Section 15.12. Official form

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

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Social Security Number

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Address

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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:

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Signature of Boxer	Date	Time
Signature of Witness	Date	Time
Commission Representative	Date	Time

Notation

Cross References

This section cited in 58 Pa. Code § 15.3 (relating to use of prohibited drugs).