CPS Grant Application with Instructions OMB Approved.pdf

United States Department of the Interior

BUREAU OF INDIAN AFFAIRS

Instructions for Completion of BIA Indian Highway Safety Program Child Passenger Safety Seat Program Grant

The Highway Safety Act of 1966, U.S.C. Title 23, Section 402, provides U.S. Department of Transportation funding to assist Indian Tribes in implementing traffic safety projects. These projects are designed to reduce the high number of traffic crashes and their resulting fatalities, injuries and property damage within Indian communities.

Tribes can apply for the Child Passenger Safety Seat Program grant with this application.

Complete the application in its entirety; do not leave any blank spaces/fields.

The BIA Indian Highway Safety Program is performance-based and data driven. The problem statement will need to justify the Tribes need for a child passenger safety seat program. All applications must contain measurable targets and performance measures, and be justified by data.

Insufficient data to justify a need for a CPS program will significantly reduce the possibility of funding for the Tribe.

These 402 funds are intended to supplement an existing traffic safety program on the reservation.

Indian Highway Safety Program grants are funded in the form of reimbursements. Tribes must first expend their funds and submit documentation for reimbursement consideration each month.

Monthly report and financial reports (requests for reimbursement) are required. 2 CFR 225 Appendix B.12 and 2 CRF Part 200.434 Contributions and Donations do not allow indirect costs to be applied to the reimbursement of car seats and car seat shipping costs.

A Tribal Resolution and approved Indirect Cost Rate letter must be submitted with the application.

Please contact the Indian Highway Safety Program at (505)563-3780 to inquire about BIA IHSP Grant Writing Training.

Grant applications are due by:

May 1, 2018 for the FY2019 Grant Year May 1, 2019 for the FY2020 Grant Year May 1, 2020 for the FY2021 Grant Year

Grant applications and attachments can be mailed to:

Bureau of Indian Affairs Office of Justice Services Indian Highway Safety Program 1001 Indian School Road N.W. Ste. 251 Albuquerque, NM 87104

Application and attachments can also be submitted via e-mail at:

ojs_indian_highway_safety@bia.gov

OMB Approved Form No. 1076-0190 Expiration Date: 09/2021

Bureau of Indian Affairs Office of Justice Services - Indian Highway Safety Program

Child Passenger Safety Seat Program Grant

APPLICATION CHECK LIST:

Use this check list to gather the necessary documents required for submission of the grant application. Do not leave any fields blank in the application, initial the Terms, Conditions, and Responsibilities, sign and date page 7. Include a Draft/Approved copy of the Tribal Resolution. Check if the A-133 is current with the tribe. Sign and date the check list stating all documents are attached.

Note: If the grant is awarded, signed approved copies are due at the time of award and should be submitted with the signed grant agreement.

FISCAL GRANT YEAR APPLYING FOR:

Indicate the grant year the application is being submitted for.

Example: FY2019 (this grant year cycle begins October 1, 2018 - September 30, 2019)

SECTION A: General Information Tribes Information:

Fill in all boxes. Complete all the field information for the federally recognized tribe applying for the grant.

Person Completing the Form:

Provide the name, title, Office/Department, Phone and Fax number along with an e-mail address, etc… of the person completing the application. This information is essential in case questions arise regarding the application and missing documents.

Tribal Grant Coordinator:

Complete the fields for the Tribal Grant Coordinator. Provide the name, title, telephone number, Office/Department, Phone and Fax number, address, along with an e-mail, etc… The Tribal Grant Coordinator is responsible for grant administration and is the main point of contact.

Grant History:

In these fields please indicate if the Tribe has received federal funding from the BIA IHSP, other federal agencies, or state(s) focused in traffic safety.

Reservation Information:

Complete all the fields with information regarding reservation size, acres, square miles, population and total road miles.

Problem Identification: (Problem Statement) Provide information to justify the tribe’s need for a child passenger safety seat program.

Crash data will also need to be provided involving infants and children if available. Only Fiscal Year (October 1 - September 30) data will be accepted.

Do not leave blank spaces. Insufficient data will significantly reduce chance of funding. Use most recent fiscal year data available.

Example: Crash data: 2014 to 2016 Total crash years 2014, 2015, 2016

Indicate the total motor vehicle crashes, crashes involving infants and children, crashes involving infants and children not wearing seat belts, for the total crash years indicated.

Problem Countermeasures:

Check the boxes to indicate if the tribe has a Child Safety Seat Law; if yes, is it primary or secondary. Provide a brief description of the tribes’ occupant protection laws.

Check the appropriate box to reflect if a survey was conducted to determine the child safety seat use rate and provide the year, date conducted and the usage rate.

If an assessment was not conducted explain how the usage rates were determined.

Check the appropriate box regarding permanent fitting station, if yes, indicate the location and if it is by appointment.

