Ad 1049

UNITED STATES 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 Sections 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 31, 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 2)
(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;

Alternative I
A.

The grantee certifies that it will or will continue to provide a drugfree 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 --

(c)

(d)

(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;

(g)

B.

Check
here.

Notifying the employee in the statement required by
paragraph (a) that, as a condition of employment under the
grant, the employee will -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 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 --

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)

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)

Making a good faith effort to continue to maintain a drug-free
workplace through implementation of paragraphs (a), (b), (c),
(d), (e) and (f).

if there are workplaces on file that are not identified

Organization Name
Award Number or Project Name
Name and Title of Authorized Representative
Signature

1

Date

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 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).

2

Form AD-1049 (REV 5/90)