R2002-0057 04-08-02RESOLUTION NO. R2002-57
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF
PEARLAND, TEXAS, ADOPTING A SUBSTANCE ABUSE
PROCEDURE FOR THE EMPLOYEES OF THE CITY OF PEARLAND.
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF PEARLAND, TEXAS:
Section 1. That City of Pearland Substance Abuse Procedure, a copy of which
is attached hereto as Exhibit "A" and made a part hereof for all purposes, is hereby
adopted.
PASSED, APPROVED and ADOPTED this the 8 day of
April , A.D., 2001.
TOM REID
MAYOR
ATTEST:
APPROVED AS TO FORM:
DARRIN M. COKER
CITY ATTORNEY
CITY OF PEARLAND
SUBSTANCE ABUSE PROCEDURE
Effective: March 1, 2002
TABLE OF CONTENTS
Statement of Policy
Qualifications for Employment and Prohibited Conduct
Substances Tested
Required Testing
Specimen Collection
Testing Methodology
Medical Review Officer
Discipline
Employee Assistance Training and Education
Confidentiality
Record Retention
Acknowledgment and Receipt of Substance Abuse Policy
Special Considerations
Appendices
A-1
A-2
B-l-B-5
B-6
C
D
E
F
G
Pa~e(s)
3-4
4-6
6-9
9-10
10-11
11-14
14-15
15-17
17
17
17
17-18
Notification of Pre-employment Drug Screen
Applicant Consent Form
Supervisor Report of Reasonable Cause
Authorization/Record Release
Specimen Collection Procedures (5 pages)
Employee Split Specimen Testing Request Form
Certification of Completion of Drug Abuse Awareness Program
Drug Testing Authorization Record Release
Acknowledgment and Receipt of Substance Abuse Policy
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STATEMENT OF POLICY
A. General Provisions
The City of Pearland recognizes that the use and/or abuse of alcohol or controlled substances by
employees present a serious threat to the safety and health of the employee and the general
public. It is the policy of the City of Pearland that employees who drive on the public roads of
Texas and throughout the nation should be free of drugs and of alcohol.
In order to further our goal of obtaining a drag/alcohol fi:ce workplace, and to come into
compliance with existing Federal Regulations, the City'ofPearland decided to implement a drug-
testing program, designed to reduce accidents and casualties in our operation. The City believes
that the implementation of such a program will discourage substance abuse and reduce
absenteeism, accidents, health care costs and other drag-related problems. The City further
believes that a drag testing program will operate as a deterrent to those individuals who might be
tempted to try drugs for the first time or who currently use drugs. Finally, the City believes that
the program will enhance the safety and health of its employees and the community by fostering
the early identification of workers with drug and alcohol abuse problems.
The City of Pearland's drug/alcohol testing program is incorporated in an overall substance abuse
policy designed to create a drug-free workplace. The program has been developed in compliance
with existing federal regulations and in a manner, which ensures accurate and reliable test
results, thereby eliminating the possibility of any "false positives". It also contains procedures
designed to recognize and respect the dignity and privacy of all City employees. More
importantly, the City recognizes that its employees are a valuable resource and wants to' assist
any employee who voluntarily comes forward and requests assistance with chemical dependency
or alcoholism. The City therefore provides information on and access to an appropriate
employee assistance program prior to any request for a drug test under this policy.
QUALIFICATIONS FOR EMPLOYMENT AND PROHIBITED CONDUCT
A. Prohibited Conduct
City policy prohibits the following conduct:
No person will be "physically qualified" to drive a motor vehicle if he or she uses,
possesses, or is under the influence of a Schedule I drag, amphetamine, narcotic
or any other habit forming drug, or if he or she has a current clinical diagnosis of
active alcoholism. This excludes any medication prescribed by a physician who
has advised the driver that the medication will not interfere with his or her ability
to safely operate a motor vehicle.
No person shall consume or be under the influence of an intoxicating beverage
within four (4) hours before going on duty, operating or having physical control
of a motor vehicle.
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No person shall consume, be under the influence, or possess any intoxicating
beverage or have any measured alcohol concentration or detected presence of
alcohol while on duty, operating or having physical control of a motor vehicle.
o
No person shall be permitted to operate a motor vehicle if his or her general
appearance, conduct or other evidence indicates that he has consumed an
intoxicating beverage within the preceding four (4) hours.
o
A person will be disqualified from driving a motor vehicle for a minimum of one
(1) year if he is convicted of operating a motor vehicle while under the influence
of a drug or alcohol, transporting, possessing or using a Schedule I drag,
amphetamine or narcotic. In this event, the person will be considered for transfer
to another position, if available, and/or qualified.
As a condition of employment, the City of Pearland requests that City employees do not use
controlled substances (without medical supervision) either in the workplace or during their off-
duty time. Furthermore, a verified positive urine drug test through this testing program
represents gross misconduct of the City of Pearland's Substance Abuse Initiative, for the
workplace and the Community as a whole.
B. Disqualification
The above rules govern an employee's qualifications to operate a motor vehicle for business
purposes as an employee of the City of Pearland. Under these rules, any driver found to be using
or under the influence of any controlled substance will not be qualified to operate a motor
vehicle. Therefore, any driver who tests positive for a controlled substance in any drug test or
positive on an alcohol test required under this policy will be disqualified from driving a motor
vehicle for the City of Pearland. Drivers testing positive after fatal accidents will not be eligible
for reinstatement to driving duties for a period of at least one (1) year from the date of the
positive test result.
In addition to any disqualification under this policy, the employee may also be subject to
discipline, up to and including discharge, for any positive or adulterated test result or conduct in
relation to a drug and/or alcohol test, depending upon the circumstance surrounding the taking of
the test and the positive result.
C. Criminal Convictions of Drug Statutes
A conviction under any criminal drug statute; or failure to notify the City of Pearland of any
arrest or conviction under any criminal drag statute, within five days after the arrest or
conviction may result in termination of employment.
SUBSTANCES TESTED
A. Controlled Substance
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Any drag test required by the City of Pearland will analyze an individual's urine to test for the
presence of the following "controlled substances" as def'med by state and/or federal laws, but are
not limited to:
Amphetamines
Marijuana (THC)
Cocaine Phencyclidine
Opiates
In addition to the above substances, the City of Pearland reserves the right to also test for other
substances in circumstances such as, but not limited to, Reasonable Cause in consultation with
the City of Pearland's Medical Review Officer (MRO). (In order to perform this additional
testing, an additional non-DOT urine specimen collection will be required.)
B. Alcohol Testing
All alcohol tests conducted under this Policy require the employee to provide a breath specimen
for any test conducted by, or on behalf of, the City ofpearland.
Alcohol tests will be administered using a breath specimen, taken by a breath alcohol technician
(BAT) using an approved breath testing device (EBT), designated by the City of Pearland;
except in cases of on-scene post-accident testing conducted by federal, state or local officials.
Before being tested by the City of Pearland, each employee will be required to (1) present his/her
personal identification, and (2) execute a "Breath Alcohol Test Form" provided by the BAT. An
employee who refuses to provide his/her identification, provides a false identification, refuses to
execute the consent forms or who otherwise refuses or fails to cooperate will be treated as though
he/she has tested positive and will be subject to disciplinary action, up to and including
discharge.
