COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Progress Report Drug-Free Workplace/ Drug-Free EZ Program:::::::Index No.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Dates of data collectiontoFromInstructions: Complete each of the items below in reporting progress annually to BWC by March 31, if you are participating in the July to June program year orby September 30, if you are particiating in the January to December program year. Completing this form is required to apply for renewal of your organization's drug-free program and to request consideration for implementing thesame level or a different level for the next program year. This report must be submitted to keep your discount as well as to renew your participation in our drug-free program. Remember that to request Level 3 for the next program year, you must have completed or be completing two years of participation in a BWC drug-free program. Dates of data collection should capture the actual dates of data collected that are included on the Progress Report. The intent is to have all data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TOreported. Thus, the from date for the initial Progress Report is the start date of your drug-free program, and the to date is the last date of data collected that is included on the Progress Report. For Dates of data collection in subsequent years, the from date should be next day following the previous to date for the previous year. Please return completed form to your BWC account representative.Select one only: Level:123 1. Select your praticipation level for the next program year.Name of organization & DBARisk/Policy numberFederal I.D. numberGREETINGS:Employer address9-digit ZIP CodePhone number (StateCity)WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofEmployee Educationo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in room2. Information on who provided education services to meet employee education requirements under this program.Name(s) and phone number(s) of qualified educator(s) who presented or supervised your employee education:() ()Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.()Supervisor Training, one of the Justices of the3. Information on who provided training services to meet supervisor training requirements under this program.Court in Witness, Honorableday of, 20 County,Name(s) and phone number(s) of qualified trainer(s) who presented or supervised your supervisor training:)(((Attorney must sign above and type name below))) (CertificationAttorney(s) forBy my signature, I hereby certify that my organization (identified below) has accurately reported the information on this Drug-Free Workplace/EZ Program Progress Report and has included all pertinent documentation requested on this form. I understand that this is a certification that my organization has met all of the applicable requirements drug-free requirements for the program level implemented and for which we are receiving a discount, and that, if not accurate, constitutes a fraudulent representation which may lead to legal action under the applicable fraud statutes.Office and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Date signed Manager signature Printed name of designated management personnelBWC-7648 (Rev. 7/18/2002) U-142 (PG. 1)Continued on reverse sideMobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comCOUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.Drug and Alcohol Testing4. Drug and Alcohol Testing Statistics for this report:JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)(a.) Actual number of new hires of personnel during reporting period: ...............................................................................(b.) Total number (i.e., annual average) of personnel employed by the organization: ...........................................................(c.) For Public Employers Only, total number of personnel (4b.), how many are safety-sensitive positions/functions:.............(d.) Of the tests you administered, please provide the numbers for each of the testing categories below:# of PositiveTests# of NegativeTestsTotal# of Tests. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(i.) Pre-employment/New hire: .......................................................................................................THE PEOPLE OF THE STATE OF NEW YORK TO(ii.) Reasonable suspicion: ..............................................................................................................(iii.) Post accident:.........................................................................................................................(iv.) Follow-up to assessment/treatment: ..........................................................................................(v.) Random: ...............................................................................................................................(vi.) Other testing (specify category): ...........................................................GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableOf the positive test results you have reported above, please indicate the number of positives for each drug listed below:,located at County ofAmphetaminesCannabinoids (Marijuana, THC)Opiateso'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomBarbituratesCocainePhencyclidine (PCP)Benzodiazepines (Valium, Librium, etc.)MethadonePropoxyphene (Darvon, Darvoset, etc.)Other (specify name of drug)Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable
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