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["FORM INFORMATION"]
["Form Name / Title","USDA AD-1052"]
["Form ID",696]
["Form Version","2.0"]
["OMB Control Number ","0505-0027"]
["OMB Expiration Date ","09/30/2025"]
["Form Family\n(select all that apply)","X","SF-424 Family"]
[null,"X","SF-424 R&R Family"]
[null,null,"SF-424 Individual Family"]
[null,null,"SF-424 Mandatory Family"]
[null,null,"SF-424 Short Organizational Family"]

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["FORM TITLE:",null,"USDA AD-1052"]
["[1]","[2]\n","[3]\n","[4]\n","[5]\n","[6]\n","[7]\n","[8]\n","[9]","[10]\n","[11]\n","[12]","[13]","[14]","[15]\n","[16]\n","[17]\n","[18]\n","[19]\n"]
["Field #","Field\nLabel","Field ID","Required?","Minimum\nOccurrences","Maximum\nOccurrences","Agency Field\nName","Field Type","Global Library\nField Name","Field Type\nSource","Business Rules","Data Type","List of\nValues","Min  # of Chars or\nMin Value","Max # of\nChars or\nMax Value","Field\nImplementation","Help Tip","Mandatory Message","Validation Message"]
["00-1","AD-1052","AD-1050 Text",{"$nulls":12},"Label"]
["00-2","OMB No. 0505-0027","OMB Number Text",{"$nulls":12},"Label"]
["00-3","Expiration Date: 09/30/2025","Expiration Date Text",{"$nulls":12},"Label"]
["01-1","Certification Regarding Drug-Free Workplace \nState and State Agencies, Federal Fiscal Year ","Fiscal Year","Yes","1","1","FiscalYear","Agency-specific",null,null,null,"YEAR",null,"4","4","Field","Enter the Federal Fiscal Year. This field is required.","Fiscal Year is required: Enter the Federal Fiscal Year.","Invalid Fiscal Year: Enter the Federal Fiscal Year."]
["01-2","The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. § 552a, as amended). This certification is required by the regulations implementing §§ 5151-5160 of the Drug-Free Workplace Act of 1998 (Pub. L.100-690, Title V, Subtitle D: 41 U.S.C. § 8101 et seq.), and 2 CFR Parts 182 and 421. The regulations, amended and published on June 15, 2009, in 74 Fed. Reg. 28150-28154 and on December 8, 2011, in 76 Fed. Reg. 76610-76611, require certification by grantees, prior to award, that they will maintain a drug-free workplace. The certification set out below is a material representation of fact upon which reliance is placed when the agency awards the grant. False certification or violation of the certification shall be grounds for suspension of payments, suspension or termination or grants, or government-wide suspension or debarment (see 2 CFR Parts 180 and 417). States and State agencies using this form should send it to the U.S. Department of Agriculture, Office of the Chief Financial Officer, Transparency and Accountability Reporting Division, Mail Stop 9011, South Building, Washington, D.C. 20250-9010. (Copies of the regulations may be obtained by contacting the Department of Agriculture agency offering the grant).","Privacy Act of 1974 Text",{"$nulls":12},"Label"]
["01-3","According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0505-0027. The time required to complete this information collection is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The provisions of appropriate criminal or civil fraud, privacy, and other statutes may be applicable to the information provided.","Paperwork Reduction Act Text",{"$nulls":12},"Label"]
["02-1","(Read instructions on page three before completing certification.)","Read Instructions Text",{"$nulls":12},"Label"]
["02-A","A.  The grantee certifies that it will or will continue to provide a drug-free workplace by:","Grantee Certifies Text",{"$nulls":12},"Label"]
["02-A-1","1.  Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the grantee’s workplace and specifying the actions that will be taken against employees for violation of such prohibition;","Unlawful Manufacture, Distribution, Dispensing, Possession, or Use of Controlled Substance Text",{"$nulls":12},"Label"]
["02-A-2","2.  Establishing an ongoing drug-free awareness program to inform employees about –","Drug-free Awareness Program Text",{"$nulls":12},"Label"]
["02-A-2-a","a.  The dangers of drug abuse in the workplace;","Drug Abuse in Workplace Text",{"$nulls":12},"Label"]
["02-A-2-b","b.  The grantee’s policy of maintaining a drug-free workplace;","Maintaining Drug-free Workplace Text",{"$nulls":12},"Label"]
["02-A-2-c","c.  Any available drug counseling, rehabilitation, and employee assistance programs; and","Drug Counseling Programs Text",{"$nulls":12},"Label"]
