Dot F 2307-1 Drug-free Workplace Act Certification For Grantee Other

OMB NO.: 2105-0555

EXPIRATION DATE: MM/DD/YYYY

DRUG-FREE WORKPLACE ACT CERTIFICATION

FOR A GRANTEE OTHER THAN AN INDIVIDUAL

1. The ___________________________________________________________________

(Name of Applicant for a Grant or Cooperative Agreement)

certifies that it will establish and continue to provide a drug-free workplace by:

1. Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the Applicant's workplace and specifying the actions that will be taken against employees for violation of such prohibition;

2. Establishing an ongoing drug-free awareness program to inform employees about--

1. The dangers of drug abuse in the workplace;

2. The Applicant's policy of maintaining a drug-free workplace;

3. Any available drug counseling, rehabilitation, and employee assistance programs; and,

4. 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 or cooperative agreement be given a copy of the statement required by paragraph (a).

4. Notifying the employee in the statement required by paragraph (a) that, as a condition of employment under the grant or cooperative agreement, the employee will--

1. Abide by the terms of the statement; and,

2. Notify the employer in writing of his or her conviction for a violation of a criminal drug statue occurring in the workplace no later than five (5) calendar days after such conviction;

5. Notifying the Federal agency in writing, within ten (10) calendar days after receiving notice under subparagraph (d)(2) from an employee or otherwise receiving actual notice of such conviction, Employers of convicted employees must provide notice, including position title, to every project officer or other designee on whose project activity the convicted employee was working. Notice shall include the identification number(s) of each affected grant or cooperative agreement.

6. Taking one of the following actions, within thirty (30) calendar days of receiving notice under subparagraph (d)(2), with respect to any employee who is so convicted--

1. Taking appropriate personnel action against such an employee, up to and including termination, consistent with the requirements of the Rehabilitation Act of 1973, as amended; or

2. 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 (a), (b), (c), (d), (e), and (f).

2. The Applicant's headquarters is located at the following address. The addresses of all workplaces maintained by the Applicant are provided on an accompanying list.

Name of Applicant: _________________________________ Address: __________________________________________ City: _____________________________________________ County:___________________________________________ State: _____________________________ Zip Code: _________________________

______________________________________ (Signature of Authorized Official) ______________________________________ (Title of Authorized Official) ______________________________________ (Name of Applicant) ____________________ (Date)

PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENT

A Federal agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current valid OMB control number. The OMB Control No. for this information collection is 2105-0555. The information requested on this form is being collected and disseminated by the U.S. Department of Transportation, Office of the Secretary as a courtesy to the public. Public reporting for this collection of information is estimated to be 15 minutes per response, including time for reviewing instructions, and completing and reviewing the collection of information. All responses to this collection of information are mandatory Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to: Information Collection Clearance Officer, Office of the Secretary, Office of Small and Disadvantaged Business Utilization, Financial Assistance Division, 1200 New Jersey Ave., S.E., 5^th Floor, W56-497, Washington, DC 20590.

PRIVACY ACT STATEMENT

The Privacy Act requires that we provide you with the following information regarding our use of your Personally Identifiable Information. The information on this application is solicited under the authority of Title 49 U.S.C. 332(b)(3)(4)(5) which authorizes DOT OSDBU to assist Disadvantage Business Enterprises and Small and Disadvantaged Business in acquiring access to working capital and to debt financing, in order to obtain transportation related contracts wholly or partially funded by DOT. Your request cannot be processed unless the data is complete. Disclosures of name and other personal identifiers are required for a benefit, as DOT requires an individual seeking assistance from DOT to provide with sufficient information for it to evaluate the risk of a loan application. In making loan guarantees pursuant to Title 49 U.S.C. 332(b)(3)(4)(5), DOT is required to have reasonable assurance that the loan is of sound value and will be repaid or that is in the best interest of the Government to grant the assistance required. Routine uses of records maintained in the system include: processing, review, and final approval of your loan by authorized Office of Small and Disadvantaged Business Utilization (OSDBU) personnel; internal loan review and independent financial analyst provided by a financial expert contractor working for OSDBU; the loan referral to a Participating Lender involved in the underwriting, loan approval, and loan servicing of the loan guarantee; and recording in the Grant Information System. Disclosure of your Social Security Number (SSN) and/or date of birth (DOB) are optional. Refusal to furnish your SSN and/or DOB will not result in the denial of any right, benefit or privilege provided by law; however, failure to provide SSN and/or DOB may result in the delay of a response of the processing of your loan application or its rejection. Routine uses of your social security number include: processing, review, and final approval of your loan by authorized Office of Small and Disadvantaged Business Utilization (OSDBU) personnel; internal loan review and independent financial analysis provided by a financial expert contractor working for OSDBU; and the loan referral to a Participating Lender involved in the underwriting, loan approval, and loan servicing of the loan guarantee.

DOT F 2307-1