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<br />DRAFT <br /> <br />CITY OF PARIS <br /> <br />INFORMED CONSENT AND <br />RELEASE OF LIABILITY MEDICAL AUTHORIZATION FORM, <br />CONSENT FORM FOR SUBSTANCE TESTING <br /> <br />I hereby give my consent to a medical examination including, but not limited to, the <br /> <br />collection of a breath, urine, or blood sample to be submitted for an alcohol, drug, and <br /> <br />controlled substance abuse screening tests, in accordance with the City of Paris's Controlled <br /> <br />Substance and Alcohol Abuse Policy. Further, I hereby consent to the release of the test <br /> <br />results to those City officials who make employment decisions for the City. I understand <br />that any positive result from such test, which indicates my inability to safely and <br />successfully peñorm the essential functions of the position for which I am being employed <br /> <br />or am currently employed, may preclude my receiving or continuing employment. I release, <br /> <br />relinquish, and remise the City of Paris, its employees, agents, and representatives, from any <br /> <br />and all causes of action or liability which I may have or which arise out of, or as a result of, <br /> <br />the examinations herein authorized. Furthermore, I understand that my failure to execute <br /> <br />this informed consent will, if I am applying for employment, result in my not being further <br />considered for employment, and may, if I am currently employed, result in my discharge. <br /> <br />Signature <br /> <br />Date <br /> <br />Name (please print) <br /> <br />DepartmentlDivision <br /> <br />75 <br /> <br />Rev. 10/27/04 <br />