Form 2007 OSHS Work Sta 2007 OSHS Work Sta 2007 OSHS Work Statements

BLS Occupational Safety and Health Statistics (OSHS) Cooperative Agreement (CA) Application Package

admins0605_FY07_CA

2007 OSHS Work Statements

OMB: 1220-0149

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U.S. Department of Labor

Bureau of Labor Statistics
2 Massachusetts Ave., N.E.
Washington, D.C. 20212

June 6, 2006
OSHS ADMINISTRATIVE MEMORANDUM NO. S-06-05

MEMORANDUM FOR:

STATE AGENCIES PARTICIPATING IN THE SOII PROGRAM
STATE AGENCIES PARTICIPATING IN THE CFOI PROGRAM
BLS REGIONAL COMMISSIONERS

FROM

ROBERT A. GADDIE
Associate Commissioner
Office of Field Operations

SUBJECT

Occupational Safety and Health Statistics (OSHS) Program
Cooperative Agreement Application Package for 2007

Purpose: The purpose of this memorandum is to transmit the 2007 OSHS Cooperative Agreement
(CA) application package and provide information about the application process.

II.

Applicability: For the sake of simplicity, all State agencies will receive this package; therefore, we
have included the work statements for the Survey of Occupational Injuries and Illnesses (SOII) and
for the Census of Fatal Occupational Injuries (CFOI) programs. We realize, however, that not all
State agencies participate in both the SOII and CFOI programs. Your regional office will be
contacting you with follow-up information.

III.

Office of Management and Budget (OMB) Paperwork Reduction Act Approval: The BLS is
seeking OMB approval of a generic OSHS CA application package. Under this generic package,
changes in work statements will be reviewed every year by the OMB and published in the Federal
Register for 30 days if any of the changes are deemed substantive to the information collection
burden. Since we do not yet have OMB approval of the generic package or work statements, the
attached 2007 OSHS CA is being issued as a draft document. Approval is expected sometime in
late August.

IV.

Changes: Along with editorial corrections and routine updates of reference dates, we have made
other, more significant changes that affect the Administrative Requirements and work statements of
the Cooperative Agreement.
PART I., Administrative Requirements
Section D., Regulations and Reference Documents
As one of the objectives of OMB and the Federal agencies in implementing the Federal
Financial Assistance Management Improvement Act of 1999 (Public Law 106-107), effective
August 31, 2005, the OMB guidance on nonprocurement debarment and suspension will be
published in Title 2, Code of Federal Regulations (CFR), Subtitle A, Chapter I, part 180, as
part of the ongoing initiative to streamline and simplify the policy framework for grants and
agreements. Title 2 of the CFR was established as the single location where the public can
find both OMB guidance for grants and agreements and the associated federal agency
implementation regulations.

Memorandum for State Agencies Participating in the SOII Program, State Agencies Participating in the
CFOI Program, BLS Regional Commissioners – Page 2

PART II. Application Instructions
Section B., Application Process
A new paragraph has been added indicating that BLS is working to make its application
available for electronic submission via www.Grants.gov. Although electronic submission is
not mandatory at this time, whether applying electronically or in paper form States are
strongly encouraged to become familiar with Grants.gov website and complete the
registration process at http://www.grants.gov/GetStarted.
PART III. Application Materials
Work Statements
ALL OSHS PROGRAMS
New Section C., Program Requirements Applicable to Both SOII and CFOI
The All OSHS Programs work statement has been expanded to include several items
common to both programs, but previously described separately in the work statements
for each program. Specific changes to these provisions include:
C.1.

Publication of Data: This paragraph has been modified to clarify the
number of copies of publications the SGA will provide BLS and to add a
requirement to provide the BLS the URL of any web-based publication of
OSHS data.

C.5.

Attendance at Conferences: This paragraph has been modified to
emphasize the importance of conference attendance.

Old Section C. has been renumbered D.
SURVEY OF OCCUPATIONAL INJURIES AND ILLNESSES
Section A., Program Activities
A.1.

This paragraph has been modified to include a web site as a publication
option for the SGA and to request the URL if known at the time the CA is
signed.

A.2.d.

This item has been added. The SGA shall review State estimates.

A.3.b.

This paragraph has been modified. The SGA shall pre-notify employers
who have not been notified by the contract printer/mailer to keep
occupational injury and illness records.

Memorandum for State Agencies Participating in the SOII Program, State Agencies Participating in the
CFOI Program, BLS Regional Commissioners – Page 3

Section B., Program Performance Requirements
B.2.

This paragraph has been modified. The SGA shall use the survey forms
provided by the BLS, unless the SGA has received written approval from
the BLS regional office. Because the BLS is concerned that SGA forms
designed to improve survey response may bias the data provided by
respondents, all such forms are required to have BLS regional office review
and approval.

Old B.3.

This requirement has been incorporated into C.3. in the All OSHS
Programs work statement.

Old Section C., Specific Administrative Requirements
The items previously in this section have been relocated to Section C. of the All OSHS
Programs work statement.
Old Sections D.-F. have been renumbered C.-E.
CENSUS OF FATAL OCCUPATIONAL INJURIES
Several items previously included in the CFOI work statement have been relocated to the All
OSHS Programs work statement. Therefore, old Sections A.-D. have been condensed to new
Sections A.-B.
Section A., Program Activities and Section B., Program Performance Requirements
The items in these sections have been reordered to emphasize the specific requirements
of the Cooperative Agreement. Substantive changes include:
A.2.

The first paragraph has been modified to better reflect current survey
procedures and automated collection methods for the handling of cases with
a single source document.

Old A.2. Para. 3.-4. have been moved to A.4. Para. 1.-2.
A.4. Para. 2. This paragraph has been modified to clarify the requirement for prior
written approval to use follow-back materials that vary from the OMBapproved questionnaire. For follow-back and data clarification, the SGA
shall use the guidelines, solicitation letter, and OMB-approved
questionnaire found in the CFOI program manual and technical
memoranda. The SGA must obtain written approval from the BLS
Regional Office for any variance from this solicitation letter prior to using it
in each reference year.
Old B.1. has been renumbered A.5.
A.5.

This paragraph has been modified to separately identify the specific
deliverables.

Memorandum for State Agencies Participating in the SOII Program, State Agencies Participating in the
CFOI Program, BLS Regional Commissioners – Page 4

Old B.2.

This deliverable has been incorporated into C.1. in the All OSHS Programs
work statement and the last paragraph of New B.2., Confidentiality, in the
CFOI work statement.

Old B.3. has been moved to C.2. in the All OSHS Programs work statement.
Old Section C., Program Performance Requirements
This section has been incorporated into B.1.
Old Section D., Specific Administrative Requirements
Old D.1. has been incorporated into B.1.
Old D.2. has been renumbered B.2.
Old D.3. has been incorporated into B.1.
Old D.4. has been renumbered B.3.
Old D.5.-7. have been moved to the All OSHS Programs work statement.
Old Section E. has been renumbered C.
Section C., Research Files
Para. 4

The language in the fourth paragraph permitting researcher access to Statespecific data has been revised to better reflect BLS operations. The text
now reads: The SGA authorizes the BLS to provide, upon request, research
files of State-specific data to designated agents of the BLS under Letters of
Agreement that contain confidentiality requirements that protect the data
from unauthorized use or disclosure. States that receive requests for
research files of State-specific data shall forward the requests to the BLS
for consideration along with a letter from the BLS cooperating
representative indicating approval of the release of State-specific data. The
BLS reserves the right to deny any request for access to confidential data.
The BLS will accommodate requests depending upon the statistical purpose
and technical merit of the requests and upon SGA authorization to provide
access to the State-specific data. (If a State does not check the box, then
BLS must go to that State on a case-by-case basis for approval to
release State-specific data. In such a case, the BLS would require a
letter from the BLS cooperating representative indicating approval of
the release of State-specific data.)

The research file data elements table has been revised to include the Actual age for the
NIOSH research file and the State Plan State indicator for the OSHS research file.
V.

Key Administrative Provisions:
A.

When submitting the final, signed cooperative agreement application, only one signed
original and two copies are required to be sent to the regional office once signed by the BLS
regional commissioner (grant officer). The original is forwarded to the BLS, one copy is
returned to the grantee and one copy is maintained at the regional office.

Memorandum for State Agencies Participating in the SOII Program, State Agencies Participating in the
CFOI Program, BLS Regional Commissioners – Page 5

VI.

By signing the CA, grantees are automatically certifying that they are in compliance with the
debarment, suspension, and other responsibility matters; drug-free workplace; and lobbying
requirements. Additional forms must be submitted only in particular situations, spelled out in
the CA.

The BLS State Cooperating Representative must sign the BLS Agent Agreement and
submit the form to his or her respective BLS Regional Office as instructed in Part II.
Application Instructions, Section C.6. of the CA.

By signing the CA, grantees are agreeing to the financial reporting requirements it contains.
These call for reporting to the Department of Health and Human Services Payment
Management System (HHS--PMS) using its PSC-272 report. Optimally, grantees will be
doing this on-line. We ask that a single hard copy of the PSC-272 report be sent to the BLS
along with the BLS-OSHS Quarterly Financial Report (BLS-OSHS2).

Only one signed original OSHS CA closeout package is required to be sent to the BLS.

Schedule:
Review and discussion with States of the 2007 CA.................July-August
Draft 2007 CA application due in regional office (RO)...........To be set by RO
Final 2006 OSHS CA modifications for deobligations
intended for national office use due in national office..........July 14, 2006
Final 2006 OSHS CA modifications affecting States only
due in national office.............................................................August 18, 2006
Final, signed 2007 CA application due in RO .........................August 18, 2006
Completed, signed 2007 CAs due in national office................September 1, 2006
Effective date of 2007 CA........................................................October 1, 2006

VII.

Clearance Required: Any variances to the 2007 CA work statements must be approved by the BLS
before the package is submitted in final.

VIII. Action Required:
A.

Grantees are requested to observe the time frame for the submission of their draft and final
CA applications as specified above.

Grantees are reminded that new obligations can not be charged to the 2006 CA after
September 30, 2006, and that closeouts of the 2006 CA are due 90 days after the end of the
fiscal year to the regional offices.

Grantees are requested to budget only whole dollar amounts for their Federal and State
Cooperative Agreement budget.

IX.

Inquiries: Questions on any aspect of this memorandum may be directed to the appropriate BLS
regional office.

Attachments:

Occupational Safety and Health Statistics Program Cooperative Agreement
Cooperative Agreement Document Numbers

OCCUPATIONAL SAFETY AND HEALTH
STATISTICS PROGRAM
COOPERATIVE AGREEMENT

PART I.

ADMINISTRATIVE REQUIREMENTS

PART II.

APPLICATION INSTRUCTIONS

PART III.

APPLICATION MATERIALS

OMB Approval Number 1220-0149; expires

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TABLE OF CONTENTS
I.

ADMINISTRATIVE REQUIREMENTS ...................................................................................................... I-1
A.

INTRODUCTION ............................................................................................................................... I-1

AUTHORIZING LEGISLATION ....................................................................................................... I-1

ELIGIBLE APPLICANTS .................................................................................................................. I-1

REGULATIONS AND REFERENCE DOCUMENTS ...................................................................... I-1

PROGRAM FUNDING....................................................................................................................... I-2

CASH MANAGEMENT ..................................................................................................................... I-2

COST GUIDELINES........................................................................................................................... I-2

FINANCIAL REPORTING................................................................................................................. I-3

MONITORING.................................................................................................................................... I-3

DEOBLIGATION OF UNDERUTILIZED FUNDS........................................................................... I-3

PROGRAM VARIANCES .................................................................................................................. I-3

CHANGES TO THE COOPERATIVE AGREEMENT ..................................................................... I-4
1.

