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<br />Drug Elimination Program Application <br />Certification for a Drug-Free Workplace <br /> <br />u.s. Oopanmonl 01 !iou,ln; <br />and Urban De.*I'"..nt .. <br />OOOoool"",,",,-_~ <br /> <br />~ <br />,r <br /> <br />01.1II No. 2577~ Co",. 11>'31.92) <br /> <br />"""" Roponng _lot.............. 01.._ ia __ ""_ 0.25 ""'" po< _. nducling tie _lor --.0 nd\Oon'. <br />.......,-d\ng .xisDng"~, ~.net rnantaftng fowI..,..cliIJd. It'd _'.A~411"ld --.0 '" c:oIec:Iion 01 :.jl....~I. $w'ld .,bl.JMntI <br />~ng .. b4.rdrM'l HtirnaIlt or WPf 01'* ~ of.... coIedion 01 ~ ~ . _ ~. let f'IGJdng .... ~. " .. AIJ.ponI "'--o-..lNrt <br />O!f<oor. Olfa 01 In_ _ and era-. U.S. DOl' .._.01 Houan; end Ur\ootI 0. " . ._.l, WaaIOnpn. D.C. 2l>l10.0000: end '" tie 0II00t 01 <br />~ end 8uclQol. p~ _ . . Pnljoc:l (2577~) W.............. D.C. 2ll503. <br /> <br />~~: <br /> <br />...._.........__G<wc~:I.........1 <br />Do'. t ronl DclAP D~Slbaklt DS0c..22LoModHouol-4 <br /> <br />II).. .14llUW: . <br />.........~y...ln....., <br />..................-~: <br /> <br />.~ .....,Of~ 22, <br />__.. PHA,-wH4', FtcI/'t.. E....... <br />".." "'* .. .... . .... ......, : <br /> <br />Acting tel behalf 01 !he above IIImed PHAIIHA as ill AIIIhorbod 0IIicial.11IlIb dle foIIowiDI .."ntv-........ e>d.....u>cDlS III dle 0.,- ~..ull <br />of Housing and Urban Devdop<ntDI (HllD) rcpn1iDI!he" tiIIcd beIcIr. <br /> <br />1. I <<rtIl'y tha11hc Ibove DOmed PHA/IHA will provide a tlro&.free "",IJ ,-- by: <br /> <br />L PubIishing a swemcnt J>OlifyiIlg employeea Ihal dle tlZlIawfa1 <br />manu!a<:llR. cli.sttibulica. clist-ang. V . "". or ... 01 a <br />controUed subslance is prohibiled in lheP!iA'I!lHA'1 WOllcpIa<:e <br />and spccifyinJ the ac:tio<u that will be 1a1= apinst c.mpIo)'eeI <br />for vio1atioa 01 sueh prohibition. <br />b. EslablishiDga drug-bee lw5...... prccram lO infCl'lll employ- <br />ees about dle foDowing: <br />(I) The danIen of dnlJ obalIe ill !he wcd:pIacc:: <br />(2) TheP!iA'I!lHA'lpoIicycilN"'~'drva.free~.II~' : <br />(3) AzJy available tlro& 1:00"_11'\1. ,.~""-. e>d e;llpo,oee <br />all' IU 1JW:+ams;1Dd <br />(4) Thep-'.ltlH Ihalllll)'beimpollld IIpCIIl '''I~~ec:a fortlro& <br />abase violaDons oc::carrinI iD die W- _1. j 'r- <br />Co Ma1:iDJ It a requi>=>eDl tbal-., " ': ee ci!he PHAIIHA be <br />Jiv= a CI:IY1 of !he .' ~ - requirecI to)' JC8PIFIla.+ <br />do NOllfyinJ !he employee ill lbe 11" - reqaired to)' ........... <br />L 1hal, as a condidClCl 01 emplol- wilb lbe PHA/IHA. lbe <br />employee wiI1 do Ihc followilll: <br /> <br />0) Abide to)' dle _ ci the -= ond <br />(2) Nocily dle emplo)'er ci..y c:rimil>aI drug SWllte convi<:titel <br />for a vioIaDca oc:=rioJ in !he wcrl:place no l.cer than fIVe <br />days afw IIICh caniclicIl: <br />.. NocifyinJ lbe HUD Field 0fIi::e within = clays arlOt rcoeivinJ <br />DOlic:e IlDllet ~ cI. (2) frc:c .. employoe or 0Iberwisc <br />r=ivm, a=aI DOlic:e ci IIICh coaviclioa: <br />r. Tama oee ci!be fcllowi.o& aoas wi1biD 30 days ci r=ivin& <br />DOlic:e IlDllet Illbpmcnrpb cI. (2) with rapecllO ..y e::np\o)'ee <br />wbo II all..c6. icled: <br />0) TaII:lDI ~ .... I acDoa apinIllllC:ll .. em. <br />plo)oee. lip 10 aDd iDcIlICIiIlI_....ftnn. or <br />(2) ReqairiJlIIlldl empIcyet lO ... ~ -'''........;!y ill a <br />draa abaIe."'; CI' ~ L ""'.,~ propam -n-'" .cd Cor <br />Illdl JAM' -. to)' a FedlnI. S-. or Ioca1 be:aIIh. law to>- <br />L .... orocber-t"t".......~apocy; <br />.. MaIciIlI a pld bldl dfon III CO"o4ft"f lO .....ntom a tlro&-free <br />_tl'-~~"'r' ~~ol~Llbnaf. <br /> <br />WARN1lICl: ,.U.a.C. 1001 proooolcloa,""""'ll_........_"-_b.tj, end-.,;,.......or_a__ .Mllorwdliltl.......J..o ..,,-.-. <br />or hl.OJwI\ ..._ or 1IffI1'/. n .." ..-.... ... jlIlodoIion "''''' '. ,...d or 0I1t""f "'... Ur*d ..... ..... be finocl .... -- _110/:1:10 or <br />ilIpriaonod lor noc I1ICft ..... ... )'WI. or ....... <br /> <br />2.. 51,," ror Work PtrlOl'1lW>Oe- TDePHAJ1HA IbaIlIill ill dle space po.illcd beIoo< the sho(l) fordle porfcrmance 01 """'" clone ill ~ ~ " <br />wilh the HUD fundin& of the propsrnJactivlI r:bowll abcM:: Place ci Perfcrmanoe sbaI1 incIs>lIe dle - adcfta. city, coanty, S-. aIlCI <br />zip code. (lfmore Ipeet is ncede4.auacll a6diIionaI pllC(l) !he_si2eu this form. 1don1ifycacb slle<t willi !he PHA/IHA llAlI>O aM addrcsI <br />and the propam/Iclivity r=ivm, Jl'AlIl flmdiDc.) <br /> <br />~1J~b'f:(NIrftt.,...a~tI~~~ <br />i'if,<:) 10"": <br /> <br />-.-: <br /> <br />x <br /> <br />torm~(IMO) <br />IOI.llo.. ~ . I 7.'7.1.7.71. \3.7-' 1 <br />