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Authority: Chip Lee �� A <br />U.S. HSE Coordinator: Eddie Oliver Co... <br />Issuing Dept: Safety/HR Health Safety & Environment Manual Page: 122 of 300 <br />DRUG AND ALCOHOL SIGNATURE FORMS <br />DRUG AND ALCOHOL POLICY ACKNOWLEDGEMENT FORM <br />acknowledge that I have been provided a copy of the C. Lee Construction Services Drug and Alcohol Policy <br />requirements. I understand that disciplinary action, up to and including termination, will result if I violate this policy. <br />Employee Signature <br />Employee Printed Name <br />Date <br />Social Security Number (last 4 digits) <br />CONSENT AND AUTHORIZATION FOR DISCLOSURE TO CLIENTS OF C. LEE CONSTRUCTION <br />SERVICES OF ALCOHOL AND DRUG TEST RESULTS AND RELATED INFORMATION <br />I hereby consent to disclosure by C. Lee Construction Services and its agents, including, but not limited to, any <br />collecting and testing agencies, of the test results identified above and any related information to clients of C. Lee <br />Construction Services and its authorized agents, assigns, or representatives. <br />Employee Signature <br />Employee Printed Name <br />Date <br />Social Security Number (last 4 digits) <br />Revision No. 2.0 Uncontrolled copy if printed. <br />Initial Issue Date: 01/01/2018 Valid on day of printing only. <br />Revision Date: 04/15/2023 <br />Next Review Date: 04/15/2024 Printed <br />31 January 2024 8:30 AM <br />Page: 122 of 300 <br />0 C. Lee Construction Services, Inc. <br />