To Be Completed by the Health Care Provider San Francisco Unified School District School Health Programs Department 1515 Quintara Street San Francisco, CA 94116-1273 TEL: 415.242.2615 FAX: 415.242.2618 Age: ____ Date of Birth:___________________ School: ______________________________ Homeroom Teacher:_______________ Grade: _______ Room :___________ Parent/C
No. AP 4255
Drug Policy - Nursing Program
Drug Testing upon Admission to the Clinical Component
Students are admitted to the nursing program pending a negative drug test. Admission
will be withdrawn for a student testing positive.
Procedure for Drug Testing Students
Students admitted to the nursing program will be notified of the procedure to follow for
the drug test by the nursing program. All costs associated with testing are the
responsibility of the student. Tests will be conducted by a qualified laboratory using
established methods and procedures. Confidentiality of the student as well as the integrity
of the urine sample will be protected.
The procedure for collection, as determined by the collection site, will involve a witness
to the voiding of the urine sample, securable urine containers, and chain of custody
procedures. The urine sample will be screened for drugs. A drug test will be presumed
positive if any of the drugs listed in Exhibit A (attached hereto) are found. Presumed
positives will be confirmed by a second test from the original urine sample. If the test is
positive, the available urine sample will be used to determine the presence or absence of
drug abuse. The testing laboratory will notify only the nursing program administrator of
the test results. The nursing program ensures confidentiality of results by making the
information available only to the student and appropriate nursing program administrators.
Drug Testing after Admission
Drug testing for any student in the clinical component can be requested by the nursing
program administrator. The cost of this drug testing will be borne by Sierra College. The
procedure for testing is described in the above section. Refusal by a student to submit to
testing will result in that student’s dismissal from the nursing program. A student with a
positive result from a drug test will be dismissed from the nursing program. Other
appropriate disciplinary action may be initiated as necessary.
Sierra College Administrative Procedure 4255 Any student who voluntarily reports that he/she has a chemical dependency problem will
be referred for counseling by the nursing program. Conditions, if any, for continued
participation in the program will be at the discretion of appropriate nursing program
administrators. The student will submit to drug tests as requested by the nursing program
administrator and will be dismissed if a positive drug test is obtained.
Admission/Readmission after a Positive Drug Test
A student whose admission is withdrawn or who is dismissed from the nursing program
due to a positive drug test will be considered for readmission if the following conditions
• Submit to an evaluation for substance abuse by a program approved for evaluation of drug use and/or a treatment program, and complete the prescribed treatment program. • Submission to a drug test prior to admission/readmission. This drug test will be at the student’s expense. A positive drug test will result in ineligibility for admission/readmission. • Submission to random drug tests as requested by the nursing program after admittance to the clinical component. This drug test will be at the student’s expense. A positive drug test will result in permanent dismissal from the nursing program.
Nursing Program Drug Testing Waiver Agreement
I understand that as a requirement for admission to the nursing program, I must submit to a drug test at a designated laboratory, which will provide the result of the test to the administrator of the nursing program. I understand that if the test result is positive, I will be denied admission to the nursing program. I further understand that I will be subject to drug tests while enrolled in the nursing program clinical component. A positive drug test or refusal to submit to testing will result in dismissal from the nursing program BY SIGNING THIS DOCUMENT, I INDICATE THAT I HAVE READ, I UNDERSTAND, AND I AGREE TO THE NURSING PROGRAM DRUG TESTING POLICY. I UNDERSTAND THAT A NEGATIVE DRUG TEST IS REQUIRED FOR ADMISSION AND FOR PROGRESSION IN THE NURSING PROGRAM. THIS SIGNED DOCUMENT CONSTITUTES MY CONSENT FOR DRUG TESTING BY A DESIGNATED LABORATORY. IT ALSO CONSTITUTES CONSENT FOR THE LABORATORY TO RELEASE THE RESULT OF MY DRUG TEST TO THE ADMINISTRATOR OF THE NURSING PROGRAM Sierra College Administrative Procedure 4255
Faculty Procedure for Reasonable Suspicion of Drug Use by Students
The nursing program maintains a drug-free environment. Random drug testing is
conducted. Additionally, any nursing student who demonstrates behavioral changes
suspected to be related to the use of drugs will be subjected to testing. The nursing
faculty member’s decision to refer a student for drug testing will be based on, but not
limited to: observable phenomena such as direct observation of drug use; or physical
symptoms or manifestations of being under the influence of a drug, including, but not
limited to, erratic behavior, slurred speech, staggered gait, flushed face, dilated/pinpoint
pupils, wide mood swings, and deterioration of work performance; or information that a
student has caused or contributed to an accident that resulted in injury requiring treatment
by a licensed health care professional; or conviction by a court, or being found guilty of a
drug or controlled substance offense.
