HMEP Grant Application Form.docx

HAZARDOUS MATERIALS EMERGENCY PREPAREDNESS (HMEP) GRANT PROGRAM

Application

Fiscal Year 2018

Persons are not required to respond to the collection of information herein unless a currently valid OMB control number is displayed. (5 CFR §§ 1320.5(b)(2) and 1320.6(a)(2) )

Planning activities funded by the Hazardous Materials Emergency Preparedness Planning and Training Grant will be used to develop, improve, and carryout emergency plans under the Emergency Planning and Community Right-To-Know Act of 1986 (42 U.S.C. 11001 et seq.), see 49 U.S.C. 5116(a). Emergency responders who receive training under the HMEP training grant will have the ability to protect nearby persons, property, and the environment from the effects of accidents or incidents involving the transportation of hazardous material in accordance with existing regulations or National Fire Protection Association standards for competence of responders to accidents and incidents involving hazardous materials. (49 U.S.C 5116(b).

Title: Hazardous Materials Public Sector Training and Planning Grants OMB Control Number: 2137-0586 Expiration Date: 06/30/2019

PART A: GRANTEE INFORMATION

1. GRANTEE NAME AND ADDRESS:

Grantee Name:

Street Address: _

City:

State: _ Zip Code

Web Page (If applicable):

2. CONTACT INFORMATION:

a. Authorized Representative:

Name (Last) First: Initial:

Title:

Phone:

Fax: Email Address:

b. Program Manager:

Name (Last) First: Initial:

Title:

Phone:

Fax: Email Address:

c. Finance Program Manager or Equivalent:

Name (Last) First: Initial:

Title:

Phone:

Fax: Email Address:

d. Other Point of Contact for Grant:

Name (Last) First: Initial:

Title:

Phone: Fax: Email Address:

e. Other Point of Contact for Grant:

Name (Last) First: Initial:

Title:

Phone: Fax: Email Address:

PART B: TRANSPORTATION FEES

Are transportation fees assessed and collected by your state, political subdivision of your State, or Indian tribe? Choose an item.

If yes, how much in transportation fees was collected in the last year?

Insert information here.

What percentage of the fees collected is used solely for the purpose related to the transportation of hazardous materials?

PART C: STATEMENT OF WORK

Please note you will be required to provide information for each sub-grant, contract, or agreement (e.g., agreement with another part of the state government) issued or awarded, entered into, or signed during the reporting period and the process of selecting sub-grantees to receive the HMEP grant funding.

1. NEEDS ASSESSMENT. Include a brief statement that indicates the HMEP planning and training needs of the jurisdiction.

Insert Information here.

2. HMEP GRANT AMOUNT REQUESTED

3. GOALS AND OBJECTIVES

Use the following table to list the programs goals and objectives for the HMEP grant funds requested. The programs goals must align with PHMSA’s mission and top priorities as outlined in the application guidance document provided in the application package. PHMSA will require a progress report during the performance period and at the end of the performance period detailing the programs accomplished goals and outcomes. (Insert more rows to the table if more space is needed)

4. ACTIVITIES SUPPORTING PROGRAM GOALS

List activities to be performed under each goal listed in Part C above. Activities must be allowable, allocable and reasonable. For planning activities, please include activities planned under section 303 of the Emergency Planning and Community Right-To-Know Act (EPCRA) (e.g. commodity flow studies, hazard risk analyses, emergency plans to be written, emergency plans to be updated, and emergency plans to be exercised). For training activities, please list all training activities including trainings that fall under the NFPA 472 core competencies or OSHA 29 CFR § 1910.120(q) you plan to carry out with HMEP funds. Provide training type, training activity description, number of courses to be held, and the projected number of individuals to be trained. PHMSA will require a progress report during the performance period and at the end of the performance period detailing other accomplished training activities (Insert more rows to the table, as needed, to document all other projected training activities).

