Opening of Bids - Sewer and Manhole Rehabilitation Project No 118-093 - Inland Waters Pollution Control Inc

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NOBODYOETSHURT Section 6.1 Rev. 0 Substance Abuse Policy March 2017 IRFR Page 8 of 8 Appendix 1 - Drug and/or Alcohol Testing Consent Form Employee Agreement and Consent to Drug and/or Alcohol Testing I hereby agree, upon a request made under the drug/alcohol testing policy of Inland Pipe Rehabilitation LLC and / or Subsidiary Business Unit further referred to as the "IPR," to submit to a drug or alcohol test and to furnish a sample of my urine, breath, hair follicle and/or blood for analysis. I understand and agree that if I at any time refuse to submit to a drug or alcohol test under IPR policy, or if I otherwise fail to cooperate with the testing procedures, I will be subject to immediate termination. I further authorize and give full permission to have IPR and/or its IPR physician send the specimen or specimens so collected to a laboratory for a screening test for the presence of any prohibited substances under the policy, and for the laboratory or other testing facility to release any and all documentation relating to such test to IPR and/or its designated employee or employees, as appropriate, and/or to any governmental entity involved in a legal proceeding or investigation connected with the test. I waive any right to privacy regarding the screening test, its results, and related documentation. Finally, I authorize the IPR to disclose any documentation relating to such test to any governmental entity involved in a legal proceeding or investigation connected with the test. will hold harmless the IPR, its IPR physician, and any testing laboratory the IPR might use, meaning that I will not sue or hold responsible such parties for any alleged harm to me that might result from such testing, including loss of employment or any other kind of adverse job action that might arise as a result of the drug or alcohol test, even if a IPR or laboratory representative makes an error in the administration or analysis of the test or the reporting of the results. I will further hold harmless the IPR, its IPR physician, and any testing laboratory the IPR might use for any alleged harm to me that might result from the release or use of information or documentation relating to the drug or alcohol test, as long as the release or use of the information is within the scope of this policy and the procedures as explained in the paragraph above. This policy and authorization have been explained to me in a language I understand, and I have been told that if I have any questions about the test or the policy, they will be answered. I UNDERSTAND THAT THE IPR WILL REQUIRE A DRUG SCREEN TEST UNDER THIS POLICY WHENEVER I AM INVOLVED IN AN ON-THE-JOB ACCIDENT OR INJURY UNDER CIRCUMSTANCES THAT SUGGEST POSSIBLE INVOLVEMENT OR INFLUENCE OF DRUGS OR ALCOHOL IN THE ACCIDENT OR INJURY EVENT. Signature of Employee Date Employee's Name — Printed Date IPR Representative Date SAFETY IS EVERYONE S BUSINESS 2187209.1