Alcohol And Drug Management Policy - PF Olsen Limited

Alcohol and Drug Management Policy 

Principal 

objective and 

commitment 

PF Olsen Ltd (PF Olsen) and its employees and contractors are 

committed to creating a workplace free of the impairment associated 

with the misuse of alcohol and drugs and to safely achieve its business 

objectives. This commitment: 

 

 

 

 

Promotes individual employee well-being, health and safety. 

Creates a work environment where employees feel safe and 

supported. 

Recognises the importance of satisfying the needs of our clients and 

providing a quality service to them. 

Improves business performance including the management of 

business risk and associated costs. 

Initiatives 

PF Olsen will achieve these goals with the following initiatives: 

Education, information and training – specialised on-going training 

and education will be provided for all employees and contractors to 

ensure familiarity with the issues of substance misuse and 

impairment, and the policies and the objectives of the company to 

maintain a workplace free of the impairment associated with the 

misuse of alcohol and drugs. 

Pre-employment testing – PF Olsen offers new appointments 

conditional on applicants returning a negative drug test. 

Post incident testing – Employees and contractors may be tested for 

the presence of drugs or alcohol when they are involved in an 

incident and their actions are seen to have contributed to the event. 

Reasonable cause testing – Employees and contractors may be tested 

for the presence of drugs or alcohol where their actions, appearance, 

behaviour or conduct clearly demonstrate that drugs or alcohol may 

be impacting on their ability to work effectively and safely. 

Random testing for the presence of drugs or alcohol in employees 

systems while in the workplace. This testing will apply to employees 

that work in „safety sensitive areas‟ only. 

Serious misconduct – Employees observed taking, selling, supplying 

or being in the possession of drugs or alcohol at work will be 

disciplined according to PF Olsen serious misconduct procedures. 

Company funded and voluntary rehabilitation programmes. 

This document, signed and dated by the CEO, certifies: 

Senior management commitment for this policy 

______________________________ 

PF Olsen Ltd – CEO Signature 

____ / ____ / ____ 

Date 

Last Review: January 2012 

Last Modified: June 2012 Printed copies of this manual are uncontrolled Page 1 

Version 3.33

Employee 

commitment 

Every employee of the company is expected to share the Company’s 

commitment to an alcohol and drug free workplace – and agrees to 

do so by: 

 

 

 

 

 

 

 

Not reporting for work impaired by substances – legal or illegal 

Not taking, selling, supplying or being in the possession of drugs or 

alcohol in any PF Olsen workplace – including operating company 

property, equipment and/or vehicles (excluding alcohol at controlled 

functions with company management approval). 

Attending alcohol and drug education awareness and training as 

provided by PF Olsen from time to time 

Voluntarily admitting to rehabilitation as required 

Disclosure of all drink-driving convictions accumulated during their 

employment with PF Olsen Ltd 

Ensuring that prospective employees comply with this Alcohol and 

Drug Policy when it is their responsibility to do so 

Taking a mature responsible approach toward legal substances 

Employee 

agreement 

Employees show their agreement with this policy by signing and dating 

the Health and Safety section of the Employee Induction form. Signing 

this form serves as an acknowledgement that employees have read the 

Alcohol and Drug Policy, are committed to its success, and fully 

understand their responsibilities. 

Privacy statement 

All information gathered as a result of drug/alcohol testing is collected 

for the purpose of implementing PF Olsen policy and achieving its 

objectives. The Administration Secretary holds this information on the 

confidential file and disclosed to the Primary Supervisor and the 

Company Health and Safety Manager. Information may be disclosed to 

others only with the consent of the employee. The information shall be 

destroyed 3 calendar months following termination. 