GRANTEE ACTIVITY INFORMATION

5. LEPCs SUB-AWARDS INFORMATION

Total Number of Active LEPCs

Total Number of Inactive LEPCs1

Total Number of LEPCs 2 projected to receive HMEP Grant Funds as sub-awards

a. Briefly explain your LEPCs/sub-grantees selection process or the methodology you plan to use to select LEPCs to sub-award the HMEP planning funds.

b. List the names of subgrantees you plan to sub-award HMEP funds to and the corresponding sub-award amount, (PHMSA will require a progress report during the performance period and at the end of grant period detailing LEPCs awarded HMEP funds, sub-award amounts, and LEPCs accomplished activities. (Insert more rows to the table if more space is needed)

1 An inactive LEPC is one that has not met in a year.

2 Number of LEPCs planned to receive HMEP grant funds through sub-awards. These are LEPCs whose proposals for HMEP grant funds have been received or proposals are under solicitation.

SUB-GRANTEE ACTIVITY INFORMATION

6. HMEP SUPPLEMENTAL FUNDING (OPTIONAL). Briefly explain what additional planning activities you would complete with supplemental HMEP funding, if provided. Provide the estimated amount of supplemental funding you would need to complete these additional activities. (Insert more rows to the table if more space is needed)

PART D: BUDGET NARRATIVE

In addition to completing the Planning and Training activities in the section above, complete a budget narrative to explain each line item of your project costs.

The budget narrative is extremely important as it provides transparency for proposed costs and justification for costs that may appear questionable to the granting agency, and it provides details of how and where the applicant will satisfy cost‐sharing requirements (matching).

Consider the following when completing the Budget Narrative section:

1. PERSONNEL

Personnel costs are the employee salaries working directly on the grant project. Include the number, type of personnel, the percentage of time dedicated to the project, hourly wage (or salary) and total cost to the grant.

· This category is limited to only persons employed by your organization. Those not employed by your agency shall be classified as subgrantees or contractors and should be listed under the “Contractual” object class.

· Only include compensation paid for employees engaged in grant activities.

· Costs should be consistent with that paid for similar types of work within the organization.

2. FRINGE BENEFITS

Fringe Benefit costs are the allowances and services provided by employers to their employees as compensation in addition to regular salaries and wages. Fringe costs are benefits paid to employees, including the cost of employer’s share of FICA, health insurance, workers’ compensation, and vacation. Include how the fringe benefit amount is calculated (i.e., actual fringe benefits estimate, approved rate, etc. Include a description of specific benefits charged to a project and the benefit percentage. Additional considerations:

· The personnel/salaries should have corresponding fringe; and vice‐versa. PHMSA cannot pay fringe benefits for a position that is not listed in the Personnel section.

· Explain what is included in the benefit package and at what percentage.

· Fringe benefits are only allowable for the percentage of time devoted to the grant project.

· The applicant should not combine the fringe benefit costs with direct salaries and wages in the personnel category.

3. TRAVEL

Travel costs are those costs requested for field work or for travel to professional meetings associated with grant activities. Provide the purpose, method of travel, number of persons traveling, number of days, and estimated cost for each trip. If details of each trip are not known at the time of application submission, provide the basis for determining the amount requested.

4. EQUIPMENT

Equipment costs includes those items that are tangible, nonexpendable, personal property having a useful life of more than one year and an acquisition cost of $5,000 or more per unit ‐ unless the applicant has a clear and consistent written policy that determines a different threshold. Include a description, quantity and unit price for all equipment.

Purchases of less than $5,000 should be listed under “Supplies” or “Other.”

Each item of equipment must be identified with the corresponding cost. General‐purpose equipment must be justified as to how it will be used on the project.

Analyze the cost benefits of purchasing versus leasing equipment, particularly high‐cost items and those subject to rapid technical advances. List rented or leased equipment costs in the “Contractual” or “Other” category, depending upon the procurement method.

5. SUPPLIES

Supplies are tangible personal property other than equipment. Include the types of property in general terms. It is not necessary to document office supplies in great detail (for example: reams of paper, boxes of paperclips, etc.). However, applicants should include a quantity and unit cost for larger cost supply items such as computers and printers.

OMB Control Number: 2137‐0586

6. CONTRACTUAL

Contractual costs are those services carried out by an individual or organization, other than the applicant, in the form of a procurement relationship. There are two ways to capture costs in this category: subgrants and contracts.