To protect each employee, the BAT will open and attach to the testing device an individually
sealed mouthpiece in the employee's view. The employee will then be directed to blow
forcefully into the breath-testing device until an adequate amount of breath has been maintained.
In the event that an employee is unable to provide an adequate amount of breath for the initial or
confirmatory test after several attempts to do so, the employee will be:
Required to submit to an evaluation by a licensed medical physician to determine
whether a valid medical condition exists. If the physician determines that a valid medical
condition does exist and the City of Pearland notified thereof, the City of Pearland will
not deem this as a refusal to test. If the physician determines that a valid medical
condition does not exist and provides a written statement of the basis for his/her
conclusion to the City of Pearland, the employee/applicant's failure to provide an
adequate amount of breath shall be regarded by the City of Pearland as a refusal to take a
test and will be subject to disciplinary action, up to and including diScharge.
C. Alcohol Testing Results (breath)
1. Alcohol test result less than 0.02 grams percent is a negative test.
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Alcohol test result of 0.02 or greater but less than 0.04 grams percent will
disqualify employee fi:om safety sensitive function for a minimum of 24 hours.
Alcohol test result of 0.04 grams percent or greater is a positive alcohol test.
Employee is medically disqualified from performing safety-sensitive duties and
will be subject to termination.
D. Prescribed Medication
An employee who has a laboratory positive urine drug test will have the opportunity to discuss
the use of medications and recent medical care with the MRO. The employee will be required to
identify the physician prescribing the medication and authorize the MRO to communicate with
that physician about the medication, its possible side effects and the condition requiring the
taking of the medication and their relationship to the employee's ability to safely perform his/her
job.
If the MRO determines that an employee is taking or is under the influence of a prescribed
medication that will adversely affect the employee's ability to safely and adequately perform his
or her job, and o/:' pose a significant risk of harm to the public or to other employees, the
employee will be placed on a medical leave of absence (utilizing the employees sick leave, if
available) or placed in another position until the employee is no longer taking the medication,
provided a safe and reasonable accommodation can be made.
REQUIRED TESTING
A. Post-Offer
Any applicant, considered for employment will be required to provide a urine, and/or breath
sample for testing. The applicant will be advised of the drug test in a letter that will be given to
him describing the time and location for the taking of the sample. Appendices Al-A2
As a condition for employment, an individual applying for a position requiring the performance
of safety-sensitive functions shall, at the request of the City of Pearland, provide written
authorization for previous employers to release to the City of Pearland any and all test results,
including records of the individual's refusal to test, administered in accordance with the Federal
Highway Association's (FHWA) Rules and Regulations concerning controlled substances and
alcohol use and testing.
B. Promotional Positions
All classified and non-classified personnel will be subject to drag testing as a part of a physical
examination required for promotional positions.
C. Transfers
All classified personnel under Chapter 143 of the Texas Local Government Code employed as
certified peace officers within the Pearland Police Department will be subject to drug testing as a
condition of transfer into any one of the following divisions/units in the Police Department:
P~e6
2.
3.
4.
5.
6.
Narcotics
Organized Crime Unit
D.A.R.T. (Direct Action Response Team)
D.A.R.E. (Drug Abuse Resistance Eduction)
C.I.D. (Criminal Investigation Division)
S.R.O. (School Resource Officer)
The City of Pearland reserves the right to amend, change, and/or expand the divisions/units in
the Police Department that are subject to testing as business needs necessitate.
All non-classified personnel transferring into safety sensitive positions as described under
"Required Testing, Section F" will be subject to drug testing as a condition of transfer.
D. Reasonable Cause
The City of Pearland will require a drug/alcohol test for an employee when there is reasonable
cause to believe that the employee is using a prohibited drug and/or alcohol in violation of this
Policy. The employee will be asked to sign the consent form. Any employee who refuses to
sign the consent form or to provide urine and/or blood sample will be considered insubordinate
and will be subject to appropriate disciplinary actions including discharge.
If possible, the reasonable cause circumstances should be witnessed by at least two (2)
Supervisors or Department Heads. Any Supervisor or Department Head will be required to
complete a "Supervisor's Report of Reasonable Cause" which will be forwarded immediately to
Human Resources for review and consideration with any positive test result. Page 1-5' of
Appendix B-1 - B-6
The employee shall be escorted to the clinic by a Supervisor or Department Head to provide a
urine sample for drug testing and breath sample for alcohol testing. After appropriate samples
are provided, arrangements will be made with a spouse, family member or other individual to
transport the employee to his/her home. In the event no such individual is available, a taxicab
will be called to take the employee home, at the employee's expense. The employee will be
reimbursed for the cost of the taxicab if the result of his/her sample test is negative. If the
employee refuses and attempts to operate his/her own vehicle, the City of Pearland will take
appropriate efforts to discourage him/her fi:om doing so, up to and including contacting local law
enforcement officials.
Pending the City of Pearland's receipt of the employees' drug/alcohol test, the employee will be
suspended without pay. If the test results are negative, the employee will be reinstated with no
loss of seniority and in appropriate instances will be awarded full back pay.
E. Post-Accident
Following any incident resulting in an injury or accident, the Human Resource Office shall be
notified at the fu'st available opportunity. In addition, any employee involved in an incident as
described below shall be required to provide a blood and urine sample as soon as possible and no
later than the end of the current work shift:
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1. A fata~ty;
Bodily injury to any person (employee, co-worker, and/or non-employee) who, as
a result of the accident is injured and receives medical treatment away from the
scene of the accident,
An incident involving one or more motor vehicles incurring disabling damage as a
result of the incident, requiring the vehicle to be transported away from the scene
by a tow truck or other vehicle, or
An incident involving moving violations that results in a citation being given by a
law enforcement officer.
The employee involved in any one of the above shall notify the City of Pearland at the first
available opportunity after the accident.
In the event a driver is seriously injured and unable to provide a urine sample, breath and/or
blood alcohol sample, he/she shall authorize the health care provider to release to the City of
Pearland any information necessary to indicate the presence of any controlled substance in
his/her system.
Any employee failing or refusing to provide a drag/alcohol sample or who has a verified positive
or adulterated test result after being involved in an accident will be subject to appropriate
disciplinary measures, up to and including discharge.
F. Random
The City of Pearland will administer, monthly, unannounced, random urine drug tests.
Employees will be selected for random testing by a computer-based random number generator,
and all employees in safety sensitive positions will have an equal chance of being selected. Any
employee selected for a random test will be subject to additional random tests in the future if
he/she is again selected. Employees in the following positions and those employees that drive
City vehicles are subject to random drug/alcohol testing include:
Police:
All Classified Personnel, Jailer, and Dispatcher.
EMS:
P.T. Paramedic, P.T. EMT, Volunteer EMT,
Inspector/Investigator, Assistant Fire Marshal, Fire Marshal.
Fire:
Volunteer Firefighter.
Engineering:
All inspectors.
