Drug-Free Self-Assessment Progress Report Employer Programs 30 W. Spring St., 22nd floor Columbus, OH 43215-2256 This form is an example to use in completing your report. Approximately one month prior to the due date, you will receive a report to complete and send to BWC at a designated fax number. Employer name: Done Freely with Pride, Inc. Policy number:    Address: 100 Main St., Alpha City, OH 44444 Current program level: L1 Federal ID: 123456 31-1234567 This form is the annual report of progress due by the nine-month mark of each program year (by Sept. 30 for the January program year and by March 31 for the July program year). Please fill in the requested information below with the understanding you must submit all attachments. If you check the No box n in response to any of the Yes/No questions, you need to attach an explanation since each of these questions involves a requirement to remain in BWC’s Drug-Free Workplace Program (DFWP) or Drug-Free EZ (DF-EZ) programs. e l Contact person/phone ( 614 ) 123-4567 Phone number John Maxim Printed name p Program Information m a *Level 0/comparable means comparable to Level 1, but is a category for state construction contractors only, and participants receive no discount from BWC. Check the requested level for the next program period (check one only). *Level 0/comparable Level 1 Level 2 Level 3 n n n n 3 Please answer each statement below and on the reverse side by checking the appropriate Yes/No box n or providing requested information, as well as checking the box next to each required attachment to show you’ve included it/them. S 1. Our company has developed a written substance policy that complies with BWC’s DFWP or DF-EZ requirements for my current program level.          Yes n 3 No n 3     Yes n No n See attached Required attachment: Copy of written substance policy [to be submitted your first program year only] 2. Our company has initiated and is maintaining employee education and supervisor training that complies with program requirements.     Yes n Required attachments: Copy of a sign-in sheet for one education session and one training session     One invoice from an education vendor and one from a training vendor            3 No n 3      Yes n No n    Yes n 3 n No Below, please include the names of vendors used this program year. Name(s) of those who provided education/training and company name for each Date(s) held Drug Free For All, Inc. 9-1-08 3. My company has initiated and is maintaining the full range of substance testing in compliance with our program level. Number of employees (average number for the program year): Number of new hires during this program year: BWC-7648 (Rev. 10/1/2008) U-142 (PG. 1) 32 5 3 No n    Yes n Continued on reverse side American LegalNet, Inc. www.FormsWorkflow.com Program Information Employer name: Done Freely with Pride, Inc. Check each type of testing done. Number of tests   Positive tests       Negative tests       Total tests 0 0 0 0 3Pre-employment and/or new hire drug testing Reasonable suspicion drug/alcohol testing 3Post-accident drug/alcohol testing n n n n n 123456 Policy number: Return-to-duty, other follow-up drug/alcohol testing Random drug testing (Level 2, Level 3, and/or state construction if required) 5 0 1 0 5 0 1 0 My company is using the collection/testing services of the following testing providers: Johnie on the Spot (name of collection site or consortium); Bill Vender 740.321.7654 (name of contact person at collection site or consortium); Apex (name of certified medical review officer used); (SAMHSA-certified laboratory used for urine analysis). Required attachments: Copy of an invoice for testing from a collection site  Yes n No n 3 e l (phone number of collection site); Dr. Ann Alysis p 4. Our company provides employee assistance in accordance with the DFWP or DF-EZ program level in which we are participating. 5. (Completed by level 2 or level 3 employers only): Our company is implementing the appropriate steps of BWC’s    10-Step Business Plan.    Y  es n 1 m a Not applicable Level 3 No n    Yes n No n   Check each step of BWC's 10-Step Business Plan that your company has implemented.   Step 1 n Step 2 n Step 3 n Step 4 n       Step 5 n        Step 6 n Step 7 n Step 8 n Step 9 n Step 10 n  Required attachments: Copy of safety policy required for Step One, signed by CEO         Yes n No n S Your signature below, as the designated employer representative for this employer, signifies you have submitted a complete and accurate report. If your company fails to submit a fully completed Self-Assessment Progress Report and required attachments by the required deadline or has failed to meet all program requirements, the bureau will remove it from BWC’s DFWP or DF-EZ. In addition, if you are a state construction contractor, BWC will remove you from its database. You will no longer be eligible to bid or work state construction projects. BWC may conduct an audit of any participating employer’s program. Your signature constitutes acknowledgment of the possibility of BWC auditing you. It also indicates your willingness to cooperate with such an audit as a condition of program participation. I hereby certify my organization has implemented all components of DFWP or DF-EZ in accordance with, at minimum, the requirements specified for our approved program level. I understand that my signature constitutes my company’s certification of compliance with BWC’s program requirements and – if this Self-Assessment Progress Report and/or any attachments are not accurate – that this is a fraudulent representation that may lead to legal action under the applicable fraud statutes. It may also result in the taking back of discounts and removal from current and/or future program participation. John Maxim Signature of designated management representative submitting report John Maxim Printed name of designated management representative signing above 9-30-08   Date of submission 9-30-08   Report due date BWC-7648 (Rev. 10/1/2008) U-142 (PG. 2) American LegalNet, Inc. www.FormsWorkflow.com