AD-1052 State Agencies

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AD-1052- CERTIFICATION REGARDING DRUG-FREE WORKPLACE
REQUIREMENTS, STATE AND STATE AGENCIES
AD-1052, Certification Regarding Drug-Free Workplace
U.S. DEPARTMENT OF AGRICULTURE
CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS
STATES AND STATE AGENCIES
FEDERAL FISCAL YEAR
This certification is required by the regulations implementing Sections 5151-5160 of the DrugFree 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. The regulations, published as Part II of the May 25, 1990 Federal
Register (pages 21681-21691), require certification by grantees, prior to award, that they will
maintain a drug-free workplace. Section 3017.630(c) of the regulation provides that a grantee
that is a State may elect to make one certification to the Department of Agriculture in each
Federal fiscal year in lieu of certificates for each grant during the Federal fiscal year covered by
the certification. The certificate set out below is a material representation of fact upon which
reliance is placed when the agency awards the grant. False certification or violation of the
certification shall be grounds for suspension of payments, suspension or termination of grants,
or Governmentwide suspension or debarment (see 7 CFR Part 3017, Sections 3017.615 and
3017.620). States and State agencies using this form should send it to: U.S. Department of
Agriculture, Office of Finance and Management, Federal Assistance and Fiscal Policy Division,
Federal Assistance Team, Room 3031 South Building, Washington, D.C. 20250.
(BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON PAGE 3)
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 –

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Form AD-1052 (REV 5/90)

29.35 - Exhibit 01--Continued
(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) Notifying the agency in writing, within ten 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;
(f) Taking one of the following actions, within 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;
(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).
This certification is for a
State (All State
Single State Agency
Agencies)
(check one)
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 above.

State / State Agency Name
____
Name and Title of Authorized Representative
Signature

Date

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Form AD-1052 (REV 5/90)