Donor Consent and Acknowledgment

Employee

Employee last 4 of SSN *

Selection # *

Job number *

Shift *

Date *

Project site *

Device / specimen ID

Employee acknowledgment

I was selected for this test by random, computer-generated selection under Liquidmetal’s Drug and Alcohol Policy. I consent to give an oral fluid (saliva) specimen for drug testing.

I understand that:

The on-site result is a preliminary screen. If it is non-negative, I will be taken to a clinic the same day to give a specimen for a certified laboratory test. A Medical Review Officer (MRO) will review that result and may contact me privately about prescriptions or other medical explanations before it is final.
I am not asked to list medications on this form.
Refusing to test, leaving before the test is done, or tampering with the specimen counts as a refusal under company policy.
My results are confidential and shared only with those who need them under the policy or as required by law.
I have received a copy of, or have been told where to find, the company Drug and Alcohol Policy.

The employee refused to test or to initial. (Collector: complete the refusal section at the bottom instead.)

By writing my initials below, I confirm I have read and understand this form.

Employee initials

Employee last 4 of SSN

Date and time

Collector certification

I confirmed the employee’s identity, and the last 4 of SSN matches the selection list.

The employee had nothing in their mouth for 10 minutes before collection.

The device package was sealed and opened in front of the employee, and the device ID matches this form.

Result shown to employee *

NegativeNon-negative – taken to clinicInvalid – recollected

Clinic name (if non-negative)

Time taken to clinic

Time result read

Collector (print name) *

Date and time

Collector signature

Only if the employee refused to test or to initial

Describe what happened, including the time and who witnessed it

Witness (print name)

Date and time

Witness signature