Form WV-72 "Certified Drug-Free Workplace Report Coversheet" - West Virginia

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What Is Form WV-72?

This is a legal form that was released by the West Virginia Department of Administration - Purchasing Division - a government authority operating within West Virginia. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2015;
  • The latest edition provided by the West Virginia Department of Administration - Purchasing Division;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form WV-72 by clicking the link below or browse more documents and templates provided by the West Virginia Department of Administration - Purchasing Division.

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Download Form WV-72 "Certified Drug-Free Workplace Report Coversheet" - West Virginia

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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:
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:
West Virginia Department of Administration - Purchasing Division West Virginia Legal Forms Legal United States Legal Forms

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