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DRUG / ALCOHOL SCREEN CONSENT FORM <br />RELEASE FORM FOR OBTAINING URINE AND/OR <br />BREATHALYZER SAMPLES FOR DRUG AND/OR ALCOHOL <br />SCREENING AND PERMISSION TO FURNISH THE RESULTS TO <br />THE EMPLOYER. <br />I authorize (insert name of <br />your employer), the M.U. S. T. Drug and Alcohol Screening Program, and any authorized <br />collection site or agent to take urine and/or breathalyzer samples from me for use in a <br />drug or alcohol screening. I understand why these samples are being requested and I give <br />permission for the results to be sent to the Medical Review Officer (MRO). The MRO <br />may communicate my status, to my employer, in accordance with the M.U.S.T. <br />program. <br />I further release and hold harmless M.U.S.T. (Management and Unions Serving <br />Together), including their constituent member organizations and affiliated Unions, as well <br />as their officers and directors from any consequences arising out of the drug and/or <br />alcohol test or results <br />there from. <br />Name (Please Print) <br />Address <br />City <br />Social Security Number <br />Signature <br />State Zip Code <br />Area Code/Phone <br />Number <br />Witness <br />Adamo CHSP Section 10.0 <br />Drug -Free Workplace 22 February 2023 Issue <br />Date <br />Dat <br />