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Office of the Assistant Secretary for Policy / Office of Compliance Assistance Policy

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Section 9: Will you use Return-to-Work Agreements?

Sample Return-to-Work Agreement

This Return-to-Work Agreement is necessitated due to the fact that:

	The employee tested positive for drugs.
	A supervisor refers the employee to the EAP or treatment due to declining job performance.
	The employee has violated a work rule that could result in termination.
	The employer is giving the employee a "last chance" to work free of alcohol or drugs.
	The employee acknowledges receipt of the organization's drug and alcohol policy and agrees to comply with all provisions.
	The employee has voluntarily signed the Release of Information form allowing the organization to receive information from medical professionals regarding continuing care recommendations and compliance.
	The employee agrees to comply with all aspects of the medical professional's recommendations.
	The employee agrees to be subject to unannounced follow-up testing for a period of five years.
	The employee agrees that the organization will monitor compliance by receiving updates from medical professionals regarding compliance with continuing care recommendations. The employee will maintain documentation of attendance.
	The employee agrees to abstain from the use of alcohol and/or other drugs except when prescribed by a physician who has been informed of the employee's difficulty with substance abuse.
	The employee agrees that all costs of treatment and monitoring not covered by the employee's insurance plan is the financial responsibility of the employee.
	If absence from work is required as part of rehabilitation, it will be regarded as family and medical leave, sick leave, vacation, personal leave or some combination thereof, depending upon accrued leave.
	The employee agrees to comply with all organization policies and procedures and understands that nothing in this agreement prohibits the organization from applying discipline for other violations.
	The employee understands this is his/her last chance to successfully address his/her problem with alcohol and/or other drugs. The employee must satisfactorily meet the organization's expectations and standards. The employee understands that failure to comply fully with this agreement will result in IMMEDIATE termination.
	Other:

________________________________________________________
Signature of Employee

________________________________________________________
Signature of Supervisor

________________________________________________________
Signature of Union Representative

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