DHE(EXHIBIT) - EMPLOYEE STANDARDS OF CONDUCT: SEARCHES AND ALCOHOL/DRUG TESTING

The forms on the following pages will be used for drug and alcohol screening of employees:

EXHIBIT A

CONFIDENTIAL

SPRING INDEPENDENT SCHOOL DISTRICT

SUPERVISOR'S DOCUMENTATION FOR DRUG AND/OR ALCOHOL TESTING

Staff Member Name (Print)

Social Security Number

Staff Member Job Classification

Supervisor's Name (Print)

Social Security Number

Supervisor Job Classification

Nature of work-related incident that causes this recommendation:

Fully describe below the event(s): a) leading up to the incident/situation, b) the work-related incident/situation itself, and, c) the results of the incident/situation. Remember, only include things that you observed, not what you think or suspect. Include job-related actions, not personal, off-duty actions. Be specific, not vague. Fill out spaces below and attach additional sheets, if necessary. Use dates, times, places, and names.

List names of individuals who witnessed the incident.

Information concerning your observations of the staff member's physical actions.

Walking/Standing

Speech

Actions

Eyes

Smell

Smell of alcoholic beverage or drugs on the person's breath.

Smell of alcoholic beverage or drugs on the person's body.

Accident

Traffic accident – circumstances surrounding event

Other accident – circumstances surrounding event

Describe interaction you had with the staff member (questions, answers, instructions, and the like)

Physical evidence (pills, bottles, broken equipment, and the like). List items, give locations, and disposition. Be specific.

Add any additional information.

Signature of Reporting Supervisor

Date

Signature of Witnessing Supervisor

Date

Signature of Assistant Superintendent of Human Resources

Date

EXHIBIT B

INFORMED CONSENT FOR DRUG AND/OR ALCOHOL TESTING

I, ____________________________________________, (Print Name) consent to this request for a urine or blood specimen or the use of other alcohol screening devices to perform a comprehensive test for drugs or alcohol pursuant to the Spring Independent School District policy DHE(LOCAL) and DHE(REGULATION). I authorize the release of the results of these tests to the authorized Spring Independent School District officials and any authorized third parties. I understand that this analysis will be conducted under the direction of a laboratory approved by the District.

I understand refusal to consent to a drug or alcohol test will subject me to disciplinary action up to and including employment termination, or if I am an applicant, will result in termination of the hiring process.

I understand the initial drug screening will be by the enzyme immunoassay techniques (EMIT) test. If this test yields a positive result, a second test by a gas chromatography/mass spectrometry (GC/MS) will be made immediately using a portion of the same test sample I provided for the first test. If the second test confirms the positive test result, I will be notified in writing within five working days. I understand that the alcohol screening test will be the Evidential Breath Testing (EBT) device. The letter of notification will identify the particular substance found.

I understand the urine or blood specimen collected pursuant to the administrative regulation will be used only to test for those drugs or alcohol included in the administrative regulation and may not be used to conduct any other analysis or test unless otherwise authorized by law.

I acknowledge I have been notified of the Spring Independent School District policy DHE(LOCAL) and DHE(REGULATION). Further, I understand that if the drug or alcohol test is confirmed to be positive, as a staff member, I am subject to disciplinary action up to and including employment termination, and I will not be assigned to operate or maintain a school bus or police vehicle. As an applicant, I understand that if the drug or alcohol test is confirmed to be positive, I will not be hired.

I do not consent to a drug or alcohol test.

I do consent to a drug or alcohol test.

SignatureDate

Social Security Number

Supervisor's SignatureDate

Witness SignatureDate

Spring ISD

DHE(EXHIBIT)-X

LDU 2013.10

DATE ISSUED: 12/4/2013