DRUG ABUSE SCREEN APPLICANT AUTHORIZATION 7PANEL DRUG SCREEN

drug abuse screen - applicant authorization 7-panel drug screen this is a confidential document applicants name:   social secur

DRUG ABUSE SCREEN - APPLICANT AUTHORIZATION
7-PANEL DRUG SCREEN
THIS IS A CONFIDENTIAL DOCUMENT
Applicant's Name:  
Social Security #: XXX-XX-  
Classification:  
JobAps Easy ID #:  
Agency/Institution:  
Appropriation Code:  
In accordance with Code of Maryland Regulation (COMAR) 17.04.09,
Testing for Illegal Use of Drugs, I am directing you to submit to a
urinalysis test to determine your suitability for State employment.
The collection will take place as follows:
Collection Location:  
Collection Date:   Time of Collection:  
At the time of the collection, you will be required to present
positive identification in the form of a valid photo driver's license,
a State-issued identification card or a State employee photo
identification card.
Phamatech, Inc., 15175 Innovation Drive San Diego, CA 92128, will
conduct the test, and the specimen will be screened for the following
drugs:
Amphetamines
Benzodiazepines
Marijuana/Cannabinoids
Phencyclidine (PCP)
Barbiturates
Cocaine
Opiates
The test will not reveal information pertaining to any prescription
and/or non-prescription drugs that are not cited above. All test
results are confidential as required by applicable laws and
regulations.
If you refuse to comply with this condition of employment, you will be
disqualified from consideration for the position for which you
applied. In addition, your name will be removed from the eligible list
for all sensitive positions or positions in sensitive classifications.
IF YOUR TEST YIELDS A VERIFIED LABORATORY POSITIVE RESULT:
*
The State Medical Director's Office will contact you and give you
an opportunity to present information to establish a legal medical
explanation for the positive result. The Office will make three
attempts to contact you within 48 hours of receipt of the positive
result.
*
If you are currently a State employee who is applying for a
position in a sensitive classification or a sensitive position,
COMAR 17.04.09.03E(3)(a) requires the State Medical Director to
notify your current appointing authority of a verified laboratory
positive test result.
*
Verified laboratory positive test results will disqualify you from
State employment in sensitive positions or positions in sensitive
classifications.
*
You may request an independent test of a portion of the original
specimen. The retest must be performed by a U.S. Department of
Health and Human Services certified laboratory that has been
licensed in accordance with the laws of Maryland. You will be
provided a list of certified laboratories from which to make your
selection. You are responsible for all costs associated with the
retest.
*
You have the right to appeal any action resulting from a positive
test by writing to the Department of Budget and Management within
five workdays of your receipt of such notification.
Agency Technical Representative:
_________________________________________
Date:  
Applicant/Applicant-Employee:
____________________________________________ Date:  
Original - AGENCY ATR ● Copy - APPLICANT ● Copy - COLLECTION
REPRESENTATIVE
FORM MS - DT2 (Revised March 2015)