Provide the date of the last CPS clinic conducted.

CPS grant awards require a certified CPS Technician on staff. Check the appropriate box and provide the name of the Lead CPS Tech, to be available if not on staff, and how training is conducted and how CPS events are publicized.

SECTION B: Partnerships List the CPS partnerships who work with the tribe.

SECTION C: Targets/Strategies Provide an estimated number of checkpoints, roadside clinics, seats to be distributed and inspected, along with hand out to be distributed. Checkpoints are optional. Provide the number of CPS training and community events to be held during the grant year.

Indicate if the Tribe would like to provide a volunteer child safety seat survey.

SECTION D: Budget All costs in this section should be reasonable and necessary and related directly to the proposed project. All items purchased under the grant will have to be approved prior to purchase by the Indian Highway Safety Program. Be as accurate as possible.

Indicate the car seat type and supplies along with quantity, item costs and shipping fees necessary to carry out the grant program. Brochures can also be requested.

The grant can cover registration fees for Child Protection Seat training and travel expense, if requested. Provide the cost of training and number of employees to be trained along with an estimated travel budget.

Equipment:

Use the drop-down menu to select the type of equipment the Tribe is requesting to assist in achieving the problem statement identified in Section B Page 3.

All equipment must be essential and justified for meeting the Targets and Strategies of the proposed project.

Budget Line Item Totals:

The grant totals calculated from the previous pages will automatically appear on this page.

SECTION G. Additional Information Space for additional narrative information the tribe would like to include. Provide information on the countermeasures the tribe intends to implement while working the grant.

SECTION H: Terms, Conditions and Responsibilities Each condition MUST be initialed. Applications received without initials, signature and date will not be considered for funding. Do not leave any fields in the form blank.

Questions regarding the grant application can be e-mailed to the BIA Indian Highway Safety Program at: ojs_indian_highway_safety@bia.gov or call (505)563-3780.

OMB Approved Form No. 1076-0190 mailto:ojs_indian_highway_safety@bia.gov

BIA INDIAN HIGHWAY SAFETY PROGRAM

Occupant Protection Grant

Child Passenger Safety Seat Program (CPS)

APPLICATION CHECKLIST

Use the checklist below to ensure the application is complete and ready to submit.

There are no blank fields left in the application

Terms, Conditions, and Responsibilities initialed (page 7)

Application signed (page 7)

Tribal Resolution Draft Copy Final Copy

A-133 (is it current?) Yes No

All of the above items have been properly completed and are contained in the grant application.

Signed: Date:

Indirect Cost Rate Approved Copy

Occupant Protection Grant

Child Passenger Safety Seat Program (CPS)

All Sections of the grant application should be completed; do not leave any blank fields. Blank fields could result in dis-qualification.

SECTION A: GENERAL INFORMATION FISCIAL GRANT YEAR APPLYING FOR:

Tribe Name:

Tribal Leader Name: Title:

Mailing Address:

City: State: Zip:

FedEx Address:

City: State: Zip:

Phone Number: Fax Number:

PERSON COMPLETING THE APPLICATION:

Name: Title:

Office/Department:

Phone Number: Fax Number:

E-Mail Address:

TRIBAL GRANT COORDINATOR INFORMATION:

If grant is awarded, please identify the Project Coordinator. (Person who will be responsible for grant administration)

Name: Title:

Office/Department:

Mailing Address:

City: State: Zip:

Phone Number: Fax Number:

E-Mail Address:

GRANT HISTORY:

How many years has the Tribe received funding from BIA IHSP?

Has the Tribe applied for and received other traffic safety related grants from other agencies in the last three years?

Yes No

If yes, please list the agencies:

Does the tribe have another traffic safety (focused) grant currently in place? (i.e. CDC, Indian Health, State, etc.):

Yes No

If yes, please list the agencies:

RESERVATION INFORMATION:

Reservation Acres:

Population:

Square Miles:

Total Number of Road Miles:

DUNS Number: SAMs Cage Code:

Child Passenger Safety Seat Program (CPS)

PROBLEM IDENTIFICATION: Problem Statement: Provide information to justify the tribe’s need for a child passenger safety seat program.

Crash Data 20____-20____ Total number of motor vehicle crashes: 20____ 20____ 20____ crashes involving infants and children involving infants and children not wearing seat belts

Yes

PROBLEM COUNTERMEASURES:

Does the Tribe have a child safety seat law? No

If yes, is it: Primary Secondary

Briefly describe all occupant protection laws:

Has the Tribe conducted a survey to determine child safety seat use rate?

If yes, when was survey conducted?

If an assessment was not conducted, how will the usage rate be determined?

20____ 20____ 20____ What was safety seat use rate in:

Yes No

Child Passenger Safety Seat Program (CPS)

Does the Tribe have a permanent fitting station? Yes No

If yes, where is it located? Is it by appointment? Yes No

When was the last child passenger safety clinic conducted?

