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DRUG AND ALCOHOL TESTING AUTHORIZATION AND CONSENT FORM

Statement of Purpose

Signature Health Services is committed to maintaining a safe, healthy, and drug-free workplace to protect patients, employees, contractors, and the public. Because positions with Signature Health Services may involve direct patient care, driving, operation of vehicles, access to medications, and work in patients' homes, drug and alcohol testing is required to promote patient safety, quality of care, and compliance with applicable laws and regulations.

Authorization for Testing

I hereby voluntarily authorize Signature Health Services (“the Agency”), its agents, and any testing facility or medical provider designated by the Agency to require me to submit to drug and/or alcohol testing in accordance with applicable federal law, Texas law, and Agency policy.

Testing may be required at any time, including but not limited to:

• Pre-employment or post-conditional offer
• Reasonable suspicion
• Post-accident or incident
• Random testing, where permitted by law
• Return-to-duty and follow-up testing

Home Health / Safety-Sensitive Duties; Driving and Medication Access: I understand that because Agency positions may involve patient care in patients’ homes, driving, and access to controlled substances and other medications, the Agency may designate certain roles or duties as safety-sensitive and may apply testing requirements and work restrictions consistent with applicable Texas and federal law and Agency policy. I understand that I must promptly report any work-related impairment concerns, medication errors, suspected diversion, or loss/theft of controlled substances in accordance with Agency policy and applicable law, and that such events may result in testing where permitted by law.

DOT / Commercial Driving (If Applicable): I understand that if my position requires operation of a commercial motor vehicle or otherwise subjects me to DOT drug and alcohol testing rules, DOT requirements will control where they differ from Agency policy, including DOT definitions of “refusal,” required testing circumstances, and return-to-duty/follow-up processes (49 C.F.R. Part 40 and applicable modal regulations). I understand that DOT-regulated test results and related records may be maintained and disclosed as required by DOT rules.

Pre-Employment / Post-Conditional Offer Testing: I understand that, where required by Agency policy for the position, drug and/or alcohol testing may be required only after I have received a conditional offer of employment (or, for current employees, a conditional offer of transfer or promotion), and that the offer may be contingent upon timely completion of the test and receipt of a verified negative result. I understand that testing will be administered in a nondiscriminatory manner and in accordance with applicable Texas and federal law, and that refusal to submit to or cooperate with required testing, or a verified positive result, may result in withdrawal of the conditional offer or disqualification from employment for the position, to the extent permitted by law.

Reasonable Suspicion: I understand that “reasonable suspicion” means a good-faith, objective belief, based on specific, contemporaneous, and articulable facts, that I may be under the influence of drugs and/or alcohol while on duty or on Agency premises, or that I may have violated the Agency’s drug and alcohol policy. Reasonable suspicion may be based on, for example: (a) direct observation of appearance, behavior, speech, body odors, or motor skills (e.g., unsteady gait, slurred speech, confusion, drowsiness, agitation); (b) observed unsafe acts, near-misses, or a pattern of errors suggesting impairment; (c) possession, use, sale, or suspected tampering with drugs/alcohol or drug-testing materials; (d) credible information from a reliable source (e.g., patient, family member, coworker, supervisor, law enforcement) that is corroborated where practicable; (e) an admission of use or impairment; or (f) other objective indicators consistent with impairment. I understand that reasonable suspicion determinations will be made and documented by the Agency in accordance with applicable Texas and federal law and Agency policy, and will not be based solely on protected characteristics or lawful conduct unrelated to job performance or workplace safety, to the extent required by law.

I understand that testing methods may include urine, saliva, blood, breath, or other lawful testing methods and will be conducted by a licensed or certified laboratory or medical provider. Testing will be conducted in a manner consistent with applicable federal and Texas law and Agency policy, including, where applicable, U.S. Department of Transportation (DOT) testing procedures (49 C.F.R. Part 40) for any position or duty subject to DOT requirements. All initial nonnegative/positive results will be confirmed by an appropriate confirmatory method (e.g., GC/MS or LC/MS/MS, as applicable) and reviewed by a Medical Review Officer (MRO) before being reported to the Agency as a verified result.

Authorization for Release of Test Results and Information

I authorize and give full permission to have Signature Health Services and/or its designated physician or Medical Review Officer send any specimen(s) collected to a certified laboratory for screening and confirmatory testing (including Gas Chromatography/Mass Spectrometry confirmation of any initial positive result) for the presence of prohibited substances under the Agency's drug-free workplace policy.

I further authorize and direct the testing laboratory or other testing facility to release documentation relating to such test to Signature Health Services and/or, as required by law or lawful process, to the decision-maker of any governmental entity (including but not limited to the Texas Workforce Commission) or a court involved in a legal proceeding or investigation connected with the test. Any such disclosure will be limited to the minimum necessary information for the stated purpose and permitted by applicable law, and may include: verified test results, confirmatory test results, chain of custody documentation, and related testadministration records.

I further authorize Signature Health Services to disclose documentation relating to such test to the decision-maker of any governmental entity (including but not limited to the Texas Workforce Commission) or a court involved in any legal proceeding or investigation connected with the test, to the extent permitted by applicable law and/or required by lawful process. I understand this authorization is intended to enable the Agency to defend its employment decisions and respond to unemployment claims or other legal actions, and that any disclosure will be limited to the minimum necessary information for that purpose.

Acknowledgements and Agreements

I acknowledge, understand, and agree to the following:

1. Consequences of Refusal or Positive Test: Refusal to submit to testing, failure to cooperate, adulteration or substitution of a specimen, or a confirmed positive test result may result in withdrawal of a job offer, disciplinary action, up to and including immediate termination of employment.

2. Unemployment Benefit Determination: A refusal or confirmed positive test result may be considered misconduct connected with the work, where applicable, for purposes including but not limited to employment decisions and unemployment benefit determinations under Texas law.

Workers’ Compensation Considerations: I understand that, to the extent permitted by Texas law and applicable workers’ compensation rules/policy terms, the Agency and/or its workers’ compensation carrier may request post-accident testing and may consider a refusal to test or a verified positive result in evaluating compensability, defenses, or benefit eligibility. I understand that nothing in this form guarantees approval or denial of any workers’ compensation claim, and determinations are made by the appropriate carrier/agency/court under applicable law.

3. Post-Accident Testing: I UNDERSTAND THAT THE AGENCY WILL REQUIRE A DRUG SCREEN AND/OR ALCOHOL TEST WHENEVER I AM INVOLVED IN AN ON-THE-JOB ACCIDENT OR INJURY UNDER CIRCUMSTANCES THAT SUGGEST POSSIBLE INVOLVEMENT OR INFLUENCE OF DRUGS OR ALCOHOL IN THE ACCIDENT OR INJURY EVENT, AND I AGREE TO SUBMIT TO ANY SUCH TEST. I AGREE TO REPORT FOR ANY REQUIRED POST-ACCIDENT/INCIDENT TEST AS SOON AS POSSIBLE AFTER BEING DIRECTED TO DO SO (AND, IF APPLICABLE, WITHIN ANY TIMEFRAMES REQUIRED BY LAW OR AGENCY POLICY), UNLESS I AM RECEIVING EMERGENCY MEDICAL CARE OR OTHER CIRCUMSTANCES BEYOND MY CONTROL PREVENT TIMELY TESTING. I UNDERSTAND THAT "INVOLVED IN AN ACCIDENT" INCLUDES NOT ONLY BEING INJURED MYSELF, BUT ALSO POTENTIALLY CONTRIBUTING TO AN ACCIDENT OR INJURY TO A PATIENT, COWORKER, OR OTHER PERSON IN ANY WAY. I UNDERSTAND THAT REFUSAL TO REPORT PROMPTLY FOR A REQUIRED POST-ACCIDENT/INCIDENT TEST, OR REFUSAL TO SUBMIT TO OR COOPERATE WITH SUCH TESTING, MAY RESULT IN DISCIPLINARY ACTION UP TO AND INCLUDING TERMINATION AND/OR MAY BE USED IN CONNECTION WITH A WORKERS’ COMPENSATION CLAIM (INCLUDING POTENTIAL DENIAL OF BENEFITS), TO THE EXTENT PERMITTED BY TEXAS AND/OR FEDERAL LAW.

4. Opportunity to Explain Results: I understand that if I test positive for a substance, I will have the opportunity to provide information regarding legally prescribed medications or other legitimate medical explanations to the Medical Review Officer before any final employment action is taken. I understand that a valid prescription does not automatically excuse a positive test result if the medication impairs my ability to safely perform my essential job duties, particularly those involving patient care, medication administration, or driving.

5. Confidentiality: Test results will be maintained as confidential medical records in a separate file from my personnel records and disclosed only to individuals with a legitimate business, regulatory, or legal need to know, as authorized by this consent form and required by law.

I understand that drug/alcohol test results and related information will be treated as confidential medical information and maintained separately from personnel records, and will be accessed and disclosed only as permitted by applicable law (including, where applicable, ADA confidentiality requirements) and Agency policy. I understand that if I disclose a prescription or medical explanation to the MRO, the Agency may receive only information necessary to determine fitness for duty and policy compliance, consistent with applicable law.

6. Ongoing Authorization: This authorization applies to all periods of employment, including any rehire, transfer, or change in position.

7. At-Will Employment: Nothing in this authorization alters the at-will employment relationship, and employment may be terminated by either party at any time, with or without cause or notice, subject to applicable law.

Release from Liability

I will hold harmless Signature Health Services, its designated physicians, Medical Review Officers, and any testing laboratory the Agency uses from claims arising solely from the collection and testing process performed in good faith and in accordance with applicable law and Agency policy. This provision does not waive or limit any rights or remedies that cannot be waived under applicable law, and does not apply to gross negligence, willful misconduct, or violations of law. I

will further hold harmless Signature Health Services, its designated physicians, Medical Review Officers, and any testing laboratory the Agency uses for any alleged harm to me that might result from the release or use of information or documentation relating to the drug or alcohol test, as long as the release or use of the information is consistent with the authorizations provided in this consent form and applicable law.

Consent and Certification

I certify that I have read and understand this authorization and consent form, have had the opportunity to ask questions, and voluntarily consent to drug and alcohol testing as described above. This policy and authorization have been explained to me in a language I understand. I understand that testing and any related collection, use, maintenance, and disclosure of testrelated information will be conducted in accordance with applicable Texas and federal law and Agency policy, including applicable nondiscrimination requirements, and that nothing in this form is intended to waive any rights or remedies that cannot be waived under applicable law.