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. _ I have not used any illegal or incapacitating. drugs or controlled <br />substances in the last sixty (60) days. <br />2. _ 1 have used the following prescription drug, or over-the-counter drug or <br />medication, within the last sixty (60) days. <br />(a) Drug(s): <br />(b) Prescribing Physician <br />Name: <br />Address: <br />Phone: <br />If I receive a positive confirmed test result, I understand that 1 may contest or explain the results <br />to the Medical Review Officer within five (5) working days after receiving written notification of <br />the test result. If my explanation or challenge is unsatisfactory to the Medical Review Officer, <br />the Medical Review Officer shall report my positive test result to the Company. 1 may contest <br />the drug test result pursuant to applicable law or pursuant to rules adopted by the agency for <br />Health Care Administration. If I choose to contest those results pursuant to applicable law or <br />pursuant to the rules for Health Care Administration, I must notify the laboratory that conducted <br />my drug test of any administrative or civil action brought by me. <br />I hereby give my consent to the Company to administer any or all of the above drug and alcohol <br />testing procedures to me and to use the results thereof in determining my employability with the <br />Company. <br />1 further release any testing facility or any physicians who have tested me from any liability arising <br />from the release of any and all test(s) results, written reports, medical records, and data concerning <br />my test(s) to the appropriate officials of the Company. <br />Applicant/Employee's Printed Name: <br />Applicant/Employee's Signature: _ <br />Social Security Number: <br />Date: <br />Witness Narne: Date: <br />Witness Signature: <br />DFW-3 <br />