DRUG FREE COVERSHEET.pdf
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- Attached to
- TO ATTACH ADDENDUM #2
- Solicitation number
- ARFQ-0512-MMB2500000005-3
- Issued by
- Cabell County, West Virginia
About this file
The document is a Certified Drug-Free Workplace Report Coversheet issued by the State of West Virginia Purchasing Division, in accordance with West Virginia Code § 21-1D-7b. The form requires contractors to submit a detailed annual report or upon project completion, documenting their drug-free workplace compliance. Contractors must provide this report to the public authority that issued the contract, with different submission requirements based on contract value (over or under $25,000).
The report must include specific content: documentation of education and training services related to drug-free workplace requirements, the name of the certified drug testing laboratory, the average number of employees involved in the public improvement project, and comprehensive drug test results categorized by type (pre-employment, reasonable suspicion, post-accident, and random testing). The form provides a structured template for vendors to report the number of positive and negative tests in each category, ensuring transparency and accountability in maintaining a drug-free workplace for state contracts.
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Text version
WV-72
Created 07/01/13
State of West Virginia Purchasing Division
CERTIFIED DRUG-FREE WORKPLACE REPORT COVERSHEET
In accordance with West Virginia Code § 21-1D-7b, no less than once per year, or upon completion of the project, every contractor shall provide a certified report to the public authority which let the contract. That report must include each of the items identified below in the Required Report Content section.
Instructions: Vendor should complete this coversheet, attach it to the required report, and submit it to the appropriate location as follows: For contracts more than $25,000, the report should be mailed to the West Virginia Purchasing Division at 2019 Washington Street East, Charleston, WV 25305. For contracts of $25,000 or less, the vendor should mail the report to the public authority issuing the contract.
Contract Identification:
Contract Number: _______
Contract Purpose:
Agency Requesting Work: _____
Required Report Content: The attached report must include each of the items listed below. The vendor should check each box as an indication that the required information has been included in the attached report.
Information indicating the education and training service to the requirements of West Virginia Code §
21-1D-5 was provided;
Name of the laboratory certified by the United States Department of Health and Human Services or its successor that performs the drug tests;
Average number of employees in connection with the construction on the public improvement;
Drug test results for the following categories including the number of positive tests and the number of negative tests: (A) Pre-employment and new hires; (B) Reasonable suspicion; (C) Post-accident; and
(D) Random.
Vendor Contact Information:
Vendor Name: ____________________ Vendor Telephone: ___________________
Vendor Address: ___________________ Vendor Fax: ________________________
| Contract Purpose: |
| Vendor Name: |
| Vendor Telephone: |
| Vendor Fax: |
| Contract Number: |
| Agency Requesting Work: |
| Check Box4: Off |
| Check Box5: Off |
| Check Box6: Off |
| Check Box7: Off |
| Address Line 1: |
| Address Line 2: |
| Address Line 3: |
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