Form 10-0143 Department of Veterans Affairs Certification Regarding D

OMB Number: 2900-0160
Estimated Burden: 5 minutes

DEPARTMENT OF VETERANS AFFAIRS CERTIFICATION REGARDING DRUG-FREE
WORKPLACE REQUIREMENTS FOR GRANTEES OTHER THAN INDIVIDUALS
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with
the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or
sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number.
We anticipate that the time expended by all individuals who must complete this form will average 5 minutes. This
includes the time it will take to read instructions, gather the necessary facts and fill out the form. Although this form
is required to obtain the grant, failure to furnish this information will have no impact on any other benefits to which
you may be entitled.
This certification is required by the regulations implementing the Drug-Free Workplace Act of 1988, 38 CFR 44,
Subpart F. The regulations, published in the January 31, 1989, 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 (see CFR Part 44, Section 44.100 through
44.420).
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)
(b)
(c)
(d)

The dangers of drug abuse in the workplace;
The grantee's policy of maintaining a drug-free workplace;
Any available drug counseling, rehabilitation, and employee assistance programs; and
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
SEP 2006 (R)

10-0143

EXISTING STOCK OF VA FORM 10-0143, DATED SEP 1998, WILL BE USED.

DEPARTMENT OF VETERANS AFFAIRS CERTIFICATION REGARDING DRUG-FREE
WORKPLACE REQUIREMENTS FOR GRANTEES OTHER THAN INDIVIDUALS
Places of Performance: 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)

ORGANIZATION NAME

GRANT NUMBER OR NAME

NAME AND TITLE OF AUTHORIZED REPRESENTATIVE

DATE

SIGNATURE

VA FORM
SEP 2006 (R)

10-0143