the sample for at least six (6) months. I have the right to have this sample split and a portion retested at my expense in the event the test results are confirmed positive. I understand that the City is requiring me to submit to this test as a condition of my employment and that alteration of the sample or failure to reasonably cooperate with the collection of a urine/blood and/or breath sample will result in disciplinary action by the City. I understand that a confirmed positive test may result in a requirement that I undergo rehabilitation. By signing this consent form, I am not waiving any of my rights under any federal, state or local law, statute, constitution, ordinance, administrative rule or regulation or common law provision. I understand that I have the right to challenge any confirmed positive test result and any employer action based thereon by filing a grievance under the Collective Bargaining Agreement. Date Employee Signature 20 60