Acknowledgement Employee Acknowledgement 

Employee name: Start date: Termination date: Signature: 

_______________ ___ / ___ / ___ ___ / ___ / ___ ________________ 

_______________ ___ / ___ / ___ ___ / ___ / ___ ________________ 

_______________ ___ / ___ / ___ ___ / ___ / ___ ________________ 

_______________ ___ / ___ / ___ ___ / ___ / ___ ________________ 

_______________ ___ / ___ / ___ ___ / ___ / ___ ________________ 

_______________ ___ / ___ / ___ ___ / ___ / ___ ________________ 

_______________ ___ / ___ / ___ ___ / ___ / ___ ________________ 

_______________ ___ / ___ / ___ ___ / ___ / ___ ________________ 



Version 3.33

About this Alcohol and Drug Management Policy 

Purpose and Aims The purpose of this policy is to address the possibility of our workplace 

safety and the safety of our employees being adversely affected by 

people who have unacceptable levels of drugs and/or alcohol in their 

system. PF Olsen aims to: 

 

 

 

 

 

Create a workplace free from substance impairment 

Ensure PF Olsen complies with its legal obligations 

Recruit only staff who comply with PF Olsen policies 

Provide quality customer service 

Support and rehabilitate staff with substance related problems 

Scope 

This Alcohol and Drug Policy covers the activities of all staff, 

contractors employed by: 

 

 

PF Olsen 

PF Olsen Nursery. 

Owner 

The owner of the Alcohol and Drug Management Policy is: 

Quality and Health & Safety Manager, PF Olsen Ltd. 

Legislation and 

important 

references 

Health and Safety in Employment Act 1992, and amendments. 

The „Plantation Forestry Code of Practice – Eliminating Drugs & 

Alcohol From the Workplace‟ and the associated brochure entitled 

„A safe workplace is a drug-free workplace.‟ 

NZQA Unit Standard 22994 „Demonstrate knowledge of factors that 

affect the performance of forestry workers‟ 

AS/NZS 4308:2008 Procedures for the Collection, Detection and 

Quantitation of Drugs of Abuse in Urine 

AS 3547-1997 “Breath Alcohol Testing devices for Personal use”. 

Human Rights Act 1993 

The Bill of Rights Act 1990 

The Privacy Act 1993 and Health Information Privacy Code (1994). 

Air New Zealand Judgement: AC 22/04; File No: ARC 42/03 

Toll New Zealand Judgement: AC21/07: File No. ARC34/07 

Common terms 

and acronyms 

Adulteration 

The forest industry uses a number of common terms and acronyms. To 

avoid confusion some are clarified below: 

Deliberate use of a dilutent or masking agent, or providing a substitute 

urine sample, in order to attempt to “beat” the drug test. 

Continued on next page... 



Version 3.33

...continued 

Alcohol 

Alcohol and 

drug free 

workplace 

Certified 

Collecting 

Agent (CCA) 

Drugs 

GC-MS 

Impaired or 

substance 

impairment 

Safety sensitive 

Refers to any beverage that contains ethyl alcohol including but not 

limited to beer, wine and spirits. 

A workplace free from the use, sale, transfer or possession of drugs or 

alcohol while on company property or a company worksite (excluding 

alcohol at controlled functions with company management approval). 

A person who has successfully completed a NZQA unit standard based 

training programme for specimen collection, storage, handling and 

dispatch in compliance with AS/NZS 4308:2008 or any future updates. 

This person may also be trained in conducting breath alcohol tests. 

Any drug or substance that cause impairment such as (but not limited to) 

cannabis and hashish, opiates (such as heroin and morphine) cocaine and 

amphetamines (speed, „P – methamphetamine, ecstasy). The term also 

includes misuse of some prescription drugs (e.g. tranquillisers, 

sedatives) and legal/illegal party drugs containing e.g. benzylpiperazines 

(e.g. Jump, Rapture), and synthetic cannabinoids. 

Gas Chromatography - Mass Spectrometry (GC-MS) is the technique 

used by testing laboratories to 'confirm' the exact identity and 

concentration of drug metabolites in urine. 

A person is said to be impaired when they: 

 

 

 

Report to a workplace with risk levels of drugs in the system 

Report to workplace with a level of alcohol in the system higher than 

that defined by the NZ Land Transport Safety Authority (see item 5, 

Alcohol Testing Procedure). 

Have a level of a substance in their system that exceeds AS/NZS 

4308:2008 (or any future updates). 

