"Application for Certification of Drug-Free Workplace Premium Credit Program" - Alabama

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APPLICATION FOR CERTIFICATION OF
DRUG-FREE WORKPLACE PREMIUM CREDIT PROGRAM
DIRECTIONS: After reading the Department’s Administrative Rules and the Drug-Free
Workplace Program Guide, please complete the following checklist and return only this checklist
and a $25.00 check for the certification fee to the address below. Keep the documentation of
your compliance in your files for review upon request by your insurer or the Department of
Labor, Workers' Compensation Division.
Alabama Department of Labor
Finance Division
Attn: Central Cashier
649 Monroe Street
Montgomery, Alabama 36131
Drug-Free Workplace Coordinator:_________________________________________________
Company:_____________________________________________________________________
Address:______________________________________________________________________
_____________________________________________________________________________
Phone number: ( _ )
Number of Employees: ___________________
Email Address: _____________________________
This is our company's first year of application for certification as a drug-free workplace.
******************************************************************************
TO BE COMPLETED BY THE DEPARTMENT OF LABOR, WORKERS'
COMPENSATION DIVISION.
Date of First Certification:_________________________
Approved By:__________________________________
******************************************************************************
1
APPLICATION FOR CERTIFICATION OF
DRUG-FREE WORKPLACE PREMIUM CREDIT PROGRAM
DIRECTIONS: After reading the Department’s Administrative Rules and the Drug-Free
Workplace Program Guide, please complete the following checklist and return only this checklist
and a $25.00 check for the certification fee to the address below. Keep the documentation of
your compliance in your files for review upon request by your insurer or the Department of
Labor, Workers' Compensation Division.
Alabama Department of Labor
Finance Division
Attn: Central Cashier
649 Monroe Street
Montgomery, Alabama 36131
Drug-Free Workplace Coordinator:_________________________________________________
Company:_____________________________________________________________________
Address:______________________________________________________________________
_____________________________________________________________________________
Phone number: ( _ )
Number of Employees: ___________________
Email Address: _____________________________
This is our company's first year of application for certification as a drug-free workplace.
******************************************************************************
TO BE COMPLETED BY THE DEPARTMENT OF LABOR, WORKERS'
COMPENSATION DIVISION.
Date of First Certification:_________________________
Approved By:__________________________________
******************************************************************************
1
Policy Statement Required for Certification:
1-a.
(Code of Alabama, 1975, §25-5-334)
_____
Statement of required types of substance abuse testing.
(Code of Alabama, 1975, §25-5-334 (a)(1)a.)
1.
Job Applicant Testing Required for Certification:
2.
Reasonable Suspicion Testing Required for Certification:
3.
Routine Fitness-for-Duty Testing Required for Certification:
4.
Post-Rehabilitation Testing Required for Certification:
5.
Post-Accident Testing Required for Certification:
_____
A statement of actions employer may take against employee or job applicant on the
basis of a positive confirmed test result.
(Code of Alabama, 1975, §25-5-334 (a)(1)b.)
_____
A statement of consequences of an employee's or job applicant's refusal to submit to a
drug test. (Code of Alabama, 1975, §25-5-334 (a)(4))
_____
A statement advising employee or job applicant of the existence of the article outlining
a certified drug-free workplace program. (Code of Alabama, 1975, §25-5-334 (a)(2))
_____
A general confidentiality statement. (Code of Alabama, 1975, §25-5-334 (a)(3))
_____
EITHER a statement advising employee of Employee Assistance Program (EAP), if
employer offers one.
OR
_____
A statement advising employee of employer's resource file of assistance programs and
other persons, entities, or organizations designed to assist employees with personal or
behavior problems. (Code of Alabama, 1975, §25-5-334 (a)(5))
_____
A statement advising employee or job applicant who receives a positive confirmed test
result that he or she may contest or explain the result to the employer within five (5)
working days after written notification of the test result.
(Code of Alabama, 1975, §25-5-334 (a)(6))
2
_____
A statement informing an employee or job applicant of the federal Drug-Free
Workplace Act, if it applies to you. If not, write NA.
(Code of Alabama, 1975, §25-5-334 (a)(7))
_____
EITHER sixty (60) days notice was given prior to implementation of testing.
