EDUCATION AND TRAINING HISTORY (Start with your most recent school or certificate training
attended) including CPR, and Continuous Educational (CE) credits courses
Professional References (List name/telephone number of 2 business/work references who are
not related to you)
IMPERIAL CAREGIVERS . DRUG AND ALCOHOL POLICY
PURPOSE TO PROVIDE A CONTROLLED SUBSTANCE, DRUG AND ALCOHOL FREE WORKPLACE FOR THE SAFETY OF ALL EMPLOYEES (LEASED, HIRED, OR OTHERWISE) AND CUSTOMERS. IN ORDER TO FURTHER THIS OBJECTIVE THE FOLLOWING RULES GOVERNING ALCOHOL AND ILLEGAL DRUGS AND INHALANTS IN THE WORKPLACE HAVE BEEN ESTABLISHED.
POLICY THE ILLEGAL MANUFACTURE, DISTRIBUTION, DISPENSING, POSSESSION, SALE, PURCHASE, RECEIPT OR TRANSMITTAL OF CONTROLLED SUBSTANCES, OR AN ATTEMPT TO ANY OF THE FOREGOING, WHILE ON IMPERIAL CAREGIVERS OR CLIENTS, COMPANY’S (COMPANY) PROPERTY OR ON COMPANY RELATED BUSINESS IS PROHIBITED. THE UNAUTHORIZED POSSESSION OF ALCOHOL OR ANY ALCOHOLIC BEVERAGES ON COMPANY PROPERTY OR ON COMPANY RELATED BUSINESS IS PROHIBITED. BEING UNDER THE INFLUENCE OF ALCOHOL OR OTHER ILLEGAL OR INTOXICATING DRUGS OR INHALANTS WHILE ON COMPANY PROPERTY OR ON COMPANY RELATED PROPERTY IS PROHIBITED.
THE UNAUTHORIZED POSSESSION OF PRESCRIPTION DRUGS OR NONPRESCIPTION OVER THE COUNTER DRUGS ON COMPANY PROPERTY OR COMPANY RELATED PROPERTY IS PROHIBITED.
EMPLOYEES WHO VIOLATE THIS POLICY WILL BE SUBJECT TO APPROPRIATE DISCPLINARY ACTIONS, INCLUDING TERMINATION. THIS POLICY APPLIES TO ALL EMPLOYEES OF THE COMPANY REGARDLESS OF RANK OR POSITION, AND INCLUDES TEMPORARY AND PART-TIME EMPLOYEES.
TESTING: TESTING OF EMPLOYEES. ALL PRESENT EMPLOYEES (LEASED, HIRED, OR OTHERWISE) WILL BE REQUESTED TO SIGN AN INFORMED CONSENT AND LEASE OF LIABILITY FORM, EMPLOYEES MAY BE TESTED FOR THE PRESENCE OF ALCOHOL, DRUGS AND INHALANTS, AND/OR A CONTROLLED SUBSTANCE IN THE PRESENT ANY OF THE FOLLOWING SITUATIONS MAY OCCUR. A CONTROLLED SUBSTANCE: THERE EXISTS A REASONABLE SUSPICION OR BELIEF THAT DRUGS, ALCOHOL, INHALANTS, OR A CONTROLLED SUBSTANCE ARE AFFECTING AN EMPLOYEES’S JOB PERFORMANCE, ATTENDANCE PATTERNS, CONDUCT, OR SAFETY OR WORKPLACE ACTIONS; WHEN REQUIRED BY A CUSTOMER OR COMPANY PURSUANT TO THE CUSTOMERS DRUG TESTING POLICY.
SUCH TESTING IS NOTCONSIDERED A COMPANY DRUG TEST AND MAY BE SUBJECT TO THE CUSTOMER’S RULES REGARDING DRUG TESTS. VOLUNTARY IN ALL INSTANCES, TESTING WILL BE PERFORMED ONLY WITH THE APPLICANT OR EMPLOYEE’S KNOWLEDGE AND CONSENT. REFUSAL TO SUBMIT TO REQUESTED TESTING, HOWEVER, MAY RESULT IN DISCIPLINARY ACTION INCLUDING TERMINATION OF EMPLOYMENT.
COMPANY TESTING URINE SPECIMENS WILL BE OBTAINED AT THE COMPANY’S OFFICE, LAB, TESTING FACILITY; HOWEVER, IN THE EVENT OF AN ACCIDENT OR INJURY SAMPLES MAY BE OBTAINED AT AN APPROPRIATE HOSPITAL, CLINIC, EMERGENCY ROOM OR DOCTOR’S OFFICE. TESTING RESULTS A POSITIVE TEST SHALL MEAN THE PRESENCE OF ALCOHOL, AN INHALANT OR OTHER DRUG OR CONTROLLED SUBSTANCE HAS BEEN FOUND. AN ATTEMPT FOR AN EMPLOYEE TO SWITCH, ADULTERATE, OR TAMPER WITH ANY TEST RESULT OR SAMPLE SUBMITTED FOR MEDICAL TESTING, OR OTHERWISE INTERFERE OR ATTEMPT TO INTERFERE WITH THE TESTING PROCESS, SHALL
RESULT IN IMMEDIATE TERMINATION. CONFIDENTIALITY THE COMPANY SHALL MAKE ALL REASONABLE ATTEMPTS TO KEEP THE RESULTS OF A POSITIVE DRUG TEST CONFIDENTIAL. SUCH RESULTS SHALL BE RELEASED TO COMPANY PERSONNEL ONLY ON A NEED TO KNOW BASIS.
