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Form
Approved – OMB No. 0505-0027
Expiration
Date: __/__/20__
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Certification
Regarding Drug-Free Workplace
State
and State Agencies, Federal Fiscal Year ____
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The
following statement is made in accordance with the Privacy Act of
1974 (5 U.S.C. § 552a, 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, amended and published
on June 15, 2009, in 74 Fed. Reg. 28150-28154 and on December 8,
2011, in 76 Fed. Reg. 76610-76611, 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 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 or grants, or government-wide suspension
or debarment (see 2 C.F.R. Parts 180 and 417). States and State
agencies using this form should send it to the U.S. Department of
Agriculture, Office of the Chief Financial Officer, Transparency
and Accountability Reporting Division, Mail Stop
9011,
South Building, Washington, D.C. 20250-9010. (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.
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(Read
Instructions On Page Three Before Completing Certification)
The
grantee certifies that it will or will continue to provide a
drug-free workplace by:
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;
Establishing
an ongoing drug-free awareness program to inform employees about
–
The
dangers of drug abuse in the workplace;
The
grantee’s policy of maintaining a drug-free workplace;
Any
available drug counseling, rehabilitation, and employee
assistance programs; and
The
penalties that may be imposed upon employees for drug-abuse
violations occurring in the workplace.
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.1.).
Notifying
the employee in the statement required by paragraph (A.1.) that,
as a condition of employment under
grant,
the employee will –
Abide
by the terms of the statement; and
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;
Notifying
the agency in writing, within ten calendar days after receiving
notice under subparagraph (A.4.b.) 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;
Taking
one of the following actions, within 30 calendar days of
receiving notice under subparagraph (A.4.b.), with respect to any
employee who is so convicted –
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
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;
Making
a good faith effort to continue to maintain a drug-free workplace
through implementation of paragraphs
(A.1.
through A.6.)
This
certification is for a (check
one):
[
] State (All State Agencies) [ ] Single State Agency
The
grantee may insert in the space provided below the site(s) for
the performance of work done in connection with the specific
grant:
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PLACE
OF PERFORMANCE (Street
Address, City, County, State, Zip Code)
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Check
[ ] if there are workplaces on file that are not identified
here.
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STATE/STATE
AGENCY
PR/AWARD NUMBER OR PROJECT NAME
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NAME(S)
AND TITLE(S) OF AUTHORIZED REPRESENTATIVE(S)
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SIGNATURE(S)
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DATE
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In
accordance with Federal civil rights law and U.S. Department of
Agriculture (USDA) civil rights regulations and policies, the USDA,
its Agencies, offices, and employees, and institutions participating
in or administering USDA programs are prohibited from discriminating
based on race, color, national origin, religion, sex, gender identity
(including gender expression), sexual orientation, disability, age,
marital status, family/parental status, income derived from a public
assistance program, political beliefs, or reprisal or retaliation for
prior civil rights activity, in any program or activity conducted or
funded by USDA (not all bases apply to all programs). Remedies and
complaint filing deadlines vary by program or incident.
Persons
with disabilities who require alternative means of communication for
program information (e.g., Braille, large print, audiotape, American
Sign Language, etc.) should contact the responsible Agency or USDA's
TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA
through the Federal Relay Service at (800) 877-8339. Additionally,
program information may be made available in languages other than
English.
To
file a program discrimination complaint, complete the USDA Program
Discrimination Complaint Form, AD-3027, found online at How
to File a Program Discrimination Complaint and at any USDA office
or write a letter addressed to USDA and provide in the letter all of
the information requested in the form. To request a copy of the
complaint form, call (866) 632-9992. Submit your completed form or
letter to USDA by: (1) mail: U.S. Department of Agriculture, Office
of the Assistant Secretary for Civil Rights, 1400 Independence
Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442.
Form
AD-1052
(REV
12/18)
Page
2 of 3
Instructions
for
Certification
By
signing and submitting this form, the grantee is providing the
certification set out on pages one and two in accordance with
these instructions
The
certification set out on pages one and two 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.
Workplaces
under grants, for State and State Agencies, 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.
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).
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).
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 subrecipients or
subcontractors in covered workplaces).
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Form
AD-1052
(REV
12/18)
Page
3 of 3
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | This form is available electronically |
Author | erica.robinson |
File Modified | 0000-00-00 |
File Created | 2021-01-15 |