Parks:
Maintenance Worker, Crew Leader, Supervisor, Superintendent.
Utility Billing:
Field Service Technician.
Fleet:
Fleet Manager, Chief Mechanic, Mechanic, Maintenance Worker.
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Streets & Drainage: All personnel.
Water & Sewer:
Maint./Constr.
All personnel.
WWTP: All personnel.
Animal Control: All personnel.
Community Services: Building Inspector, Code'Enforcement Officer, Health Officer
Plans Examiner, and Deputy Building Official.
The City of Pearland reserves the right to amend, change, and/or expand the safety sensitive
positions that are subject to random drug/alcohol testing as business needs necessitate.
Any employee refusing to submit to
("Refusal to Test").will be subject to
discharge.
a random drag/alcohol test at the time of the request
appropriate disciplinary measures, up to an including
G. Return-to-Work Testing
For those employees who come forward voluntarily and ask for assistance with a substance
abuse problem and who have obtained a formal Substance Abuse Professional (SAP) assessment,
diagnosis, treatment and formal return-to-work release by the SAP or treatment provider, this test
must be completed and negative before the employee may return to work (if work is available).
H. Follow-Up Testing
Any employee who returns to work after participating in a rehabilitation or employee assistance
program will be subject to additional unannounced alcohol and/or drug tests (at least six (6) in 12
months) at any time for up to 60 months after returning to work.
I. Voluntary Testing
The City of Pearland recognizes that situations may arise during which an employee may request
to be tested on a voluntary basis. Prior to performing this voluntary test, the City of Pearland
will review the situation, on a case-by-case basis, in order to determine if the test will be
authorized to be done.
J. Refusal to Submit / Insubordination
Any employee who refuses to submit to any drag and/or alcohol test required under this section
(Refusal to Test) OR who refuses to cooperate with the City of Pearland's representatives (MRO,
Human Resources, Department Head, Supervisor, collection facility) will be subject to
disciplinary action up to and including discharge.
SPECIMEN COLLECTION
P~e9
General Standards
To ensure the integrity and accuracy of each test, any person required to provide a urine, breath
and/or blood sample will be insured that the procedures will follow the Department of Health
and Human Services (DHHS) protocol. Urine Specimen Collection Procedure: Appendix C.
This includes, among other things:
(a) Procedures to ensure the correct identity of each employee at the time of
collection;
(b)
A strict chain-of-custody procedure to ensure that the employee's specimen is not
tampered with; and
(c) The use of a trained breath alcohol technician (BAT) and a DOT approved testing
device for conducting alcohol tests.
To further facilitaie' the integrity and accuracy of each test, the City of Pearland will provide
employees with written and/or oral instruction regarding the conduct of the specific test before
each testing event. Employees who refuse or otherwise fail to comply with all such instructions
will be subject to disciplinary action, up to and including discharge.
TESTING METHODOLOGY
A. Laboratory.
All urine specimens to be tested for the presence of controlled substances must be analyzed by a
laboratory certified under the DHHS guidelines for Federal Workplace Drug Testing Programs
and this laboratory will be selected by the City of Pearland.
All urine specimens will be initially tested for the use of controlled substances by an
immunoassay screen. The cut-off levels are as follows:
2.
3.
4.
5.
Marijuana metabolites
Cocaine metabolites
Opiate metabolites
Phencyclidine
Amphetamines
50 ng/ml
300 ng/ml
2,000 ng/ml (25 ng/ml if specific for free morphine)
25 ng/ml
1,000 ng/ml
Any positive test results in an initial test will be confirmed by a second analytical procedure,
which uses a different chemical technique and procedure through gas chromatography/mass
spectrometry (GC/MS). The em-off levels used to establish the existence of a "confirmed
positive" result are as follows:
Marijuana metabolites
Cocaine metabolites
Opiate metabolites
15 ng/ml (THC)
150 ng/ml (Benzoylecgonine)
2,000 ng/ml (Codeine & Morphine)
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4. Phencyclidine
5. Amphetamines
25 ng/ml
500 ng/ml (Amphetamine & Methamphetamine)
Where appropriate, the laboratory will also analyze the specimen for the presence of adulterants.
In the event the laboratory has reason to believe a specimen has been adulterated, the laboratory
shall report the result to the MRO as follows:
1. Low Specific Gravity and Creatinine;
2. Specimen not suitable for testing; and
Specimen adulterated: Presence of ("Name of Adulterant") detected.
B. Reporting of Test Results
The laboratory will report the test results to the City of Pearland's MRO within five (5) working
days atter the receipt of the specimen. Test results may not be reported verbally, by telephone
and the laboratory will not report any test results to the City of Pearland, but only to its MRO.
The MRO may request from the laboratory and the laboratory will provide quantification of test
results. The MRO will not, however, disclose the quantification of test results to the City of
Pearland unless disclosure of the same to the employer, employee or decision-maker is necessary
in a lawsuit, grievance or other proceeding initiated by or on behalf of the employee arising from
a verified drag test.
The laboratory will also provide the employer or its agent with a quarterly statistical summary of
the testing program, but will not include any personal identifying information.
MEDICAL REVIEW OFFICER / MRO VERIFICATION / MRO REPORTS
A. Medical Review Officer (MRO)
The MRO will be a licensed physician with knowledge of substance abuse disorders. The MRO
will review and interpret test results received from the laboratory and may also request
quantification of the test results from the lab. The MRO will also review the chain-of-custody to
ensure that it is sufficient and complete.
This is called the MRO verification process, which renders the final MRO Report.
B. MRO VERIFICATION
In order to assure that employees are not being harmed by the possibility of any false positive
results, the MRO will explore possible alternative medical explanations for the specified
laboratory result. The MRO will conduct a medical interview with the individual, over the
telephone, and give the individual the opportunity to discuss the laboratory result. He may also
review the individual's medical history and any other relevant biomedical factors. In addition, if
the laboratory test result could have results from a legally prescribed medication, the MRO will
review all medical records made available by the employee.
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C. MRO / EMPLOYEE CONTACT
The MRO will contact the individual, on a confidential basis, to determine whether the employee
wishes to discuss the test result.
If, after making and documenting reasonable efforts to contact the individual, the MRO is unable
to reach the individual directly, the MRO will contact a designated management official who will
direct the individual to contact the MRO prior to going on duty.
The MRO may verify a test without having communicated directly with an employee/applicant
about the results:
If employee/applicant expressly declines the opportunity to discuss the test; or
If, after reasonable efforts to contact the employee/applicant (in concert with the
assistance of the designated management official) contact has not been achieved,
and in the MRO's professional opinion, a potential safety-sensitive risk exists
(MR0 Result will have qualifying statement: "Unable to Contact").
Ifa test is verified because of the employee/applicant's failure to contact the MRO (No. 2 above)
the employee will have the opportunity to provide the MRO with the appropriate evidence or
other ckcumstances, which prevent him/her from timely contacting the MRO. The MRO, based
on the information obtained, may reopen the verification and allow the employee/applicant to
present information concerning a legitimate explanation for the laboratory result. If the MRO
concludes that there is a legitimate explanation, the MRO will verify the test to be negative.
