10-0388-8 Certification Regarding Drug-free Workplace Requirements

OMB Number: 2900-0661
Estimated Burden: 6 hour

CERTIFICATION REGARDING DRUG-FREE WORKPLACE
REQUIREMENTS FOR GRANTEES OTHER THAN INDIVIDUALS
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements
of section 3507 of this Act. The public reporting burden for this collection of information is estimated to average 6 hours per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. We may not collect or sponsor and you are not required to respond to, a collection unless it has a valid OMB Control
Number. This collection of information is collected under the authority of 38 U.S. Code Sections 8133(a) and 8135(a). VA will use this
information, along with other documents submitted by the States to determine the feasibility of the projects for VA participation, to meet VA
requirements for a grant award and to rank the projects in establishing the annual fiscal year priority list. Although response is voluntary, VA will
be unable to authorize a grant without a complete package. Your failure to furnish this information will have no effect on any of other benefits to
which you are entitled.
This certification is required by the regulations implementing the Drug-Free Workplace Act of 1988, 38 CFR 44, Subpart F. The
regulations, published in the January 31, 1989, Federal Register (pages 4950-4952) require certification by grantees, prior to award,
that they will maintain a drug-free workplace. The certification set out below is a material representation of fact upon which reliance will
be placed when the agency determines to award the grant. False certification or violation of the certification shall be grounds for
suspension of payments, suspension or termination of grants, or government-wide suspension or debarment (see CFR Part 44, Section
44.100 through 44.420).
The grantee certifies that it will provide a drug-free workplace by:
(1) Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession or use of
acontrolled substance is prohibited in the grantee's workplace and specifying the actions that will be taken against employees for
violation of such prohibition;
(2) Establishing a drug-free awareness program to inform employees about
(a) The dangers of drug abuse in the workplace;
(b) The grantee's policy of maintaining a drug-free workplace;
(c) Any available drug counseling, rehabilitation, and employee assistance programs; and
(d) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace;
(3) Making it a requirement that each employee to be engaged in the performance of the grant be given a copy of the statement
required by paragraph (1);
(4) Notifying the employee in the statement required by paragraph (1) that, as a condition of employment under the grant, the
employee will
(a) Abide by the terms of the statement; and
(b) Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five
days after such conviction;
(5) Notifying the agency within ten days after receiving notice under subparagraph (4) (b) from an employee or otherwise receiving
actual notice of such convictions;
(6) Taking one of the following actions, within 30 days of receiving notice under subparagraph (4) (b), with respect to any employee
who is so convicted;
(a) Taking appropriate personnel action against such employee, up to and including termination; or
(b) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such
purposes by a Federal, State, or local health, law enforcement, or other appropriate agency;
(7) Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (1), (2), (3), (4),
(5) and (6).
VA FORM
MAR 2005

10-0388-8

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CERTIFICATION REGARDING DRUG-FREE WORKPLACE
REQUIREMENTS FOR GRANTEES OTHER THAN INDIVIDUALS
The grantee shall insert in the space provided below the site(s) for performance of work done in connection with the specific grant
(street address, city, county, state, zip code).

Street Address
City
County
State
ZIP Code

Remarks

ORGANIZATION NAME

NAME OF AUTHORIZED REPRESENTATIVE

MAR 2005

TITLE OF AUTHORIZED REPRESENTATIVE

DATE (mm/dd/yyyy)

SIGNATURE

VA FORM

GRANT NUMBER OR NAME

10-0388-8

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