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I have read the Substance Abuse Policy and Drug/Alcohol Testing Policy of Kentucky State University School of Nursing and Kentucky State University's Drug-Free Campus and Work Place Policy and, agree to comply with all aspects of these policies.

I understand that if I engage in substance abuse as defined in the policy, or if I violate the Kentucky State University Drug-Free Campus and Work Place Policy while engaged in any clinical experience or any University/School of Nursing sanctioned event, or if I violate any drug/alcohol related state or federal statue and/or fail to notify the Administrative Leader of the School of Nursing within five days of such violation, that I may be dismissed perpetually from the School of Nursing.

I understand that it is a requirement for students accepted into any Kentucky State University School of Nursing program to provide a true and accurate, signed statement indicating whether I do or do not engage in chemical substance abuse or misuse and whether I am involved in any administrative actions or have prior legal convictions pertaining to the abuse/misuse of alcohol or any other chemical substance. In compliance with this requirement, I hereby verify under penalty of perjury that:

I (am) (am not) (check/circle the appropriate response) over the age of 18 years.

I (am) (am not) (check/circle the appropriate response) using any chemical substance for any reason other than its intended proper use.

I (am) (am not) (check/circle the appropriate response) personally using a chemical substance that is specifically proscribed (forbidden) or prohibited by law or by regulation pursuant to legal authority.

I (am) (am not) (check/circle the appropriate response) personally misusing any legally controlled substances or personally using any normally legal chemical substance (e.g., alcohol) in a manner that produces significant impairment or that produces the likelihood of the development of an impairment.

I (have been) (have not been) (check/circle the appropriate response) convicted of a crime pertaining to the manufacture, use, possession, sale or other distribution of illegal or legally controlled substances or pertaining to or related to the abuse of alcohol or any other chemical substance

Student's Printed Name

Student's Signature ___ Date ___

[1] Substance abuse means (a) the manufacture, use, sale, purchase, distribution, transfer, or possession of an illegal drug by any nursing student while on University or affiliated clinical premises or while participating in any University or affiliated clinical site-sponsored or relate activity, including any nursing-related course or clinical training activity; (b) the consumption, possession, or distribution of alcohol, unless approved by the university or clinical agency, by any nursing student while University or affiliated clinical premises or while participating in any University or affiliated clinical site-sponsored or relate activity, including any nursing-related course or clinical training activity (c) a nursing student's use of alcohol or any drug in such a wat that the student's performance in any nursing school course , including activities at any clinical site, is impaired. Illegal drug means any drug which is not legally obtainable; any drug which is legally obtained but has not been legally obtained; any prescribe drug not legally obtained; any prescribe drug not being used for the prescribed purpose of by the person for whom it was prescribed; any over-the-counter drug being used at a dosage level other than that recommended by the manufacturer, or being used for a purpose other than the purpose intended by the manufacturer; and any drug being used for a purpose or by a person not in accordance with bona fide medical therapy. Examples of illegal drugs include, but are not limited to, stimulants, depressants, narcotic or hallucinogenic drugs, cannabis substances, such as marijuana and hashish, cocaine, heroin, methamphetamine, phencyclidine (PCP), and so-called designer drugs and look-alike drugs.

This form will be maintained by Kentucky State University and will be disclosed to appropriate clinical agencies upon their request.