Budget Changes......................................................................................................................... I-4

Programmatic Changes.............................................................................................................. I-4

Obtaining Prior Approval.......................................................................................................... I-4

BLS-Initiated Budget Changes.................................................................................................. I-5

EQUIPMENT........................................................................................................................................ I-5

PROCUREMENT ................................................................................................................................ I-5
1.

Forms and Survey Material ....................................................................................................... I-5

Subcontracting........................................................................................................................... I-5

CLOSEOUTS AND AUDITS ............................................................................................................. I-6

RECORDS ........................................................................................................................................... I-6
1.

Retention ................................................................................................................................... I-6

Disposal..................................................................................................................................... I-6

CONFIDENTIALITY.......................................................................................................................... I-6

DATA COLLECTION INTEGRITY .................................................................................................. I-9

PUBLICATION OF DATA................................................................................................................. I-9

CERTIFICATIONS ............................................................................................................................. I-9

Debarment, Suspension, and Other Responsibility Matters ...................................................... I-9

Drug-Free Workplace Requirements....................................................................................... I-10

Lobbying Activities................................................................................................................. I-10

ASSURANCES.................................................................................................................................. I-10

Attachments: BLS-OSHS Quarterly Reporting Form
Instructions for BLS-OSHS Quarterly Reporting Form

-i-

II.

III.

APPLICATION INSTRUCTIONS ............................................................................................................... II-1
A.

GENERAL RESPONSIBILITIES ...................................................................................................... II-1

APPLICATION PROCESS ................................................................................................................ II-1

INSTRUCTIONS FOR COMPLETING FORMS.............................................................................. II-2
1.

Application for Federal Assistance (SF-424) ........................................................................... II-2

Certification Regarding Debarment, Suspension, and Other Responsibility Matters .............. II-2

Drug-Free Workplace Certification.......................................................................................... II-5

Certification Regarding Lobbying Activities ........................................................................... II-7

Disclosure Of Lobbying Activities (SF-LLL) .......................................................................... II-8

BLS Agent Agreement ........................................................................................................... II-10

Budget Information - Non-Construction Programs (SF-424A).............................................. II-10

Work Statements .................................................................................................................... II-12

APPLICATION MATERIALS ................................................................................................................... III-1
A.

APPLICATION FOR FEDERAL ASSISTANCE (SF-424)

BUDGET INFORMATION FORM - NON-CONSTRUCTION PROGRAMS (SF-424A)

CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS

DISCLOSURE OF LOBBYING ACTIVITIES (SF-LLL)

DISCLOSURE OF LOBBYING ACTIVITIES (SF-LLL-A)

BLS AGENT AGREEMENT

WORK STATEMENTS

Attachment:

2007 OSHS Cooperative Agreement Document Numbers

- ii -

I. ADMINISTRATIVE REQUIREMENTS
A.

INTRODUCTION
The Bureau of Labor Statistics (BLS) is the Federal agency responsible for carrying out the
responsibilities of the Secretary of Labor under Section 24 of the Occupational Safety and
Health Act of 1970. Since 1971, the BLS has had cooperative arrangements with States to
collect occupational injury and illness data. This statistical program now extends to about 50
political jurisdictions, including the District of Columbia, Commonwealth of Puerto Rico,
Guam, and the Virgin Islands.

AUTHORIZING LEGISLATION
The Occupational Safety and Health Statistics (OSHS) program is authorized by the
Occupational Safety and Health Act of 1970. Specifically, Section 24(a) of the Act
authorizes the collection, compilation, and analysis of occupational safety and health
statistics. Section 24(b)(2) authorizes the Secretary to make grants to States or political
subdivisions thereof to assist them in developing and administering programs dealing with
occupational safety and health statistics. Section 24(c) limits the Federal share of the grants
authorized under Section 24(b) to an amount up to 50 percent of the State's total cost. Section
24(d) authorizes the Secretary to accept the services and facilities of State agencies or
political subdivisions with or without reimbursement.
The BLS is using the cooperative agreement as the vehicle for funding the OSHS program
because of the Bureau's ongoing involvement in the program, pursuant to the Federal Grant
and Cooperative Agreement Act of 1977 (31 USC 6301-08). For purposes of brevity,
however, the term "grant" is often used synonymously for "cooperative agreement."

ELIGIBLE APPLICANTS
Eligible applicants are State agencies or political subdivisions thereof. Throughout this
document, these agencies will be referred to as "State Grant Agencies" or "SGAs.”

REGULATIONS AND REFERENCE DOCUMENTS
The BLS-OSHS program is administered in accordance with the following:
1.

Title 29 Part 93 of the Code of Federal Regulations (hereinafter cited as 29 CFR 93), New
Restrictions on Lobbying;

Title 29 Part 96 and 99 of the Code of Federal Regulations (hereinafter cited as 29 CFR 96
and 99), Audit Requirements for Grants, Contracts and Other Agreements;

Title 29 Part 97 of the Code of Federal Regulations (hereinafter cited as 29 CFR 97),
Uniform Administrative Requirements for Grants and Cooperative Agreements to State and
Local Governments;

Title 29 Part 98 of the Code of Federal Regulations (hereinafter cited as 29 CFR 98) and
2 CFR Chapter 1, part 180, Government-wide Debarment and Suspension (Nonprocurement)
and Government-wide Requirements for Drug-Free Workplace (Grants); and

OMB Circular A-87 and Title 2 Subtitle A of the Code of Federal Regulations, Cost
Principles for State, Local and Indian Tribal Governments.

I-1

BLS administrative directives provide instructions and guidelines for implementing
regulatory requirements in the areas of reporting, monitoring, procurement, closeout and
audit, property management, cash management, and other administrative and financial
management functions that specifically apply to the OSHS program.

PROGRAM FUNDING
All Federal funding is subject to the enactment of a Department of Labor appropriation (or
other action, such as a continuing resolution). The OSHS cooperative agreements are often
negotiated and executed prior to the enactment of the appropriation. Since they are based on
the President's budget, which may be more or less than the final appropriation, the BLS
reserves the right to renegotiate the grant amount, if the appropriation differs from the
President's budget.
The Federal financial assistance awarded under this Agreement is available for obligation by
a SGA during the Federal fiscal year beginning October 1 and ending September 30, unless,
under rare circumstances, an extension of the Agreement period is specifically approved by
the BLS.

CASH MANAGEMENT
Cash advances to qualified SGAs will be made under the Department of Health and Human
Services Payments Management System (HHS-PMS), an automated clearinghouse system.
The BLS is responsible for establishing HHS-PMS accounts for OSHS grantees. The BLS
will make withdrawals of funds on behalf of SGAs unable to use the HHS-PMS.
The HHS-PMS is designed to make Federal funds available immediately upon receipt of a
request. The amount requested therefore should be based on actual disbursement needs
whenever possible, and should be disbursed by the SGA as soon as possible after receipt.
(See 29 CFR 97.20(a)(7), "Cash Management.") For this purpose, a disbursement is
considered to be the time of actual release of checks or transfer of funds electronically by the
SGA to the payees.

COST GUIDELINES
Allowable costs are determined in accordance with the provisions of OMB Circular A-87.
They are costs for program staff, administrative support and technical services, and
non-personal services.
Indirect costs are defined as all costs benefiting more than one project, activity or other cost
objective. The process for allocating indirect costs charged to Department of Labor grants
and contracts must be approved by the Department of Health and Human Services (DHHS)
or, the DOL Office of Acquisition Integrity. Any State that uses an indirect cost rate,
regardless of the cost allocation methodology employed, must obtain approval of its indirect
cost rate annually from the DOL Division of Cost Determination, within the Office of
Acquisition Integrity, or from the cognizant Federal agency approving the rate.
The cost of audits made in accordance with the provisions of 29 CFR 96 and 99 (formerly
OMB Circular A-133) are allowable charges to Federally-assisted programs. The charges
may be considered a direct cost or an allocated indirect cost, determined in accordance with
the provisions of OMB Circular A-87. Such costs generally may not exceed the percentage
that Federal funds expended represent of total funds expended by the recipient during the
fiscal year. In the case of the BLS-OSHS agreements, charges would be limited to 50 percent
of the OSHS program's prorated share of the cost of conducting the audit. The percentage
may be exceeded if the State demonstrates and documents higher actual costs.

I-2

FINANCIAL REPORTING
The SGAs Financial Accounting System must be able to provide the financial information
necessary to comply with audit requirements and to complete the PMS-272, Federal Cash
Transactions Report, and the BLS-OSHS2 Quarterly Financial Report, (Addendum to PMS272). The BLS-OSHS2 should be submitted to the regional office within 30 days after the
end of each quarter. However, since the due date for submission of the PMS-272 to the
Department of Health and Human Services Payment Management System (HHS-PMS) is 45
days after the end of the quarter, SGAs may submit the PMS-272 copy and the BLS-OSHS2
form at the same time (within five working days after submitting the PMS-272 to HHS).
Upon receipt, the regional office will immediately forward the original-signature copy of the
BLS-OSHS2 to the national office (Office of Field Operations), which will, in turn, forward it
to the Division of Financial Planning and Management's Branch of Grants and Funds
Management. Those grantees that draw down funds by means of the HHS-PMS will receive
the Federal Cash Transactions Report Form directly from HHS-PMS. Grantees will also
complete and return the PMS-272 to HHS-PMS, according to HHS-PMS instructions.
Failure to submit the reports on time may result in withholding of payments by the BLS.
Financial reporting requirements specified at 29 CFR 97.41 are superseded by this
requirement. The BLS also waives its right to require submission of the Financial Status
Report (SF-269), except at closeout.

MONITORING
The BLS will review the financial reports from SGAs to monitor fund utilization and identify
potential over-spending or under-spending. The primary objectives of financial monitoring
are to: ensure that program objectives are met; prevent significant imbalances of funds at the
end of the fiscal year; and identify instances where it may be necessary to provide Federal
administrative assistance to SGAs.
Pursuant to 29 CFR 97.20, the BLS may also conduct periodic on-site reviews to ensure the
adequacy of the SGA's financial management systems.
In accordance with 29 CFR 97.40, SGAs are responsible for managing the day-to-day
operations of grant-supported activities and monitoring their performance under the
agreement to assure compliance with applicable Federal requirements and to assure that
performance goals are being met. Also per 29 CFR 97.40, the BLS may make site visits as
required by program needs.

DEOBLIGATION OF UNDERUTILIZED FUNDS
To obtain maximum benefits from the funds available, each grant will be reviewed by the
BLS during the fourth quarter to determine the status of funds. Funds identified as having the
potential for being unused by the end of the fiscal year will be subject to deobligation.
Usually, deobligation of funds will be accomplished through bilateral agreement. Additional
instructions applicable to a particular fiscal year will be issued separately. The BLS will
work with the SGA to ensure that funding is sufficient to support program operations through
the end of the fiscal year before any deobligation action is carried out.

PROGRAM VARIANCES
If the SGA does not intend to comply fully with all performance requirements, including
financial reporting requirements, for the entire period of the Cooperative Agreement, an
explanation of the variance should be developed in cooperation with the BLS regional office,
and shown in the appropriate section of the work statement to which it applies. If the SGA
failed during the previous period to meet agreed-upon work requirements but the problem has

I-3

already been corrected and the SGA expects to meet the requirements in the current year, then
no variance is required. However, if the SGA failed to meet the requirements in the previous
period, and must do work during the current period to improve performance, then a variance
must be developed and included in the Cooperative Agreement, as explained above. An
explanation of variance must include the following:

Background of the problem;

Performance during the previous period, such as the previous survey year for the Survey or
the previous fiscal year for financial reporting;

Proposed performance; and

Milestones that enable the SGA to meet standard deliverables required by the work
statements for the OSHS program by the end of the fiscal year.

