Appendix B Activity Checklist_PRS_10.6.21.pdf

Appendix B

Pandemic Response and Safety Grant Program Assistance Listing Number: 10.181

Pandemic Response and Safety Grant Program Round One: Application Form Example Instructions: Column A provides the outcomes and activities funded by PRS. In Column B, you must estimate your funding request to offset costs associated with the outcomes and activities; the total request in Column B must be between $1,500 and $20,000. In Column C, you can optionally indicate the actual costs you incurred for each of the outcomes and activities.

A: Eligible Outcomes and Activities B: Funding Request C: Actual Costs Incurred (Optional)

Implement workplace safety measures to protect workers against COVID-19

• Provide personal protective equipment, thermometers, cleaning supplies, sanitizer, or hand washing stations

• Installation and purchase of air filters or new signage

[Enter $ Amount] [Enter $ Amount]

Implement market pivots to protect workers against COVID–19

• Develop and implement online platforms

• Utilize online or print materials to communicate market pivots

[Enter $ Amount] [Enter $ Amount]

Retrofit facilities for worker and consumer safety to protect against COVID–19

• Installation and purchase of protective barriers made of plexiglass or plastic sheeting, walk up windows, heat lamps/heaters, fans, tents, propane, weights, tables, chairs and lighting

[Enter $ Amount] [Enter $ Amount]

Provide additional transportation options to maintain social distancing and worker and consumer safety to protect against COVID-19

• Secure additional transportation services for workers

• Offer new delivery routes or distribution services

[Enter $ Amount] [Enter $ Amount]

Provide worker housing that protects workers against COVID-19

• Secure additional housing resources/services to maintain social distancing or to allow for quarantining of new or exposed employees [Enter $ Amount] [Enter $ Amount]

Provide health services to protect workers against COVID-19

• Offer or enable vaccinations, testing, or healthcare treatment of infected employees, including any paid leave due to COVID-19 infection.

[Enter $ Amount] [Enter $ Amount]

Total Funding Request (This amount must be between $1,500 and $20,000) [Auto Sum] N/A

Total Actual Costs Incurred (Optional) N/A [Auto Sum]

By submitting this application, I attest that:

• My entity meets the small business standard specified by the PRS grant program for the industry code selected above.

• Between January 27, 2020 and December 31, 2021, my entity has implemented and/or plans to implement the activity or activities selected below, and the funding amount requested in my application reflects the fair market value of the goods and services associated with the selected activity or activities and the corresponding outcome(s).

• No other Federal funds were used to cover the cost of the activity or activities selected below.

• I certify that the statements herein are true, complete, and accurate to the best of my knowledge. I also agree to comply with any resulting terms if I accept an award.

• I am aware that any false, fictitious or fraudulent statements or claims may subject me to criminal, civil or administrative penalties (U.S. Code, Title 2018, Section 1001)