ALL POSITIVE WRITTEN TEST RESULTS WILL BE STORED IN A CONFIDENTIAL FILE AND BE VIEWED ONLY BY AUTHORIZED COMPANY PERSONNEL AND KEPT ONLY AT THE COMPANY. DISCIPLINARY ACTION EMPLOYEES SUSPECTED OF VIOLATING ANY OF THE POLICIES CONTAINED HERIN MAY BE SUSPENDED OR REMOVED FROM THE WORKPLACE PENDING A COMPLETE INVESTIGATION.
EMPLOYEES TESTING POSITIVE FOR DRUGS, ALCOHOL, INHALANTS OR OTHER CONTROLLED SUBSTANCES WILL BE SUBJECT TO IMMEDIATE DISCHARGE. ANY EMPLOYEE WHO IS OTHERWISE FOUND TO HAVE VIOLATED THE POLICIES HEREIN WILL BE SUBJECT TO DISCIPLINARY ACTION, INCLUDING TERMINATION OF EMPLOYMENT. SHOULD THE DETERMINATION BE MADE THAT NO VIOLATION OF THE POLICIES CONTAINED HEREIN HAVE OCCURRED, THE EMPLOYEE BE REINSTATED WITHOUT PENALTY. EXCEPTION AN EMPLOYEE WHO POSSESSES OR USES A DRUG AUTHORIZED BY A LICENSED PHYSICIAN OR MEDICAL PRACTITIONER THROUGH A PRESCRIPTION, SPECIFICALLY FOR THE EMPLOYEE’S USE WHILE ON THE JOB, AND WHOSE FACILITIES AE NOT NOTICEABLY IMPAIRED BY THE USE OF SUCH DRUG, WILL NOT BE CONSIDERED TO HAVE VIOLATED THIS POLICY. EMPLOYEES SHALL BE RESPONSIBLE FOR DISCUSSING WITH THE PRESCRIBING MEDICAL PRACTITIONER WHETHER ANY PRESCRIBED DRUG WILL OR MAY AFFECT THE EMPLOYEE’S PERFORMANCE ON THE JOB.
IN THE EVENT AN EMPLOYEE IS ADVISED THAT MEDICATION MAY AFFECT PERFORMANCE, IT IS
THE EMPLOYEE’S RESPONSIBILITY TO NOTIFY HIS/HER SUPERVISOR OF THE CIRCUMSTANCES PRIOR TO REPORTING TO WORK. CONVICTION UNDER CRIMINAL DRUG STATUS EVERY EMPLOYEE, AS A CONDITION OF CONTINUED EMPLOYMENT, IT IS REQUIRED TO IMMEDIATELY NOTIFY THE COMPANY IF THEY ARE CONVICTED UNDER A FEDERAL OR STATE CRIMINAL DRUG STATUTE, WHETHER THE
ACT GIVING RISE TO SUCH CONVICTION OCCURRED OR IF COMPANY TIME OR WITHIN OR WITHOUT THE STATE OF TEXAS.
COORDINATION WITH LAW ENFORCEMENT AGENCIES THE SALE, USE, PURCHASE, TRANSFER OR POSSESSION OF AN ILLEGAL DRUG OR DRUG PARAPHERNALIA IS A VIOLATION OF THE LAW. THE COMPANY WILL REPORT INFORMATION CONCERNING POSSESSION, DISTRIBUTION, OR
USE OF ANY ILLEGAL DRUGS TO LAW ENFORCEMENT OFFICIALS AND WILL TURN OVER TO THE CUSTODY OF LAW ENFORCEMENT OFFICIALS ANY SUCH SUBSTANCES FOUND DURING A SEARCH OF AN INDIVIDUALS PROPERTY. THE COMPANY WILL COOPERATE FULLY IN THE PROSECUTION AND/OR CONVICTION OF ANY VIOLATION OF THE LAW. INFORMED CONSENT AND RELEASE OF LIABILITY
I AUTHORIZE IMPERIAL CAREGIVERS OR CLIENT COMPANY (“COMPANY”) TO OBTAIN A SPECIMEN OF MY URINE FOR CHEMICAL ANALYSIS. I UNDERSTAND THAT THE ANALYSIS IS TO DETERMIN OR EXCLUDE THE PRESENCE OF ALCOHOL, DRUGS OR OTHER SUBSTANCES, IN ACCORDANCE WITH THE SUBSTANCE ABUSE AND DRUG TESTING POLICY OF COMPANY. I UNDERSTAND THAT DECISIONS
REGARDING MY CONTINUED EMPLOYMENT MAY BE MADE AS A RESULT OF THIS ANALYSIS.
I UNDERSTAND THAT TEST RESULTS WILL BE DIVULGED ONLY TO AUTHORIZED PERSONNEL. I HEREBY CONSENT TO THIS TEST AND RELEASE IMPERIAL CAREGIVERS FROM ANY
LIABILITY FOR DECISIONS RESULTING FROM THIS TEST.