4-TOPB Drug Free Workplace Form.pdf

TOWN OF PALM BEACH

DRUG FREE WORKPLACE

CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS 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;

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 (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 each conviction;

5. Notifying the agency within ten days after receiving notice under subparagraph (4b) from an employee or otherwise receiving actual notice of such conviction;

6. Taking one of the following actions, within 30 days of receiving notice under subparagraph (4b), with respect to any employee who is so convicted—

a. Taking appropriate personnel action against such an 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, 6.

As the person authorized to sign the statement, I certify that this firm complies fully with the above requirements.

Firm: Date:

Authorized Agent: Title:

Email: Phone:

Signature: