5228F2 Request for Records

REQUEST FOR RECORDS
POLICY 5228F2

 

I, _____________________________________, an employee serving as a commercially licensed driver for Stevensville School District complete this form to request any records pertaining to my use of drugs or alcohol, including any records pertaining to my drug or alcohol tests in accordance with School District Policies 5228 and 5228P. If I chose to have these records forwarded to a third party, I am noting the contact information in the space provided on this form.

 

Employee Signature:

Signature:______________________________________    Date:_____________

 

Supervisor Receipt:

Signature:______________________________________   Date:_____________

 

Ο    I authorize the School District to send the requested records to the following individual or entity in accordance with the authorization outlined on this form:

 

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