R2001-92 AUTHORIZING SUBMISSION OF GRANT APPLICATION

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. �.- Pro'ect Numbe r 17-01-000014 1 Altemate I. (Grantees Other Than Individuals) A. The gantee certifies that it will or conlinue to provide a drug-free workplace by: (a)Publishing a statement notifying employees that the unlawful manufacture,distribution,dispensing,possession,or use of a controlled substance is prohibited in the gantee's workplace and specifying the actions that will be taken against employees for violation of such prohibition; (b) Establishing an ongoing drug-free awareness progam to inform employees about-- (1) The dangers of drug abuse in the workplace; (2) The tee's lic of maintainin a drug-free workplace; � P� Y 8 (3) Any available drug counseling,rehabilitation,and employee assistance progams;and (4) The peaalues that may be imposed upon employees for drug abuse violatioas occurring in the workplace; (c) Making it a requirement that each employee to be engaged in the performance of the gant be given a copy of the statement required by paragraph(a); (d) Notifying the employee in the statement required by pazagaph(a)that,as a condidon of employment under the grant,the employee will-- (I) Abide by the terms of the statement;and (2) Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occuiring in the workplace no later than five calendar days after such conviction; ' (e) Notifying the agency in writing, within ten calendar days after receiving notice under subparagraph(d)(2) from an employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must provide notice,including posidon dde, to every grant o�cer on whose grant activiry the convicted employee was working,unless the Federal agency has designated a central ' point for the receipt of such nodces. Nodce shall include the idendfication numbers(s)of each affected grant; (� Taking one of the following actions, within 30 calendar days of receiving notice under subparagaph (d)(2), with respect to any employee who is so convicted— (1) Taking appropriate personnel acaon against such an employee, up to and including termination, consistent with the requiremenu of the Rehabilitation Act of 1973,as amended;or (2) Requiring such employee to participate sadsfactorily in a drug abuse assistance or rehabilitadon program approved for such purposes by a Federal,State,or local health,law enforcement,or other appropriate agency; (g) Making a good faith effort to continue to maintain a drug-free workplace through unplementadon of paragraphs(a)(b),(c),(d),(e) and(�. B. The grantee may insert in the space provided below the site(s for the performance of work done in connection with the specific grant: Place of Performance(Street address,city,county,state,zip code) r The Decatur Club 158 West Prairie, Decatur, Illinois Check_if there are workplaces on file that are not idenafied here. PART D: Certification Regarding Drug-Free Workplace Requirements CHECK !F THlS CERTIFICATION IS FOR AN APPLICANT WKO IS AN INDlVfDUAL Alternate II. (Grantees Who Are Individuals) (a) The gantce certifies that,as a condition of the grant,he or she will not engage in the unlawful manufacture,distribudon,dispensing, possession,or use of a controlled substance in conducting any activity with the grant; (b) If convicted of a criminal drug offense resulting from a violation occurring during the conduct of any gant activity,he or she will report the conviction,in writing,within 10 calendar days of the conviction,to the grant o�cer or other designee,unless the Federal agency designates a central point for the receipt of such notices. When notice is made to such a central point,it shall include the identification number(s)of each affected grant. DI-2010June 1995 (1Lis form rcplaccs DI-1953,DI-1954, DI•1955,D[•1956 aod DI-1%3)