Acknowledgement of Receipt of Drug-Free Workplace Policy and Consent to Drug Testing Form

As explained in Colas Inc.’s Drug-Free Workplace Policy (Policy), Colas. Inc. is committed to providing its employees with a safe workplace that is free from unlawful drugs and alcohol. Pursuant to that Policy, current employees of and applicants for employment with Colas. Inc. will be tested for drugs and alcohol at certain times before and during their employment with Colas Inc.

I, the undersigned, acknowledge that:

1. I have received and understand the Company’s Drug-Free Workplace Policy. I understand that my compliance with the Company’s Policy on drugs and/or alcohol is a condition of my employment with Colas Inc. and I agree to abide to all terms of the Policy. I further understand that non-compliance may result in disciplinary action up to and including termination.
2. I agree to submit to and cooperate fully with the Company’s drug and alcohol testing (“drug test”) requirements as described in the Policy. I agree to provide a urine, hair or other appropriate sample upon request, and undergo other necessary procedures, as required to perform the drug test. I acknowledge that the drug test will be conducted by a certified laboratory, which will collect and test the drug test samples, and verified by the Company’s Medical Review Officer (“MRO”). I agree to be monitored by a laboratory employee of my gender when I provide the test sample. I authorize the release of the laboratory test results in accordance with the Company’s Policy to the selected MRO. In doing so, I understand that I will be given an opportunity to discuss a positive drug test result with the MRO before the result is reported to the Company as a verified positive. I also authorize the collection site, laboratory and/or MRO retained by Colas Inc. or its designated agent, Applicant Insight to disclose the drug test results to Colas Inc. I understand that the drug test results will remain confidential to the extent required by law and all records related to the test will be kept separately from my personnel file.
3. I consent to undergo a pre-employment drug test before I begin my employment with Colas Inc. After commencing employment, I consent to undergo random drug tests that the Company may require for employees in my position. I also consent to be tested if I am involved in a workplace incident or injury, if the Company has reasonable suspicion to believe that I was under the influence of unlawful drugs or alcohol while working for Colas Inc. or on the Company’s premises, and under any other circumstances permitted by applicable law.
4. The Genetic Information Non-Discrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. In compliance with this law, I understand that I am not being asked to provide any genetic information when responding to a request for medical information related to a drug test. Genetic information, as defined by the GINA, includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.
5. I understand that I may be tested for any of the following substances as well as any other substances the Company deems necessary: marijuana, cocaine, opiates, amphetamines, phencyclidine, and alcohol to determine my eligibility for employment or continued employment.
6. I understand that the Company will pay for any initial drug test that it requires and that I will be compensated at my regular rate of pay for the time spent submitting to a drug test required by the Company.
7. I understand that if I test positive for unlawful drugs or alcohol, I will be in violation of the Company’s Policy and subject to discipline, up to and including termination or withdrawal of a conditional job offer. I understand that I have the right to a retest at my own expense if an initial test indicates use of unlawful drugs or alcohol, and that I will have the opportunity to explain to the Company that a positive test result is due to my legitimate use of prescription medication. I understand that my refusal to take, failure to complete or tampering with a drug test required by the Company will be grounds for discipline, up to and including my termination or withdrawal of a conditional job offer. I understand that the test results will not be used for any other purpose than described in this form and the Policy.
8. I hereby release from liability Colas Inc. and its subsidiaries and their respective officers, directors, employees, agents, and all other parties involved in testing for any actions taken during or after a drug test, including any violation of state drug testing laws, as well as errors in testing and any actions taken by Colas Inc. following a test.
9. I understand that I have a right to receive a copy of this Acknowledgment and Consent form. I understand that I have the right to inspect and/or receive a copy of the information to be released and that I will be charged a fee for any copies of the medical records that I receive in accordance with applicable state law. I understand that information used or disclosed based on this authorization may be subject to re-disclosure and no longer protected by federal privacy standards. I agree that a photocopy of this signed Acknowledgment and Consent form has the same validity as an original.
10. I understand that I may revoke this authorization at any time by providing a written statement of withdrawal to the Designated Employer Representative (DER), except to the extent that action has already been taken in reliance upon it. I am aware that my withdrawal will not be effective until received by the DER. I am also aware that my withdrawal will not be effective regarding uses and/or disclosures of my health information that have been made prior to receipt of my withdrawal statement.
11. I acknowledge that I have fully read and understand this Acknowledgement and Consent form and I consent to drug and alcohol testing under the terms discussed above and in Colas Inc.’s Drug-Free Workplace Program Policy. I acknowledge and agree that I have had an opportunity to ask questions about this form before signing it. Unless otherwise revoked, this authorization is to remain in effect for one year from the date of signature, or upon termination of employment, whichever is later.