Fillable Printable VA Form 10-0143

VA Form 10-0143

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 part 48.

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

(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

(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;

(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).

(a) The dangers of drug abuse in the workplace;

(b) The grantee's policy of maintaining a drug-free workplace;

(d) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace;

(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;

(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;

10-0143

VA FORM

MAY 2014

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

SIGNATURE

DATE

VA FORM

MAY 2014

10-0143