D. MRO Reports
The following represent possible MRO REPORTS from the initial Laboratory Results.
1. Verified Positive
A laboratory confirmed positive result. The MRO verifies this result as a verified
positive, if there are no medical, legal or biomedical factors to explain why this certain
substance(s) is present in the specimen.
o
Verified Negative
A laboratory negative result OR a laboratory confirmed positive result. The MRO
verifies this result as a verified negative, if there are appropriate biomedical factors (such
as prescription medication, foreign medication, dietary concerns and/or medical care),
which explain the initial laboratory result.
Verified Adulterated
A laboratory result of adulteration, interference or negative (creatinine and/or specific
gravity out of range). The IVlRO verifies that this specimen is NOT a physiologic
specimen: "not human urine." This may be accomplished through additional testing
requested by the MRO. The MRO verifies this result as a verified adulterated or
adulterated/substituted specimen report.
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Verified Canceled
A laboratory result of interference, unable to rest or test not performed. The MRO
identifies that the employee is taking a prescription medication known to cause this
scientific phenomena. The MRO verifies this result as a verified canceled test report.
The MRO may request, if medically feasible that the applicant cease the medication for a
time period and to have re-collection (this applies to those employees who require a
"negative test" BEFORE performing a covered position); OR specimen temperature out-
of-range; OR technical problems with the specimen and/or chain-of-custody form; OR
Split Sample testing non-confirmatory.
Verified/Recommended Immediate Witness Re-collection
A laboratory result of interference, unable to test or test not performed. The MRO
investigation reveals no prescription medication known to cause this scientific
phenomena. This first test is neither positive nor negative. A second test is requested (as
soon as it can be arranged). This second test should be witnessed since the MRO cannot
role in or rule out adulteration with the first specimen. The witnessed second specimen
virtually eliminates adulteration by the individual.
o
Verified Negative "Medically Unqualified" Status
A laboratory confirmed positive result. The MRO verifies this result as negative, but
"medically unqualified" to perform safety-sensitive function/duties. Which means,
formal review has discovered that there are direct or indirect biomedical factors, which
suggest a potential "safety sensitive risk". Formal medical evaluation/clearance should
be conducted before the employee performs a safety-sensitive function/duties.
Verified Negative "Creatinine and Specific Gravity Out of Range"
A laboratory negative result, with the qualifying statement that the indices of the urine
"watery-ness" being out of the normal ranges. This test is negative. The next "test" shall
be witnessed.
Additional Testing
1. Re-analysis of original specimen
a. MRO Requested Re-analysis
If a question arises as to the validity or accuracy of a positive test result, the MRO will be
authorized to order a re-analysis of the original sample at an appropriate laboratory.
b. Employee Split Specimen Testing
The employee with a verified positive report, can request within 72 hours of notification
of the positive verification, for the original specimen to be reanalyzed at the same or
another Substance Abuse Mental Health Services Administration (SAMHSA) certified
laboratory. The costs of shipping of the specimen, re-analyzing and MRO processing fee
are the responsibility of the individual, unless the results from the re-analysis are
negative, at which time the employee will be reimbursed the City of Pearland for his/her
costs. The M RO will facilitate this testing and reserves the right to receive payment for
this testing prior to initiating this re-analysis process.
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If the Split Sample Testing fails to reconfirm "positive", the MRO will cancel the test and
report the case to the City of Pearland and the employee.
The MRO will not withhold reporting a verified positive test pending an employee
requested Split Sample testing.
F. DISCLOSURE OF INFORMATION
The MRO will not disclose to any third party medical information provided by the individual as
a part of the testing verification process, unless:
MRO's medical judgment, the information could result in the determination that
the employee is medically unqualified; or
The information indicates that continued performance by the employee of his or
her safety-sensitive function could pose a significant safety risk.
The MRO, before obtaining medical information fxom the employee, will advise the employee
that the information may be disclosed to third parties as stated above.
DISCIPLINE
The following discipline will be taken in the event of a "Verified MRO Report" under any of the
following circumstances and/or a positive alcohol test (0.02 grams percent or greater):
A. Post-Offer
Any prospective employee who has a positive or adulterated test as a result of a post-offer
alcohol and/or drug test will be considered disqualified for employment for a period of twelve
(12) months. After which time the prospective employee may submit documentation of a
Substance Abuse Professional's (SAP) Assessment, Treatment (if prescribed), on-going
treatment and current status to the City of Pearland's designated evaluator (e.g., Medical Review
Officer).
B. Reasonable Cause
Any employee who has a positive or adulterated test as a result of a reasonable cause alcohol
and/or drug test will be terminated.
C. Post-Accident
Any employee who has a positive or adulterated test as a result of an alcohol and/or drug test
taken after an accident will be terminated.
D. Random
Any employee who has a positive or adulterated test as a result of a random alcohol and/or drug
test will be terminated.
E. Return-to-Work
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Any employee who has a positive or adulterated test as a result of a return-to-work alcohol
and/or drug test will be terminated.
F. Follow-up
Any employee who has a positive or adulterated test in a return to work or follow-up drug test
and/or an alcohol test of 0.02 grams percent or greater will be terminated.
G. Voluntary
Any employee who has a positive or adulterated test in a voluntary test will be disciplined on a
case-by-case basis. '
H. Insubordination
Any employee who refuses to test, refuses to sign a release and consent form, fails to properly
cooperate with collection site personnel and/or BAT, or creates reason to believe a sample has
been altered, subStituted or adulterated, will be subject to discipline, up to and including
discharge, depending upon the offense.
EMPLOYEE ASSISTANCE~ TRAINING AND EDUCATION
A. Education
The City of Pearland will provide an education program for its employees about the dangers of
drug abuse, available community resources, treatment, rehabilitation and assistance providers.
This program will include:
1. Distribution of informational material;
2. Distribution of the City of Pearland's employee assistance program and telephone
number; and
3. Distribution of the City of Pearland's policy regarding the use of prohibited drugs.
B. Training'
Any supervisory personnel responsible for determining whether an employee must be drug tested
based on reasonable cause will be required to complete at least two (2) hours of training on the
specific, contemporaneous physical, behavioral and performance indicators of probable drug use
and alcohol use.
All employees participating in education and training programs will be required to sign a
certification of completion of a qualified drug abuse course. Appendix E
Co
Employee Assistance Program
Page 15
In addition to the education and training program described above, the City of Pearland also has
available an employee assistance program to which employees may refer for additional
consultation and referral.
D. Insurance Benefits
Please refer to plan documents for information on eligibility, benefits and coverage.
E. Rehabilitation
1. Alcoholism and Chemical Dependency
Consistent with the City of Pearland's philosophy that its employees are its most valuable
resource, the City of Pearland is willing to recognize and provide assistance to those
employees whose use of alcohol or controlled substances may be the result of problems
such as alcoholism or chemical dependency.
Any employee who comes forward and voluntarily requests assistance for alcoholism
and/or chemical dependency prior to any request for a drug test under this policy will be
provided the opportunity to undergo an approved drug/alcohol assessment by a qualified
health care provider (also called: substance abuse professional "SAP") and to participate
in any treatment recommended by that provider. These services will be at the employee's
expense unless coverage for the same is provided by any otherwise applicable health
insurance plan.