CHANGES TO THE COOPERATIVE AGREEMENT
1.

BUDGET CHANGES
Budget changes that require SGAs to obtain prior written approval from the BLS include:

Any revision that would result in the need for additional funding; and

Cumulative transfers among cost categories that exceed or are expected to exceed ten
percent of the current total approved program budget, whenever the total funded by the
BLS is greater than $100,000.

PROGRAMMATIC CHANGES
Programmatic changes that require the BLS prior written approval include:

Any revision of the scope or objectives of the Cooperative Agreement;

Any significant deviation from the timetables specified in the manual or technical
memoranda; or

Need to extend the period of availability of funds.

OBTAINING PRIOR APPROVAL
A request for prior approval of any budget revision will include the Budget Information Form
(BIF), the appropriate page(s) of the program work statement (if applicable), and a narrative
justification for the proposed revision, included in the transmittal letter.
To obtain written approval from the BLS for programmatic or budget changes to the
Cooperative Agreement, the SGA should submit one original and two copies of materials, as
follows:
a.

SF-424 reflecting the revision;

SF-424A annotated to reflect the modified budget elements; and

The appropriate page(s) of the work statement annotated to reflect the change to the
scope or duration of work originally agreed upon.

I-4

Changes must be approved prior to the beginning of the quarter in which they would take
effect.
The SGA's request for prior approval must be received at least 30 days before the beginning
of the quarter.
4.

BLS-INITIATED BUDGET CHANGES
In the event of legislatively mandated reductions to appropriated funds, necessitating the BLS
to reduce the original award amount of the Cooperative Agreement, a modification to the
Cooperative Agreement will be executed. The BLS prefers that bilateral modifications be
used to effect these budget reductions. However, where a SGA prefers that the BLS initiate
and execute a unilateral modification, because, for example, of the workload and time
expense involved in obtaining State-required review and signature of bilateral modifications,
a unilateral modification will be used, and the BLS will notify the SGA, in writing, of its
action. The notification will specifically state what was done on behalf of the SGA.

EQUIPMENT
The SGA shall use, manage, and dispose of equipment acquired under the cooperative
agreement in accordance with State laws and procedures. Title to equipment purchased with
cooperative agreement funds shall vest upon acquisition in the SGA. However, the BLS, per
29 CFR 97.32(g), reserves the right to transfer title to the Federal Government or a third party
named by the BLS when such a third party is otherwise eligible under existing statutes. Such
transfers are subject to the standards appearing at 29 CFR 97.32(g) (1) - (3). Pursuant to
those standards, specifically, 29 CFR 97.32 (g) (1), the BLS reserves the right to transfer title
of any ADP equipment, purchased with cooperative agreement funds, upon termination of
financial assistance or when the equipment is no longer needed by the SGA. BLS-owned
equipment, provided to a SGA, must be used and disposed of according to standards
appearing at 29 CFR 97.32 (f) (1) - (3). The SGA will maintain an inventory of BLS-owned
equipment and respond promptly to BLS requests for information about its location,
operating status, and condition.

PROCUREMENT
The provisions of 29 CFR 97.36, Procurement, apply to OSHS cooperative agreements.
1.

FORMS AND SURVEY MATERIAL
The State will obtain the BLS regional office approval to use the following before final
arrangements are made:
a.

All State forms equivalent to Federal forms--survey reporting forms and the
prenotification booklet;

State originated solicitation and prenotification letters to employers;

State originated survey verification forms and letters; and

State inserts in the prenotification booklet and any other survey instrument.

I-5

SUBCONTRACTING
Substantive program work under the Cooperative Agreement may not be subgranted or
contracted by the SGA without prior approval. Substantive program work includes the
sampling, data collection, estimation and validation activities.

CLOSEOUTS AND AUDITS
Closeouts and audits shall be performed in accordance with the requirements of
29 CFR 97.50, regarding closeout, and 29 CFR 96, regarding the Single Audit Act, and as
may be augmented by specific guidance and instructions issued by the BLS.
Prior to the completion date of the Cooperative Agreement, the Grant Officer will send a
preliminary closeout notice to all SGAs reminding them of the forms necessary for closeout.
Closeout packages are due 90 days after the end of the Cooperative Agreement period. SGAs
may request an extension to the due date. Such a request must be in writing and sent to the
Grant Officer. The Grant Officer will respond in writing to the request. Once the closeout
materials are received, the Grant Officer will inform the SGA of any missing reports and
inquire about the status of funding for completion of the project.

RECORDS
1.

RETENTION
Records will be retained in accordance with 29 CFR 97.42, Retention and Access
Requirements for Records. Generally, the SGA will retain all records pertinent to the
agreement, including financial records and supporting documents for a period of three years
after the close of the agreement period. States will retain the hard copy forms (Survey and
CFOI statistical records) from respondents and enter the establishment or fatality micro-data
into the BLS computer systems. States shall also retain any electronic version of the forms
received through e-mail submission of the Survey or scanned and transmitted by the print
vendor. Typically, unless instructed otherwise, States may destroy these electronic and hard
copies 30 days after the State’s final Case and Demographic estimates have been generated or
one year after submitting the final updated CFOI data file for the reference year.

DISPOSAL
The Cooperating Representative (see below) is responsible for ensuring that appropriate
precautions are taken in disposing of records after the required retention period to ensure that
confidentiality is protected. SGAs may follow their own records disposal policies and
procedures, provided they contain safeguards for protecting confidentiality.

CONFIDENTIALITY
1.

The Confidential Information Protection and Statistical Efficiency Act (CIPSEA) of 2002
(Title 5 of Public Law 107-347) safeguards the confidentiality of individually identifiable
information acquired for exclusively statistical purposes under a pledge of confidentiality by
controlling access to and uses of such information. BLS officers, employees, and agents are
subject to CIPSEA and other Federal laws governing confidentiality. In addition, BLS policy
on confidentiality is stated in Commissioner’s Order No. 3-04, “Confidential Nature of BLS
Records," dated October 4, 2004. It is applicable to the State agency and the State agency's
employees and agents. The majority of data collected by the BLS is provided on a voluntary
basis by respondents who have agreed to provide the information for the purpose(s) specified
by the BLS. A violation of the confidence that respondents place in the BLS would endanger
the BLS ability to carry out its duties.

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For the purposes of this cooperative agreement, “confidential information” includes all
names, addresses, and other information about an establishment from which data are
requested; all identifiable respondent submissions; and any other information in any medium
and format that would reasonably disclose the identity by either direct or indirect means of
any participant in a statistical program under the auspices of the BLS.

The State agency agrees to use the confidential information only for statistical purposes.

The State agency agrees to assign BLS State Cooperating Representative(s) for the OSHS
programs it undertakes under the cooperative agreement (the Survey of Occupational Injuries
and Illnesses and Census of Fatal Occupational Injuries) prior to its execution in accordance
with BLS requirements. The Cooperating Representative will be designated an agent by the
BLS and must sign a BLS Agent Agreement each year a cooperative agreement is executed.
A copy of this form is included as part of the application materials in Part III.

For the purposes of this cooperative agreement, “authorized agents” are defined as
individuals who have been designated by the BLS as agents to work directly on the activities
that are covered by this cooperative agreement under the control of the BLS Regional
Commissioner or other official who the BLS designates and who have signed a BLS Agent
Agreement. A copy of this form is attached at the end of Part III.

The State agency agrees not to divulge, publish, reproduce, or otherwise disclose, orally or in
writing, the confidential information, in whole or in part, to any individual other than
authorized agents unless the State agency has obtained the approval of the BLS and written
consent has been obtained from the respondent prior to disclosure.

The State agency agrees to notify the BLS immediately upon discovering:

any breach or suspected breach of security, or

any disclosure of the confidential information not authorized by this cooperative
agreement.

Upon receipt of any legal, investigatory, or other demand for access to the confidential
information in any form the State agency agrees:
a.

Not to disclose the confidential information in any form to anyone who is not an
authorized agent or employee of the BLS.

To immediately notify the BLS upon receipt of any demand for access to the
confidential information.

To refer the demand for confidential information to the BLS to be handled under
Federal Law.

The State agency agrees to obtain BLS approval prior to using the confidential information
for any statistical activity not authorized under this cooperative agreement. For activities
approved by the BLS, the State agency agrees to enter into a Memorandum of Understanding
with the BLS authorizing that work and stating the terms of access to the confidential
information.

10.

In the event of termination of this agreement, or at an earlier time if required by the BLS, all
confidential information that is provided to the State agency by the BLS and any documents
or other media created by the State agency that contain confidential information must be
returned to the BLS or, with the BLS permission, be destroyed. The State agency's failure to

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surrender or destroy such materials promptly or the State agency's conversion of such
materials to a use that is not authorized by this cooperative agreement may be a violation of
18 U.S.C. Section 641.

11.

The State agency agrees to implement safeguards to prevent unauthorized access by
electronic or physical means to the confidential information.

12.

The BLS reserves the right to review and approve or disapprove of all of the security
safeguards that are instituted to comply with the requirements of this cooperative agreement.
The BLS also reserves the right to make unannounced inspections of the State agency's
facilities to determine whether or not they are in compliance with the requirements.

13.

The State agency will assure that there will be no access to confidential information by any
person other than an agent designated pursuant to this agreement. Neither the State agency
nor any agent designated pursuant to this agreement will use confidential information for any
purpose other than a BLS-approved statistical purpose. The BLS may require the submission
of any output(s) produced from confidential information intended for release or publication
for review and approval to ensure adherence to the terms and provisions of this cooperative
agreement. The State agency and designated agents will be bound by the determinations of
the BLS.

14.

The State agency agrees to include adequate and appropriate confidentiality provisions in all
contracts awarded, pursuant to this cooperative agreement, and that involve the disclosure of
any confidential information orally, in writing, or in any other form, in whole or in part, to
the contractor. In particular, provisions from the following list must be included.
a.

contractor officers and employees must adhere to CIPSEA and all applicable Federal
laws regarding the handling of all confidential statistical data and also must adhere to
the BLS confidentiality policy as stated in Commissioner’s Order 3-04;

access to the confidential information must be limited to contractor officers and
employees who have been designated as agents by the BLS to work directly on the
contract and who have signed the BLS Agent Agreement in advance;

reliability of personnel;

no subcontracting permitted;

right of inspection of contractor facilities;

physically secure work site and computer/communications environment;

exclusive storage facilities for confidential information;

immediate notification of the State and the BLS upon discovering: any breach or
suspected breach of security; any disclosure of the confidential information not
authorized by the contract; or upon receipt of any legal, investigatory, or other demand
for access to the confidential information in any form;

right of termination for failure to comply with security requirements;

right to review outputs produced from confidential information prior to release or
publication; and

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return or destruction of confidential information upon termination of the contract.

DATA COLLECTION INTEGRITY
To maintain the integrity of the data collection process, SGAs must comply with the BLS
Commissioner's Order 3-91, "Bureau Policy on Data Collection Integrity," July 29, 1991.
"The integrity of the Bureau of Labor Statistics data collection process requires that all survey
information be sound, complete, and of the highest possible quality. Data must be obtained
from the appropriate official or respondent and the data entries must accurately report data
and responses they provided."
Commissioner's Order 3-91 covers "all aspects of data collection, reconciliation and
processing including, but not limited to, the following: personal visits, telephone collection,
telephone clarification, mail, tape reformatting, computer assisted telephone interviews
(CATI), computer assisted personal interviews (CAPI), telephone data entry (TDE), voice
recognition and computer assisted data collection and processing (CADCAP)."
The SGA agrees to acquaint all employees involved in data collection for OSHS programs
with the data collection integrity policy, and to ensure that they understand that the source of
the data, the method of data collection, and the data received from respondents must not be
deliberately misrepresented.

PUBLICATION OF DATA
1.

