I, ___, a ___ year-old student enrolled in the Kentucky State University School of Nursing, having read the School of Nursing Substance Abuse Policy and Drug/Alcohol Testing Policy, understand that as a precondition to assignment to or placement with any affiliating clinical agency, I am subject to that particular agency's substance abuse policy and/or drug/alcohol testing policies, and I may be required to submit to pre-clinical placement drug testing, random drug testing, or drug testing when there is reasonable suspicion to believe that I may be impaired or have been engaged in substance abuse as defined by the KySU School of Nursing's substance abuse policy or by the affiliating clinical agency. I understand that the cost of any drug testing required by any affiliating clinical agency with which I may be placed shall be borne by me. By my signature, I hereby give my complete and voluntary consent to submit to any such drug test(s) at a designated laboratory or other locations as required by any affiliating clinical agency at which I am placed for nursing requirements.

I further understand that I may by subject to drug testing based on reasonable suspicion for substance abuse while attending any Kentucky State University School of Nursing course or clinical activity.

I understand that pursuant of the School of Nursing policy, a positive drug test for substance abuse will result in dismissal from the program in which I am enrolled. I also understand that if I refuse to submit to drug testing required by the affiliating clinical agency, the School of Nursing will have no responsibility to find me another clinical placement and I may be dismissed from the nursing program. I understand that if I refuse to submit to drug testing based upon reasonable suspicion for substance abuse, I will be dismissed from the nursing program.

I understand that the clinical agency and the Kentucky State University School of Nursing have a legitimate need to receive the results of any drug tests performed in accordance with this policy. I give my consent to, and hereby authorize any drug testing facility and its physicians, including the Medical Review Officer, employees, and representatives, that conducted drug testing pursuant to the drug testing policies of the affiliating clinical agency or the Kentucky State University School of Nursing and that has control over any documents, records, or other information pertaining to any drug testing of me, to furnish originals or copies of any such documents, records, or other information to the affiliating clinical agency requesting the test and/or to the Student Health Center (if the test was requested by the School of Nursing) and to the Kentucky State University School of Nursing and/or its officers, employees, and representatives. I further consent to and hereby authorize any drug testing entity to answer questions and inquiries concerning me and those documents, records, and other information, including, without limitation, drug testing results, medical records, medical reports, analyses, questionnaires, and other materials which may have been made or prepared pursuant to or in connection with my drug tests posed by the Academic Leader for the School of Nursing.

I waive, release, and discharge forever the drug testing facility and its physicians, including the Medical Review Officer, employees, and representatives that conducted drug testing required by the School of Nursing Policy and every persons, firm and institution (including the School of Nursing and/or Student Health Center) which shall comply in good faith with this authorization and consent from any and all claims whatsoever kind and nature arising out of or resulting from the drug testing, disclosing, inspection, releasing and furnishing of such documents, records or other information.