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City of St. Louis Department of Personnel Administrative Regulation NO. 120B - Form |
The City of St. Louis Administrative Regulations have been converted to electronic format by the staff of the St. Louis Public Library. This electronic version has been done for the interest and convenience of the user. These are unofficial versions and should be used as unofficial copies.
Official printed copies of the City of St. Louis Administrative Regulations may be obtained from the Personnel Office at 1114 Market Street, Room 703, St. Louis, Missouri 63101.
ONE COPY EMPLOYEE
ONE COPY DEPARTMENT
ORIGINAL DEPARTMENT OF PERSONNEL
CERTIFICATION AND DECLARATION
Administrative Regulation No. 120 B (Non-DOT)
I hereby certify that on the date indicated below I received a copy of the City of St. Louis drug and alcohol policy Administrative Regulation No. 120 B (Non-DOT) that is effective on October 1, 2010. I am aware that employees who test positive for drugs will be considered guilty of misconduct and will be dismissed. I am also aware that employees who test positive for alcohol will be considered guilty of misconduct and will either be directed to mandatory treatment and/or be disciplined up to and including dismissal. I acknowledge that I can get confidential, professional help with a drug and/or alcohol problem by contacting the City's Employee Assistance Program (E.A.P.) at (314) 729-4030, or by calling the Department of Personnel at 622-3563.
| ___________________________________ | _______________________________________ |
| Employee’s Name (Print) | Class Title |
| ___________________________________ | ___________________________________ |
| Signature | Date |
___________________________________________________
Department
I certify that the employee named above was provided with a copy of the City's policy on drugs and alcohol and a copy of this form on the date indicated above.
| ___________________________________ | _______________________________________ |
| Supervisor’s/Manager’s Signature | Class Title |
| ___________________________________ | ___________________________________ |
| Department | Date |
This Certification and Declaration must be signed and dated by the employee and the issuing supervisor/manager.
Rev. 10/10
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