Attachment F "Employee Drug Testing Referral Form" - Florida

What Is Attachment F?

This is a legal form that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Florida Department of Juvenile Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Attachment F by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

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Download Attachment F "Employee Drug Testing Referral Form" - Florida

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FLORIDA DEPARTMENT OF JUVENILE JUSTICE
POLICY AND PROCEDURES
ATTACHMENT F
EMPLOYEE DRUG TESTING REFERRAL FORM
EMPLOYEE DRUG TESTING REFERRAL FORM
DRUG TEST REQUEST DATE:
REQUEST TIME:
You (
) are hereby ordered to appear at the following drug
testing collection site for the purpose of specimen collection.
(Name of approved drug testing collection site and site location)
The reason for drug testing specimen collection is indicated below:
(CHECK APPROPRIATE BOX)
PRE-EMPLOYMENT TESTING
RANDOM DRUG TESTING
REASONABLE SUSPICION TESTING
If you do not appear at the collection site within the specific time frame for the random or
reasonable suspicion testing, you will be considered to have refused to submit to drug testing. You
will be subject to disciplinary action up to and including dismissal for failure to report to the
collection site unless the employee provides sufficient justification for failure to appear, subject to
approval by the Regional Director or equivalent level administrator.
If the test results are positive, you will be notified by the Medical Review Officer (MRO) and
offered the opportunity to produce valid documentation of lawful ingestion of the appropriate
identified controlled substance. You must present within 5 working days documentation that would
provide a legitimate explanation of the positive test results, such as prescriptions or over the counter
medications that may have been taken that would cause a positive result. You must submit this
information to the Medical Review Officer (MRO). If the MRO determines that the positive test
result is a result of legitimate prescription or over the counter medication, the MRO shall report a
negative test result for the specimen.
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FLORIDA DEPARTMENT OF JUVENILE JUSTICE
POLICY AND PROCEDURES
ATTACHMENT F
EMPLOYEE DRUG TESTING REFERRAL FORM
EMPLOYEE DRUG TESTING REFERRAL FORM
DRUG TEST REQUEST DATE:
REQUEST TIME:
You (
) are hereby ordered to appear at the following drug
testing collection site for the purpose of specimen collection.
(Name of approved drug testing collection site and site location)
The reason for drug testing specimen collection is indicated below:
(CHECK APPROPRIATE BOX)
PRE-EMPLOYMENT TESTING
RANDOM DRUG TESTING
REASONABLE SUSPICION TESTING
If you do not appear at the collection site within the specific time frame for the random or
reasonable suspicion testing, you will be considered to have refused to submit to drug testing. You
will be subject to disciplinary action up to and including dismissal for failure to report to the
collection site unless the employee provides sufficient justification for failure to appear, subject to
approval by the Regional Director or equivalent level administrator.
If the test results are positive, you will be notified by the Medical Review Officer (MRO) and
offered the opportunity to produce valid documentation of lawful ingestion of the appropriate
identified controlled substance. You must present within 5 working days documentation that would
provide a legitimate explanation of the positive test results, such as prescriptions or over the counter
medications that may have been taken that would cause a positive result. You must submit this
information to the Medical Review Officer (MRO). If the MRO determines that the positive test
result is a result of legitimate prescription or over the counter medication, the MRO shall report a
negative test result for the specimen.
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All employees with a first positive confirmed random or reasonable suspicion drug test will be given
the opportunity to participate in, at the employee’s own expense or pursuant to coverage under a
health insurance plan, an employee assistance program or alcohol and drug rehabilitation program.
All information, interviews, reports, statements, memoranda, and drug test results (written or
otherwise) received by the agency through a drug testing program are confidential communications
and will not be used or received in evidence, obtained in discovery, or disclosed in any public or
private proceedings, except in accordance with the Florida Drug-Free Workplace Act.
Any questions regarding this drug testing referral should be directed to the Designated Agency
Authority.
ONCE THE TESTING HAS BEEN COMPLETED, PLEASE HAVE THE COLLECTION
SITE SIGN AND DATE THIS FORM IN THE SECTION BELOW AND RETURN THIS
FORM TO THE DESIGNATED AGENCY AUTHORITY OR DESIGNEE WITHIN ONE (1)
WORK DAY.
Collection Site Name
Date of Test
Collection Site Staff Signature
Time of Test
Print Staff’s Name
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