WV72.pdf
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- Solicitation number
- ARFQ-0512-MHC2500000001-4
- Issued by
- Marshall County, West Virginia
About this file
This is a Certified Drug-Free Workplace Report Coversheet (Form WV-72) from the West Virginia Purchasing Division, which must be completed by contractors in accordance with West Virginia Code § 21-1D-7b. The form serves as a coversheet for mandatory drug-free workplace reporting that must be submitted at least annually or upon project completion. For contracts exceeding $25,000, reports must be submitted to the West Virginia Purchasing Division at 2019 Washington Street East, Charleston, WV 25305, while reports for contracts of $25,000 or less should be sent to the issuing public authority.
The required report content must include documentation of education and training services provided under West Virginia Code § 21-1D-5, the name of the U.S. Department of Health and Human Services certified laboratory performing drug tests, average number of employees involved in public improvement construction, and drug test results across four categories: pre-employment/new hires, reasonable suspicion, post-accident, and random testing. The form includes fields for contract identification details and vendor contact information, with checkboxes to verify inclusion of all required report elements.
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Text version
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:
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