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Drug Consent Form

  • *Required fields
  • Drug Test Consent and Policy Acknowledgement

    I have applied for employment with Fusion Medical Staffing (“Fusion”). Upon receiving an employment offer, I acknowledge that I will be required to undergo substance testing in accordance with this policy. I understand that I may be required to provide a list of prescription drugs taken before the test and may need to provide proof of prescriptions to the testing lab personnel and/or Medical Review Officer (MRO).

    I understand that testing will be conducted by a third-party facility selected by Fusion and that such testing will be completed in accordance with applicable law and under procedures established by the laboratory to ensure my privacy while also protecting against tampering/alteration of the test results.

  • Refusal to Test

    I acknowledge that if I refuse to submit to a drug test, my employment offer will be rescinded, and I will not be considered for future employment with Fusion. Refusal to drug test may be determined by Fusion and/or the testing laboratory. In addition, I further understand that I may be subject to further testing during the course of my employment with Fusion. I acknowledge that if I refuse to submit to a lawful request from Fusion to undertake a drug test after being hired, my employment with Fusion shall be terminated.

  • Test Results

    I understand that if my test results are positive, my employment offer will be rescinded, and I will not be considered for future employment with Fusion. .

    I understand that if any urine drug test results are dilute or dilute negative, I will be required to take a second urine drug test within 24 hours of Fusion’s receipt of the result. I understand that if the second urine drug test result is also dilute or dilute negative, I will be required to undergo blood drug testing. Blood drug testing must be completed within 24 hours of Fusion’s receipt of the result. A hair follicle test will not be offered.

    Fusion has a zero-tolerance policy for all forms of medical and recreational marijuana use.

  • Reasonable Suspicion or Workplace Injury

    If Fusion has a reasonable suspicion that I have engaged in substance use or impairment in the workplace, I understand that I may be subject to substance testing.

    In addition, I further understand that if I am injured or involved in an accident or injury in the workplace, I may be subject to substance testing where the circumstances suggest that alcohol or drugs may have played part in the accident or injury.

    For instances of both reasonable suspicion and workplace injury, I hereby agree to submit to substance testing if requested by Fusion.

    Drugs that are tested are subject to change. Testing may include but is not limited to the following substances:

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

    • Marijuana - THC (recreational and/or medical)
    • 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 understand that all testing described in this policy acknowledgement form shall be carried out in accordance with applicable law. Should any information in this policy acknowledgement form conflict with any applicable federal, state, or local law, the applicable provision of law will take precedence. I acknowledge that only duly-authorized officers, employees, and agents of Fusion will have access to information furnished or obtained in connection with a substance test I take. I understand that such individuals will maintain and protect the confidentiality of such information to the greatest extent possible.

    I hereby authorize any physician, laboratory, hospital or medical professional retained by Fusion for testing purposes to conduct such testing and to provide the results to Fusion. I release Fusion, any person affiliated with Fusion, and any such institution or person conducting the testing, from any and all liability which may arise by virtue of such testing and the results therefrom.

    I agreed to hold harmless Fusion, its company physician, and any testing laboratory Fusion might use related to the substance testing outlined in this policy acknowledgement. This means 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 substance test, even if Fusion or its selected 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, its company physician, and any testing laboratory Fusion might use for any alleged harm to me that might result from the release or use of information or documentation relating to the substance test, if the release or use of the information is within the scope of this policy acknowledgement. This policy acknowledgement has been explained to me in a language I understand, and I have been told that if I have any questions about any substance test or the policy acknowledgement, they will be answered.

  • *NOTE: Fusion Medical Staffing is an Equal Opportunity Employer, and does not discriminate on the basis of Gender, Race, Religion, Age, Disability, National Origin, or any other class or status protected by applicable law.

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