States will obtain clearance from their BLS Regional Commissioner for all reports for which
any activity, collection, compilation, analysis and publication are funded under the grant.

States will acknowledge the U.S. Department of Labor, BLS financial assistance when
publishing data developed through the BLS-OSHS program.

States are required to publish survey data that are validated by the BLS. (Note that if a State
is using only the data tables and charts BLS sends them in Profiles, no BLS validation is
needed.) A press release, hard copy report, or Internet web site count as publication. If hard
copies are published, States should submit three copies to the BLS regional office (the
regional office will forward two copies to BLS-Washington); if a web site is used they should
provide the URL address.

The BLS reserves the right to publish State data from the OSHS programs funded under this
agreement. Normally, the BLS will provide States a ten-day period in which to publish State
data prior to making it available to the public.

CERTIFICATIONS
1.

DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS
29 CFR 98.100(a) states that, under the government-wide system for nonprocurement
debarment and suspension, any party who is debarred or suspended shall be excluded from
Federal financial and non-financial assistance and benefits under Federal programs and
activities. Accordingly, before being awarded funding, each SGA shall certify as instructed
in Part II., Application Instructions, that it is in compliance with the provisions of the
Certification Regarding Debarment, Suspension, and Other Responsibility Matters--Primary
Covered Transactions. In addition, each SGA shall require participants in lower-tier covered
transactions to submit the Certification Regarding Debarment, Suspension, and Other

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Responsibility Matters--Lower-Tier Covered Transactions [29 CFR 98.510(a) and
29 CFR 98.510(b)].
2.

DRUG-FREE WORKPLACE REQUIREMENTS
29 CFR 98.630(a) requires that all grantees receiving grants (and cooperative agreements)
from any Federal agency certify to that agency that they will maintain a drug-free workplace.
Making the required certification is a precondition for receiving a grant from a Federal
Agency. Accordingly, before being awarded funding, each SGA shall certify as instructed in
Part II, Application Instructions, that it is maintaining or will continue to maintain a drug-free
workplace.

LOBBYING ACTIVITIES
Pursuant to 29 CFR 93, each applicant for a cooperative agreement, which will be funded at a
level in excess of $100,000, must certify that the applicant will not use the funds awarded
under the cooperative agreement to pay any person for influencing or attempting to influence
an officer or employee of any agency, a Member of Congress, an officer or employee of
Congress, or an employee of a Member of Congress in connection with any of the following
covered Federal actions: the awarding of any Federal contract, the making of any Federal
grant, the making of any Federal loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment, or modification of any Federal contract, grant,
loan, or cooperative agreement. Making the required certification is a precondition for
receiving a grant from a Federal agency. Accordingly, before being awarded funding, each
grantee shall certify as instructed in Part II, Application Instructions.
29 CFR 93 also requires that each applicant for a cooperative agreement with a Federal
agency file with that agency a disclosure form if the applicant has made or has agreed to
make any payment using nonappropriated funds (to include profits from any covered Federal
action), which would be prohibited if paid for with appropriated funds.

ASSURANCES
The standard assurances that follow specify terms and conditions with which SGAs must
comply, as prescribed by OMB Circular A-102, Standard Form 424B, Standard Assurances.
Pursuant to SF-424B, certain assurances (Nos. 7 and 9 through 16 of SF-424B) are not
applicable to this Agreement and have been deleted from the list below.
By placing an "X" or check mark in the "Agree to Comply" box next to the requirement
concerning the assurances in the Work Statement: General Requirements, the SGA assures
and certifies that it will comply with all guidelines and requirements that apply to the
application for, and the acceptance and use of Federal funds for this federally-assisted
program. Specifically, the SGA assures and certifies that it:
1.

Has the legal authority to apply for Federal assistance, and the institutional, managerial and
financial capability (including funds sufficient to pay the non-Federal share of project costs)
to ensure proper planning, management and completion of the project described in this
application.

Will give the awarding agency, the Comptroller General of the United States, and if
appropriate, the State, through any authorized representative, access to and the right to
examine all records, books, papers, or documents related to the award; and will establish a
proper accounting system in accordance with generally accepted accounting standards or
agency directives.

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Will establish safeguards to prohibit employees from using their positions for a purpose that
constitutes or presents the appearance of personal or organizational conflict of interest, or
personal gain.

Will initiate and complete the work within the applicable time frame after receipt of approval
of the awarding agency.

Will comply with the Intergovernmental Personnel Act of 1970 (42 USC 4728-4763) relating
to prescribed standards for merit systems for programs funded under one of the nineteen
statutes or regulations specified in Appendix A of OPM's Standards for a Merit System of
Personnel Administration (5 CFR 900, Subpart F).

Will comply with all Federal statutes relating to nondiscrimination. These include but are not
limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits
discrimination on the basis of race, color or national origin; (b) Title IX of the Education
Amendments of 1972, as amended (20 USC 1681-1683, and 1685-1686), which prohibits
discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as
amended (29 USC 794), which prohibits discrimination on the basis of handicaps; (d) the
Age Discrimination Act of 1975, as amended (42 USC 6101-6107), which prohibits
discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972
(P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the
Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation
Act of 1970 (P.L. 91-616), as amended relating to nondiscrimination on the basis of alcohol
abuse or alcoholism; (g) Sections 523 and 527 of the Public Health Service Act of 1912 (42
USC 290 dd-3 and 290 ee-3), as amended relating to confidentiality of alcohol and drug
abuse patient records; (h) Title VIII of the Civil Rights Act of 1968 (42 USC 3601 et seq.) as
amended, relating to nondiscrimination in the sale, rental or financing of housing; (i) any
other nondiscrimination provisions in the specific statute(s) under which application for
Federal assistance is being made; and (j) the requirements of any other nondiscrimination
statute(s) which may apply to the application.

Will comply with the provisions of the Hatch Act (5 USC 1501-1508 and 7324-7328) which
limit the political activities of employees whose principal employment activities are funded in
whole or in part with Federal funds.

Will cause to be performed the required financial and compliance audits in accordance with
the Single Audit Act Amendments of 1996 and OMB Circular No. A-133, “Audits of States,
Local Governments, and Non-Profit Organizations.”

Will comply with all applicable requirements of all other Federal laws, executive orders,
regulations and policies governing this program.

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BLS-OSHS QUARTERLY FINANCIAL REPORT (Addendum to PMS-272)

BLS-OSHS2--OMB Approval No. 1220-0149; Expires ___________

State Grant Agency: _______________________________________ Cooperative Agreement No.: ___________________ Reporting Period Ending: _______________
SECTION A – FINANCIAL ACTIVITY SUMMARY

Grant Program
Function
or Activity
(a)

Catalog of Federal
Domestic Assistance
Number
(b)

Expenditures for the Quarter
Federal
(c)

Cumulative Expenditures

Non-Federal
(d)

Federal
(e)

Non-Federal
(f)

Total
(g)

2.
3.
4.
5. TOTALS

SECTION B -- TOTAL EXPENDITURES BY BUDGET CATEGORY FOR THE CURRENT QUARTER

GRANT PROGRAM, FUNCTION, OR ACTIVITY
6. Object Class Categories
a. Personnel

TOTAL

(1)

(2)

(3)

(4)

(5)

b. Fringe Benefits
c. Travel
d. Equipment
e. Supplies
f. Contractual
g. Construction
h. Other
i. Total Direct Charges (sum of 6a-6h)
j. Indirect Charges
k. TOTALS (sum of 6i and 6j)
7. Program Income

CERTIFICATION: I certify that to the best of my knowledge and belief the information provided above is accurate and complete, and was obtained from agency accounting records.

Authorized Signature: _________________________________________________________________________________________

Authorized for Local Reproduction

BLS-OSHS QUARTERLY FINANCIAL REPORTING FORM

GENERAL INSTRUCTIONS
This form is designed to capture actual expenditures for the quarter and cumulatively for the fiscal year. Reporting
is separate by program activity, i.e., Annual Survey and CFOI, and by object class categories. The report form
parallels the Budget Information -- Non-Construction Programs form (SF-424A) and requires reporting by object
class and program activity quarterly, based on the projections by program and object provided in SF-424A at the
time application is made for the Cooperative Agreement. A completed original of this report is due in the BLS
regional office no later than thirty days following the close of each quarter the agreement remains open, whether or
not financial activity took place within the reporting period.
SPECIFIC INSTRUCTIONS
Section A - Financial Activity Summary. Columns (a) and (b). Enter the abbreviated title of the program
activity; i.e., SURVEY or CFOI, and the Catalog of Federal Domestic Assistance number “17.005.”
Lines 1-4, Columns (c) and (d). Enter the Federal and Non-Federal expenditures for the current quarter for each
program activity listed in Column (a).
Lines 1-4, Columns (e) and (f). Enter the Federal and Non-Federal expenditures for all quarters (including the
current quarter) since the beginning of the agreement and the total cumulative of Federal and Non-Federal
expenditures in Column (g).
Section B - Total Expenditures by Budget Category. In column headings (1) through (4), enter the abbreviated
titles of the same program activities shown on Lines 1-4, Column (a), Section A. For each program activity, fill in
the total expended (both Federal and Non-Federal combined), during the quarter, by object class categories in Lines
6a through h.
Line 6i, Enter the total of Lines 6a through h for each column used.
Line 6j, Enter the amount of Indirect Cost.
Line 6k, Enter the total amounts of Lines 6i and 6j.
Line 7, Enter the amount of program income, if any, during the quarter.
CERTIFICATION
A duly authorized official of the State must sign and date the form. Only forms bearing an original signature will be
valid and acceptable to the BLS.
PAPERWORK BURDEN STATEMENT
We estimate that it will taken an average of one hour to complete this form including time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the information. If you have any comments
regarding this estimate or any other aspect of this form, including suggestions for reducing this burden, please send them to the Bureau
of Labor Statistics, Division of Financial Planning and Management (1220-0149), 2 Massachusetts Avenue, N.E., Washington, D.C.
20212-0001. You are not required to respond to this collection of information unless it displays a currently valid OMB Approval
Number.

II. APPLICATION INSTRUCTIONS
A.

GENERAL RESPONSIBILITIES
The cooperating State agency is responsible for:
1.

Preparing draft and final Cooperative Agreement application packages in accord with these
Application Instructions and the schedule of due dates as provided by the BLS; and,

Verifying all items in the package for accuracy, reasonableness, and consistency with past budgets.
The BLS is responsible for:

Reviewing the applications for: conformity with the application instructions and Federal
requirements; reasonableness; accuracy; and consistency with prior-year budgets and program
objectives;

Requesting clarification from the SGA, if needed, to resolve any issues arising from the review; and

Notifying the SGA of the award decision prior to the start of fiscal year, and, once issued, notifying
the SGA of its obligational authority under the Cooperative Agreement.

APPLICATION PROCESS
The SGA is requested to submit a copy of a draft application, which may, at the State's option, be
submitted without the original signature of the duly authorized representative of the SGA. The draft
application will consist of the following application materials:
1.

