Form AD-1049 Certification Regarding Drug-Free Workplace Requirements

OMB APPROVAL NO. 0991-0002

U.S. DEPARTMENT OF AGRICULTURE
CERTIFICATION REGARDING
DRUG-FREE WORKPLACE REQUIREMENTS (GRANTS)
ALTERNATIVE I - FOR GRANTEES OTHER THAN INDIVIDUALS
This certification is required by the regulations implementing Sections 5151-5160, of the Drug-Free Workplace Act of 1988
(Pub. L. 100-690, Title V, Subtitle D; 41 U.S.C. 701 et seq.), 7 CFR Part 3017, Subpart F, Section 3017.600, Purpose. The
January 31, 1989, regulations were amended and published as Part II of the MAY 25, 1990, Federal Register (pages 2168121691). Copies of the regulations may be obtained by contacting the Department of Agriculture agency offering the grant.
(BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON REVERSE)
Alternative I
A.

The grantee certifies that it will or will continue to provide a drug-free workplace by:
(a)

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

(b)

Establishing an ongoing drug-free awareness program to inform employees about -(1)

The dangers of drug abuse in the workplace;

(2)

The grantee'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;

(c)

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 (a):

(d)

Notifying the employee in the statement required by paragraph (a) that, as a condition of employment under the
grant, 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 statute occurring in
the workplace no later than five calendar days after such conviction;

(e)

Notify the agency in writing, within 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 grant officer on whose grant activity the convicted employee was working,
unless the Federal agency has designated a central point for the receipt of such notices. Notice shall include the
identification number(s) of each affected grant;
(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;

(g)

Making a good faith effort to continue to maintain a drug-free workplace through implementation of
paragraphs (a), (b), (c), (d), (e) and (f).

1-1
Form AD-1049 (REV 5/90)
Microsoft Word 2000

B.

The grantee may insert in the space provided below the site(s) for the performance of work done in connection with the specific grant:

Place of Performance (Street address, city, county, State, zip code)

Check

if there are workplaces on file that are not identified here.

Organization Name

Award Number or Project Name

Name and Title of Authorized Representative

Signature

Date
Instructions for Certification

1.

By signing and submitting this form, the grantee is providing the certification set out on pages 1 and 2.

2.

The certification set out on pages 1 and 2 is a material representation of fact upon which reliance is placed when the agency awards the grant. If it is
later determined that the grantee knowingly rendered a false certification, or otherwise violates the requirements of the Drug-Free Workplace Act, the
agency, in addition to any other remedies available to the Federal Government, may take action authorized under the Drug-Free Workplace Act.

3.

Workplaces under grants, for grantees other than individuals, need not be identified on the certification. If know, they may be identified in the grant
application. If the grantee does not identify the workplaces at the time of application, or upon award, if there is no application, the grantee must keep
the identity of the workplace(s) on file in its office and make the information available for Federal inspection. Failure to identify all known workplaces
constitutes a violation of the grantee's drug-free workplace requirements.

4.

Workplace identifications must include the actual address of buildings (or parts of buildings) or other sites where work under the grant takes place.
Categorical descriptions may be used (e.g., all vehicles of a mass transit authority or State highway department while in operation, State employees in
each local unemployment office, performers in concert halls or radio studios).

5.

If the workplace identified to the agency changes during the performance of the grant, the grantee shall inform the agency of the change(s), if it
previously identified the workplaces in question (see paragraph three).

6.

Definitions of terms in the Nonprocurement Suspension and Debarment common rule and Drug-Free Workplace common rule apply to this certification.
Grantees' attention is called, in particular, to the following definitions from these rules:
``Controlled substance'' means a controlled substance in Schedules I through V of the Controlled Substances Act (21 U.S.C. 812) and as further
defined by regulation (21 CFR 1308.11 through 1308.15);
``Conviction'' means a finding of guilt (including a plea of nolo contendere) or imposition of sentence, or both, by any judicial body charged with the
responsibility to determine violations of the Federal or State criminal drug statutes;
``Criminal drug statute'' means a Federal or non-Federal criminal statute involving the manufacture, distribution, dispensing, use, or possession of any
controlled substance;
``Employee'' means the employee of a grantee directly engaged in the performance of work under a grant, including: (i) all ``direct charge'' employees;
(ii) all ``indirect charge'' employees unless their impact or involvement is insignificant to the performance of the grant; and, (iii) temporary personnel
and consultants who are directly engaged in the performance of work under the grant and who are on the grantee's payroll. This definition does not
include workers not on the payroll of the grantee (e.g., volunteers, even if sued to meet a matching requirement; consultants or independent contractors
not on the grantee's payroll; or employees of subrecipients or subcontractors in covered workplaces).

1-2
Form AD-1049 (REV 5/90)