ATLANTA POLICE DEPARTMENT

Random Drug Test Notice

Section A	Date: _________________________	Unique ID: _________
Employee’s name: _____________________________ Watch: M D E
Division: ______________	Section: _____________	Unit: _______________
As authorized by City Code Section 114-572 and APD.SOP.2024, “Random Drug Screening,” you have been randomly selected to provide a urine sample for a drug screen and to take a breath alcohol test. You are hereby given a direct order to report to the collection site at Caduceus Occupational Medical Clinic at 145 North Avenue in Atlanta or 535 North Central Avenue in Hapeville.

Drug Screen Program Coordinator: __________________________________________

Print or type

Signature: __________________________________________ Date and time: _______________
Section B	Time notified:

____________

Supervisor’s signature: ________________________________

Employee’s signature: ________________________________
Departure time from worksite:	__________	Supervisor’s initials:	__________
Section C	Arrival time at collection site:

________	Collector’s

signature: _______________________
Sample given satisfactorily:	Yes No	Collector’s initials:	__________
Departure time from collection site: ________	Collector’s initials:	__________
Comments:

Employees must report directly and immediately to the collection site for testing after being notified by his or her supervisor. Failure to report to the collection site within one hour or refusing to test or attempting to circumvent the test is grounds for dismissal.

You must have your City identification card at the collection site.

The employee is to turn this form in to his or her supervisor when it is completed.

Form APD 280 Revised 3/18/10

ATLANTA POLICE DEPARTMENT

vlivsey

2010-03-18