Application for Federal Assistance (SF-424);

Budget Information -- Non-Construction Programs (SF-424A);

Work Statements
The BLS regional office staff will review the draft application and work with SGA staff by telephone
or on site to resolve any problem areas that are identified.
The SGA will revise the draft to reflect the results of the discussions held with the BLS and submit
one original and three copies of the final, official Cooperative Agreement application package with the
original signature of the duly authorized State official on the original. In addition to items 1. through
3., listed above, the final application will also include the Certification Regarding Drug-Free
Workplace Requirements and, if applicable, the Certification Regarding Lobbying Activities.
Parts I and II of the OSHS Cooperative Agreement, Administrative Requirements and Application
Instructions, respectively, are not to be submitted as part of the application package, but should be
retained by the SGA as part of its official OSHS Cooperative Agreement file.
Regional office staff will review the final application package, assign the Cooperative Agreement
number, and, finding no outstanding issues, the BLS Regional Commissioner, as Grant Officer, will
execute the Cooperative Agreement by signing and dating the SF-424 in Block 19, which has been
modified by the BLS to provide space for this purpose. The original and one copy will be sent to the
BLS Washington, Office of Field Operations. One copy of the executed agreement with the original

II-1

signature of the Grant Officer will be returned to the SGA with a cover letter notifying the SGA of the
grant award. The Cooperative Agreement will become effective on October 1, the first day of the
fiscal year. Once the BLS issues obligational authority under the Cooperative Agreement, the SGA
will be notified by the BLS regional office.
BLS is working to make its application available for electronic submission via www.Grants.gov.
Although electronic submission is not mandatory at this time, whether applying electronically or in
paper form States are strongly encouraged to become familiar with Grants.gov website and complete
the registration process at http://www.grants.gov/GetStarted.
Specific information about the application materials, and instructions for their completion, follow.

INSTRUCTIONS FOR COMPLETING FORMS
1.

APPLICATION FOR FEDERAL ASSISTANCE (SF-424)
The SGA will follow the instructions that appear on the reverse side of the form, incorporating the
following specific information:
Item 4: (To be assigned by the BLS.)
Item 10: Enter "17.005, Occupational Safety and Health Statistics"
Item 11: Enter "BLS Occupational Safety and Health Statistics, pursuant to Sec. 24, Occupational
Safety and Health Act of 1970, and equivalent State laws."
Item 18: Note that a copy of the authorization referred to here must be on file at the SGA's office.
The BLS does not require that this authorization be submitted as part of the application.

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS
a.

Instructions--Primary Covered Transactions
(1)

By signing and submitting this proposal, the prospective primary participant is
providing the certification set out below (see paragraph b., below).

(2)

The inability of a person to provide the certification required below will not necessarily
result in denial of participation in this covered transaction. The prospective participant
shall submit an explanation of why it cannot provide the certification set out below. The
certification or explanation will be considered in connection with the department or
agency's determination whether to enter into this transaction. However, failure of the
prospective participant to furnish a certification or explanation shall disqualify such
person from participation in this transaction.

(3)

The certification in this clause is a material representation of fact upon which reliance
was placed when the department or agency determined to enter into this transaction. If it
is later determined that the prospective primary participant knowingly rendered an
erroneous certification, in addition to other remedies available to the Federal
Government, the department or agency may terminate this transaction for cause or
default.

(4)

The prospective primary participant shall provide immediate written notice to the
department or agency to which this proposal is submitted if at any time the prospective

II-2

primary participant learns its certification was erroneous when submitted or has become
erroneous by reason of changed circumstances.

(5)

The terms "covered transaction", "debarred", "suspended", "ineligible", "lower tier
covered transaction", "participant," "person", "primary covered transaction", "principal",
"proposal", and "voluntarily excluded," as used in this clause, have the meanings set out
in the Definitions and Coverage sections of the rules implementing Executive Order
12549 [29 CFR 98.105 and 29 CFR 98.110]. You may contact the department or agency
to which this proposal is being submitted for assistance in obtaining a copy of those
regulations.

(6)

The prospective primary participant agrees by submitting this proposal that, should the
proposed covered transaction be entered into, it shall not knowingly enter into any lower
tier covered transaction with a person who proposed for debarment under 48 CFR Part 9,
Subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from
participation in this covered transaction, unless authorized by the department or agency
entering into this transaction.

(7)

The prospective primary participant further agrees by submitting this proposal that it will
include the clause titled "Certification Regarding Debarment, Suspension, Ineligibility
and Voluntary Exclusion--Lower Tier Covered Transactions," provided by the
department or agency entering into this covered transaction, without modification, in all
lower tier covered transactions and in all solicitations for lower tier covered transactions.

(8)

A participant in a covered transaction may rely upon a certification of a prospective
participant in a lower tier covered transaction that is not proposed for debarment under
48 CFR Part 9, Subpart 9.4, debarred, suspended, declared ineligible, or voluntarily
excluded from the covered transaction, unless it knows that the certification is erroneous.
A participant may decide the method and frequency by which it determines the eligibility
of its principals. Each participant may, but is not required to, check the List of Parties
Excluded from Federal Procurement and Nonprocurement Programs.

(9)

Nothing contained in the foregoing shall be construed to require establishment of a
system of records in order to render in good faith the certification required by this clause.
The knowledge and information of a participant is not required to exceed that which is
normally possessed by a prudent person in the ordinary course of business dealings.

(10)

Except for transactions authorized under paragraph 6 of these instructions, if a participant
in a covered transaction knowingly enters into a lower tier covered transactions with a
person who is proposed for debarment under 48 CFR Part 9, Subpart 9.4, debarred,
suspended, declared ineligible, or voluntarily excluded from participation in this
transaction, in addition to other remedies available to the Federal Government, the
department or agency may terminate this transaction for cause or default.

Certification--Primary Covered Transactions
This certification is required by the regulations implementing Executive Order 12549,
Debarment and Suspension, 29 CFR 98.510, Participants' responsibilities.
(1)
The prospective primary participant certifies to the best of its knowledge and belief,
that it and its principals:

II-3

(2)

(a)

Are not presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded from covered transactions by any Federal
department or agency;

(b)

Have not within a three-year period preceding this proposal been convicted of or
had a civil judgment rendered against them for commission of fraud or a criminal
offense in connection with obtaining, attempting to obtain, or performing a public
(Federal, State or local) transaction or contract under a public transaction;
violation of Federal or State antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;

(c)

Are not presently indicted for or otherwise criminally or civilly charged by a
governmental entity (Federal, State or local) with commission of any of the
offenses enumerated in paragraph 1.b. of this certification; and

(d)

Have not within a three-year period preceding this proposal had one or more
public transactions (Federal, State or local) terminated for cause or default.

Where the prospective primary participant is unable to certify to any of the statements in
this certification, such prospective participant shall attach an explanation to this
application/proposal.

Instructions--Lower-Tier Covered Transactions
(1)

By signing and submitting this proposal, the prospective lower tier participant is
providing the certification set out below.

(2)

The certification in this clause is a material representation of fact upon which reliance
was placed when this transaction was entered into. If it is later determined that the
prospective lower tier participant knowingly rendered an erroneous certification, in
addition to other remedies available to the Federal Government, the department or
agency with which this transaction originated may pursue available remedies, including
suspension and/or debarment.

(3)

The prospective lower tier participant shall provide immediate written notice to the
person to whom this proposal is submitted if at any time the prospective lower tier
participant learns its certification was erroneous when submitted or has become
erroneous by reason of changed circumstances.

(4)

The terms "covered transaction", "debarred", "suspended", "ineligible", "lower tier
covered transaction", "participant," "person", "primary covered transaction", "principal",
"proposal", and "voluntarily excluded," as used in this clause, have the meanings set out
in the Definitions and Coverage sections of the rules implementing Executive Order
12549 [29 CFR 98.105 and 29 CFR 98.110]. You may contact the person to which this
proposal is submitted for assistance in obtaining a copy of those regulations.

(5)

The prospective lower tier participant agrees by submitting this proposal that, should the
proposed covered transaction be entered into, it shall not knowingly enter into any lower
tier covered transaction with a person who is proposed for debarment under 48 CFR Part
9, Subpart, 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from
participation in this covered transaction, unless authorized by the department or agency
with which this transaction originated.

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(6)

The prospective lower tier participant further agrees by submitting this proposal that it
will include the clause titled "Certification Regarding Debarment, Suspension,
Ineligibility and Voluntary Exclusion--Lower Tier Covered Transactions," provided by
the department or agency entering into this covered transaction, without modification, in
all lower tier covered transactions and in all solicitations for lower tier covered
transactions.

(7)

(8)

(9)

Except for transactions authorized under paragraph 5 of these instructions, if a participant
in a covered transaction knowingly enters into a lower tier covered transactions with a
person who is suspended, debarred, ineligible, or voluntarily excluded from participation
in this transaction, in addition to other remedies available to the Federal Government, the
department or agency with which this transaction originated may pursue available
remedies, including suspension and/or debarment.

Certification--Lower-Tier Covered Transactions
This certification is required by the regulations implementing Executive Order 12549,
Debarment and Suspension, 29 CFR 98.510, Participants' responsibilities. The regulations were
published as Part VII of the May 26, 1988, Federal Register (pages 19160-19211).

(1)

The prospective lower tier participant certifies, by submission of this proposal, that
neither it nor its principals are presently debarred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded from participation in this transaction by any
Federal department or agency.

(2)

Where prospective lower tier participant is unable to certify to any of the statements in
this certification, such prospective participant shall attach an explanation to this proposal.

DRUG-FREE WORKPLACE CERTIFICATION
a.

Instructions
(1)

By signing and/or submitting this application or grant agreement, the grantee is
providing the certification set out below (see Section b.(1); however, see also Section
b.(2)).

(2)

The certification set out below is a material representation of fact upon which reliance is
placed when the agency awards the grant. If it is later determined that the grantee
knowingly rendered a false certification, or otherwise violates the requirements of the
Drug-Free Workplace Act, the agency, in addition to any other remedies available to the
Federal Government, may take action authorized under the Drug-Free Workplace Act.
II-5

(3)

Workplaces under grants, for grantees other than individuals, need not be identified on
the certification. If known, they may be identified in the grant application. If the grantee
does not identify the workplaces at the time of application, or upon award, if there is no
application, the grantee must keep the identity of the workplace(s) on file in its office and
make the information available for Federal inspection. Failure to identify all known
workplaces constitutes a violation of the grantee's drug-free workplace requirements.

(4)

Workplace identifications must include the actual address of buildings (or parts of
buildings) or other sites where work under the grant takes place. Categorical
descriptions may be used (e.g., all vehicles of a mass transit authority or State highway
department while in operation. State employees in each local unemployment office,
performers in concert halls or radio studios).

(5)

If the workplace identified to the agency changes during the performance of the grant,
the grantee shall inform the agency of the change(s), if it previously identified the
workplaces in question (see paragraph (3)).

(6)

Definitions of terms in the Nonprocurement Suspension and Debarment common rule
and Drug-Free Workplace common rule apply to this certification. Grantees' attention is
called, in particular, to the following definitions from these rules:
"Controlled substance" means a controlled substance in Schedules I through V of the
Controlled Substances Act (21 USC. 812) and as further defined by regulation (21 CFR
1308.11 through 1308.15);
"Conviction" means a finding of guilt (including a plea of nolo contender) or imposition
of sentence, or both, by any judicial body charged with the responsibility to determine
violations of the Federal or State criminal drug statutes;
"Criminal drug statute" means a Federal or non-Federal criminal statute involving the
manufacture, distribution, dispensing, use, or possession of any controlled substance;
"Employee" means the employee of a grantee directly engaged in the performance of
work under a grant, including: (i) All "direct charge" employees; (ii) all "indirect charge"
employees unless their impact or involvement is insignificant to the performance of the
grant; and, (iii) temporary personnel and consultants who are directly engaged in the
performance of work under the grant and who are on the grantee's payroll. This
definition does not include workers not on the payroll of the grantee (e.g., volunteers,
even if used to meet a matching requirement; consultants or independent contractors not
on the grantee's payroll; or employees of subrecipients or subcontractors in covered
workplaces).

