NOTIFICATION AND CONSENT FORM FOR
PRE-EMPLOYMENT DRUG AND ALCOHOL TESTING
Data Practices Advisory: Minnesota Statute §13.04, Subd. 2
I acknowledge that I have seen the City of Minneapolis Pre-employment Drug and Alcohol Testing Policy. I
hereby consent to undergo drug and alcohol testing pursuant to said policy, and I authorize the City of
Minneapolis through its agents and employees to collect a breath and/or urine and/or blood sample from me
for that purpose.
I understand that the procedure employed in this process will ensure the integrity of the sample and is
designed to comply with medicolegal requirements.
I understand that the results of this drug testing may be discussed with and/or made available to the City of
Minneapolis. I further understand that the results of this testing may affect my job offer as described in the
policy.
The purpose of collecting a body component sample of breath, blood, or urine is to test that sample for the
presence of drugs and alcohol. A sample provided for drug and alcohol testing will not be tested for any other
purpose. The name, initials and social security number of the person providing the sample may be requested
so that the sample can be identified accurately but confidentially. Information about medications and other
information relevant to the reliability of, or explanation for, a positive test result is requested to ensure that the
test is reliable and to determine whether there is a valid medical reason for any drug, alcohol, or their
metabolites in the sample. All data collected, including that in the notification form and the test report, is
intended for use in determining the suitability of the job applicant for employment. The job applicant may refuse
to supply the requested data; however, refusal to supply the requested data may affect the job applicant’s job
offer.
A Medical Review Officer may only disclose to the City of Minneapolis test result data regarding presence or
absence of drugs, alcohol, or their metabolites, in a sample tested. The City of Minneapolis or laboratory may
not disclose the test result reports and other information acquired in the drug testing process to another
employer or to a third party individual, governmental agency, or private organization without the written consent
of the person tested, unless permitted by law or court order. Evidence of a positive test result on a
confirmatory test may be: (1) used in an arbitration proceeding pursuant to a collective bargaining agreement,
an administrative hearing under Minnesota Statutes, Chapter 43A or other applicable state or local law, or a
judicial proceeding, provided that information is relevant to the hearing or proceeding; (2) disclosed to any
federal agency or other unit of the United States government as required under federal law, regulation, or
order, or in accordance with compliance requirements of a federal government contract; and (3) disclosed as
required by law, court order, or subpoena. Positive test results may not be used as evidence in a criminal
action against the applicant tested.
______________________________ _____________________________________
Name (Please Print or Type) Position Being Considered for and Department
______________________________ Date _________________
Signature
______________________________ Date _________________
Witness (Hiring Authority)
______________________________
Signature