AD-1049 Certification Regarding Drug-Free Workplace Requirements

OMB No. 0572-0121

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 Section 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 13, 1989, regulations were amended and published as Part II of the May 25,
1990 Federal Register (pages 21681-21691). Copies of the regulations may be obtained by contacting the
Department of Agriculture agency offering the grant.

(BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON PAGE 3)
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) 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
AD-1049 (REV 5/90)

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).
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

Clear Form
AD-1049 (REV 5/90)

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
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
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
States 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)
According to 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 0572-0146. The time
required to complete this information is estimated to average 10 minutes, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed.
AD-1049 (REV 5/90)