F059 Notice of Result that is Not Negative Info Consent
1. F059 - Notice of Result that is Not Negative & Info Consent Page 1 of 1
F059 - NOTICE OF A RESULT THAT IS NOT A NEGATIVE
& INFORMATION CONSENT FORM
I ______________________________________________________________ (insert name) of
__________________________________________________________________ (the Firm) underwent a
drug and alcohol screen on _________________________________.
1. Acknowledgement of Result
(Cross out one of the text sections below if not relevant)
I understand that my result to the alcohol screen was positive i.e. alcohol was detected at a level
of _______________% blood alcohol content which is above the firm’s agreed threshold limit, and
that in accordance with the firm’s Drug and Alcohol Management Procedure I am to be stood down
from work until ___________________________________ or until I pass an alcohol test
(whichever is greater).
AND / OR
I understand that my result to the drug screen was not negative/ unconfirmed (being a
reading(s) of):
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
and that laboratory confirmatory analysis of my sample is required. I understand that as the firm’s
Drug and Alcohol Management Procedure, I may be stood down from work on my base rate of pay
until results of the confirmatory analysis are obtained.
2. Acknowledgement of Information Provided and Representation
I confirm that I have been provided with access to the firm’s Drug and Alcohol Management Procedure and
Policy, the opportunity to review it, and the opportunity to call a representative to be present.
3. Information Consent
I authorise the firm to OBTAIN and RELEASE information, either verbal or written, in relation to my incident
management from representatives of the agencies / parties nominated below, as necessary:
Nominated Treating Doctor
Employee Representative
Work Options (the firm’s D&A management service provider)
Other Health Professionals related to my case
Laboratory
Other parties’ ____________________________________________________
I understand that I may change or cancel this authority at any time, however my incident management and
employment status may be affected.
Employee: __________________________ Manager: ____________________________
Signature: __________________________ Signature: ____________________________
Date: __________________________ Date: ____________________________
