Release and Consent for Drug Screening (1375/E1375)

RELEASE AND CONSENT FOR DRUG SCREENING

· Branches providing service in Maine: Remove and discard this document. Instead use the Notification of Substance Abuse Screening for the State of Maine (e426).

· Branches providing service in Iowa: Also provide the Drug-Free Workplace and Substance Abuse Policy for Temporary Employees (e2400), and ensure the applicant checks the box below to acknowledge receipt of e2400.

For employment-related purposes, I understand that Kelly may ask me to submit to screening for drugs, alcohol, inhalants, and/or any other controlled substances (altogether referred to as “drug(s)” for the purposes of this Release and Consent form), unless prohibited by law. Where permitted by law, this may include screening prior to starting a specific customer assignment, after an accident occurs on the job, on a periodic and/or random basis, or based on reasonable cause to believe I am under the influence of drugs during work hours while on an assignment.

I hereby consent to submit to drug screening. I further authorize Kelly, its customers, or any hospital, clinic, laboratory, or medical review officer/organization to conduct and analyze the drug screening and to share the results among themselves. I agree to complete and sign any paperwork required by the laboratory to perform the screening and to provide the results as indicated in this Release and Consent form.

I agree that if I refuse to take or delay a required drug screening, alter a specimen, or refuse to complete necessary paperwork for a drug screening, Kelly may deny me employment, remove me from an assignment, and/or terminate my employment.

If the screening results are considered unfavorable by Kelly or the customer, I agree that Kelly may deny me employment, remove me from an assignment, and/or suspend or terminate my employment. The results of the screening shall be conclusive.

I release Kelly, its customers, and any organization conducting a drug screening(s) from any liability for the above actions.

I agree to notify Kelly within five days of any criminal conviction for a drug-related offense occurring during my employment.

I have read this Release and Consent for Drug Screening, I understand it, and I agree to its terms.

Full Legal Name (Printed) Last 4 digits of Social Security No.

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Signature Date

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Electronic Signature* Date

*If you are submitting this form electronically, type your name on the Electronic Signature line and check the box to the right next to “I agree.” This is your electronic signature. By electronically signing this form, you agree that you have reviewed this entire form and agree to all the terms contained in it. / I agree.

Applicants for positions in Iowa: By checking this box, I acknowledge that I received a copy of Kelly’s
Drug-Free Workplace and Substance Abuse Policy for Temporary Employees (e2400).