Medical College of Georgia
Administrative Policies and Procedures
Office of Primary Responsibility: Human Resources Division
No. 1.4.32 Substance Abuse Policy
Attachment B
FOR CAUSE DRUG TESTING AUTHORIZATION
To be completed by the supervisor of the employee to be tested.
1. Name of employee suspected of substance abuse.
_________________________________________________
2. Reasons why you suspect them of substance abuse. Be as specific as possible,
including times and dates where unusual behavior was observed, and the names and
whereabouts of those witnessing the behavior. If you suspect the employee of abusing any
particular substance, please list it.
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________.
3. Based on the information above, it is my opinion that there is reasonable cause to
believe that this employee has engaged in substance abuse.
_______________________________, ___________ / ____________.
Signature, Date / Time
Name of supervisor completing this form. __________________.
Approval obtained from:
(1) Division of Human Resources by _____________________ (name); and,
(2) Other (see section 6.4) by _______________________ (name).
To be completed the employee to be tested (optional).
Are you taking any medications, or is there any other information you believe might
explain your behavior or assist the physician interpreting your test?
_________________________________________________
_________________________________________________.
The original of this form must be given to the Human Resources Division for inclusion
in the employees records, with one copy kept by the supervisor and one given to the
employee. |