Safety sensitive positions are those where there is a significant and 

foreseeable risk of injury. PF Olsen have defined this as: 

 

 

All forest industry tasks, excluding solely administrative positions 

Tasks, where serious harm has occurred historically. 

Synthetic 

Cannabinoids 

Workplace(s) 

Synthetic cannabinoids are psychoactive herbal and chemical products 

which, when consumed mimic the effects of cannabis. As at the 17 th 

August 2011 (for one year), it is illegal to manufacture, import, export, 

sell, or supply the substances or any product containing them. It should 

be noted that possession and use are not criminal offences. 

The term „work place‟ refers to all PF Olsen areas/sites including but not 

limited to forests, offices, buildings and plant. „Work place‟ includes the 

vehicle being used while driving or being driven to and from a work site. 



Version 3.33

Testing Procedures 

Drug testing 

Procedures 

The following drug testing procedures will be followed on all occasions: 

1. The requirements of the Privacy Act will be strictly adhered to. 

2. A consent form will be signed by the employee (Schedule B) or a 

consent form will be signed by the applicant (Schedule C). 

3. When chain of custody procedures are required: The employee will 

be asked to read, sign and date the chain-of-custody agreement 

(Schedule F) certifying the specimen is theirs and has not been 

changed or altered between the time guardianship (custody) 

commenced to the time of the collection. 

4. The employee will be able to observe the entire collection, 

processing and chain-of-custody procedure of the specimen, 

including the splitting of the sample into two bottles. 

5. Urine specimens shall be taken by an certified collecting agent and 

either screened using a verified on-site device or tested at an 

approved accredited laboratory in accordance with AS/NZS 

4308:2008 (or any future updates). 

6. A „non negative‟ screen will only be reported „positive‟ by the 

testing facility if GCMS or LCMS confirms the level of a drug or 

metabolite, which is equal to or above the confirmation cut-off level 

tabulated later this section. 

7. Employees returning a „non negative‟ screen will be immediately 

removed from all Safety Sensitive work. 

8. Employees confirming a „positive‟ test continue „stood down‟ until a 

negative test is completed; rehabilitation shall commence. 

Alcohol testing 

procedure 

The following alcohol testing procedures will be followed on all 

occasions: 

1. The requirements of the Privacy Act will be strictly adhered to. 

2. A consent form will be signed by the applicant (Schedule C) or the 

existing employee (Schedule D) 

3. When chain of custody procedures are required: The employee will 

be asked to read, sign and date the chain-of-custody statement 

(Schedule F) certifying the sample provided has not been changed or 

altered between the times guardianship (custody) commenced to the 

time of the collection. 

4. Breath alcohol tests will be conducted using an Approved Testing 

Device, which meets the Australian Standard: AS 3547-1997. 

5. The threshold levels are the Land Transport (Road Safety and Other 

Matters) Amendment Act 2011 limits for breath alcohol tolerance; to 

not exceed any level of alcohol above 400 micrograms of alcohol per 

litre of breath (over 20 years of age) or above „0‟ micrograms of 

alcohol per litre of breath (under 20 years of age). Results in excess 

of these denote a non negative test. 

Continued on next page... 



Version 3.33

...continued 

6. NB: If the test is in excess of the tolerance, a witness is needed for a 

confirmatory alcohol test. If the confirmatory test shows positive, 

both the CCA and the witness shall sign the result, because the result 

of this test is final. 

7. Employees returning a „positive‟ test will be immediately removed 

from all Safety Sensitive work. Rehabilitation shall commence. 

Random testing 

Random testing provides a mechanism to ensure the workplace remains 

free from persons impaired by alcohol and/or drugs. 

The selection process, completed by a third party, will ensure a random 

selection of candidates. Every person in the pool of candidates will have 

an equal chance for testing (target rate = 50% of the population). 

Following selection, the testing process outlined in Schedule G will be 

used. 

Reasonable Cause 

testing 

Reasonable cause testing provides a mechanism to test employees when 

there is good reason to believe an accident or incident or a persons 

behaviour has resulted or is the result of the presence of alcohol and/or 

drugs in that employees system. 