Before any employee will be allowed to participate in any recommended treatment
program and later reinstated to his or her job upon the successful completion of that
program, there must be a clinical diagnosis of a need for such treatment by a SAP.
Normal procedures for requesting a medical leave of absence must then be followed. The
employee will also be required to admit him or herself into any prescribed program and
actively participate in the same. Accordingly, proof of admission into the program,
regular attendance and "drag/alcohol free" participation will be required. The City of
Pearland will also require participation in any recommended or prescribed after care or
similar follow-up treatment program. Failure to participate in any such prescribed
program or failure to attend any scheduled after-care or follow-up sessions will disqualify
the individual from further employment. In addition, the employee will be required to
notify the City of Pearland of the identity of the rehabilitation program counselor and
authorize the counselor to communicate with the City of Pearland about the employee's
progress and to release to the City of Pearland any and all information relating to the
employee's treatment, participation, etc.
2. Return to Work and Follow-up Testing
Upon successful completion of a rehabilitation program, the employee will be reinstated
to his/her former position as if returning to work from a medical leave of absence - if
he/she is qualified to return to work under applicable City of Pearland rules and
regulations. Before returning, however, the employee will be required to undergo an
Page 16
additional alcohol and drug test. If the results are negative, the employee will be returned
to work. If the drug test results are verified positive or adulterated; or the alcohol test is
0.02 grams percent or greater, then the employee will be disqualified from further
employment.
Any employee who has passed a return to work alcohol and/or drug test after having
successfully completed a treatment program will be required to submit to additional
follow-up tests (at least six (6) within 12 months) and at any time within 60 months from
the date the employee returns to work. If the employee subsequently has a verified
positive or adulterated urine drug test or an alcohol test of 0.02 grams percent or greater,
the City of Pearland may conclude that the employee has made himself or herself unfit
for continued employment, resulting in the termination of the employment relationship.
3. "Second Chance" Program
Any emploYee who voluntarily came forward and admits to renewed substance abuse
problems, other than as a consequence of a positive or adulterated test result, will be
afforded the opportunity to take an additional medical leave of absence in order to
readmit themselves into an appropriate treatment program without jeopardizing their
continued employment status. (Employee must come 'forward before management
goes forward with reasonable suspicion or post accident/random request.)
CONFIDENTIALITY
Information regarding an individual's drug test results or rehabilitation will only be released-upon
the written consent of the employee. The MRO will not reveal individual tests results to anyone
other than the City of Pearland representative, unless the MRO has been presented with a written
authorization from the tested individual. Appendix F
The City of Pearland's contract with its laboratory requkes it to maintain all employee test
records in confidence. However, the laboratory will disclose information related to a positive
drug test of an individual to the individual, the City of Pearland, or the decision-maker in a
lawsuit, grievance or other proceeding initiated by or on behalf of the individual and arising from
or related to a certified positive or adulterated drug test.
RECORD RETENTION
The MRO will retain results for five (5) years. The City of Pearland will maintain records
relating to the results of drug testing for a minimum of five (5) years beyond separation for
employees. All other test results will be maintained for a minimum of two (2) years.
ACKNOWLEDGEMENT AND RECEIPT OF SUBSTANCE ABUSE POLICY
This form will be kept in the Employee's File. Appendix G
SPECIAL CONSIDERATIONS
State Legalization of Controlled Substances
Page 17
additional alcohol and drug test. If the results are negative, the employee will be returned
to work. If the drug test results are verified positive or adulterated; or the alcohol test is
0.02 grams percent or greater, then the employee will be disqualified f~om further
employment.
Any employee who has passed a return to work alcohol and/or drug test after having
successfully completed a treatment program will be required to submit to additional
follow-up tests (at least six (6) within 12 months) and at any time within 60 months f~om
the date the employee returns to work. If the employee subsequently has a verified
positive or adulterated urine drag test or an alcohol test of 0.02 grams percent or greater,
the City of Pearland may conclude that the employee has made himself or herself unfit
for continued employment, resulting in the termination of the employment relationship.
3. "Second Chance" Program
Any employee who voluntarily came forward and admits to renewed substance abuse
problems, other than as a consequence of a positive or adulterated test result, will be
afforded the opportunity to take an additional medical leave of absence in order to
readmit themselves into an appropriate treatment program without jeopardizing their
continued employment status. (Employee must come forward before management
goes forward with reasonable suspicion or post accident/random request.)
CONFIDENTIALITY
Information regarding an individual's drag test results or rehabilitation will only be released upon
the written consent of the employee. The MRO will not reveal individual tests results to anyone
other than the City of Pearland representative, unless the MRO has been presented with a written
authorization from the tested individual. Appendix F
The City of Pearland's contract with its laboratory requires it to maintain all employee test
records in confidence. However, the laboratory will disclose information related to a positive
drug test of an individual to the individual, the City of Pearland, or the decision-maker in a
lawsuit, grievance or other proceeding initiated by or on behalf of the individual and arising from
or related to a certified positive or adulterated drug test.
RECORD RETENTION
The MRO will retain results for five (5) years. The City of Pearland will maintain records
relating to the results of drag testing for a minimum of five (5) years beyond separation for
employees. All other test results will be maintained for a minimum of two (2) years.
ACKNOWLEDGEMENT AND RECEIPT OF SUBSTANCE ABUSE POLICY
This form will be kept in the Employee's File. Appendix G
SPECIAL CONSIDERATIONS
A. State Legalization of Controlled Substances
Page 17
Recent legislation in various states has legalized certain controlled substances within that
jurisdiction. At the present time, the City of Pearland will follow all Federal Guidelines related
to controlled substance testing.
B. Hemp Products
There are various over-the-counter products containing help or hemp-derivatives. Use of these
products could possibly yield a positive urine drug test for marijuana. Consequently, current
employees are prohibited f~om using such hemp products (as a condition of employment).
Furthermore, the testing and MRO cannot distinguish between use of marijuana and ingestion of
a hemp-containing product. The MRO will only over-tm a lab positive test for marijuana to a
verified negative with proof of prescription marijuana (called Marinol). This follows the Federal
Guidelines established by the Department of Health and Human Services.
Page 18
NOTIFICATION OF PRE-EMPLOYMENT ALCOHOL AND DRUG TEST
{Applicant's Name}
{Address}
Dear {Applicant}:
We are pleased to advise you that we have made our initial hiring decisions and
would like to consider you as a candidate for employment with the City of Pearland.
However, you Will first have to undergo a post-offer Hman Performance Evaluation and
drag test. This will require you to provide a urine sample to be tested for the use of
controlled substances.
If you are still interested in a position with the City of Pearland, you will be
expected to report to
(eolleetion site)
., on
(address) (date)
located at
(address)
, prior to 4:00 p.~
Yom FAILURE TO APPEAR FOR THIS TEST ON THE ABOVE DATE WILL DISQUALIFY
YOU FROM FURTHER CONSIDERATION FOR EMPLOYMENT. If you have any questions
regarding any of the above, please do not hesitate to contact us.