Certification Regarding Drug-Free Workplace Requirements
(1)

The grantee certifies that it will or will continue to provide a drug-free workplace by:
(a)

Publishing a statement notifying employees that the unlawful manufacture,
distribution, dispensing, possession or use of a controlled substance is prohibited
in the grantee's workplace and specifying the actions that will be taken against
employees for violation of such prohibition;

(b)

Establishing an ongoing drug-free awareness program to inform employees about:
the dangers of drug abuse in the workplace; the grantee's policy of maintaining a
drug-free workplace; any available drug counseling, rehabilitation, and employee
II-6

assistance programs; and the penalties that may be imposed upon employees for
drug abuse violations occurring in the workplace;

(2)

(c)

Making it a requirement that each employee to be engaged in the performance of
the grant be given a copy of the statement required by paragraph (a);

(d)

Notifying the employee in the statement required by paragraph (a) that, as a
condition of employment under the grant, the employee will abide by the terms of
the statement; and notify the employer in writing of his or her conviction for a
violation of a criminal drug statute occurring in the workplace no later than five
calendar days after such conviction;

(e)

Notifying the agency in writing within ten calendar days after receiving notice
under (d), above, from an employee or otherwise receiving actual notice of such
conviction. Employers of convicted employees must provide notice, including
position title, to every grant officer or other designee on whose grant activity the
convicted employee was working, unless the Federal agency has designated a
central point for the receipt of such notices. Notice shall include the identification
number(s) of each affected grant;

(f)

Taking one of the following actions within 30 calendar days of receiving notice
under subparagraph (d), above, with respect to any employee who is so convicted:
taking appropriate personnel action against such an employee, up to and including
termination, consistent with the requirements of the Rehabilitation Act of 1973, as
amended; or requiring such employee to participate satisfactorily in a drug abuse
assistance or rehabilitation program approved for such purposes by a Federal,
State, or local health, law enforcement, or other appropriate agency;

(g)

Making a good faith effort to continue to maintain a drug-free workplace through
implementation of paragraphs (a), (b), (c), (d), (e), and (f).

The grantee may insert in the spaces provided on the attached page (See Part III,
Application Materials) the sites(s) for the performance of work done under this
agreement, if the site(s) is/are different than that listed on the SF-424; and submit the
attached page as part of its application for Federal Assistance.

CERTIFICATION REGARDING LOBBYING ACTIVITIES
a.

Instructions
By signing and/or submitting this application or grant agreement, the grantee is providing
the certification set out below (see Section b.1.).

Certification for Contracts, Grants, Loans, and Cooperative Agreements
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1)

No Federal appropriated funds have been paid or will be paid, by or on behalf of the
undersigned, to any person for influencing or attempting to influence an officer or
employee of an agency, a Member of Congress, an officer or employee of Congress, or
an employee of a Member of Congress in connection with the awarding of any Federal
contract, the making of any Federal grant, the making of any Federal loan, the entering
into of any cooperative agreement, and the extension, continuation, renewal, amendment,
or modification of any Federal contract, grant, loan, or cooperative agreement.
II-7

(2)

If any funds other than Federal appropriated funds have been paid or will be paid to any
person for influencing or attempting to influence an officer or employee of any agency, a
Member of Congress, an officer or employee of Congress, or an employee of a Member
of Congress in connection with this Federal contract, grant, loan, or cooperative
agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure
Form to Report Lobbying," in accordance with its instructions.

(3)

The undersigned shall require that the language of this certification be included in the
award documents for all subawards at all tiers (including subcontracts, subgrants, and
contracts under grants, loans, and cooperative agreements) and that all subrecipients shall
certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this
transaction was made or entered into. Submission of this certification is a prerequisite for
making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any
person who fails to file the required certification shall be subject to a civil penalty of not less
than $10,000 and not more than $100,000 for each such failure.
5.

DISCLOSURE OF LOBBYING ACTIVITIES (SF-LLL)
a.

General Guidelines
The SF-LLL is an OMB-approved standard form for the disclosure of lobbying activities. If
applicable, this disclosure form shall be completed by the SGA upon entering into the
cooperative agreement or a material change to a previous filing, pursuant to title 31 USC
section 1352. The SGA must file this form each time it makes a payment or an agreement to
make a payment to any lobbying entity for influencing or attempting to influence an officer or
employee of any agency, a Member of Congress, an officer or employee of Congress, or an
employee of a Member of Congress in connection with a covered Federal action. Use the
SF-LLL-A Continuation Sheet for additional information if the space on the form is inadequate.
Complete all items that apply for both the initial and material change report. Refer to the
implementing guidance published by the Office of Management and Budget for additional
information.
Please Note: Submission of this form is necessary only if the State agency meet s the
above criteria.

Instructions for Completion of SF-LLL, Disclosure of Lobbying Activities
(1)

Identify the type of covered Federal action for which lobbying activity is and/or has been
secured to influence the outcome of a covered Federal action.

(2)

Identify the status of the covered Federal action.

(3)

Identify the appropriate classification of this report. If this is a follow-up report caused
by a material change to the information previously reported, enter the year and quarter in
which the change occurred. Enter the date of the last previously submitted report by this
reporting entity for this covered Federal action.

(4)

Enter the full name, address, city, State, and zip code of the reporting entity. Include
Congressional District, if known. Check the appropriate classification of the reporting
entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the
tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. Subawards
include but are not limited to subcontracts, subgrants and contract awards under grants.
II-8

(5)

If the organization filing the report in item 4 checks "subawardee", then enter the full
name, address, city, State, and zip code of the prime Federal recipient. Include
Congressional District, if known.

(6)

Enter the name of the Federal agency making the award or loan commitment. Include at
least one organizational level below agency name, if known. For example, Department
of Transportation, U.S. Coast Guard.

(7)

Enter the Federal program name or description for the covered Federal action (item 1). If
known, enter the full Catalog of Federal Domestic Assistance (CFDA) number for grants,
cooperative agreements, loans and loan commitments.

(8)

Enter the most appropriate Federal identifying number available for the Federal action
identified in item 1 (e.g., Request for Proposal (RFP) number; Invitation for Bid (IFB)
number; grant announcement number; the contact, grant, or loan award number; the
application/proposal control number assigned by the Federal agency). Include prefixes,
e.g., "RFP-DE-90-001."

(9)

For a covered Federal action where there has been an award or loan commitment by the
Federal agency, enter the Federal amount of the award/loan commitment for the prime
entity identified in item 4 or 5.

(10a) Enter the full name, address, city, State, and zip code of the lobbying entity engaged by
the reporting entity identified in item 4 to influence the covered Federal action.
(10b) Enter the full names of the individual(s) performing services, and include full address if
different from 10a. Enter Last Name, First Name, and Middle Initial (MI).
(11)

Enter the amount of compensation paid or reasonably expected to be paid by the
reporting entity (item 4) to the lobbying entity (item 10). Indicate whether the payment
has been made (actual) or will be made (planned). Check all boxes that apply. If this is a
material change report, enter the cumulative amount of payment made or planned to be
made.

(12)

Check the appropriate box(es). Check all boxes that apply. If payment is made through
an in-kind contribution, specify the nature and value of the in-kind payment.

(13)

Check the appropriate box(es). Check all boxes that apply. If other, specify nature.

(14)

Provide a specific and detailed description of the services that the lobbyist has
performed, or will be expected to perform, and the date(s) of any services rendered.
Include all preparatory and related activity, not just time spent in actual contact with
Federal officials. Identify the Federal officials(s) or employee(s) contacted or the
officer(s), employee(s), or Member(s) of Congress that were contacted.

(15)

Check whether or not a SF-LLL-A Continuation Sheet(s) is attached.

(16)

The certifying official shall sign and date the form, print his/her name, title, and
telephone number.

II-9

BLS AGENT AGREEMENT
a.

General Guidelines
The purpose of the BLS Agent Agreement is to inform persons of their responsibilities as
agents of the BLS for ensuring compliance with BLS confidentiality policies within the State
agencies.

Instructions
(1)

Each State Cooperating Representative should provide the BLS with a list of candidates
to be designated as agents of the BLS, including the name and title of each candidate.
The Cooperating Representative should include his or her own name and title on this list.

(2)

Each BLS Regional Commissioner will review the list of agent candidates provided by
the Cooperating Representatives within their respective regions. Each BLS Regional
Commissioner then will prepare an Agent Agreement for each approved agent candidate
and will signify BLS approval by signing the Agent Agreement.

(3)

The Agent Agreements then will be forwarded to the State Cooperating Representative,
who will be responsible for ensuring that each approved agent candidate signs their
respective Agent Agreement.

(4)

State designees must review Commissioner’s Order No. 3-04, “Confidential Nature of
BLS Records,” dated October 4, 2004, and the confidential information protection
provisions of the Confidential Information Protection and Statistical Efficiency Act of
2002.

(5)

State designees must review the BLS Agent Agreement and sign the form.

(6)

The State Cooperating Representative is responsible for forwarding to their respective
BLS Regional Office all signed Agent Agreements.

(7)

The BLS Regional Office is responsible for maintaining on file the signed original copies
of all BLS Agent Agreements received from their respective SGAs.

BUDGET INFORMATION -- NON-CONSTRUCTION PROGRAMS
a.

General Instructions
In general, the standard instructions for the SF-424A, which accompany the form, will apply, as
modified or supplemented by the information below. The information is organized around the
same bold-faced headings used in the standard instructions.
In preparing the budget, amounts must be separately shown for the different program activities
that comprise the OSHS program. Sections A,B,C, and D must include budget estimates for the
entire Federal fiscal year.

Specific Instructions
Section A. Budget Summary

II-10

Lines 1-4, Columns (a) and (b): Enter the appropriate program activity names on the
lines in column (a) and "17.005" (the catalog number) in the corresponding lines of
column (b).
Lines 1-4, Columns (c) and (g): The first and third paragraphs of the standard
instructions apply.
Section B. Budget Categories
Enter the same program activity names shown on Lines 1-4, Column (a) in the column
headings (1) through (4), as appropriate (normally, only two columns will be needed).
Lines 6a-h: Enter totals for the object class categories for each program activity.
Line 6j: The correct reference for determining indirect charges is OMB Circular A-87.
Line 6k: The sum of the totals from columns (1) and (2) must equal the total of column
(5); i.e., the sum of the parts must equal the whole.
Section C. Non-Federal Resources
Follow the standard instructions.
Section D. Forecasted Cash Needs
The estimates provided should reflect realistic quarterly requirements based on past
experiences for funding various phases of the program activity.
The sum of the four quarters should equal the total for the first year and they should be
the same as those shown in line 5, columns (e), (f) and (g), respectively, of Section A,
Budget Summary.
Section E. Budget Estimates of Federal Needs for Balance of the Project
These estimates will be aggregated by the national office for all States participating in the
program and used for projecting future fiscal budgets. Section E reflects Federal funds
only.
These estimates will not be binding on individual States.
Section F. Other Budget Information
Line 21: Follow the standard instructions.
Line 22: Indirect Costs. An approved current indirect cost rate in accordance with OMB
Circular A-87 may be applied to the Cooperative Agreement. Use of the rate contained
in the agreement is subject to any statutory or administrative limitations and is applicable
to the extent that funds are available. In the absence of an approved current rate, a State
which has submitted a proposed, indirect cost-rate package to the Office of Cost
Determination or submits a letter to the BLS that indicates its intention, may apply the
previously approved rate, pending approval of the new rate. When the new rate is
finalized, a signed copy of the approved, negotiated agreement must be submitted to the
BLS national office. If a rate is not approved at the start of the fourth quarter, the
agreement should be reduced by the amount that is set aside for a rate in the budget.

II-11

When rates cover the fiscal year of the State, generally July 1 through June 30, the rate
will be applied to the entire 12 months of the Cooperative Agreement period, October
through September with the understanding that the agreement may be modified for the
fourth quarter, subject to the availability of funds, to reflect changes in the new rate
effective at the start of the State's new fiscal year on July 1.
Administrative costs covered by an indirect cost rate may not be applied as direct costs.
Cost allocation plans should be reviewed to determine whether such costs as printing,
computer services, duplicating services, or space are duplicated wholly, or in part, as an
indirect cost.
Line 23: To be used at the applicant's discretion.
8.