Reasonable cause and post accident/incident testing must be based on 

observation. The evaluation procedure, that analyses the employees 

behaviour, attitude and conduct will be used before and reasonable 

cause test in conducted. This procedure is outlined in Schedule A will 

be used. 

Following the „schedule A‟ procedure, the testing process outlined in 

Schedule G will be used. 

Employee refuses 

testing 

The right to test employees is well founded in New Zealand law. For 

example: AC22/04 ARC 42/03 Air New Zealand vs. Combined Trade 

Unions (6 unions) accepted that… „The Employer has the right to 

manage its business as it sees fit...‟ (4) also that the Employer not only 

„may but must monitor employees for the purpose of ascertaining 

whether they are or could be a cause of harm to themselves or any other 

person…‟ (247) 

Where an employee refuses to undergo a test, the refusal shall be treated 

under the serious misconduct procedures in PF Olsen rules and 

appropriate disciplinary procedures will be applied. 



Version 3.33

Education and 

training 

From time to time, educational on the implications of the Drug & 

Alcohol policy, the drug testing options, and the manner in which drug 

and alcohol tests, and how to access professional drug and alcohol 

treatment/ counselling will be made available to all employees. The 

primary source of guidance is The „Plantation Forestry Code of Practice 

– Eliminating Drugs & Alcohol From the Workplace‟ and the associated 

brochure entitled „A safe workplace is a drug-free workplace.‟ 

Attendance is compulsory for all PF Olsen Limited employees. 

Emergency 

situations 

Where it is not practical for a test to be carried out immediately due to 

the injuries to the employee or other corrective actions: 

First, attend to the other corrective actions 

Ensure the chain of custody is not broken. (Schedule F) 

Carry out the testing at the first appropriate opportunity. 

Serious Misconduct 

Serious 

misconduct 

The serious misconduct company rule will apply where: 

1. An employee is observed taking, selling, supplying, or being in 

possession of drugs or alcohol at work (other than alcohol at PF 

Olsen controlled functions with management approval). This may 

result in summary dismissal. 

2. An employee refuses to take a test and there is documented evidence 

(minimum two persons using Schedule A) that the employee 

displays the behaviours of someone substance impaired. 

3. An employee refuses to take a test (being part of the Company 

Random Testing programme) and the employee is engaged in or is 

required to engage in „Safety Sensitive‟ work. 

NB: Any employee refusing a test will not be able to undertake „Safety 

Sensitive‟ work until such time as a negative result is produced. 



Version 3.33

Procedure 

1. The Primary Supervisor must conduct an investigation into the 

incident as soon as possible, including questioning the complainant, 

witnesses and the employee. 

2. The employee has the right to have a representative present. If the 

complaint appears substantive the employee will be suspended on 

pay and advised that a disciplinary hearing will be convened. 

3. The employee will be formally advised of the date of the 

disciplinary meeting and that the outcome could be dismissal. The 

employee shall be advised about the right to have a representative 

present. 

4. At the meeting the Primary Supervisor and the Company Health and 

Safety Manager must present the facts as they have collected them 

and the employee must be allowed to answer and explain any 

allegations. The employee must be advised in writing of the 

conclusions reached and disciplinary action to be taken. 

5. All investigations, discussions, advice of meetings and minutes must 

be recorded in writing and held on the confidential file. 

Rehabilitation 

General 

Any employee of the company that returns a „non-negative‟ screen or a 

confirmed „positive‟ test shall not perform „Safety Sensitive‟ work until 

a negative test result is achieved. 

If they wish to continue employment with the Company, they shall 

undertake rehabilitation. The employee may be required to initiate his or 

her own rehabilitation including any follow-up testing. Sessions shall be 

taken outside work hours or leave entitlements may be taken. 