Sincerely,
The City of Pearland
APPENDIX A-1
APPLICANT CONSENT FORM
An offer of employment from the City of Pearland is contingent upon satisfactory
completion of a post-offer employment Human Performance Evaluation, which includes
substance abuse testing for the presence of drugs, adulterants and/or alcohol. All
applicants are required to complete this test. If an applicant does not complete this test
they will not be considered for employment. Further, any job applicant whose test results
are verified positive or adulterated by the Medical Review Officer will not be eligible for
employment at this time. I agree to take the required test at
the collection facility designated by the City of Pearland. In addition, I authorize the
Collection Facility, the Laboratory, the City of Pearland, and the Medical Review Officer.
to conduct such testing and the test results and any other relevant information to each
other.
Date:
Date:
Applicant:
Witness:
I have read and understand this form and hereby refuse to take the required test. I
understand that my refusal means that I will not complete my post-offer employment
Human Performance Evaluation and/or drug screen and therefore I will not be eligible for
employment with the City of Pearland at this time.
Date: Applicant:
Date: Witness:
APPENDIX A-2
REASONABLE CAUSE CHECKLIST
(STRICTLY CONFIDENTIAL)
EMPLOYEE: DATE
EVALUATION BEGUN
SUPERVISOR #1, NAME AND TELEPHONE:
SUPERVISOR #2, NAME AND TELEPHONE:
TIME NOTIFIED:
TIME PRESENT:
This checklist is intended to assist a supervisor in referring a person for alcohol and drag testing.
Has the employee manifested any of the following? Indicate with a check where appropriate.
NATURE OF INCIDENT / CAUSE FOR SUSPICION
2.
3.
4.
5.
6.
Observed/Reported possession or use of a prohibited substance.
Apparent drug or alcohol intoxication.
Observed abnormal or erratic behavior.
Arrest or conviction for drag-related offense.
Evidence of tampering on a previous drag test.
OTHER (Please explain):
YES
NO
2.
3.
4.
5.
6.
7.
8.
ATTENDANCE
Unauthorized absence of the job.
Habitual absences whether disciplinary action results or not.
Excessive use of sick leave in last 12 months.
Frequent Monday/Friday absence or other pattern.
Frequent unexplained disappearances.
Excessive "extension" of breaks or lunch.
Frequently leaves work early: Number of days per week or month:
OTHER (Please explain):
APPENDIX B-1
YES
NO
BEHAVIOR
1. Serious misconduct.
2. Refusal of supervisor instruction.
3. Verbal abusiveness.
4. Physical abusiveness.
5. Extreme aggressiveness or agitation.
6. Withdrawn, depression, tearfulness, unresponsiveness.
7. Inappropriate verbal response to questions or instructions.
8. Significant CHANGE in relations with co-workers, supervisors, others.
9. Frequent or intense arguments.
10. Less involved with people.
11. Intentional avoidance of supervisor.
12. Persistent expressions of fi'ustration or discontent.
13. CHANGE in ~equency or nature of complaints.
14. Complaints by co-workers or subordinates.
15. Persistent cynical, negative comments/attitude.
16. Unusual sensitivity to advice or critique of work.
17. Unpredictable response to supervision.
18. CHANGES in or unusual level of activity: __ reduced ~
19. Increasing irritable or tearful.
20. Presents himself/herself as "invincible" (grandiose/all-powerful).
21. Mood swings (out-of-context displays of emotion, unpredictable).
22. Makes unfounded accusations toward others.
23. Expressed feelings of persecution.
24. Makes unreliable or false statements.
25. Demanding, rigid, inflexible.
26. OTHER (Please explain):
increased
YES
NO
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
PERFORMANCE OF JOB
Clear refusal to do assigned tasks.
Significant increase in errors.
Repeated errors in spite of increase guidance.
Reduced quality of work.
Inconsistent "up and down" quantity or quality of work.
Behavior disrupts workflow.
Procrastination on significant decisions or tasks.
More than usual supervision necessary.
Frequent, unsupported explanations for poor work performance.
Does not follow through on job performance recommendation.
CHANGE in written or verbal communication.
OTHER (Please explain):
APPENDIX B-2
YES
NO
Appearance:
PHYSICAL SIGNS
Odor of Alcohol (circle): BREATH
Paraphernalia/" StuiT' Found:
(Describe):
[] normal [] disheveled
[] possible "needle tracks"
[] nausea/vomiting
General Well-Being:
5. Eyes: [] normal
Pupils: [] large/dilated
6. Nose: [] normal
7. Mouth: [] normal
8. Speech: [] normal
9. Awareness/Mental Status:
[] profuse perspiration
[] tremors
[] fainting [] flushed
[] breathing irregular and/or labored
[] no apparent physical distress
[] wearing of sunglasses
[] small/constricted [] normal
[] runny nose/sniffles
[] dry mouth, ]~equent swallowing, lip wetting
[] slurred [] incoherent
[] normal [] confused
[] sleepy but arouse-able
[] cooperative
10. Concentration:
[] THREE THINGS TO REMEMBER:
CLOTHING
86 79
88 82
[] normal
[] normal
[] normal
[] Serial 7's: 100 93
or
[] Serial 6's: 100 94
11. Motor Skills/Balance:
[] Finger to Nose:
[] Heel to Toe Walk:
[] Walk/Gait:
[] flushed/pale
10. Concentration (continued):
Record "Recall" of the THREE THINGS:
[] "looks ill"
[] bloodshot [] watery/"glassy"
[] other:
[] silent []"pressured" [] slow
[] euphoric [] combative
[] sleepy and unarouse-able/"out-cold"
[] uncooperative [] crying ~ bizarre
72 65 58 51 44 37 30 23
76 70 64 58 52 46 40 34
[] missed [] used L or R instead of instructed: L or R
[] falls to side
[] swaying [] stumbling [] falling
[] arms raised for balance
1692
28 22
APPENDIX B-3
YES NO
2.
3.
4.
5.
6.
7.
PHYSICAL SIGNS (continued)
Sub acute Signs
CHANGES in or unusual personal appearance (dress, hygiene).
CHANGES in or unusual speech: (stuttering, loud, pressured, slurred).
CHANGES in or unusual mannerisms (gestures, posture).
CHANGES in physical health.
Frequent colds, flu or other illnesses.
Noticeable loss of weight.
OTHER (Please explain)~
*For any "yes" marked in this "sub acute signs" section: Indicate Number and the Date when you first observed this:
YES NO
PARAPHERNALIA
Possessing, dispensing or using prohibited substance.
If "yes"; describe:
Complaints from co-workers of employee using, possessing or dispensing
prohibited substances during work hours and/or in the workplace.
Paraphernalia Found. Describe:
OTHER (Please explain):
YES NO
SAFETY ISSUES
Flagrant violation of safety.
'Actual incident (date):
3. Near miss. Describe and date:
5.
6.
7.
Increased concern about safety offenses involving employee.
Interferes with or ignores established procedures.
Lacks appropriate caution.
