Ad 1050

This form is available electronically.

Form Approved - OMB No. 0505-0027
Expiration Date: 12/31/2018

United States Department of Agriculture

AD-1050

Certification Regarding Drug-Free Workplace Requirements (Grants)
Alternative II – For Grantees Who Are Individuals
The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. § 552(a), as amended). This
certification is required by the regulations implementing §§ 5151-5160 of the Drug-Free Workplace Act of 1998 (Pub.
L.100-690, Title V, Subtitle D: 41 U.S.C. § 8101 et seq.), and 2 C.F.R. Parts 182 and 421. The regulations were amended
and published on June 15, 2009, in 74 Fed. Reg. 28150-28154 and on December 8, 2011, in 76 Fed. Reg. 76610-76611.
Copies of the regulations may be obtained by contacting the Department of Agriculture agency offering the grant.
According to the Paperwork Reduction Act of 1995 an agency may not conduct or sponsor, and a person is not required to
respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0505-0027. The time required to complete this information collection is estimated to average 15
minutes 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. The provisions of appropriate
criminal and civil fraud privacy, and other statutes may be applicable to the information provided.

(Read Instructions On Page Two Before Completing Certification)
A. The grantee certifies that, as a condition of the grant, he or she will not engage in the unlawful manufacture,
distribution, dispensing, possession, or use of a controlled substance in conducting any activity with the grant.
B. If convicted of a criminal drug offense resulting from a violation occurring during the conduct of any grant activity,
he or she will report the conviction, in writing, within 10 calendar days of the conviction, to the grant officer or
other designee, unless the Federal agency designates a central point for the receipt of such notices. When notice
is made to such a central point, it shall include the identification number(s) of each affected grant.

ORGANIZATION NAME

PR/AWARD NUMBER OR PROJECT NAME

NAME(S) AND TITLE(S) OF AUTHORIZED REPRESENTATIVE(S)
Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
Title:
SIGNATURE(S)

DATE

The U.S. Department of Agriculture (USDA) prohibits discrimination in all of its programs and activities on the basis of race, color, national origin, age,
disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, political beliefs, genetic information,
reprisal, or because all or part of an individual’s income is derived from any public assistance program. (Not all prohibited bases apply to all programs).
Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact
USDA’s TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA, Assistant Secretary for Civil Rights,
Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Stop 9410, Washington, DC 20250-9410, or call toll-free at
(866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish Federal-relay). USDA is an
equal opportunity provider and employer.

Instructions for Certification
(1) By signing and submitting this form, the grantee is providing the certification set out on page one in accordance with
these instructions.
(2) The certification set out on page one 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 known,
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 (3) above).
(6) Definitions of terms in the Nonprocurement Suspension and Debarment common rule and Drug-Free Workplace
common rule apply to this certification. Grantee’s 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 21 C.F.R. §§ 1308.11-1308.15.
· “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 used to meet a matching
requirement, consultants or independent contractors not on the grantee’s payroll, or employees of subrecip ients
or subcontractors in covered workplaces).

Form AD-1050 (REV 12/15)
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