HTML Preview Drug Test Consent Acknowledgement Form page number 1.
TEXAS DEPARTMENT OF LICENSING AND REGULATION
COMPLIANCE DIVISION/Tow Truck/Vehicle Storage/Booting Program
P.O. Box 12157 Austin TX 78711
Email: cstowing@tdlr.texas.gov Website Address: www.tdlr.texas.gov
DRUG AND/OR ALCOHOL TESTING PROCEDURES
CONSENT AND ACKNOWLEDGEMENT FORM
I___________________________________. an applicant or an employee with ___________________________ (the Company)
consent to and acknowledge that I am scheduled to undergo drug and/or alcohol testing.
Test Specimen and Substances: A. All Tow Operators are required to take the alcohol test. B. The drug and/or alcohol test will
involve an analysis of a urine sample, which I will provide at a designated site. The purpose of the test will be to test for the presence
of the following substances: marijuana, cocaine, amphetamines, phencyclidine (PCP), opiates, and alcohol.
Specimen Collection: I allow qualified personnel to take and have analyzed suitable specimens to find out if drugs and/or alcohol are
present in my system.
Release of Test Results: I agree that positive drug and/or alcohol screen test results be made available for review by the medical
review officer (MRO), the company, and the Texas Department of Licensing and Regulation (TDLR) in connection with determining
whether I violated the drug and/or alcohol testing policies established by 16 Texas Administrative Code, Chapters 85 and 86 (the
Rules). I further agree that TDLR may use verified positive test results in an administrative hearing to enforce an alleged violation of
the rules. I understand this authorization and consent form is valid until revoked by me in writing.
Procedures for Confirming and Verifying Positive Results: I understand that a second test of the same specimen will confirm an
initial positive test. After receiving a confirmed positive, but before verifying that result, I understand the MRO will make all
reasonable attempts to contact me to discuss the test result. If contacted by the MRO, following our discussion and any other proper
inquiry, the MRO will determine whether to verify the test result. If the MRO verifies the confirmed positive result, I also understand
and consent to the MRO sending the verified positive test results to the company and the company notifying the Texas Department of
Licensing and Regulation according to the regulations governing my state issued license.
Refusal to Undergo or Obstruct Drug and/or Alcohol Testing: I understand that I must appear at the designated test site for drug
and/or alcohol testing with a minimum of 15 minutes and a maximum of two hours notification. My failure to appear during the
prescribed time will result in a verified positive drug and/or alcohol test. I also understand that failure to provide adequate urine for
controlled substances testing without a valid medical explanation, and engaging in conduct that clearly obstructs the testing are the
same as refusing to test.
Effects of Positive Drug and/or Alcohol Test: As an applicant, I am aware that a confirmed and verified positive drug and/or alcohol
test will cause my removal from towing operation and/or VSF duties and I may be subject to disciplinary action up to termination. I
will present a copy of this form to the collection site when I report for my scheduled drug test.
Right to have split-sample analyzed: I understand that if a urine sample is verified positive, I have the right to request analysis of the
split-sample in a different certified laboratory for the presence of the drug(s) and/or alcohol for which a positive result revealed. I also
understand I must give written request to the MRO within 72 hours of the MRO notification to me of a verified positive test result.
By execution of this consent form, I acknowledge the company has notified me of the company’s drug and/or alcohol testing policy.
__________________________________________ ________________________________________________
Printed Name of Applicant or Employee Applicant’s Social Security Number or Licensee’s TDLR License Number
____________________________________________ ______________________________________
Signature of Applicant or Employee Date
Texas Department of Licensing and Regulation Model Drug and/or Alcohol Testing Policy Consent Form
Tow Operators and VSF employees must include their TDLR license number