["02-A-2-d","d.  The penalties that may be imposed upon employees for drug-abuse violations occurring in the workplace.","Penalties for Drug-abuse Text",{"$nulls":12},"Label"]
["02-A-3","3.  Making it a requirement that each employee to be engaged in the performance of the grant be given a copy of the statement required by paragraph A.1.","Engaged in Performance Text",{"$nulls":12},"Label"]
["02-A-4","4.  Notifying the employee in the statement required by paragraph A.1 that, as a condition of employment under the grant, the employee will –","Notifying the Employee Text",{"$nulls":12},"Label"]
["02-A-4-a","a.  Abide by the terms of the statement; and","Abide By Terms of the Statement Text",{"$nulls":12},"Label"]
["02-A-4-b","b.  Notify the employer in writing of his or her conviction for a violation of a criminal drug statute occurring in the workplace no later than five calendar days after such conviction; ","Notify Employer in Writing Text",{"$nulls":12},"Label"]
["02-A-5","5.  Notifying the agency in writing, within 10 calendar days after receiving notice under subparagraph A.4.b from an employee or otherwise receiving actual notice of such conviction. Employers of convicted employees must provide notice, including position title, to every grant officer on whose grant activity the convicted employee was working, unless the Federal agency has designated a central point for the receipt of such notices. Notice shall include the identification number(s) of each affected grant;","Notify Agency in Writing Text",{"$nulls":12},"Label"]
["02-A-6","6.  Taking one of the following actions, within 30 calendar days of receiving notice under subparagraph A.4.b, with respect to any employee who is so convicted –","Taking One of the Following Actions Text",{"$nulls":12},"Label"]
["02-A-6-a","a. Taking appropriate personnel action against such an employee, up to and including termination, consistent with the requirements of the Rehabilitation Act of 1973, as amended; or","Appropriate Personnel Action Text",{"$nulls":12},"Label"]
["02-A-6-b","b. Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or, local health, law enforcement, or other appropriate agency;","Participate in Drug Abuse Assistance Program Text",{"$nulls":12},"Label"]
["02-A-7","7.  Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs A.1 through A.6.","Maintain Drug-free Workplace Text",{"$nulls":12},"Label"]
["02-A-8","This certification is for a (check one):","This certification is for a (check one)","Yes",1,1,"CertificationType","Radio Group",null,"CertificationType",null,"LIST",null,null,null,"Radio Group","One selection is required."]
["02-A-8-1","State (All State Agencies)","State (All State Agencies)","No","0","1",null,"Radio Group",null,"CertificationType",null,null,"State (All State Agencies)",null,null,"Radio","Check to select."]
["02-A-8-2","Single State Agency","Single State Agency","No","0","1",null,"Radio Group",null,"CertificationType",null,null,"Single State Agency",null,null,"Radio","Check to select."]
["02-B","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:","Site for Performance Text",{"$nulls":12},"Label"]
["03","PLACE OF PERFORMANCE (Street Address, City, County, State, Zip Code)","Place of Performance Header",{"$nulls":12},"Label"]
["03-01","Delete Entry","Delete Place of Performance Button",{"$nulls":4},"Agency-specific",null,null,"Deletes this entry. This button will only be enabled if more than one entry has been added.",{"$nulls":4},"Button","Click to delete this Place of Performance entry."]
["03-02","Street1:","Street 1","No",0,10,"Street1","Global","globLib:Street1",null,"Required if data entered for this address.","AN",null,0,55,"Field","Enter the first line of the Street Address.","Street 1 is required: Enter the first line of the Street Address."]
["03-03","Street2:","Street 2","No",0,10,"Street2","Global","globLib:Street2",null,null,"AN",null,0,55,"Field","Enter the second line of the Street Address."]
["03-04","City:","City","No",0,10,"City","Global","globLib:City",null,"Required if data entered for this address.","AN",null,0,35,"Field","Enter the City.","City is required: Enter the City."]
["03-05","County:","County","No",0,10,"County","Global","globLib:County",null,null,"AN",null,0,30,"Field","Enter the County."]
["03-06","Country:","Country","No",0,10,"Country","Global","globLib:Country",null,"Required if data entered for this address.","LIST","GENC Standard Ed3.0 Update 11",0,49,"Popup","Select the Country.","Country is required: Select the Country."]