The Company has a preference for „voluntary rehabilitation‟ – 

Voluntary (or self) admittance is, in most cases, free to New Zealand 

citizens. Additionally, „voluntary rehabilitation‟ is in keeping with the 

philosophy that people „that need to change‟ must first „want to change.‟ 

The employee must sign a contract stating that they have enrolled 

thereby agreeing to the programme and to follow up testing (see 

Schedule E). NB: This contract allows information, concerning their 

progress, to flow back to appropriate servants of the Company. 

Failure to take part or complete the programme, as per the contract, may 

result in disciplinary action including dismissal. 

Any employee may voluntary join rehabilitation at any time and PF 

Olsen will not enquire of facts relating to rehabilitation unless the 

Voluntary Rehabilitation Agreement (see Schedule E) has been signed. 



Version 3.33

Company funded 

rehabilitation 

PF Olsen, at its sole discretion, may fund rehabilitation according to the 

following procedure: 

1. Employee must sign a contract agreeing to the programme and 

follow up testing (see Schedule E). NB: The contract allows 

information, concerning the progress, to flow back to appropriate 

servants of the Company. 

2. The Company Health and Safety Manager will arrange an initial 

appointment for the employee to meet with the Substance Abuse 

Specialist (SAS) 

3. The employee will be given contact details of the SAS. 

4. Communications between the SAS, the employer and employee are 

confidential 

5. The SAS will arrange for treatment or further specialist advice as 

considered necessary 

6. The SAS will advise the manager if an alternative (non Safety 

Sensitive) employment situation would be advisable in the interim 

7. Rehabilitation will commence and the rehabilitation provider will 

provide the Company Health and Safety Manager with information 

on the attendance of the employee 

8. The SAS will report to the Company Health and Safety Manager 

after the agreed to number of sessions on the necessity or value of 

further treatment 

9. The employee may be required to fund additional sessions required 

beyond those provided by PF Olsen. 

Follow-up testing 

The employee will be subject to up to six unannounced follow-up drugs 

and/or alcohol tests during and after rehabilitation. Any testing, relative 

to this round of rehabilitation, must be completed within the following 2 

years. Any subsequent positive test within the 2-year period may result 

in disciplinary action including dismissal. 



Version 3.33

Confirmatory Test Cut-Off Levels for Drugs – AS/NZS 4308:2008 

Compound 

Morphine 

Codeine 

6-Acetylmorphine* 

Amphetamine 

Methylamphetamine 

Methylenedioxymethamphetamine 

Methylenedioxyamphetamine 

Benzylpiperazine* 

Phentermine* 

Ephedrine* 

Pseudoephedrine 

11-nor- 9- tetrahydrocannabinol-carboxylic acid 

All Synthetic Cannabinoid Compounds 

Benzoylecgonine 

Ecgonine methyl ester 

Oxazepam 

Temazepam 

Diazepam 

Nordiazepam 

Alpha-hydroxy-alprazolam 

7-amino-clonazepam 

7-amino-flunitrazepam 

7-amino-nitrazepam 

Cut-off level 

# (ng/mL) 

300 

300 

10 

150 

150 

150 

150 

500 

500 

500 

500 

15 

10 

150 

150 

200 

200 

200 

200 

100 

100 

100 

100 

* These drugs may be optionally tested within each class and the specified cut-off concentrations shall apply. 

# All cut-off levels are expressed as total concentration of drug or metabolite after hydrolysis of conjugates. 

Test Cut-Off Concentrations for Alcohol – AS 3547:1997 

Those set by the Land Transport New Zealand for legal drink 

driving and the Land Transport (Road Safety and Other Matters) 

Amendment Act 2011 

For people over twenty years of age 

For people under twenty years of age 

Cut-off level 

#(micrograms/litre of 

breath) 

400 

0 



Version 3.33

Schedule A – Reasonable Cause Indicators and Observations 

Assessing 

When assessing for reasonable cause, there will usually be more than 

one indicator present. Examples of reasonable cause include, but are not 

limited to the following: 

