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Policy DOP-P02 EFFECTIVE DATE: October 1, 1991 REVISION DATE: December 18, 2020 7 APPENDIX A DRUG- AND ALCOHOL-FREE WORKPLACE EMPLOYEE ACKNOWLEDGMENT FORM I certify that I have received a copy of the West Virginia Division of Personnel Drug- and Alcohol-Free Workplace policy. I agree to abide by the terms of the policy and I am aware that with any violation of this policy, I will be subject to disciplinary action, up to and including dismissal. I may also be required to participate in a drug or alcohol abuse assistance or rehabilitation program as a condition of continued employment or reemployment. I understand that I must also comply with any agency-issued safety standards. In addition, I understand that if I am a federal contractor or federal grant recipient or an employee of a federal contractor or federal grant recipient, under federal law and as a condition of employment, if I am convicted of any violation of a criminal drug offense in the workplace, I must report this conviction to my supervisor and the appointing authority in writing within five (5) calendar days of the conviction. My signature acknowledges my receipt of the policy and my understanding of its contents and requirements. My signature does not indicate that I agree or disagree with the content of the policy. ____________________________________________ Name (Print) ____________________________________________ Signature ____________________________________________ Date TO BE COMPLETED BY SUPERVISOR I certify that I have discussed with and provided the above-named employee a copy of the West Virginia Division of Personnel Drug- and Alcohol-Free Workplace policy. ____________________________________________ Name (Print) ____________________________________________ Signature ____________________________________________ Date FORM DOP-P2-AF Distribution: Original – Human Resources Copy – Employee