["03-07","State:","State","No",0,10,"State","Global","globLib:State",null,"Conditionally required and active if Country is US.  If Country is not US, then inactive.","LIST","50 US States, US possessions, territories, military codes.",0,55,"Popup","Select the state, US possession or military code from the provided list.","State is required: Select the state, US possession or military code from the provided list."]
["03-08","Province:","Province","No",0,10,"Province","Global","globLib:Province",null,"If Country is US then inactive.  If Country is not US, then active.","AN",null,0,30,"Field","Enter the Province.  "]
["03-09","Zip / Postal Code:","Zip / Postal Code","No",0,10,"ZipPostalCode","Global","globLib:ZipPostalCode",null,"Conditionally required if Country is US then required. If Country is not US, then optional.","AN","Required if data entered for this address.",0,10,"Field","Enter the Postal Code (e.g., ZIP code). This field is required if the Country is United States.","Zip / Postal Code is required if the Country is United States: Enter the Postal Code (e.g., ZIP code).","Invalid Zip / Postal Code: Enter the Postal Code (e.g., ZIP code)."]
["03-10","Add Place of Performance","Add Place of Performance Button",{"$nulls":4},"Agency-specific",null,null,"Clicking will add one row, button is disabled if 10 rows have already been added.",{"$nulls":4},"Button","Click to add a Place of Performance entry."]
["04-1","Check ","Workplaces Not Identified Here ","No",0,1,"CheckWorkplaces","Agency-specific","globLib:YesNoDataType",{"$nulls":6},"Check","Check to select."]
["04-2","if there are workplaces on file that are not identified here.","Workplaces Not Identified Text",{"$nulls":12},"Label"]
["05-1","ORGANIZATION NAME","Organization Name","Yes","1","1","AgencyName","Global","globLib:AgencyNameDataType",null,null,"AN",null,1,60,"Field","Enter the Organization Name. This field is required.","Organization Name is required: Enter the Organization Name."]
["05-2","PR/AWARD NUMBER OR PROJECT NAME","PR/Award Number or Project Name","Yes","1","1","ProjectName","Global","globLib:ProjectNameDataType",null,null,"AN",null,1,60,"Field","Enter the PR/Award Number or Project Name. This field is required.","PR/Award Number or Project Name is required: Enter the PR/Award Number or Project Name."]
["06-1","NAME(S) AND TITLE(S) OF AUTHORIZED REPRESENTATIVE(S)","Name and Title of Authorized Representative Header",{"$nulls":12},"Label"]
["06-2","Prefix:","Prefix","No",0,1,"Prefix","Forward-populated","globLib:PrefixName","SF424 block 21-Prefix\nRR SF424 block 19-Prefix",null,"LIST","Mr.; Mrs.; Miss; Ms.; Dr.; Rev.; Prof.",0,10,"Combobox","Pre-populated from the Application cover sheet."]
["06-3","First Name:","First Name","Yes",1,1,"FirstName","Forward-populated","globLib:FirstName","SF424 block 21-First Name\nRR SF424 block 19-First Name",null,"AN",null,1,35,"Field","Pre-populated from the Application cover sheet."]
["06-4","Middle Name:","Middle Name","No",0,1,"MiddleName","Forward-populated","globLib:MiddleName","SF424 block 21-Middle Name\nRR SF424 block 19-Middle Name",null,"AN",null,0,25,"Field","Pre-populated from the Application cover sheet."]
["06-5","Last Name:","Last Name","Yes",1,1,"LastName","Forward-populated","globLib:LastName","SF424 block 21-Last Name\nRR SF424 block 19-Last Name",null,"AN",null,1,60,"Field","Pre-populated from the Application cover sheet. This field is required."]
["06-6","Suffix:","Suffix","No",0,1,"Suffix","Forward-populated","globLib:SuffixName","SF424 block 21-Suffix\nRR SF424 block 19-Suffix",null,"LIST","Jr.; Sr.; M.D.; Ph.D",0,10,"Combobox","Pre-populated from the Application cover sheet."]
["06-7","Title:","Title","Yes","1","1","Title","Forward-populated","globLib:HumanTitleDataType","SF424 block 21-Title\nRR SF424 block 19-Title",null,"AN",null,"1",45,"Field","Pre-populated from the Application cover sheet. This field is required."]
["07-1","SIGNATURE(S)","Signature","Yes","1","1","AORSignature","Post-Populated","globLib:SignatureDataType",null,null,"AN",null,1,144,"Label","Completed by Grants.gov upon submission. This field is required."]
