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ATTACHMENT 3
HEPACO, INC.
VOLUNTARY PRE-TESTING DISCLOSURE FORM
Various lawful or authorized drugs and substances may affect drug and alcohol tests (see
attached list). This is an opportunity, if you choose, to voluntarily advise the collection and/or testing
facility of any such drugs or substances so that the testing will be accurate.
I voluntarily state that I have taken the following prescription and/or non-prescription drugs in
the 30 days immediately preceding this test (if none, I have indicated “NONE”). I hereby authorize the
prescribing physician or personnel identified below to release information to HEPACO confirming that
such drug(s) or substance(s) were prescribed to me or consumed by me and the prescription and
consumption dates.
Name of Drug/ Date of Prescription/
Substance Physician Name Consumption Over The Counter
In the space below, please provide any other information that may be relevant to the test.
Date Signature of Applicant/Employee
Social Security Number
Document No. 804: Drug and Alcohol Abuse Policy
Revised December 2000 Attachment 3
