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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 />Appendix — F: <br />Notification of Medication: <br />Employee notification of medications <br />EMPLOYEE'S PORTION <br />Employee Name: <br />Date: <br />Describe Medication: <br />Time: a.m. / p.m. <br />REV #: 1 <br />Next Rev.: <br />6/15/2021 <br />Describe warnings contained on the medication, which may affect your ability to safely perform your <br />position. <br />Time medication taken: a.m. / p.m. <br />Stated time medication side effects remain: <br />Employee's signature: <br />SUPERVISOR'S PORTION <br />Date: <br />Based on the review of medication information provided above and a discussion with the employee's <br />physician, if necessary, the employee is: <br />Allowed to continue to perform current duties: <br />Date: Time a.m. / p.m. <br />Temporarily reassigned to non -safety sensitive duty: <br />Date: Time a.m. / p.m. <br />Temporary reassignment in place until: <br />- - - - - - - - - - - - - - - - - - - - - - - - - - - - <br />Sent home as no non -safety sensitive duties are available; Pay will be handled as appropriate <br />under the sick pay policy. <br />Page 21 of 22 <br />