Testing will be conducted using the following procedure:
• The faculty member will have another faculty member or licensed health care professional confirm the suspicious behavior. If a witness reports behavioral changes, the faculty member will ask the witness to have another licensed health care professional confirm the behavior. • The student will be asked to leave the area and go with a faculty member and a witness (as defined above) to discuss the situation in a location ensuring privacy and confidentiality. The discussion will be documented, and the decision to refer for drug and/or alcohol testing will be made. In the case of a clinical situation, faculty may visit the site or confer by telephone with the student. A witness should be included in the telephone conference. • If the decision is to refer the student for drug testing, the student should be instructed on where and when to report for testing: o Provide the student with a list of collection sites (available in the nursing o Instruct the student to report for testing immediately if possible, or if this is not reasonable, provide a time frame not to exceed 24 hours. • The faculty member notifies the nursing program administrator of the referral. • The faculty member completes a Faculty Report of Reasonable Suspicion of
Drug Use form and submits the report to the nursing program administrator as
soon as possible.
• The student will be suspended from all clinical activity until the case has been reviewed by the nursing program administrator. If the drug screen is negative, the nursing program administrator will notify the faculty to readmit the student to the course without penalty. If the test is positive the student will be dismissed from Sierra College Administrative Procedure 4255 Faculty Report of Reasonable Suspicion of Drug Use
Please use the space below to provide a detailed description of the student’s behavior. All information is to be kept confidential. Please return the form in a sealed envelope to the nursing program administrator as soon as possible. Notify the nursing program administrator by telephone immediately to request a drug test. 1. Name of Student:_______________________________________________________ 2. Date of Incident:________________________________________________________ 3. Time of Incident:________________________________________________________ 4. Location of Incident:_____________________________________________________ 5. Detailed description: include any behavioral, visual, olfactory or auditory observations. Speech (normal, incoherent, confused, change in speech, slurred, rambling, shouting, using profanity, slow, etc.). ________________________________________________________________________________________________________________________________________________________________________________________________________________________ Coordination (normal, swaying, staggering, lack of coordination, grasping for support). ________________________________________________________________________________________________________________________________________________________________________________________________________________________ Performance (unsafe practices, unsatisfactory work). ________________________________________________________________________________________________________________________________________________________________________________________________________________________ Alertness (change in alertness, sleepy, confused). ________________________________________________________________________________________________________________________________________________________________________________________________________________________ Demeanor (change in personality, fighting, excited, combative, aggressive, violent, argumentative, indifferent, threatening, antagonistic). ________________________________________________________________________________________________________________________________________________________________________________________________________________________ Eyes (bloodshot, dilated). ________________________________________________________________________ Sierra College Administrative Procedure 4255 ________________________________________________________________________________________________________________________________________________ Clothing (dirty, disheveled). ________________________________________________________________________________________________________________________________________________________________________________________________________________________ Other observed actions or behaviors. ________________________________________________________________________________________________________________________________________________________________________________________________________________________ List reports of complaints of student behavior from personnel or other students. ________________________________________________________________________________________________________________________________________________________________________________________________________________________ List unexplained absences or tardiness. ________________________________________________________________________________________________________________________________________________________________________________________________________________________ 6. Did the student admit to use of drugs? ______No _____ Yes Comments: ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________ 7. Were drugs discovered? _____No _____Yes Comments: ________________________________________________________________________________________________________________________________________________________________________________________________________________________ 8. List witnesses to student’s behavior: ________________________________________________________________________________________________________________________________________________________________________________________________________________________ 9. Was the student referred for drug testing? _____No _____Yes If Yes: What were your instructions including the time frame. ________________________________________________________________________________________________________________________________________________________________________________________________________________________ Faculty Name: ____________________________________________________ ____________________________________________________ Sierra College Administrative Procedure 4255 Exhibit A
The Medical Professional Panel Drug Screens includes alcohol, common street drugs, and those drugs that health care workers have access to and abuse. Drugs monitored include: Sierra College Administrative Procedure 4255
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