OR sixty (60) days notice was not required because implementation of program
occurred prior to July 1, 1996. (Code of Alabama, 1975, §25-5-334 (b))
_____
Effective date of your Drug-Free Workplace/Substance Abuse Policy.
_____
Notice of substance abuse testing is included on vacancy announcements for positions
in which testing is required. (Code of Alabama, 1975, §25-5-334 (c))
_____
Notice of substance abuse testing is posted in an appropriate and conspicuous location
on employer's premises. (Code of Alabama, 1975, §25-5-334 (c))
_____
Copies of policy are available to employees and job applicants in employer's personnel
office or other suitable location. (Code of Alabama, 1975, §25-5-334 (c))
2.
Substance Abuse Testing Required for Certification:
(Code of Alabama, 1975, §25-5-335)
_____
Job Applicant Testing Required for Certification:
(Code of Alabama, 1975, §25-5-335 (a) (1))
_____
Reasonable Suspicion Testing Required for Certification:
(Code of Alabama, 1975, §25-5-335 (a) (2))
_____
Routine Fitness-for-Duty Testing Required for Certification:
(Code of Alabama, 1975, §25-5-335 (a) (3))
_____
Post Rehabilitation Testing Required for Certification:
(Code of Alabama, 1975, §25-5-335 (a) (4))
_____
Post-Accident Testing Required for Certification:
(Code of Alabama, 1975, §25-5-335 (a) (5))
2-b.
Procedures for Substance Abuse Testing Required for Certification.
(Code of Alabama, 1975, §25-5-335 (c))
Specimen Collection Responsibilities Required for Certification:
(Code of Alabama, 1975, §25-5-335 (c) (1) through (5))
3
_____
Collection of job applicant and employee specimens is performed in accordance with
the standards and procedures outlined in the guidelines for certification.
Employer Responsibilities Required for Certification:
(Code of Alabama, 1975, §25-5-335 (c)(6) through (12))
_____
The employer is complying with the procedures that are outlined in the guidelines for
certification.
Laboratory Responsibilities Required for Certification:
(Code of Alabama, 1975, §25-5-335 (d)(1) through (3))
_____
The laboratory that the employer is using is complying with the procedures that are
outlined in the guidelines for certification.
Name and address of laboratory: ___________________________________________________
______________________________________________________________________________
Phone Number: ( _ )________________________________
Certification of laboratory NIDA___________CAP__________
3.
Employee Assistance Required for Certification:
(Code of Alabama, 1975, §25-5-336)
_____
EITHER you have an employee assistance program (EAP)
OR you maintain and post other means of employee assistance
4.
Employee Education Required for Certification:
(Code of Alabama, 1975, §25-5-337 (a))
_____
Hour One of the Employee Education program has been conducted for employees.
(Date of Program _______________)
_____
Hour Two of the Employee Education program has been conducted for employees.
(Date of Program _______________)
4
5.
Supervisor Training Required for Certification:
(Code of Alabama, 1975, §25-5-337 (b))
_____
Participation of supervisors with the employees in the above education program.
AND
_____
Once a year, two hours of supervisor training on how to recognize signs of substance
abuse, how to document and collaborate signs of employee substance abuse, and how
to refer substance abusing employees to the proper treatment providers.
NOTE: Second half of supervisor training program may be completed within six
months after certification.
6.
Confidentiality Required for Certification:
(Code of Alabama, 1975, §25-5-339)
_____
All information received through substance abuse testing is confidential, but may be
used or received in evidence, or obtained in discovery, or disclosed in any civil or
administrative proceeding when the information is relevant to the employer's defense,
e.g., a workers' compensation hearing.
NOTE: Employers should ensure that they have read and understand the Disclaimers of a
drug-free workplace program and the information on Maintenance and Revocation of
certification.
7.
Notarization of Certified Drug-Free Workplace Program
______________________________
______________________________
Employer Name
Officer/Owner Signature*
______________________________
______________________________
Date
Title of Officer/Owner
*
Application must be signed by an officer or owner.
Sworn to and subscribed before me this __________ day of _____________20____.
____________________________________
Notary Public
My Commission Expires________________
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