Form AD-1050 Certofocatopm Regarding Drug-Free Workplace Requirements

OMB Control No. 0505-0027
Expiration Date: 04/30/2022

This form is available electronically.

Certification Regarding Drug-Free Workplace Requirements (Grants)
Alternative II – For Grantees Who Are Individuals

AD-1050

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 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,
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)

SIGNATURE(S)

DATE

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
(https://www.ascr.usda.gov/filing-program-discrimination-complaint-usda-customer) 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.

Instructions for Certification
(1)

By signing and submitting this form, the grantee is providing the certification set out on pages one and two in accordance with these
instructions.

(2)

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.

(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. Grantees’ attention is called, in particular, to the following definitions from these rules:
•
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•
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“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).

Form AD-1050 (REV 12/18)
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