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 issued by the State of West Virginia Purchasing Division in accordance with West Virginia Code 21-1D-7b. The form requires every contractor to submit a certified drug-free workplace report to the public authority that awarded the contract either annually or upon project completion. Contractors must complete the coversheet and attach it to the required report, then submit it to either the West Virginia Purchasing Division at 2019 Washington Street East, Charleston, WV 25305 for contracts exceeding $25,000, or directly to the public authority issuing the contract for contracts of $25,000 or less.
The required report content must include documentation that education and training services were provided in accordance with West Virginia Code 21-1D-5, the name of the United States Department of Health and Human Services-certified laboratory performing drug tests, the average number of employees involved in the public improvement construction, and detailed drug test results categorized by pre-employment and new hires, reasonable suspicion, post-accident, and random testing, with the number of positive and negative results for each category. The coversheet requires vendors to provide their name, telephone number, address, fax number, and email address, and to check boxes confirming that all required information has been included in the attached report.
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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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