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SUBSTANCE ABUSE POLICY <br />EH&S Procedures <br />Standard Owner: EH&S Department <br />DOCUMENT No.: EHS-000146 <br />Date of Issue: 8/23/2016 <br />Issued By: Corporate Safety Director <br />Date of Approval: 6/15/2017 <br />Approved By: Safety <br />Appendix — E: <br />Refusal to Test <br />REV M 1 <br />Next Rev.: <br />6/15/2021 <br />, hereby refuse to provide a specimen to <br />appropriate medical personnel or to the person administering the instant so that a drug - <br />screening test can be performed. I recognize that this refusal constitutes a presumption of a <br />positive result, which will result in disqualification and discipline up to and including termination. <br />Date: <br />Time: <br />Supervisor: <br />Comments: <br />Employee Refusal to Sign ( <br />(Supervisor) <br />Employee: <br />Date: <br />Page 20 of 22 <br />