WV72DrugFreeWorksheet.pdf
PDF 76 KB Posted
- Solicitation number
- CRFQ 0313 DEP1600000014 5
- Issued by
- Taylor County, West Virginia
About this file
This 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 serves as a mandatory reporting document that contractors must submit no less than once per year or upon project completion to the public authority that issued the contract. The coversheet requires vendors to attach a comprehensive report that documents compliance with drug-free workplace requirements, including evidence that education and training services were provided per West Virginia Code 21-1D-5, identification of the HHS-certified laboratory conducting drug testing, and the average number of employees involved in the public improvement project.
The required report content must include detailed drug test results broken down by category—pre-employment and new hires, reasonable suspicion, post-accident, and random testing—with the number of positive and negative results for each category. Submission requirements vary based on contract value: contracts exceeding $25,000 must be submitted to the West Virginia Purchasing Division at 2019 Washington Street East, Charleston, WV 25305, while contracts of $25,000 or less are submitted directly to the issuing public authority. The coversheet includes fields for vendor contact information, contract identification number, contract purpose, and agency identification, with checkboxes to confirm inclusion of all required report components.
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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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