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EMPLOYEE AGREEMENT AND CONSENT TO DRUG AND/OR ALCOHOL TESTING I hereby agree, upon a request made under the drug/alcohol testing policy of the Village of Gowanda (the Village), to submit to a drug or alcohol test and-to furnish a sample of my urine, breath, and/or blood for analysis. I understand and agree that if lat any time refuse to submit to a drug or alcohol test under Village 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 the Village and/or physician designated by the Village, send the specimen or specimens so collected to a laboratory for a screening test for the presence of any prohibited substances under policy, and for the laboratory or other testing facility to release any and all documentation relating to such test to the Village and/or to any governmental entity involved in a legal proceeding or investigation connected with the test. I will hold harmless the Village, its designated physician, and any testing laboratory the Village 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 kind of adverse that might arise as a result of the drug or alcohol test, even if a Village 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 the Village, its designated physician and any testing laboratory the Village 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. 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 THE VILLAGE WILL REQUIRE A DRUG SCREEN 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. Employee’s Name Name of company Representative Date Date