WV72.pdf

WV-72

Approved / Revised 08/01/15

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: ________________________

___________________ Vendor E-Mail: