Background Check and Drug Test Authorization

CONSENT TO DRUG AND/OR ALCOHOL TESTING: I hereby agree, upon a request made under the drug/alcohol testing policy of Trusting Connections, to submit to a drug or alcohol test and to furnish a sample of my urine, breath, saliva, hair, sweat, and/or blood for analysis. I understand and agree that if I at any time refuse to submit to a drug or alcohol test under company policy, or if I otherwise fail to cooperate with the testing procedures, I will be subject to immediate termination. I further authorize and give full permission to have Trusting Connections and/or its company physician send the specimen or specimens so collected to a laboratory for a screening test for the presence of any prohibited substances under the policy, and for the laboratory or other testing facility to release any and all documentation relating to such test to Trusting Connections and/or to any governmental entity involved in a legal proceeding or investigation connected with the test. Finally, I authorize the Trusting Connections staff to disclose any documentation relating to such test to any existing or potential client or governmental entity involved in a legal proceeding or investigation connected with the test. I understand that only duly-authorized Trusting Connections officers, employees, clients and agents will have access to information furnished or obtained in connection with the test; that they will maintain and protect the confidentiality of such information to the greatest extent possible; and that they will share such information only to the extent necessary to make employment or referral decisions and to respond to inquiries or notices from government entities. I will hold harmless Trusting Connections, its company physician, and any testing laboratory Trusting Connections might use, meaning that I will not sue or hold responsible such parties for any alleged harm to me that might result from such testing, including loss of employment or any other kind of adverse job action that might arise as a result of the drug or alcohol test, even if a Trusting Connections or laboratory representative makes an error in the administration or analysis of the test or the reporting of the results. I will further hold harmless Trusting Connections, its company physician, and any testing laboratory Trusting Connections might use for any alleged harm to me that might result from the release or use of information or documentation relating to the drug or alcohol test, as long as the release or use of the information is within the scope of this policy and the procedures as explained in the paragraph above. I understand that I am financially responsible for my own drug testing before I can be considered for employment. If employed, and after the 90-day probation period, I will be reimbursed in-full for drug testing costs. The only exception to this refund is for per diem (non-active employees). Per Diem employees will not be reimbursed for drug testing costs. If employee changes from active to non-active status within the 90-day probation period, he/she will not be eligible for drug testing reimbursement. Placement candidates are not required to pay for drug testing. The agency will cover all of candidates’ drug test costs when a client expresses the desire to hire candidate. This policy and authorization have been explained to me in a language I understand, and I have been told that if I have any questions about the test or the policy, they will be answered. I UNDERSTAND THAT TRUSTING CONNECTIONS WILL REQUIRE A DRUG SCREEN AND/OR ALCOHOL TEST UNDER THIS POLICY WHENEVER I AM INVOLVED IN AN ON-THE-JOB ACCIDENT OR INJURY UNDER CIRCUMSTANCES THAT SUGGEST POSSIBLE INVOLVEMENT OR INFLUENCE OF DRUGS OR ALCOHOL IN THE ACCIDENT OR INJURY EVENT, AND I AGREE TO SUBMIT TO ANY SUCH TEST.*
- Yes, I accept.
- No, I do not accept.
BACKGROUND CHECK AUTHORIZATION: In connections with my application for employment (including referral for placement services) with Trusting Connections, I understand that consumer reports which may contain public information may be requested from Kroes Detective Agency. The reports may include the following types of information: public record information concerning my driving record, worker’s compensation claims, bankruptcy, criminal and civil records from federal, state and country agencies and all previous driving records from other states. I authorize with complete understanding and without reservation any and all agencies needed to furnish the above mentioned information. I understand that I have the right to make a request to Kroes Detective Agency and Trusting Connections, LLC and all affiliated companies, upon proper identification, the substance of all information in its files on me at the time of my request, including the source of information. I hereby consent for Trusting Connections to obtain the above information from Kroes Detective Agency. I also consent for Trusting Connections to share the results of this background investigation with Trusting Connections clients, upon request.
- Yes, I accept.
- No, I do not accept.
Name*
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Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
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Signature*
Date*
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Trusting Connections Nanny Agency is an award-winning nanny placement agency and sitter service.

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