Attachment 3
CITY OF BURBANK
CITY OF BURBANK
MANAGEMENT SERVICES DEPARTMENT
INCORROATED 1911.
MEMORANDUM
DATE: DATE
TO: Council Member
FROM: Management Services Department
SUBJECT: VOLUNTARY DRUG TESTING
including whether or not you have been randomly selected to submit to the testing, whether or not you actually submit to the testing and what the results are, are confidential and subject to disclosure only pursuant to your direction.
If you choose to participate and disclose any information regarding the testing process you will need to place this completed form with the City Clerk's Office. Following are your disclosure choices:
• Provide a copy of this form indicating you were selected to take the test but took no further action.
• Provide a copy of this form indicating you were selected to take the test and took the test but have not attached test results.
• Provide a copy of this form indicating you were selected to take the test, took the test and you have attached the test results.
If you choose to take the test, a copy of your test results will be provided to you directly by the Medical Collection Facility - Concentra Urgent Care, 2550 N. Hollywood Way Suite 100, Burbank, California, 91505, (818) 524-3730.
If you have chosen to participate, please indicate what you are authorizing for disclosure.
I hereby authorize the City of Burbank to publicly disclose the information items I have checked below with respect to my participation in voluntary drug and alcohol testing pursuant to the City Council's Drug and Alcohol Testing Policy:
• On DATE, my name was randomly selected to participate in a drug and alcohol testing. • On DATE, I voluntarily submitted to a drug and alcohol testing according to the City's Policy. • The results of my test are attached to this memorandum and may be publicly disclosed in accordance with the City's Policy.
Dated: Signed:
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