UNIVERSITY OF TEXAS AT EL PASO
DRUG SCREEN CONSENT AND RELEASE
My signature below indicates that I have been advised that a drug screening is required for admittance to or continued enrollment in majors and/or courses that include or may include a clinical component in a clinical health care facility. A favorable review of this information by UTEP as a condition of admission and enrollment is not binding upon a clinical facility. A clinical facility may refuse to permit a student to participate in the clinical component at the facility if the drug screening information is not provided, or if upon review of a student’s drug screening it is determined that the student is disqualified. This Consent and Release Form provides my irrevocable consent for the drug screening to be conducted and the results of such drug screening to be released to UTEP officials, and the results or a certification concerning the results to be released to the affiliated clinical facility. The purpose of requesting this information is to permit the clinical facility to verify my qualifications to participate in the educational program offered at that facility. My signature below further grants authorization to access and release certain personal identifying information, i.e. UTEP identification number, for the purposes stated herein.
Please provide the following information/authorization:
Major______UTEP ID #______
Social Security No.*______OR DOB* ______[mm/dd/yyyy]
______Drug screening Access Code______
Signature
______
Printed Name
______
Date
Mail or Hand Delivery to the
Compliance Coordinator
University of Texas at El Paso
College of Health Sciences
1101 N. Campbell Street
El Paso, Texas 79902
* Disclosure of your social security number is requested so that UTEP may verify your identity in reviewing drug screenings online. Disclosure is not mandated by law. If you chose not to provide your social security number, your date of birth is needed as a positive identifier with the vendor’s report.