Indicators – note down observations, dates and times Date Time Date Time 

Excessive lateness 

Absences often on Monday, Friday or in conjunction with holidays 

Increased health problems or complaints about health 

Emotional signs – outbursts – anger, aggression 

Changes in personality from previous history 

Changes in alertness – difficulty with attention span 

Changes in appearance – clothing, hair personal hygiene 

Less energy or a sudden unexplained drop in performance 

Involvement in various minor accidents 

Feigning sickness or emergencies to get out of work early 

Going to vehicle, smoko hut, the bathroom more than necessary or normal 

Defensive when confronted about behaviour – violent 

Dizziness or disorientation, impaired judgement of distance/objects 

Slow or slurred speech, 

Hangovers 

Sudden, violent behaviour – high energy levels 

Impaired motor skills, slow gait 

Bloodshot eyes, fully dilated pupils, constricted pupils, stuffy nose, 

Impaired or reduced short term memory 

Reduced ability to perform tasks requiring concentration and co-ordination 

Intense anxiety or panic attacks 

Impairments in learning and memory, perception and judgement 

Irritability 

Depression – concern expressed by fellow workmates 

Employee observed: 

Comments: 

Manager Signature: 

Witness Signature: 

It is important to document actual „observations‟. Tick the behaviour 

observed and mark the date and time of the observation made. Have a 

witness sign this form. Hold the form on confidential file. 



Version 3.33

Schedule B – Existing Employee, Consent for Drug Testing 

I consent to undergo a drug test, to be undertaken by a certified collecting agent (CCA) and 

a confirmatory test to be undertaken by a an accredited laboratory, both appointed by PF 

Olsen Ltd. I acknowledge these tests are to determine whether illicit or restricted drug(s) or a 

misused prescribed drug(s) present in my urine, at concentrations higher than the accepted 

international standard as defined by the AS/NZS 4308:2008. 

I understand that a urine sample will be collected and the drugs being tested for are 

cannabinoids, opiates, amphetamine-type substances (including benzylpiperazine), cocaine, 

benzodiazepines, (and others if applicable). 

PF Olsen Ltd undertakes that the result of the test will be used only for the purpose for which 

they were obtained, and that any collection, storage or exchange of medical information 

concerning the test will be in accordance with the Privacy Act. 

I undertake to advise the CCA collecting my urine of any medication that I am taking. I also 

agree to provide the collecting agent with photograph identity, if required to do so. 

I consent to the results of the drug test(s) being communicated confidentially to the authorised 

representative of PF Olsen Limited. 

I understand that I may request a second confirmatory test be conducted on the „duplicate 

specimen‟ and analysed within 14 days of receiving the result. For the second test to be „nonnegative‟ 

there need only be the presence of drug or metabolite detected (i.e. not cut off 

limits). This will be accepted as a conclusive result and costs associated with this test will be 

borne by me. If the second test proves negative this will be accepted as a conclusive result and 

PF Olsen Ltd will reimburse costs associated with this test. 

I understand that a refusal to sign this form for the drug test, or the return of a non-negative 

result means the PF Olsen Ltd disciplinary procedure for serious misconduct will follow and 

that I will be required to voluntarily join rehabilitation. In the case of an internal transfer, the 

job offered/applied for will not be confirmed or offered to me. 

I have read this consent form, or have had it explained to me, and I understand its contents. 

Employee‟s signature __________________________________ Date ___ / ___ / ___ 

Employee‟s name 

__________________________________ 

CCA signature __________________________________ Date ___ / ___ / ___ 

CCA name 

__________________________________ 

Tick those that apply: 

( ) Negative ( ) Non-negative 

( ) Reasonable cause ( ) Post incident ( ) Internal transfer 

( ) Random ( ) Rehabilitation follow-up 



Version 3.33

Schedule C – Job Applicant, Consent for Drug and Alcohol Testing 

I consent to undergo a drug test to be undertaken by a certified collecting agent (CCA) and 

an accredited laboratory appointed by PF Olsen Ltd and an alcohol 1 breath test to be 

conducted by a person trained in the use of an approved breath testing device. 

