Page 146 - Personnel Policy and Procedures Manual

SUBSTANCE ABUSE TEST CONSENT FORM

I, , do hereby give my consent to the Augusta, Georgia (or its
agent(s)) to collect a urine, breath and/or blood sample from me to determine if I have used illegal drugs or
misused alcohol and/or drugs or controlled substances (including the misuse of any legal drugs).

I further give my consent to Augusta, Georgia to forward the sample(s) to a qualified laboratory for its
performance of appropriate tests thereon to identify the presence of substances illegal under the Substance
Abuse Policy.

I further give the testing laboratory my permission to release the results of such test to Augusta, Georgia
Risk Management and/or the Medical Review Officer for the Augusta, Georgia government.

I understand that refusal to submit to testing or providing false information in connection with a test is
considered the same as a positive test result.

I hereby certify that I will not adulterate or substitute any urine sample given under the Substance Abuse
Policy.

Employee Signature:

DATE:

WITNESS:

DATE:
FORM SA-3THIS PAGE INTENTIONALLY LEFT BLANK

All Rights Reserved – As approved by the Commission on 05-07-2019 146 | P a g e