Does the Tribe have current certified technicians? Yes No

If yes, from what agency?

Name of Lead CPS Technician:

Yes No Does the CPS technician provide training to parents/care givers?

If yes, what type of training is provided? Hands on installation Video Handout

Other:

Does the Tribe publicize CPS Events? Yes No

SECTION B: CPS Partnerships Provide information on CPS partnerships the Tribe has with other outside entities.

Does the Tribe partner with outside entities for CPS? Yes No

Local Fire Department Other: State Highway Safety Office IHS

SECTION C: TARGETS

The following information represents the targets which must be reported for child passenger safety seat grant award. Indicate the number of Tribal events to be held. Please estimate the number at this time.

Provide the number of:

Checkpoints to be held (optional)

Roadside clinics to be held

Seats to be distributed

Seats to be inspected

CPS training events to be conducted

Community CPS training events to be held

Handouts to be distributed

Would the Tribe be willing to provide volunteers to conduct a child safety seat survey? Yes No

Child Passenger Safety Seat Program (CPS)

SECTION D: BUDGET

Budgets must support the project being proposed. Federal guidelines requires costs to be reasonable and necessary to carry out/or operate the grant. 2 CFR 225 Appendix B.12 and 2 CRF Part 200.434 Contributions and Donations do not allow indirect costs to be applied to the reimbursement of car seats and car seat shipping costs. Indirect Cost can be applied to other items if allowable in the negotiated rate.

Cost per seat: Total:

Quantity: Total:

Quantity Shipping cost per seat:

Quantity Cost per seat: Total:

Shipping cost per seat: Quantity: Total:

Cost per seat: Total:

Quantity: Total:

Quantity Shipping cost per seat:

Car Seat Type Other:

Quantity Cost per seat: Total:

Shipping cost per seat: Quantity: Total:

Supplies:

Quantity Cost per item: Total:

Shipping cost per item: Quantity: Total:

Supplies Quantity Cost per item: Total:

Shipping cost per item: Quantity: Total:

Brochures:

Quantity Cost per brochure: Total:

Total shipping cost:

SECTION E: Training & Travel The grant can cover CPS training and conference registration. Travel is a reimbursable expense under this grant program. Provide an estimated budget to cover travel expenses if needed.

CPS Certification Training Registration Fee:

Number to be trained Cost per person:

CPS Re-Certification Training Registration Fee Cost per person: Number to be trained:

Total:

Total:

CPS Related Conferences/Training:

Estimated Travel Budget:

Number to be trained: Cost per person: Total:

Child Passenger Safety Seat Program (CPS)

SECTION F: Equipment Equipment must support the project being proposed. Federal guidelines requires costs to be reasonable and necessary to carry out/or operate the grant.

Quantity Cost per sign: Total:

Total shipping cost:

Quantity Cost per item: Total:

Total shipping cost:

Quantity Cost per item: Total:

Total shipping cost:

Quantity Cost per item: Total:

Total shipping cost:

BUDGET LINE ITEM GRAND TOTALS:

Total Car Seat Shipping

Supplies

Supplies Shipping Costs

Brochures

Brochures Shipping Costs

CPS Training & Travel

Equipment

Equipment Shipping Costs

Grant Total Budget:

Other:

Indirect Cost Rate %

Occupant Protection Program

Child Passenger Safety Seat Program (CPS)

SECTION G: CERTIFICATIONS AND ACKNOWLEDGEMENTS

Read and initial to acknowledge each condition in this section.

In order to comply with the provisions of FAST ACT, and the required State Certifications and Assurances, the BIA IHSP may allocate funds on behalf of the Tribes to meet certain conditions and comply with all applicable rules and regulations for administering a national traffic safety program.

Tribes participating in the federal grant processes must comply with the Single Audit Act of 1984.

Tribe understands the BIA Indian Highway Safety Program is a REIMBURSABLE grant program.

The Tribe must expend their funds and seek reimbursement based upon an approved budget and application.

Tribe understands Indirect Cost Rate does not apply to car seats and car seat shipping costs (2 CFR 225 Appendix B.12 and 2 CRF Part 200.434 Contributions and Donations); but may apply to other budget line items if the negotiated rate allows.

A current draft/approved Tribal Resolution must be attached, if not attached, the application is incomplete.

Approved Indirect Cost Rate letter must be attached, if not attached, the application is incomplete.

Tribe understands if the grant is awarded all travel, training, and purchases made under the Indian Highway Safety grant require prior approval.

I, , do hereby state and affirm: I have authority to submit this application on behalf of the Tribal government named herein. I further understand and affirm: I have obtained all necessary approvals, and have discussed this application with the necessary and appropriate people.

Signature: Date:

Name (Print): Title: