Download Failed pre-employment drug test result confirmation form (PDF 35.67

Failed pre-employment drug test
result confirmation form
This form enables an employer to talk about and record the result of a pre-employment drug test with
candidates who are also Work and Income clients. It also provides an opportunity to talk about whether any
further testing is required.
Employers are encouraged to keep a copy of this form.
Client’s
details
1
What is your full name?
First and middle names
2
What date were you born?
Day
Confirming
the result
3
4
You accept
the result
5
Surname or family name
Month
Year
I have taken a pre-employment screening drug test and have had the
result explained to me.
Do you accept the result?
Yes
Go to question 5
No
Go to question 6
I accept the result of the pre-employment screening drug test.
I understand that this means:
• There is no requirement to send this sample to a laboratory for evidential
(confirmatory) testing.
• This information will be passed on to Work and Income.
• I will have to repay Work and Income for the cost of the failed drug test.
• Work and Income will contact me about failing my obligations.
Go to signature section
You do not
accept the
result
6
I do not accept the result of the pre-employment screening drug test.
I understand that this means
• This information will be passed on to Work and Income.
• If the employer decides to send this failed sample to a laboratory for evidential
testing and the evidential test also produces a failed result, I will be required to
repay Work and Income for the cost of the failed screening test as well as the
failed evidential test.
Signature
Your name (print)
Your signature
Date
Day
V28W – JUL 2013
Month
Failed pre-employment drug test result confirmation
Year
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