Free ann- 10- 0388- 8- form.xdp - Federal

CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS FOR GRANTEES OTHER THAN INDIVIDUALS
This certification is required by the regulations implementing the Drug-Free Workplace Act of 1988, 41 U.S.C. §§ 701 et seq. The regulations, published on January 31, 1989 in the Federal Register (pages 4950-4952), 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 will be placed when the agency determines to award the grant. False certification or violation of the certification shall be grounds for suspension of payments, suspension or termination of grants, or government-wide suspension or debarment. The grantee certifies that it will provide a drug-free workplace by: (1) 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; (2) Establishing a drug-free awareness program to inform employees about: (a) The dangers of drug abuse in the workplace; (b) The grantee's policy of maintaining a drug-free workplace; (c) Any available drug counseling, rehabilitation, and employee assistance programs; and (d) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace; (3) 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 (1); (4) Notifying the employee in the statement required by paragraph (1) that, as a condition of employment under the grant, the employee will: (a) Abide by the terms of the statement; and (b) Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five days after such conviction; (5) Notifying the agency within ten days after receiving notice under subparagraph (4) (b) from an employee or otherwise receiving actual notice of such convictions; (6) Taking one of the following actions, within 30 days of receiving notice under subparagraph (4) (b), with respect to any employee who is so convicted; (a) Taking appropriate personnel action against such employee, up to and including termination; or (b) 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; (7) Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (1), (2), (3), (4), (5) and (6).

VA FORM JUL 2009

40-0895-8

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CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS FOR GRANTEES OTHER THAN INDIVIDUALS
INSTRUCTION: The grantee shall insert in the space provided below the site(s) for performance of work done in connection with the specific grant (street address, city, county, state, zip code).
STREET ADDRESS

CITY

COUNTY

STATE

ZIP CODE

REMARKS

NAME OF ORGANIZATION

PROJECT FAI (Federal Application Identifier) NO.

NAME OF AUTHORIZED STATE OR TRIBAL GOVERNMENT REPRESENTATIVE

TITLE OF AUTHORIZED STATE OR TRIBAL GOVERNMENT REPRESENTATIVE

SIGNATURE

DATE (mm/dd/yyyy)

VA FORM JUL 2009

40-0895-8

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