I acknowledge these tests are to determine whether illicit or restricted drug(s) or a misused 

prescribed drug(s) present in my urine, at concentrations higher than the accepted 

international standard as defined by the AS/NZS 4308:2008. I understand that the drugs being 

tested for are cannabinoids, opiates, amphetamine-type substances (incl. benzylpiperazine), 

cocaine, benzodiazepines, (and others if applicable). Also, to determine whether I have a level 

of alcohol in my breath above 400 micrograms of alcohol per litre of breath (over 20 years of 

age), or above 0 micrograms of alcohol per litre of breath (under 20 years of age). 

PF Olsen Ltd undertakes that the results of the tests will be used only for the purpose for 

which they were obtained, and that any collection, storage or exchange of medical 

information concerning the test will be in accordance with the Privacy Act. 

I undertake to advise the CCA collecting my urine of any medication that I am taking. I also 

agree to provide the collecting agent with photograph identity, if required to do so. 


representative of PF Olsen Limited. I understand that the decision whether or not to employ 

me will be based on many factors, including testing results, and that PF Olsen Ltd is not 

required to explain the basis for it‟s decision. I may request a copy of my results. 

I understand that I may request a second confirmatory test be conducted on the „duplicate 

specimen‟ and analysed within 14 days of receiving the result. For the second test to be „nonnegative‟ 

there need only be the presence of drug or metabolite detected (i.e. not cut off 

limits). This will be accepted as a conclusive result. I reserve the right to waiver a second 

confirmatory and do so by signing here________________________________________. 


Applicant‟s signature ______________________________ Date ___ / ___ / ___ 

Applicant‟s name 

______________________________ 

CCA signature ______________________________ Date ___ / ___ / ___ 

CCA name 

______________________________ 

Witness signature ______________________________ Date ___ / ___ / ___ 

Witness name ______________________________ Reading ____________ 

Tick those that apply: Drugs ( ) Negative ( ) Non-negative 

Breath alcohol ( ) Negative ( ) Non-negative 

1 A witness is needed for a confirmatory alcohol test, because the result of the test is final. The witness shall 

record the reading. 



Version 3.33

Schedule D – Existing Employee, Consent Breath Alcohol Testing 

I consent to undergo a breath alcohol test, which I acknowledge is to determine whether I 

have alcohol in my breath at levels higher than those set out in the PF Olsen Ltd drug and 

alcohol policy. 

PF Olsen Ltd undertakes that the result of the test will be used only for the purpose for which 

they were obtained, and that any collection, storage or exchange of medical information 

concerning the test will be in accordance with the Privacy Act. 

I understand that the test(s) are to determine whether I have a level of alcohol in my breath 

above 400 micrograms of alcohol per litre of breath (over 20 years of age), or above 0 

micrograms of alcohol per litre of breath (under 20 years of age). 

I understand that a refusal to sign this form, undergo a breath test, or the return of a nonnegative 

alcohol test result means the PF Olsen Ltd disciplinary procedure for serious 

misconduct will follow and that I will be required to voluntarily join rehabilitation. In the case 

of an internal transfer, the job offered/applied for will not be confirmed or offered to me. 

I hereby authorise the collection and testing of a breath sample for alcohol. 


representative of PF Olsen Limited. 


Applicant‟s signature ______________________________ Date ___ / ___ / ___ 

Applicant‟s name 

______________________________ 

CCA signature ______________________________ Date ___ / ___ / ___ 

CCA name 

______________________________ 

Witness signature ______________________________ Date ___ / ___ / ___ 

Witness 1 name ______________________________ Reading ____________ 

Tick those that apply: Drugs ( ) Negative ( ) Non-negative 

Breath alcohol ( ) Negative ( ) Non-negative 

1 A witness is needed for a confirmatory alcohol test, because the result of the test is final. The witness shall 

record the reading. 



Version 3.33

Schedule E – Voluntary Rehabilitation Agreement 

I acknowledge that I have voluntarily joined rehabilitation and that my continued employment 

with PF Olsen Ltd is subject to the following: 

I am committed to full participation in a „Rehabilitation Management Plan‟ (drug and/or 

alcohol assessment, treatment and case management) with a service provider(s) suitable to 

PF Olsen Ltd. 

