Drug Conviction Notification Form

DRUG CONVICTION NOTIFICATION FORM
(For use in connection with SOP 228.07.01.001, Drug-Free Workplace)
This form must be filed with Personnel Officer within 2 working
days of notice of conviction.

EMPLOYEE NAME: TITLE:

WORK LOCATION:

was convicted of

on .
Yes No_

Disciplinary action deemed necessary

If yes, action taken and date implemented.

Was employee directed to satisfactorily participate in an
approved drug assistance or rehabilitation program?

Yes No

Date enrolled .

NAME OF SUPERVISOR/MANAGER COMPLETING FORM:

_________________________________________

DATE COMPLETED:

_________________________________________