BY SIGNING THIS DOCUMENT, I INDICATE THAT I HAVE READ, I UNDERSTAND, AND I TO THE WSON DRUG TESTING POLICY. I UNDERSTAND THAT A NEGATIVE DRUG TEST IS REQUIRED FOR PROGRESSION IN THE SCHOOL OF NURSING. THIS NOTORIZED DOCUMENT CONSTITUTES MY CONSENT FOR DRUG TESTING BY WSON DESIGNATED LABORATORY. IT ALSO CONSTITUES CONSENT FOR THE LABORATORY TO RELEASE THE RESULT OF MY DRUG TESTS TO THE WSON. In Witness Whereof, this statement is executed this the_________ day of _______________ , 2016 . ________________________________ Student’s Signature ________________________________ Student’s Printed Name STATE OF Georgia COUNTY OF Cobb On this_________________2016, before me appeared ____________________________to be known to be the person described in and who executed the foregoing instrument, and acknowledged that ___________________________ executed the same as free act and deed. under my hand and seal on the day and year above written. _________________________________________ NOTARY PUBLIC SEAL My commission expires: _____________________ Adapted from the University of South Alabama College of Nursing Drug Testing and Procedure Policy Appendix E Kennesaw State University WellStar School of Nursing Symptoms and Other Indicators of Substance Abuse or Dependence Physiologic Slurred or rapid speech Blackouts Trembling Agitation or restlessness Persistent rhinorrhea Sweating Altered pupil dilation or constriction Flushed complexion Swollen face Bloodshot or glassy eyes
BY SIGNING THIS DOCUMENT, I INDICATE THAT I HAVE READ, I UNDERSTAND, AND I TO THE WSON DRUG TESTING POLICY. I UNDERSTAND THAT A NEGATIVE DRUG TEST IS REQUIRED FOR PROGRESSION IN THE SCHOOL OF NURSING. THIS NOTORIZED DOCUMENT CONSTITUTES MY CONSENT FOR DRUG TESTING BY WSON DESIGNATED LABORATORY. IT ALSO CONSTITUES CONSENT FOR THE LABORATORY TO RELEASE THE RESULT OF MY DRUG TESTS TO THE WSON. In Witness Whereof, this statement is executed this the_________ day of _______________ , 2016 . ________________________________ Student’s Signature ________________________________ Student’s Printed Name STATE OF Georgia COUNTY OF Cobb On this_________________2016, before me appeared ____________________________to be known to be the person described in and who executed the foregoing instrument, and acknowledged that ___________________________ executed the same as free act and deed. under my hand and seal on the day and year above written. _________________________________________ NOTARY PUBLIC SEAL My commission expires: _____________________ Adapted from the University of South Alabama College of Nursing Drug Testing and Procedure Policy Appendix E Kennesaw State University WellStar School of Nursing Symptoms and Other Indicators of Substance Abuse or Dependence Physiologic Slurred or rapid speech Blackouts Trembling Agitation or restlessness Persistent rhinorrhea Sweating Altered pupil dilation or constriction Flushed complexion Swollen face Bloodshot or glassy eyes
drug%20and%20alcohol%20appendix.docx