Fillable Printable VA Form 40-0895-8

VA Form 40-0895-8

OMB NUMBER: 2900-0559

Respondent Burden: 15 minutes

CERTIFICATION REGARDING DRUG-FREE WORKPLACE

REQUIREMENTS FOR GRANTEES OTHER THAN INDIVIDUALS

Respondent Burden: Public reporting burden for this collection of information is estimated to average 15 minutes. Statutory

authority for a State Cemetery Grant is 38 U.S.C. 2408. The information requested is necessary to ensure that State or Tribal

government has complied with the Drug-Free Workplace Act of 1988 at the location where the construction will occur. VA may not

conduct or sponsor and you are not required to respond to this collection of information unless it displays a valid OMB number.

Respond to this collection is voluntary. Send comments regarding the burden estimate or any other aspects of this collection of

information, including suggestions for reducing the burden to VA Clearance Officer (005R1B), 810 Vermont Avenue NW,

Washington, DC 20420. SEND COMMENTS ONLY. Please do not send applications for a grant to this address.

This certification is required by the regulations implementing the Drug-Free Workplace Act of 1988, 41 U.S.C. §§ 701 et seq. The

regulations, published on January 31, 1989 in the 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.

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) 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;

(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

OCT 2010

40-0895-8

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OMB NUMBER: 2900-0559

Respondent Burden: 15 minutes

CERTIFICATION REGARDING DRUG-FREE WORKPLACE

REQUIREMENTS FOR GRANTEES OTHER THAN INDIVIDUALS

INSTRUCTION: 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).

STREET ADDRESS

CITY

COUNTY

STATE

ZIP CODE

REMARKS

NAME OF ORGANIZATION PROJECT FAI (Federal Application Identifier) NO.

NAME OF AUTHORIZED STATE OR TRIBAL GOVERNMENT REPRESENTATIVE

TITLE OF AUTHORIZED STATE OR TRIBAL GOVERNMENT REPRESENTATIVE

SIGNATURE DATE (mm/dd/yyyy)

VA FORM

OCT 2010

40-0895-8

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