Drug Consent Form

  • *Required fields
  • I have applied for employment with Fusion Medical Staffing. As a condition for my application being considered, I understand and agree to undergo substance screening. I understand that if my test results are positive, I shall not be considered further by Fusion Medical Staffing.

    I hereby authorize any physician, laboratory, hospital or medical professional retained by Fusion Medical Staffing for screening purposes to conduct such screening and to provide the results to Fusion Medical Staffing and I release Fusion Medical Staffing and any person affiliated with Fusion Medical Staffing and any such institution or person conducting the screening, from liability.

  • COC AMP mAMP THC MTD TCA OPI PCP BAR BZO:

    • Marijuana - THC
    • Cocaine - COC
    • Amphetamine - AMP
    • Methamphetamine - mAMP
    • Phencyclidine - PCP
    • Benzodiazepines - BZO
    • Methadone - MTD
    • Opiate - OPI
    • Barbiturates - BAR
    • Tricyclic Antidepressants - TCA
  • Adulteration tests:

    • Oxidants
    • Specific gravity
    • pH
    • Nitrite
    • Glutaraldehyde
    • Creatinine
  • I will hold harmless Fusion Medical Staffing, its company physician, and any testing laboratory Fusion Medical Staffing might use, meaning that I will not sue or hold responsible such parties for any alleged harm to me that might result from such testing, including loss of employment or any other kind of adverse job action that might arise as a result of the drug or alcohol test, even if Fusion Medical Staffing or laboratory representative makes an error in the administration or analysis of the test or the reporting of the results. I will further hold harmless Fusion Medical Staffing, its company physician, and any testing laboratory Fusion Medical Staffing might use for any alleged harm to me that might result from the release or use of information or documentation relating to the drug or alcohol test, as long as the release or use of the information is within the scope of this policy and the procedures. This policy and authorization have been explained to me in a language I understand, and I have been told that if I have any questions about the test or the policy, they will be answered.

  • *NOTE: Fusion Medical Staffing is an Equal Opportunity Employer, and does not discriminate on the basis of Sex, Race, Religion, Age (40 and over), Handicap or National Origin. Remember, "involved in an on-the-job accident or injury" means not only the one who was injured, but also anyone who arguably or potentially contributed to the accident or injury event in any way, i.e., the person suspected of causing someone else to get hurt gets tested as well. Testing only accident or injury victims can, in the eyes of some, appear to be a way of discouraging workers from filing workers' compensation claims, and that in turn can have a very unfavorable effect on workers' compensation retaliatory discharge lawsuits. Drugs that are tested are subject to change.

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