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Volunteer Applicant’s
Drug Screening Consent Form
I understand that Salem Regional Medical Center requires drug testing as a part of its
selection process for volunteers. I also understand that such drug testing will consist of a urinalysis
and/or a blood test. I further understand that if such testing indicates the presence of unprescribed
and/or illegal drugs in my body in any detectable amount, I will be disqualified from further
volunteering. If I am taking any prescription medication and the results of the testing indicate the
presence of the prescribed drug, I do hereby give my permission to contact the prescribing
physician for verification of the prescription.
I hereby give my consent to SRMC to administer any or all of the above drug testing
procedures on me and to use the results thereof in any further determining of my status as a
volunteer with SRMC. I also consent to SRMC’s administration or reasonable cause testing as
outlined in the Hospital’s Substance Abuse Policy. I further consent to SRMC’s release of my test
results to an independent laboratory for result confirmation.
I represent that I have used the following prescription and/or over-the-counter drugs
within the last thirty (30) days.
a.
Over-the-Counter Drugs:
b.
Prescription Drugs:
c.
Prescribing Physician:
d.
Physician’s Address(es):
e.
Physician’s Telephone Number:
I hereby certify that the information contained in this application is correct to the best of my
knowledge and understand that falsification or omission in this application in any detail is grounds
for disqualification from further consideration or for dismissal from volunteering at the time CRMC
discovers the omission and falsification. I agree to abide by the rules and regulations of SRMC.
Date of Application
Legible Signature as shown on Social
Security Card
ID Verification
Print Name
Witness
Social Security Number