Opening of Bids - 2018 Street Paving Project No 118-070 - Walsh & Kelly Inc

Home Browse Search

ACKNOWLEDGEMENT OF RECEIPT OF DOT DRUG AND ALCOHOL POLICY AND TESTING PROGRAM FOR NALSH & KELLY, INC. I acknowledge that I have received a copy of the DOT Drug mid Alcohol Policy for WALSH R KELLY, INC. I understand that it is my responsibility to read the policy in its entirety. I understand Lhat as an employee of WALSH & KELLY, INC., I ran required la abide by the rules and regulations established by [his policy, and dial I am subject to consequences if I violate the policy. I understand that The policy may change to comply with federal and slate Ions, and that I may oblain a cumin copy of the policy at any lime during business )sours 6mn my employer's designated employer representative (DER), I understand that if I have any questions about this policy, or if I need ussislance or resources related to alcohol andlor drug -related issues or problems, I only mite those questions and contents to my employer's DER. Name of Gmployee (Print name) Social Security No. Signature of Supervisor or DER Employee's signature vale Instructions: DOT requires all DOT -covered employees in sign this ackmowledgement form. The original of this form Will be retained in the employee's file in compliance with DOT regulations. An emplo) ee alto refuses to sign this acknowledgement foot is disqualified from providing safely -sensitive function for WALSH & KELLY, INC. INFORi1tATION FOR APPLICANTS FOR DOT -COVERED POSITIONS Walsh & Kelly, Inc. Federal ]an'squires aFP]icaiHs ro indicate a]ieJrer Wey bare previously refused colic tested or eicVd u positive test resuh on any pre-employmcm rest for any other DOT employer. Please provide This infnonavon bclorv- l; is a federal ofcnsc to falsify Ibis [n$rmntion- El I lure NOT tested positive on a precmploymenl dmg test for wry other DOT employer in the past are years, nor have I refired to be tested, (If so, please sign helms, and complete the mmainderof dais fomn.) Ll Yes, I tested positive (or I refused to be tested) on a prccmploynical drug test for o rountr DOT employer in the past hso years. (irso, please sign beimv, and do net comin ic.) Sig,ralme ofApplieam Dale Each upplieant for u DOTcovcrcd position at Employer, after heingnotified drat helshe hill be ofcred ajob, must be dmg Icaled, in accordance witii federal rcgulalioirs 49 CFR par13g2_ If Jic test result is positive, or if the applicant noses to submil to a preemployment test, [lie job offer Will be ivilli irawn. We must have a negative test result in our file before are can request or allow an employ" m provide safetvaensitila function for us, The cast of the initial screening lest and the conf sntory test null W paid by (Company Nome), Every applicant who provides a positive test resuh frill hose an opportunity to speak wilh a Medical Revdesv Officer about uny rcccai use or prescription and non-prescription drugs llmt migla csplain the positive test result An applicant whose test result is positive may, within 72 boon, mquesl a re -test, al htsmerowzt expense. The re -lest will be conducted on the same sample as was provided for the initial lest, and must be conducted by a different testing laboratory that meets die requirements of eertificasion DOT's letting requirements_ I have not tested positive (or refused to be tested) on a DOT preemployment drug test, at any lime in the previous two years_ My signilme bctow means thm I hoe road this itd'ormation, Jot I love had an opportunity to review a copy of (Company Name) drug and alcohol testing policy, and Ilia if 1 am oftescd n Position, 1 consent to being tested fordmgs as a condition of empioymem, Signature of Applicant Date 61 62 Agreement BY AND BETIVEEN INDIANA CONSTRUCTORS, INC LABOR RELATION DIVISION And LOCAL UNIONS OF LABORERS' INTERNATIONAL SUBSTANCE ABUSE POLICY UNION OF NORTH AMERICA APPENDIX 3 STATE OF INDIANA DISTRICT COUNCIL MARCH 1, 2012 Through MARCH 31, 2017 Ly 64