AD-1052 DrugFreeCert-FedFY 4-2022

This form is available electronically.

Form Approved – OMB No. 0505-0027
Expiration Date: 04/30/2022

Certification Regarding Drug-Free Workplace
State and State Agencies, Federal Fiscal Year

AD-1052

The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. § 552a, as amended). This certification is required by the
regulations implementing §§ 5151-5160 of the Drug-Free Workplace Act of 1998 (Pub. L.100-690, Title V, Subtitle D: 41 U.S.C. § 8101 et seq.), and
2 C.F.R. Parts 182 and 421. The regulations, amended and published on June 15, 2009, in 74 Fed. Reg. 28150-28154 and on December 8, 2011, in 76 Fed.
Reg. 76610-76611, 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 is placed when the agency awards the grant. False certification or violation of the certification shall be grounds for
suspension of payments, suspension or termination or grants, or government-wide suspension or debarment (see 2 C.F.R. Parts 180 and 417). States and
State agencies using this form should send it to the U.S. Department of Agriculture, Office of the Chief Financial Officer, Transparency and Accountability
Reporting Division, Mail Stop 9011, South Building, Washington, D.C. 20250-9010. (Copies of the regulations may be obtained by contacting the
Department of Agriculture agency offering the grant).
According to the Paperwork Reduction Act of 1995 an agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0505-0027. The time required to
complete this information collection is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The provisions of appropriate criminal and
civil fraud privacy, and other statutes may be applicable to the information provided.

(Read instructions on page three before completing certification.)
A. The grantee certifies that it will or will continue to 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 an ongoing 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 A.1.
4. Notifying the employee in the statement required by paragraph A.1 that, as a condition of employment under
grant, the employee will –
a. Abide by the terms of the statement; and
b. 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;
5. Notifying the agency in writing, within ten calendar days after receiving notice under subparagraph A.4.b
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;
6. Taking one of the following actions, within 30 calendar days of receiving notice under subparagraph A.4.b, with
respect to any employee who is so convicted –
a. 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

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
A.1 through A.6.
This certification is for a (check one):
State (All State Agencies)

Single State Agency

B. 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)

Check

if there are workplaces on file that are not identified here.

ORGANIZATION NAME

PR/AWARD NUMBER OR PROJECT NAME

NAME(S) AND TITLE(S) OF AUTHORIZED REPRESENTATIVE(S)

SIGNATURE(S)

DATE

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its agencies, offices, and employees, and
institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender
expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior
civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or
incident.
Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact
the responsible agency or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program
information may be made available in languages other than English.
To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint
(https://www.ascr.usda.gov/filing-program-discrimination-complaint-usda-customer) and at any USDA office or write a letter addressed to USDA and provide in the letter all of the
information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of
Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442.

Form AD-1052 (REV 12/18)
Page 2 of 3

Instructions for Certification
(1)

By signing and submitting this form, the grantee is providing the certification set out on pages one and two in accordance with these
instructions.

(2)

The certification set out on pages one and two 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 (3) above.

(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 21 C.F.R. §§ 1308.11-1308.15.
“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).

Form AD-1052 (REV 12/18)
Page 3 of 3