A Subgrant – is an award provided by a pass‐through entity (State or Territory) to a subrecipient.

That subrecipient carries out part of a program for which the State or Territory received Federal support. A subgrantee has its performance measured in relation to whether objectives of a Federal program were met; has responsibility for programmatic decision making; is responsible for adherence to applicable Federal program requirements specified in the Federal award; and (in accordance with its agreement), uses the Federal funds to carry out a program for a public purpose specified in authorizing statute, as opposed to providing goods or services for the benefit of the pass‐through entity.

A Contract ‐ is a legal instrument by which a Grantee Recipient purchases property or services needed to carry out the project or program under an award. A contract/contractor provides the goods and services within normal business operations; provides similar goods or services to many different purchasers; normally operates in a competitive environment; and provides goods or services that are ancillary to the operation of the Federal program.

For all contractual line‐item costs, include the rationale for the amount of the costs and include the specific contract goods and/or services provided and the related expenses for those goods and services. Simply entering the statement “contractual services” will not be considered sufficient for the requirement of completing this section.

Subgrants must be listed under Contractual in the SF‐424A. They must be clearly identified as subgrants in the budget narrative.

OMB Control Number: 2137‐0586

7. OTHER

Other costs do not fit any of the aforementioned categories, such as rent for buildings used to conduct project activities, utilities, leased equipment, employee training tuition, etc. “Other” direct costs must be itemized.

8. INDIRECT

Indirect Costs (if applicable): Indirect costs are allowable in the HMEP grant. If the rate will not be approved by the application due date, attach the letter of renewal or letter of request that you sent to your cognizant agency to your application. The applicant must include a signed copy of the approved negotiated rate agreement that is valid as of the date of the application. If the applicant does not have an approved indirect cost rate agreement, the applicant may be eligible for the 10% de minimis rate provided by 2 CFR § 200.414.

9. MATCH

Match: The total matching requirement should be listed in Section A and Section C of the SF‐ 424A line‐item budget. Please only include the Federal‐share of costs in Section B of the SF‐ 424A. The budget narrative is where the matching requirements should be captured. Within the applicable object class category in the budget narrative, (Personnel, Supplies, etc), detail the matching requirements.

Please ensure that the match is clearly identified in the budget narrative. Provide an explanation as to the amount to be matched and how it was determined. Matching funds should be described in the same manner as if they were the Federal share of costs. List all staff positions by title. Give annual salary exclusive of fringe benefits, job title, role in the HMEP grant (this may differ from the organizational job title), percentage of time assigned to the HMEP grant, and total cost for the budget period. Base the allocation of salaries for individuals that have responsibilities in both the planning and training areas on realistic estimates of where the time is actually spent. Include only those positions directly funded by the HMEP grant (in whole or in part) or that are part of required matching. For the salaries used as third‐party in‐ kind contributions (“soft match”), explain the methodology and assumptions used.

PART E: CERTIFICATIONS

Authorized Representatives should initial next to each statement below to indicate that your agency understands and agrees with the following:

1. The Applicant certifies that the total amount the State or Indian tribe expends (except amounts of the Federal Government) to develop, improve, and carry out emergency plans will at least equal the average level of expenditure for the last 5 years.

2. The Applicant certifies that all training activities conducted are consistent with the competencies identified in NFPA 472 or OSHA 29 § 1910.120.

3. The Applicant certifies that it is complying with Sections 301 and 303 of EPCRA (42 U.S.C. 11001, 11003).

4. The Applicant certifies that it will make available not less than 75 percent of the funds granted for the purpose of planning or training public sector emergency response employees.

5. I certify that the agency is compliant with the National Incident Management System (NIMS).

6. The applicant certifies that the person(s) it authorized to provide training has an auditable accounting system.

7. The Applicant certifies that the State or Tribal Emergency Response Commission were provided the opportunity to review the grant application.

APPLICATION CERTIFICATION

The Grantee certifies to the best of its knowledge and belief that this application is correct and complete for the planned activities under the HMEP Grant Program Funding Requirements.

Grantee Authorized Representative Signature

Printed Name:

Title:

Date: