Pennsylvania Code › Title 58 - RECREATION › Part I - State Athletic Commission › Subpart A - General Provisions › Chapter 15 - PROHIBITED DRUG TESTING › Section 15.12 - Official form

Current through Register Vol. 54, No. 28, July 13, 2024
The following official form is to be used in conjunction
					 with this chapter: SAC:UDT-1 Urinalysis/Drug Test Consent Form.
SAC:UDT-1
URINALYSIS/DRUG TEST CONSENT
					 FORM
Individual's Name
______________________________________
Social Security Number
______________________________________
Address
______________________________________
______________________________________
I hereby voluntarily submit a urine sample and authorize an
					 approved laboratory to test such sample for the presence of a prohibited drug.
					 Such test will be performed by an approved laboratory designated by the
					 Pennsylvania State Athletic Commission to conduct such tests. I hereby consent
					 to the results of said test being released to the Pennsylvania State Athletic
					 Commission. Since medications can affect test results, I have listed below all
					 medications I have taken during the past ten (10) days (both over-the-counter
					 and prescribed). I understand that the failure to supply a urine sample,
					 refusing to submit to a test, tampering with the sample or falsifying any
					 information obtained in connection with this test will result in an immediate
					 suspension of not less than ninety (90) days, a civil penalty of $100 and a
					 forfeiture of any purses or prizes which have been earned from the day's event.
					 I also understand that if the analysis of this urine sample results in a
					 confirmed positive test result I will be suspended and a civil penalty imposed
					 depending on whether I have had any prior confirmed positive test results. I
					 understand that I am entitled to a hearing regarding any disciplinary action
					 taken against me in accordance with the State Athletic Code. I agree to hold
					 the Pennsylvania State Athletic Commission, its agents, directors, officers and
					 employees harmless from any liability in connection with the drug test
					 conducted. I have noted any perceived irregularities in the collection
					 procedures in the space provided below.
During the past ten (10) days, or at the
					 present time, are you taking:
Over-the-counter
								medication
yes
no
Prescription
								medication
yes
no
If "yes" to either question, please describe
					 in detail below:
Medication
Last
								Taken
Physician's Name, Address and Telephone
								Number
______________
______________
____________________________________________
______________
______________
____________________________________________
______________
______________
____________________________________________
ANY PERCEIVED IRREGULARITIES IN THE COLLECTION PROCEDURES
					 MUST BE NOTED BELOW:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
______________________
_____________
____________
Signature of
								Boxer
Date
Time
______________________
_____________
_____________
Signature of
								Witness
Date
Time
______________________
_____________
____________
Commission
								Representative
Date
Time
This section cited in 58 Pa. Code §
												15.3 (relating to use of
						prohibited drugs).