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<br /> 63 <br />Section 17 Consent for Sampling and Release of Information Form <br /> <br />CONSENT/RELEASE <br /> <br />Subject to my rights under Article 38 of the Collective Bargaining Agreement between Local 46 of the <br />IAFF and the City of Everett, I consent to the collection of a urine/blood, and/or breath sample by <br />___________________________________________________________________ and its analysis by <br />_____________________________________________________________ for alcohol and those drugs <br />specified in the Collective Bargaining Agreement. <br /> <br />Laboratory test results will be allowed to be released to the City only after the results have been reviewed <br />and interpreted by the Medical Review Officer. Information provided to the employer shall be only <br />whether the tests were confirmed positive or were negative and not any other results of the test without <br />my written consent. The laboratory is not authorized to release the results of this test to any other person <br />or entity other than the City without my written consent. <br /> <br />I understand I have the right to my complete test results and that the laboratory will preserve the sample <br />for at least six (6) months. I have the right to have this sample split and a portion retested at my expense <br />in the event the test results are confirmed positive. <br /> <br />I understand that the City is requiring me to submit to this test as a condition of my employment and that <br />alteration of the sample or failure to reasonably cooperate with the collection of a urine/blood and/or <br />breath sample will result in disciplinary action by the City. <br /> <br />I understand that a confirmed positive test may result in a requirement that I undergo rehabilitation. <br /> <br />By signing this consent form, I am not waiving any of my rights under any federal, state or local law, <br />statute, constitution, ordinance, administrative rule or regulation or common law provision. I understand <br />that I have the right to challenge any confirmed positive test result and any employer action based thereon <br />by filing a grievance under the Collective Bargaining Agreement. <br /> <br /> <br />_________________________ <br />Date <br />____________________________________________________ <br />Employee Signature <br /> <br /> <br />