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403.19-E3 - Drug & Alcohol Program and Pre-Employment Testing Written Consent to Share Information Form

Click here to download the Consent to Share Form

I,                                                 , understand that as part of my employment in a position that requires a commercial driver’s license in the Linn-Mar Community School District, I grant consent for the district to conduct queries of the Federal Motor Carrier Safety Administration (FMCSA) Commercial Driver’s License Drug and Alcohol Clearinghouse to determine whether drug or alcohol violation information about me exists in the Clearinghouse. I further consent to the district sharing information related to my drug and alcohol testing results with prior, current and future employers, as well as the FMCSA Clearinghouse in accordance with state and federal laws.

I understand that the district will check and perform queries of my drug and alcohol testing results prior to my employment in any position which requires the use of a commercial driver’s license. I further understand the district will check and perform queries of my testing results annually and is required to report any drug and alcohol violations of this policy to the FMCSA Clearinghouse.

I understand that I am not required to consent to the query of the FMCSA Clearinghouse or the district sharing of drug and alcohol testing information with past, present or future employers of the FMCSA Clearinghouse; but that without my consent I understand I will be prohibited from performing safety sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations.

I hereby give my consent to the district to perform queries of the FMCSA Clearinghouse and share my drug and alcohol testing results with past, present, and future employers, as well as the FMCSA Clearinghouse.

Signature of Employee:
Date Signed:

Please return this signed form to:
Linn-Mar Community School District
Human Resources Office
2999 N 10th Street
Marion IA 52302

Adopted: 6/20
Reviewed: 4/23
Related Policy: 403.19; 403.19-E1-E2
Legal Reference (Code of Iowa): § 124; 279.8; 321.375; 730.5
IASB Reference: 403.06-E(3)