WORK STATEMENTS
The work statements are the core documents in the application. They describe the work to be
performed, list major deliverables and/or milestones, identify methods that must be used, and
qualitative standards SGAs are expected to achieve. Instructions for completing the work statements
follow.
a.

State Abbreviation and Cooperative Agreement Number. Enter the standard two-letter postal
abbreviation for the State and the Cooperative Agreement number in the upper right-hand
corner of each page of the work statement in the spaces provided. If pages are added to the
work statement, enter the abbreviation and Cooperative Agreement number on each.

Compliance. Indicate agreement to comply with specified deliverables and milestones,
performance requirements, and quality assurance requirements by placing an "X" or check mark
in the appropriate boxes. Indicate responses to "yes-no" questions in the same way.

Explanation of Variances. If a SGA does not intend to comply fully with all performance
requirements for the entire period of the Cooperative Agreement, an explanation of the variance
must be developed in conjunction with the BLS regional office and shown in the space provided
for the work statement to which it applies. If the SGA failed during the previous period to meet
agreed-upon work requirements, for example, due dates for mailings or publishing of data, but
the problem has already been corrected and the SGA expects to meet the requirements in the
current year, then no variance is required. However, if the SGA failed to meet the requirements
in the previous period, and must perform work during the Cooperative Agreement period to
improve performance, then a variance must be developed and included in the Cooperative
Agreement. An explanation of the variance must include-(1)

Background of the problem;

(2)

Performance during the previous period, such as the previous survey year or the previous
fiscal year for financial reporting;

(3)

Proposed performance; and

(4)

Milestones for activities to bolster performance.
These milestones should enable the SGA to meet standard deliverables by the end of the
fiscal year.

II-12

If the explanation of the variance requires more than one page, place the State two-letter
abbreviation and Cooperative Agreement number at the top of each page and number the
additional pages sequentially.
d.

The work statement is to be completed only once, when the original cooperative agreement
application is submitted. The requirements will continue in effect (as appropriate) for any
modifications to the original cooperative agreement. If a SGA is unable to comply with any of the
requirements for all programs, or failed to meet requirements in the previous period, the box
should be left blank and an explanation of variance provided. No variances will be accepted for
the requirement that the SGA comply with the Administrative Requirements, which include the
Assurances.

II-13

[this page intentionally left blank]

III. APPLICATION MATERIALS

This Part contains all the forms required to apply for Federal financial assistance for the OSHS program.
Information and instructions specific to the OSHS program, needed for completing these forms, appear in Part II,
Application Instructions. General instructions accompanying OMB standard forms are also included in this Part.
Included here are:

•

Application for Federal Assistance (Standard Form 424)

•

Budget Information--Non-Construction Programs (SF-424A)

•

Drug-Free Workplace Certification (if applicable)

•

Disclosure of Lobbying Activities (if applicable)

•

BLS Agent Agreement

•

Work Statements

[this page intentionally left blank]

Version 7/03

APPLICATION FOR
FEDERAL ASSISTANCE

2. DATE SUBMITTED

Applicant Identifier

1. TYPE OF
SUBMISSION
Pre-application
Application
Construction
Construction
Non Construction
Non-Construction
5. APPLICANT INFORMATION
Legal Name:

3. DATE RECEIVED BY STATE

State Application Identifier

4. DATE REC’D BY FEDERAL AGENCY

Federal Application Identifier

Organizational Unit:
Department:

Organizational DUNS No.:

Division:

Address:
Street:

Name and phone number of the person to be contacted on matters
Involving this application (give area code):
Prefix:
First Name:

City:

Middle Name

County:

Last Name

State:

Zip Code:

Suffix:

Country:

Email:

6. EMPLOYER IDENTIFICATION NUMBER (EIN):

Phone Number (give area code)

Fax Number (give area code)

-
8. TYPE OF APPLICATION:

New

7. TYPE OF APPLICANT: (See back of form for Application Types)

Other (specify):

Revision
Continuation
If Revision, enter appropriate letter(s) in box(es):

9. NAME OF FEDERAL AGENCY:

(See back of form for description of letters.)
Other (specify):

10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER:

11 .DESCRIPTIVE TITLE OF APPLICANT’S PROJECT:

-
TITLE (Name of Program):
12. AREAS AFFECTED BY PROJECT (Cities, Counties, States, etc.):
13. PROPOSED PROJECT:
a. Start Date

b. Ending Date

15. ESTIMATED FUNDING:
a. Federal

.00

b. Applicant

.00

c. State

.00

d. Local

.00

e. Other

.00

f. Program Income

.00

g. TOTAL

.00

14. CONGRESSIONAL DISTRICTS OF:
a. Applicant

b. Project

16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE ORDER 12372
PROCESS?
a. YES. THIS PREAPPLICATION/APPLICATION WAS MADE AVAILABLE TO
THE STATE EXECUTIVE ORDER 12372 PROCESS FOR REVIEW ON:
DATE: _______________________________________
b. NO PROGRAM IS NOT COVERED BY E.O. 12372
OR, PROGRAM HAS NOT BEEN SELECTED BY STATE FOR REVIEW

17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT?
YES (if “YES”, attach an explanation.) NO

18. TOTHEBESTOFMYKNOWLEDGEANDBELIEF,ALLDATAINTHISPREAPPLICATION/APPLICATIONARETRUEANDCORRECT. THEDOCUMENTHASBEENDULYAUTHORIZEDBYTHEGOVERNINGBODYOF
THEAPPLICANTANDTHEAPPLICANTWILLCOMPLYWITHTHEATTACHEDASSURANCESIFTHEASSISTANCEISAWARDED.
a. Authorized Representative
Prefix
First Name
Last Name

Middle Name
Suffix

b. Title

c. Telephone Number (give area code)

d. Signature of Authorized Representative

e. Date Signed

Previous Edition Not Usable
Authorized for Local Reproduction
19. a.
Typed Name of BLS Grant Officer
d.

Signature of BLS Grant Officer

b. Title

Standard Form 424 (Rev. 9-2003)
Prescribed by OMB Circular A-102
c. Telephone Number
e. Date Signed

INSTRUCTIONS FOR THE SF-424
Public reporting burden for this collection of information is estimated to average 45 minutes per response, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the Office
of Management and Budget, Paperwork Reduction Project (0348-0043), Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS
PROVIDED BY THE SPONSORING AGENCY.

This is a standard form used by applicants as a required face sheet for preapplications and applications submitted for Federal
assistance. It will be used by Federal agencies to obtain applicant certification that States which have established review and comment
procedures in response to Executive Order 12372 and have selected the program to be included in their process, have been given an
opportunity to review the applicant’s submission.
Item:
1.

Entry:
Select Type of Submission.

Item:
11.

Date application submitted to Federal agency (or State if applicable)
and applicant’s control number (if applicable).

12.

State use only (if applicable).

13.

Enter the proposed start date and end date of the project.

Enter Date Received by Federal Agency.
Federal identifier number: If this application is a continuation or
revision to an existing award, enter the present Federal Identifier
number. If for a new project, leave blank.

14.

List the applicant’s Congressional District and any District(s)
affected by the program or project.

Enter legal name of applicant, name of primary organizational unit
(including division, if applicable), which will undertake the assistance
activity, enter the organization's DUNS number (received from Dun
and Bradstreet), enter the complete address of the applicant
(including country), and name, telephone number, e-mail and fax of
the person to contact on matters related to this application.

15.

Enter Employer Identification Number (EIN) as assigned by the
Internal Revenue Service.

16.

Enter the appropriate letter in the space provided:
A.
State
I.
State Controlled
B.
County
Institution of Higher
C.
Municipal
Learning
D.
Township
J.
Private University
E.
Interstate
K.
Indian Tribe
F.
Intermunicipal
L.
Individual
G.
Special District
M.
Profit Organization
H.
Independent School
N.
Other (Specify)
District
O.
Not for Profit
Organization
Select the type from the following list:
"New" means a new assistance award
"Continuation" means an extension for an additional funding/budget
period for a project with a projected completion date.
"Revision" means any change in the Federal Government's financial
obligation or contingent liability from an existing obligation. If a
revision enter the appropriate letter:
A. Increase Award
B. Decrease Award
C. Increase Duration
D. Decrease Duration
Name of Federal agency from which assistance is being requested
with this application.

17.

Amount requested or to be contributed during the first
funding/budget period by each contributor. Value of in-kind
contributions should be included on appropriate lines as
applicable. If the action will result in a dollar change to an
existing award, indicate only the amount of the change. For
decreases, enclose the amounts in parentheses. If both
basic and supplemental amounts are included, show
breakdown on an attached sheet. For multiple program
funding, use totals and show breakdown using same
categories as item 15.
Applicants should contact the State Single Point of Contact
(SPOC) for Federal Executive Order 12372 to determine
whether the application is subject to their State
intergovernmental review process.
This question applies to the applicant organization, not the
person who signs as the authorized representative.
Categories of debt include delinquent audit disallowances,
loans, and taxes.

10.

Entry:
Enter a brief descriptive title of the project. If more than one
program is involved, you should append an explanation on a
separate sheet. If appropriate (e.g., construction or real
property projects), attach a map showing project location.
For preapplications, use a separate sheet to provide a
summary description of this project.
List only the largest political entities affected (e.g., State,
counties, cities).

18.

To be signed by the authorized representative of the
applicant. A copy of the governing body’s authorization for
you to sign this application as official representative must be
on file in the applicant’s office. (Certain Federal agencies
may require that this authorization be submitted as part of
the application.)

19.

Item added to SF-424 to provide a block for the Grant
Officer’s signature, which indicates approval of the
cooperative agreement, and award of the funding amount
shown in block 15.g.

Use the Catalog of Federal Domestic Assistance number and title of
this program under which assistance is requested.
SF-424 (Rev. 7-97) Back

OMB Approval No. 0348-0044
BUDGET INFORMATION -- Non-Construction Programs

SECTION A – BUDGET SUMMARY

Grant Program
Function
Or Activity
(a)

Catalog of Federal
Domestic Assistance
Number
(b)

Estimated Unobligated Funds
Federal
(c)

New or Revised Budget

Non-Federal
(d)

Federal
(e)

Non-Federal
(f)

Total
(g)

2.
3.
4.
5. TOTALS

SECTION B -- BUDGET CATEGORIES

6. Object Class Categories
a. Personnel

(1)

GRANT PROGRAM, FUNCTION, OR ACTIVITY
(2)
(3)
(4)

TOTAL
(5)

b. Fringe Benefits
c. Travel
d. Equipment
e. Supplies
f. Contractual
g. Construction
h. Other
i. Total Direct Charges (sum of 6a-6h)
j. Indirect Charges
k. TOTALS (sum of 6i and 6j)
7. Program Income

Authorized for Local Reproduction

Standard Form 424A (4-88)
Prescribed by OMB Circular A-102

INSTRUCTIONS FOR THE SF-424A
General Instructions

Lines 1-4, Columns (c) through (g) (continued)

This form is designed so that application can be made
for funds from one or more grant programs. In
preparing the budget, adhere to any existing Federal
grantor agency guidelines which prescribe how and
whether budgeted amounts should be separately
shown for different functions or activities within the
program. For some programs, grantor agencies may
require budgets to be separately shown by function or
activity. For other programs, grantor agencies may
require a breakdown by function or activity. Sections
A, B, C, and D should include budget estimates for
the whole project except when applying for assistance
which requires Federal authorization in annual or
other funding period increments. In the latter case,
Sections A, B, C, and D should provide the budget
for the first budget period (usually a year) and Section
E should present the need for Federal assistance in the
subsequent budget periods. All applications should
contain a breakdown by the object class categories
show on Lines a-k of Section B.

