Name: Signal Health Group
Address: 10475 Crosspoint Blvd, Indianapolis, IN, 46256, US
Telephone: 800-953-6183
Price range: $$

Drug Screen Consent and Results
I give my consent to be drug tested for employment at this agency.
Required Agency Actions for a Positive Test Result
Unless the employee has a valid prescription for the controlled substance for which the employee tested positive, the agency must take an action as follows:
a) If the employee’s test result is positive, the agency must have the test verified by a confirmation test. The employee shall pay for the confirmation test.
b) If a confirmation test verifies a positive result, the agency shall:
a. Discharge the employee; or
b. Suspend the employee from direct patient care for at least six months. [Ind. Code 16-27-2.5-3] Demonstration

Employee Signature:	Date
Test Administered By:	Date

BZO Neg/Pos	COC Neg/Pos	THC Neg/Pos
MET Neg/Pos	OPI Neg/Pos	AMP Neg/Pos

Witness:

Date

Drug Screen Consent and Results