OTHER (Please explain):
APPENDIX B-4
WRITTEN SUMMARY
( ) Employee "Refuses to Cooperate" with Evaluation.
[] ONE: Explained this is a "Refusal to Cooperate" and considered an admission of guilt.
[] TWO: Offered to get Employee a ride home.
[] THREE: If Employee does not take offer for ride home, the police will be notified.
( ) Employee "Refuses to Sign" Consent Form for testing (also complete "Refusal to Cooperate" above).
( ) Other:
( ) "Reasonable Cause" exists to test this Employee. Per procedure the Employee will be tested for both
alcohol and drugs.
( ) "DRUG TESTING AUTHORIZATION & RECORD RELEASE" form signed.
( ) Arrangements made to escort Employee to testing facility:
Please describe:
( ) Time Evaluation completed:
( ) Arrangements made to get Employee home fi:om collection facility.
SIGNATURE OF SUPERVISOR #1
DATE
SIGNATURE OF SUPERVISOR #2
DATE
APPENDIX B-5
DRUG & ALCOHOL TESTING
AUTHORIZATION / RECORD RELEASE
I understand that as required by City policy, certain employees and prospective employees must
undergo a drug and alcohol test to detect the presence of drugs and/or alcohol.
All drug tests are subject to testing procedures with mandatory confirmation of any preliminary
positive tests.
I will be given a reasonable opportunity to explain a confn'med positive drug test result to a
trained physician serving as a Medical Review Officer.
I consent to provide a urine specimen and a breath specimen at a collection facility designated by
., and consent to having the specimen tested at a laboratory
selected by
I further agree that the drug test results will be disclosed only to
and to the Medical Review Officer selected by
interviews when positive results are reported by the laboratory.
to conduct
Print Employee/Applicant Name
Date
Employee/Applicant Signature
Print witness Name
Witness Signature
** A copy of this form must accompany Employee to the Collection Facility
Appendix B-6
o
Urine Specimen Collection Procedure
To deter the dilution of specimens at the collection site, toilet bluing agents will be
placed in toilet tanks wherever possible, so the reservoir of water in the toilet remains
blue. Where practicable, there shall be no other source of water (e.g., no shower or
sink) in the enclosure where urination occurs. If there is another source of water in
the enclosure, it shall be effectively secured or monitored to ensure it is not used
(undetected) as a source for diluting the specimen.
Upon arriving at the collection site, the individual to be tested shall present the
collection site person with proper identification to ensure that he/she is positively
identified as the person selected for testing (by presenting a driver's license or other
photo ID, or by identification by the City's representative). If the individual's
identity cannot be established, the collection site person shall not proceed with the
collection and the City shall be notified. If the employee requests, the collection site
person shall show his/her identification to the employee.
If the individual to be tested fails to arrive at the collection site at the assigned time,
the collection site person shall contact the City to obtain guidance on the action to be
taken. Failure to report for a urine test at the assigned time may result in discipline or
disqualification from further consideration for employment.
The individual to be tested will be required to remove any unnecessary outer
garments (coat or jacket) that might conceal items or substances that could be used to
tamper with or adulterate the urine specimen. The collection site person will ensure'
that all personal belongings such as purses or briefcases remain with the outer
garments. The individual may retain his or her wallet. If the employee requests it,
the collection site personnel shall provide the employee with a receipt for any
personal belongings.
Before the collection process begins, the individual shall provide the collection site
person with a Urine Custody and Control form, if it has not been previously
forwarded to the collection site by the employer.
The individual shall be instructed to wash and dry his/her hands prior to urination.
After washing his/her hands, the individual shall remain in the presence of the
collection site person and shall not have access to any water fountain, faucet, soap
dispenser, cleaning agent or any other materials which could be used to adulterate the
specimen.
The individual may provide his/her specimen in the privacy of a stall or otherwise
partitioned area that allows for individual privacy. The collection site person shall
provide the individual with a specimen bottle or container, if applicable, for this
purpose.
APPENDIX C
o
10.
11.
12.
The collection site person shall note any unusual behavior or appearance on the urine
custody and control form.
In the exceptional event that a City-designated collection site is not accessible and
there is an immediate requirement for specimen collection (e.g. an accident
investigation), a public rest room may be used according to the following procedures:
A collection site person of the same gender as the individual shall accompany the
individual into the public rest room, which shall be made secure during the collection
procedure. If possible, a toilet bluing agent shall be placed in the bowl and any
accessible toilet tank. The collection site person shall remain in the rest room, but
outside the stall, until the specimen is collected. If no bluing agent is available to
deter specimen dilution, the collection site person shall instruct the individual not to
flush the toilet until the specimen is delivered to the collection site person. After the
collection site person has possession of the specimen, the individual will be instructed
to flush the toilet and to participate with the collection site person in completing the
chain of custody' procedure.
Upon receiving the specimen from the individual, the collection site person shall
determine if it contains at least 45 milliliters of urine. If the individual is unable to
provide 45 milliliters of urine, the collection site person shall direct the individual to
drink fluids and, alter a reasonable time, again attempt to provide a complete
sampling using a fresh specimen bottle (and fresh collection container). The original
specimen shall be discarded. If the individual is still unable to provide a complete
specimen, the following rules apply:
In the case of a post-accident or reasonable cause test, the individual shall remain
at the collection site and continue to consume not more than 40 ounces of fluid
until the specimen has been provided or until the expiration ora period up to 3
hours from the beginning of the collection procedure.
In the case of a post-offer, random, periodic test or other test not for cause, the
City may elect to proceed as specified in paragraph (a) or may elect to discontinue
collection and conduct a subsequent collection at a later time.
Co
If the individual cannot provide a comPlete sample within the up to 3 hour period
or at the subsequent collection, as applicable, then the MRO shall refer the
individual for a medical evaluation to develop pertinent information concerning
whether the individual's inability to provide a specimen is genuine or constitutes a
refusal to provide a specimen. (In post-offer testing, if the City does not wish to
hire the individual, the MRO is not required to make such a referral). Upon
completion of the examination, the MRO shall report his or her conclusions to the
employer in writing.
The following procedures are to be followed for the mandatory Split Sample:
APPENDIX C
13.
14.
15.
The individual-donor shall urinate into a collection container or a specimen bottle
capable of holding at least 60 ml.
Ifa collection container is used, the collection site person, in the presence of the
donor, pours the urine into two specimen bottles. Thirty (30) ml shall be poured
into one bottle, to be used as the primary specimen. At least 15 ml shall be
poured into the other bottle, to be used as the split specimen.
Both bottles shall be shipped in a single shipping container, together with copies
1, 2, and the split specimen copy of the chain of custody form, to the laboratory.
If the test result of the primary specimen is positive, the individual-donor may
request that the MRO direct that the split specimen be tested in a different DHHS
certified laboratory for presence of the drag(s) for which a positive result was
obtained in the test of the primary specimen. The MRO shall honor such a
request if it is made within 72 hours of the employee having been notified of a
verified positive test result.
when'the MRO informs the laboratory in writing that the donor has requested a
test of the split specimen, the laboratory shall forward, to a different DHHS
approved laboratory, the split specimen bottle, with seal in tact, a copy of the
MRO request, and the split specimen copy of the chain of custody form with
appropriate chain of custody entries.
