Free Kentucky Drug-Free Workplace Application - Kentucky

APPLICATION / AFFIDAVIT / CHECKLIST FOR CERTIFICATION OF KENTUCKY DRUG-FREE WORKPLACE PROGRAM PURSUANT TO 803 KAR 25:280

1. Filing directions for application: Please fully complete the application which includes sections A, B, C, D and E and return it to the Kentucky Office of Workers' Claims (OWC) with all required attachments. The OWC will review the application to determine if all sections have been completed, required signatures have been given, and the form has been notarized. If the criteria ha ve been met, the OWC will return a copy of the application and a Kentucky Drug-Free Workplace Certificate to you. If an incomplete form has been sent to the OWC, it will be returned to you. 2. Annual Certification: An employer must be certified annually and must maintain its certified drug-free workplace program each year. 3. Documentation of Certified Drug-Free Workplace: For purposes of documenting your certified drug-free workplace program, it is necessary to maintain your policy and the records required by this application in a separate file for review by your insurer upon request. Files demonstrating your compliance and management of your program should also be maintained for review by your insurer. 4. Contact your Insurer: An employer should contact its workers' compensation insurer with questions about the availability and application of premium discounts if a Drug-Free Workplace Certificate is obtained from OWC. An employer should be prepared to provide the certification of a drug free workplace and a copy of its application and attached documents to its workers' compensation insurer. NOTE: The Kentucky Office of Workers' Claims is not responsible for the implementation of an employer's drug-free workplace policy. All employers are strongly advised to seek counsel from experts prior to implementing drug-free workplace policies.

THIS APPLICATION / AFFIDAVIT MUST BE SUBMITTED TO THE OFFICE OF WORKERS' CLAIMS ANNUALLY Kentucky Office of Workers' Claims Attn: Drug-Free Workplace Program 657 Chamberlin Avenue Frankfort, Kentucky 40601 502.564.5550 Part A - Type of Form (check one): New Application Part B - Applicant Information: Drug-Free Workplace Coordinator: Company Name: FEIN: Address: City: County: Phone: E-mail Address: Number of Employees: Type of business: State: Zip: Renewal

Workers' Compensation Insurance Carrier: Mailing Address: City: State: Zip:

To Be Completed By The Kentucky Office of Workers' Claims Date of First Certification: ___________________________ Or Date of Re-Certification: ____________________________ Approved By: _____________________________________ Certificate Sent By: _______________ Date: ____________

Part C -Checklist: A copy of a drug-free workplace statement is given to each employee and posted in a prominent place at the place of employment; The copy notifies employees that the unlawful manufacture, distribution, dispensation, possession, or use of alcohol or a controlled or illicit substance is prohibited in the workplace; The copy specifies the actions that will be taken against employees for violations of such prohibition; An alcohol and substance abuse education and awareness training program for all employees and supervisory personnel has been established; A program has been established that includes alcohol and drug testing ; An Employee Assistance Program is provided which includes professional assessment of employee personal concerns; confidential and timely identification services with regard to employee alcohol or substance abuse; referrals to employees for appropriate diagnosis, treatment and assistance with regard to employee alcohol or substance abuse; and follow-up services for employees who participate in a drug or alcohol rehabilitation program; A drug-free workplace will be maintained throughout the workers' compensation insurance policy period; The drug-free workplace program is in compliance with all applicable federal and state laws and regulations ; All of the above complies with the regulatory requirements of 803 KAR 25:280. Part D - Copies of the following documents shall be attached to the initial application. The documents shall not be attached to renewal application unless a substantive change is made to the documents previously filed with the OWC: Drug-free workplace policy A statement identifying each alcohol and drug test that will be conducted A statement identifying the company's Employee Assistance Program A description of the alcohol and substance abuse education and awareness training program for employee and supervisory personnel A statement describing the confidentiality of the company's drug -free workplace program Documents provided to employees

Part E - Employer Certification & Affidavit: As a duly authorized agent of the license applicant named above, I hereby certify: (a) that the frequency and duration of each employee and supervisor training session meets the requirements of 803 KAR 25:280; (b) that all employees and supervisory personnel have participated or will participate during the calendar year in the required alcohol and substance abuse education and awareness training; and (c) that the information I have provided in this Application/Affidavit is true and correct to the best of my knowledge.

Signature: ________________________________ Name in Print: _____________________________ Title: _____________________________________

STATE OF _____________________________) COUNTY OF ___________________________) Subscribed and sworn to before me by _________________________________ This _______ day of ___________, 20____.

_____________________________________ Notary Public

My Commission expires:_______________________________