POST ACCIDENT DRUG TESTING CONSENT FORM

This is to acknowledge that a representative of KRAKER INC D.B.A. K & D ELECTRIC has explained to me that if I am injured in a work related accident, I will be asked to submit a drug test including any of the following types of test or combinations of test: breath analysis, urinalysis, and/or blood test to test for the presence of alcohol, illegal drugs, and/or pharmaceutical drugs and/or controlled substance.

It has been explained to me and I understand that testing for drugs, controlled substance and/or other medications which have been lawfully prescribed to me by a duly licensed physician will only be used to determine whether or not I have been taking the prescribed medication in accordance with my physician's orders.

It has been explained to me and I understand that if I refuse to submit to a drug test, my employment may be terminated and I may not be entitled to any worker's compensation benefits including, but not limited to, medical benefits, income benefits, and rehabilitation benefits. I also understand that a positive drug or alcohol test could result in immediate termination of my employment and forfeiture of entitlement to worker's compensation benefits.