The result of the split specimen test is transmitted by the second laboratory to the
MRO.
Action required by City procedures as the result of a positive drag test (e.g.,
removal from performing a safety sensitive function) is not stayed pending the
result of the split specimen test.
If the result of the split specimen test fails to reconfirm the presence of the drug(s)
or drag metabolite(s) found in the primary specimen, the MRO shall cancel the
test, and report the cancellation and the reasons for it to the City, and the
individual donor.
No portion of any sample collected under these procedures may be used for any
purpose other than drag testing required under City policy.
After the specimen has been provided and submitted to the collection site person, the
individual shall be allowed to wash his/her hands.
Immediately after the specimen is collected, the collection site person shall measure
the temperature of the specimen. The temperature measuring devise used must
accurately reflect the temperature of the specimen and not contaminate the specimen.
APPENDIX C
16.
17.
18.
19.
20.
21.
22.
23.
24.
The time from urination to temperature measure is critical and in no case shall exceed
4 minutes.
If the temperature of a specimen is outside the range of 90.0 degrees - 100.0 degrees
F, there will be reason to believe that the individual may have altered or substituted
the specimen, and another specimen shall be collected under direct observation of a
collection site person of the same gender and both specimens shall be forwarded to
the laboratory for testing. An individual may volunteer to have his or her oral
temperature taken to provide evidence to counter the reason to believe the individual
may have altered or substituted the specimen caused by the specimen's temperature
falling outside the prescribed range.
Immediately after the specimen is collected, the collection site person shall also
inspect the specimen to determine its color and look for any signs of contaminants.
Any unusual findings shall be noted on the urine custody and control form.
All specimens suspect of being adulterated shall be forwarded to the laboratory for
testing.
Whenever there is reason to believe that a particular individual has altered or
substituted the specimen, a second specimen shall be obtained as soon as possible
under the direct observation of a same gender collection site person.
Prior to requiring any individual to provide another urine specimen under direct
observation because of circumstances constituting reason to believe the specimen
may have been altered or substituted, the collection site person shall first contact a
higher level supervisor or a designated employer representative to review and concur
in advance with the decision to require observation.
After the urine specimen is provided, both the individual being tested and the
collection site person shall keep the specimen in view at all times prior to its being
sealed and labeled. The specimen shall be sealed and labeled in the presence of the
employee.
The collection site person, in the presence of the individual, shall place securely on
the bottle(s) an identification label which contains the date, specimen number, and
any other identifying information provided or required by the employer. If separate
from the label, the tamper-proof seal shall also be applied.
The individual shall, in the presence of the collection site person, initial the
identification label on the specimen bottle for the purpose of certifying that it is the
specimen collected from him or her.
The collection site person shall, in the presence of the individual, enter on the urine
custody and control form all information identifying the specimen. The collection
APPENDIX C
25.
26.
27.
28.
29.
30.
site person shall sign the urine custody and control form certifying that the collection
was accomplished according to the instructions provided.
The individual shall be asked to read and sign a statement on the urine custody and
control form cert~ng that the specimen identified as having been collected from he
or she is in fact that specimen he or she provided.
After signing the urine custody and control form, the individual will also be required
to sign a consent and release form authorizing the collection of the specimen, analysis
of the specimen for designated controlled substances and release of the test result to
the employer and its medical review officer. 'The individual will not be required to
waive liability with respect to negligence on the part of any person participating in the
collection, handling or analysis of the specimen or to indemnify any person for the
negligence of others.
After a proper sample has been provided, labeled and sealed, the collection site
person shall complete the chain of custody portion of the urine custody and control
form to indicate receipt from the individual donor and shall certify proper completion
of the collection process.
The urine specimen and chain of custody form will then be shipped to an appropriate
laboratory for analysis. If the specimen is not immediately prepared for shipment, it
shall be appropriately safeguarded during temporary storage.
While any part of the above chain of custody procedures is being performed the urine
specimen and custody documents must remain under the control of the involved
collection site person. If the involved collection site person leaves his or her work
station momentarily, the specimen and urine custody and control form shall be taken
with him or her or shall be secured. After the collection site person returns to the
work station, the custody process will continue. If the collection site person is
leaving for an extended period of time, the specimen shall be packaged for mailing
before he or she leaves the site.
The collection site person shall not leave the collection site in the interval between
presentation of the specimen by the employee and securement of the sample with an
identif~g label bearing the employee's specimen identification number and seal
initialed by the employee. If it becomes necessary for the' collection site person to
leave the site during this interval, the collection shall be modified and (at the election
of the City) a new collection begun.
Note: This collection procedure follows the Federal Guidelines as outlined in
CFR, Part 40. There may be specific company/agency procedural modification&
APPENDIX C
DRUG TESTING AUTHORIZATION
RECORD RELEASE
SPLIT SPECIMEN REQUEST FORM ·
I, .(donor name), give my permission to Concentra Medical
Centers and their affiliated drug testing laboratory, to release a copy of my Drug Test Result with
Specimen # of ., and tested at (name of laboratory)
with collection date of to the address noted below.
I've enclosed a money order or cashier check in the amount of $100.00 to cover the cost of
duplication. This authorization/record release will remain in effect for 30 days from the date of
the signature below.
Signature Date
Print Name
Social Security Number
Address
Phone Number w/Area Code
City / State / Zip
APPENDIX D
CERTIFICATION OF COMPLETION OF
DRUG & ALCOHOL ABUSE AWARENESS PROGRAM
I, , hereby certify that I have completed the City of
(print employee or supervisor's name)
Pearland's and that I am familiar with all of the
(identify drag & alcohol awareness course)
information discussed during the program, as well as the additional information and resources
available from the City of Pearland on drag/alcohol abuse.
Date:
Employee:
Supervisor:
APPENDIX E
DRUG & ALCOHOL TESTING
AUTHORIZATION / RECORD RELEASE
I understand that as required by City policy, certain employees and prospective employees must
undergo a drug and alcohol test to detect the presence of drags and/or alcohol.
All drag tests are subject to testing procedures with mandatory confmnation of any preliminary
positive tests.
I will be given a reasonable opportunity to explain a confirmed positive drug test result to a
trained physician serving as a Medical Review Officer.
I consent to provide a urine specimen and a breath specimen at a collection facility designated by
, and consent to having the specimen tested at a laboratory
selected by
I further agree that'the drug test results will be disclosed only to
and 'to the Medical Review Officer selected by to conduct
interviews when positive results are reported by the laboratory.
Print Employee/Applicant Name
Date
Employee/Applicant Signature
Print Witness Name
Witness Signature
** A copy of this form must accompany Employee to the Collection Facility **
APPENDIX F
ACKNOWLEDGEMENT AND RECEIPT OF
SUBSTANCE ABUSE POLICY
I, , hereby certify that I have received a copy of the
(employee)
City of Pearland's Substance Abuse Policy, and that I have read it and understand its contents.
Date:
Employee:
Witness:
APPENDIX G