["07-2","DATE","Date","Yes","1","1","DateSigned","Post-Populated","globLib:DateSignedDataType",null,"Date will be displayed as MM-DD-YYYY.","DATE",null,null,null,"Label","Completed by Grants.gov upon submission. This field is required."]
["08","In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.\n\nPersons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.\n\nTo file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov.\n\nUSDA is an equal opportunity provider, employer, and lender.","Prohibits Discrimination Text",{"$nulls":7},"Link \"How to File a Program Discrimination Complaint\" to https://www.usda.gov/oascr/how-to-file-a-program-discrimination-complaint. Provide link for email address \"mailto:program.intake@usda.gov\"",{"$nulls":4},"Label"]
["09","Form AD-1052 (REV 12/22)\nPage 2 of 3","Form AD-1052 Front Text",{"$nulls":12},"Label"]
["10-0","Instructions for Certification","Instructions for Certification Text",{"$nulls":12},"Label"]
["10-1","(1)  By signing and submitting this form, the grantee is providing the certification set out on pages 1 and 2 in accordance with these instructions.","By Signing and Submitting Text",{"$nulls":12},"Label"]
["10-2","(2)  The certification set out on pages 1 and 2 is a material representation of fact upon which reliance is placed when the agency awards the grant. If it is later determined that the grantee knowingly rendered a false certification, or otherwise violates the requirements of the Drug-Free Workplace Act, the agency, in addition to any other remedies available to the Federal Government, may take action authorized under the Drug-Free Workplace Act.","Material Representation of Fact Text",{"$nulls":12},"Label"]
["10-3","(3)  Workplaces under grants, for grantees other than individuals, need not be identified on the certification. If known, they may be identified in the grant application. If the grantee does not identify the workplaces at the time of application, or upon award, if there is no application, the grantee must keep the identity of the workplace(s) on file in its office and make the information available for Federal inspection. Failure to identify all known workplaces constitutes a violation of the grantee’s drug-free workplace requirements.","Workplaces Under Grants Text",{"$nulls":12},"Label"]
["10-4","(4)  Workplace identifications must include the actual address of buildings (or parts of buildings) or other sites where work under the grant takes place. Categorical descriptions may be used (e.g., all vehicles of a mass transit authority or State highway department while in operation, State employees in each local unemployment office, performers in concert halls or radio studios).","Workplace Identifications Text",{"$nulls":12},"Label"]
["10-5","(5)  If the workplace identified to the agency changes during the performance of the grant, the grantee must inform the agency of the change(s). If it previously identified the workplaces in question, see instruction (3) above.","Workplace Changes Text",{"$nulls":12},"Label"]
["10-6","(6)  Definitions of terms in the Nonprocurement Suspension and Debarment common rule and Drug-Free Workplace common rule apply to this certification. Grantees’ attention is called, in particular, to the following definitions from these rules:","Definitions of Terms Text",{"$nulls":12},"Label"]
["10-6-1","•  “Controlled substance” means a controlled substance in Schedules I through V of the Controlled Substances Act, 21 U.S.C. §812, and as further defined by 21 CFR §§ 1308.11-1308.15.","Controlled Substance Text",{"$nulls":12},"Label"]
["10-6-2","•  “Conviction” means a finding of guilt (including a plea of nolo contendere) or imposition of sentence, or both, by any judicial body charged with the responsibility to determine violations of the Federal or State criminal drug statutes.","Conviction Text",{"$nulls":12},"Label"]
["10-6-3","•  “Criminal drug statute” means a Federal or non-Federal criminal statute involving the manufacture, distribution, dispensing, use, or possession of any controlled substance.","Criminal Drug Statute Text",{"$nulls":12},"Label"]
["10-6-4","•  “Employee” means the employee of a grantee directly engaged in the performance of work under a grant, including: (i) all “direct charge” employees (ii) all “indirect charge” employees unless their impact or involvement is insignificant to the performance of the grant and, (iii) temporary personnel and consultants who are directly engaged in the performance of work under the grant and who are on the grantee’s payroll. This definition does not include workers not on the payroll of the grantee (e.g., volunteers, even if used to meet a matching requirement, consultants or independent contractors not on the grantee’s payroll, or employees of subrecipients or subcontractors in covered workplaces).","Employee Text",{"$nulls":12},"Label"]
["11","Form AD-1052 (REV 12/22)\nPage 3 of 3","Form AD-1052 Back Text",{"$nulls":12},"Label"]