Medical Marijuana Certification Submission

Medical Marijuana Certification Submission Form
Instructions:

All employees with a valid written certification issued by a health care practitioner for the treatment of the employee’s diagnosed condition or disease pursuant to Virginia Code § 54.1-3408.3, as amended must submit certification documentation to the Department of Human Resources on their first day of employment or within 15 calendar days of obtaining certification. Additionally, employees are required to submit annual recertifications within 15 days of the expiration date. Notwithstanding the information above, all forms of cannabis remain a Schedule 1 drug pursuant to federal law. As such, federal law may supersede certain state protections.
Name*

Last NameFirst Name
Employee Identification Number (EID)*
Your EID is 2-5 digits and provided to you by Human Resources. Please ask your payroll clerk for this information if unknown.
Employee Department Number*
Phone Number*
Please enter a valid phone number to reach you in the event there are questions about your submission.
Medical Marijuana Certification Upload
Medical Marijuana Certification Effective Date*

MonthDayYear
In conjunction with the submission of my medical marijuana certification, I acknowledge (Please select all):*

I shall not report to work or be on duty while impaired; possess, use or consume while on duty or on City property; sell, provide or distribute to another while on duty or on City property.Sworn members of the Police Division and Sheriff's Office are not covered by the medical marijuana certification and shall refer to their internal policies/procedures.CDL drivers and those in safety sensitive positions designated by the City shall be subject to applicable state and federal law.I shall submit my recertification annually within 15 days of the expiration date.
Certification Upload*

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I certify that the foregoing information is true and correct. I understand that failure to complete this form, or failure to comply with the Substance Abuse Policy may lead to disciplinary action up to and including dismissal.
Signature*

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Medical Marijuana Certification Submission Form

Instructions:

Medical Marijuana Certification Upload