I authorise the service provider to release the following information to PF Olsen Ltd, as and 

when required by the company: 

1. Whether I have kept appointments 

2. Whether the service provider has recommended a course of treatment 

3. Whether I am following that course 

4. Whether a return to work is appropriate and within what timeframe 

5. Whether I can work in a safety sensitive area 

6. Whether I have completed the required treatment 

7. Whether return to work is to full or alternative duties 

I agree to take this course outside work hours or use leave entitlements if required to 

participate during work hours. 

I agree to be subject to up to six unannounced follow-up drugs and/or alcohol tests during and 

after rehabilitation. Testing, relative to this round of rehabilitation will be completed within 2 

years of the date on the bottom of this form. 

I accept that if: 

 

 

 

I do not attend or complete the required course 

On any future occasion, including the tests above, I return a positive test 

I refuse to take any of the subsequent tests the consequence may be dismissal without 

notice. 

I accept the terms of this agreement, which I acknowledge may be in addition to the terms of 

my current employment agreement and agree to be bound by both contracts. 



__________________________________ 

Witness signature __________________________________ Date ___ / ___ / ___ 

Witness name 

__________________________________ 



Version 3.33

Schedule F – Chain of Custody Agreement 

Section 1 – Custodian statement and warranties 

I ______________________________________ (Full name of employee), acting as 

custodian, am employed by PF Olsen Ltd and act in the capacity of [Health and Safety 

Representative /custodian – or similar] for the Company. 

I have received training in chain of custody procedures as they relate to the management of 

the PF Olsen Ltd Alcohol & Drug Policy and Management Plan. 

I am the custodian, solely as it relates to the management of PF Olsen Ltd Alcohol & Drug 

Policy for ______________________________________ (Full name of employee 

undergoing tested – henceforth known as the employee). I warrant that the employee I have in 

my custody is the same person completing and signing section 2 of this form. 

I warrant that I have accompanied the employee to the PF Olsen Ltd approved specimen 

collecting agent. I further warrant that there has been no opportunity for the employee to 

consume drugs or alcohol between the times guardianship (custody) commenced and when 

the employee provided the sample/specimen to the collection agent. 

Section 2 – Employee warranties 

I ______________________________________ (Full name of employee undergoing testing 

– henceforth known as the employee) am the subject of these proceedings. 

I warrant that the (sample of breath provided / the specimen of urine provided) is mine and 

that it has not been changed or altered between the times guardianship (custody) commenced 

to the time of providing the sample/specimen to the collection agent. 



__________________________________ 

Custodian signature __________________________________ Date ___ / ___ / ___ 

Custodian name 

___________________________________ 



Version 3.33

Schedule G – Testing Flowchart 

Front end – i.e. reason for testing process: 

Pre-employment – when applicant approved → 

Post-incident (RC) – follows incident analysis → 

Random – when employee group is selected → 

Refuses to 

take test 

Employee or 

approved job 

applicant asked to 

take test 

Random 

screen 

administered 

Agrees and signs appropriate consent form 

Person accompanied to 

Collection centre → 

← Agents vehicle 

Pre-employment, 

Post Incident or 

Reasonable Cause 

(RC) screen 

administered 

Disciplinary 

procedure for 

employee – stood 

down until 

employee 

produces negative 

test. 

Person stood down 

from work, 

confirmatory lab 

evaluation 

completed 

Test results 

received by 

Manager 

Pre-employment 

candidates with a 

positive test not 

awarded job 

Not rehabilitated 

or doesn‟t want to 

be rehabilitated 

Non-negative 

___________________________________________________________ 

Positive results 

Person informed 

of results by 

Manager 

Disciplinary 

Interview 

Negative result 

Rehabilitation 

declined 

Agrees to 

rehabilitation, 

signs agreement & 

commences 


Rehabilitation and 

subsequent testing 

at random (3 pa) 

Employee returns 

to work, 


process continues, 

Applicant 

continues in 

employment 

process 

END 



Version 3.33

Alcohol And Drug Management Policy - PF Olsen Limited

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