Employee Acknowledgement/Receipt of Notice Position Designated Senstive for Drug Testing Purposes

• Legal Form Number: BP-A0592
• Date: 2010-06
• Year: 2010
• Section: Federal Bureau of Prisons

EMPLOYEE ACKNOWLEDGEMENT/RECEIPT OF NOTICE

POSITION DESIGNATED SENSITIVE FOR DRUG TESTING PURPOSESU.S. DEPARTMENT OF JUSTICE

FEDERAL BUREAU OF PRISONS

BP-A0592

JUN 10

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE TO EMPLOYEE

WHOSE POSITION IS DESIGNATED SENSITIVE

FOR DRUG TESTING PURPOSES

I acknowledge receiving notice of the establishment of the Federal Bureau of Prisons' employee drug testing

program. I understand that I may be selected for screening by urinalysis testing for the presence of

controlled substances. I understand that a confirmed positive result of that testing or refusal to submit to

testing may result in disciplinary action up to and including dismissal from Federal service. I further

understand that I will have an opportunity to submit medical documentation to the Medical Review Officer to

support my legitimate use of a drug. I further understand that, in the event of a positive test result, I may

request a portion of the original sample to be retested at another NIDA certified laboratory of my choice.

I have read the notice announcing the establishment of an employee drug testing program. I also

acknowledge that I have received a copy of the Bureau of Prisons' Program Statement on employee drug

testing.

Printed or Typed Name

Signature of Employee

Date

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