Ad 1049 Certificate for a Drug Free Workplace

OMB APPROVAL NO.
9000 - 0101

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 Sections 5151-5160 of the DrugFree 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 regulations were published as Part II of

the January 31,1989 Federal Register (pages 4947-4952).

Copies of the regulations may be

obtained by contacting the Department of Agriculture agency offering the grant.

(BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON REVERSE)

Alternative I
(A) The grantee certifies that it will 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 a 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

Form AD-1049 (REV 2-89)

(2) Notify the employer of any criminal drug statute conviction for a violation
occurring in the workplace no later than five days after such conviction;

(e) Notifying the agency within ten days after receiving notice under subparagraph (d)(2)
from an employee or otherwise receiving actual notice of such conviction;

(f) Taking one of the following actions, within 30 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; 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 shall 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)

Organization Name

PR/Award Number or Project Name

Name and Title of Authorized Representative

Signature

Date

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 was placed when the agency determined to award 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.

2

Form AD-1049(REV 2-89)
*U.S. GPO: 1989-654-006/81520