For continuing grant program applications, submit
these forms by the end of each funding period as
required by the grantor agency. Enter in Columns (c)
and (d) the estimated amounts of funds which will
remain unobligated at the end of the grant funding
period only if the Federal Grantor agency instructions
provide for this. Otherwise, leave these columns
blank. Enter in columns (e) and (f) the amounts of
funds needed for the upcoming period. The
amount(s) in Column (g) should be the sum of
amounts in Columns (e) and (f).

Section A. Budget Summary

For supplemental grants and changes to existing
grants, do not use Columns (c) and (d). Enter in
Column (e) the amount of the increase or decrease of
Federal funds and enter in Column (f) the amount of
the increase or decrease of non-Federal funds. In
Column (g), enter the new total budgeted amount
(Federal and non-Federal) which includes the total
previous authorized budgeted amounts plus or minus,
as appropriate, the amounts shown in Columns (e)
and (f). The amount(s) in Column (g) should not
equal the sum of amounts in Columns (e) and (f).

Lines 1-4, Columns (a) and (b)
Line 5 - Show the totals for all columns used.
For applications pertaining to a single Federal grant
program (Federal Domestic Assistance Catalog
number) and not requiring a functional or activity
breakdown, enter on Line 1 under Column (a) the
catalog program title and the catalog number in
Column (b). For applications pertaining to a single
program requiring budget amounts by multiple
functions or activities, enter the name of each activity
or function on each line in Column (a), and enter the
catalog number in Column (b). For applications
pertaining to multiple programs where none of the
programs require a breakdown by function or activity,
enter the catalog program title on each line in Column
(a) and the respective catalog number on each line in
Column (b).

Section B. Budget Categories
In the column headings (1) through (4), enter the
titles of the same programs, functions and activities
shown on Lines 1-4, column (a), Section A. When
additional sheets are prepared for Section A, provide
similar column headings on each sheet. For each
program, function or activity, fill in the total
requirements for funds (both Federal and nonFederal) by object class categories.
Lines 6a- i - Show the totals of Lines 6a to 6h in each
column.
Line 6j - Show the amount of indirect cost.

For applications pertaining to multiple programs
where one or more programs require a breakdown by
function or activity, prepare a separate sheet for each
program requiring the breakdown. Additional sheets
should be used when one form does not provide
adequate space for all breakdown of data required.
However when more than one sheet is used, the first
page should provide the summary totals by programs.
Lines 1-4, Columns (c) through (g)
For new applications, leave Columns (c) and (d)
blank. For each line entry in Columns (a) and (b),
enter in Columns (e), (f), and (g) the appropriate
amounts of funds needed to support the project for
the first funding period (usually a year).

Line 6k - Enter the total of amounts on Lines 6i and
6j. For all applications for new grants and
continuation grants the total amount in column (5),
Line 6k, should be the same as the total amount
shown in Section A, Column (g), Line 5. For
supplemental grants and changes to grants, the total
amount of the increase or decrease as shown in
Columns (1)-(4), Line 6k should be the same as the
sum of the amounts in Section A, Columns (e) and (f)
on Line 5.

SF-424A(Rev 4-92) Page 2

SECTION C -- NON-FEDERAL RESOURCES
(a) Grant Program

(b) Applicant

(d) Other Sources

(e) TOTALS

9.
10.
11.
12. TOTALS (sum of lines 8 and 11)

SECTION D – FORECASTED CASH NEEDS
Total for 1st Year
13. Federal

1st Quarter

2nd Quarter

3rd Quarter

4th Quarter

14. Non-Federal
15. TOTALS (sum of lines 13 and 14)

SECTION E -- BUDGET ESTIMATES OF FEDERAL FUNDS NEEDED FOR BALANCE OF THE PROJECT
(a) Grant Program
16.

FUTURE FUNDING PERIODS (years)
(c) Second
(d) Third

(b) First

(e) Fourth

17.
18.
19.
20. TOTALS (sum of lines 16 - 19)

SECTION F -- OTHER BUDGET INFORMATION
(Attach Additional Sheets if Necessary)

21. Direct Charges:

22. Indirect Charges:

23. Remarks
Authorized for Local Reproduction

Standard Form 424A (4-88) Page 2
Prescribed by OBM Circular A-102

INSTRUCTIONS FOR THE SF-424A (continued)
Line 7 - Enter the estimated amount of income, if
any, expected to be generated from this project. Do
not add or subtract this amount from the total project
amount. Show under the program narrative statement
the nature and source of income. The estimated
amount of program income may be considered by the
Federal grantor agency in determining the total
amount of the grant.

Line 14 - Enter the amount of cash from all other
sources needed by quarter during the first fiscal year.

Section C. Non-Federal Resources

Column (a) - Enter the program titles
identical to Column (a), Section A. A
breakdown by function or activity is not
necessary.

Lines 16-19 - Enter in Column (a) the same grant
program titles shown in Column (a), Section A. A
breakdown by function or activity is not necessary.
For new applications and continuation grant
applications, enter in the proper columns amounts of
Federal funds which will be needed to complete the
program or project over the succeeding funding
periods (usually in years). This section need not be
completed for revisions (amendments, changes, or
supplements) to funds for the current year of existing
grants.

Column (b) - Enter the contribution to be
made by the applicant.

If more than four lines are needed to list the program
titles, submit additional schedules as necessary.

Column (c) - Enter the amount of the State’s
cash and in-kind contribution if the applicant
is not a State or State agency. Applicants
which are a State or State agencies should
leave this column blank.

Line 20 - Enter the total for each of the Columns (b) (e). When additional schedules are prepared for this
Section, annotate accordingly and show the overall
totals on this line.

Lines 8-11 - Enter the amounts of non-Federal
resources that will be used on the grant. If in-kind
contributions are included, provide a brief
explanation on a separate sheet.

Line 15 - Enter the totals of amounts on Lines 13 and
14.
Section E. Budget Estimates of Federal Funds
Needed for Balance of the Project

Section F. Other Budget Information
Column (d) - Enter the amount of cash and
in-kind contributions to be made from all
other sources.
Column (e) - Enter totals of Columns (b),
(c), and (d).
Line 12 - Enter the total for each of Columns (b) (e). The amount in Column (e) should be equal to the
amount on Line 5, Column (f), Section A.

Line 21 - Use this space to explain amounts for
individual direct object-class cost categories that may
appear to be out of the ordinary or to explain the
details as required by the Federal grantor agency.
Line 22 - Enter the type of indirect rate (provisional,
predetermined, final or fixed) that will be in effect
during the funding period, the estimated amounts of
the base to which the rate is applied and the total
indirect cost expense.

Section D. Forecasted Cash Needs
Line 13 - Enter the amount of cash needed by quarter
from the grantor agency during the first fiscal year.

Line 23 - Provide any other explanations or
comments deemed necessary.

SF-424A (Rev 4-92) Page 4

CERTIFICATION REGARDING
DRUG-FREE WORKPLACE REQUIREMENTS

This page may be included in the applicant's application for Federal assistance, as part of its Certification Regarding DrugFree Workplace Requirements, if the place(s) of performance of work done in connection with this cooperative agreement
is/are other than that listed on the SF-424 (see Part II, Application Instructions, for further information).

Place(s) of performance of work done in connection with this cooperative agreement, if other than that listed on SF-424,
Application for Federal Assistance:

(Street Address, City, County, State, Zip Code)

_______________________________________________________________________________

Check [___] if there are workplaces on file that are not identified here.

SGA Name: _________________________________________________________________

SGA Authorized Representative:

Signature: _______________________________________________________________

Name: __________________________________________________________________

Title: ___________________________________________________________________

[this page intentionally left blank]

DISCLOSURE OF LOBBYING ACTIVITIES
Complete this form to disclose lobbying activities pursuant to 31 USC 1352
(See below for public burden disclosure.)

2. Status of Federal Action
S a. bid/offer/application
S b. initial award
S c. post award

1. Type of Federal Action
S a. contract
S b. grant
S c. cooperative agreement
S d. loan
S e. loan guarantee
S f. loan insurance

3. Report Type:
S a. initial filing
S b. material change
For Material Change Only:
year _________ quarter _______
date of last rept.______________
5. If Reporting Entity in No. 4 is Subawardee, Enter Name and
Address of Prime:

4. Name and Address of Reporting Entity:
S Prime
S Subawardee; Tier _____, if known.

Congressional District, if known:

Congressional District, if known:
6. Federal Department/Agency

7. Federal Program Name/Description

CFDA Number, if applicable:_________________
8. Federal Action Number, if known:

9. Award Amount, if known:
$____________________________

10a. Name and Address of Lobbying Entity (if individual, last name, first
name, MI):

13. Type of Payment (check all that apply):
S a. retainer
S b. one-time fee
S c. commission
S d. contingent fee
S e. deferred
S f. other; specify:_____________________________

11. Amount of Payment (check all that apply):
$__________ S actual

10b. Individuals Performing Services (including address if different from
No. 10a.) (last name, first name, MI):

S planned

12. Form of Payment (check all that apply):
S a. cash
S b. in-kind; specify: nature ______
value _______

14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s), employee(s), or Member(s) contacted,
for Payment Indicated in Item 11:
(Attach Continuation Sheet(s) SF-LLL-A, if necessary)
15. Continuation Sheet(s) SF-LLL-A attached: S yes S no
16. Information requested through this form is authorized by title 31 USC section 1352. This disclosure of
activities is a material representation of fact upon which reliance was placed by the tier above when
this transaction was made or entered into. This disclosure is pursuant to 31 USC 1352. This
information will be reported to the Congress semi-annually and will be made available for public
inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of no
less than $10,000 and not more than $100,000 for each such failure.

Signature:_________________________________
Print Name:________________________________
Title:______________________________________
Tel. No.:______________________ Date:_____/_____/_____

Authorized for local reproduction

Standard Form - LLL

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of
Management and Budget, Paperwork Reduction Project (0348--0046), Washington, DC 20503

OMB Approval No. 0991-0002

[this page intentionally left blank]

DISCLOSURE OF LOBBYING ACTIVITIES

CONTINUATION SHEET

Reporting Entity:_______________________________________________________

Page ________ of ________

Authorized for Local Reproduction

Standard Form - LLL - A

[this page intentionally left blank]

BLS AGENT AGREEMENT
1. I, [Name BLS Designating Official], an authorized official of the Bureau of Labor Statistics (BLS), U.S. Department
of Labor, hereby designate [Name of Agent] as a temporary Agent of the BLS, within the meaning of the Confidential
Information Protection and Statistical Efficiency Act of 2002 (CIPSEA), Public Law 107-347 (Exhibit A), to serve in
accordance with this Agent Agreement, the Cooperative Agreement and any other agreements entered into between
the BLS and [Name of Organization], and in accordance with applicable Federal law.
2. I, [Name of Agent], hereby accept the designation as Agent in paragraph 1. I certify that I have read all applicable
agreements between the BLS and the State agency and promise that I will comply with all provisions of this Agent
Agreement, the Cooperative Agreement or any other agreements between the BLS and the State agency, and
applicable law. I will assure that my actions or inactions do not cause the State agency to violate its responsibilities
under those agreements. I specifically swear to comply with all provisions of law that affect information acquired by
the BLS, including, but not limited to, the Trade Secrets Act and the Confidential Information Protection and Statistical
Efficiency Act of 2002, and I understand that my failure to comply with these provisions may subject me to criminal
sanctions. I also agree to comply with all other BLS information policies.
3. We, the parties to this agreement understand that the BLS is granting the Agent access to confidential information
only for the purpose of carrying out the Agent's responsibilities under written agreements between the BLS and the
State agency. The Agent will not seek or obtain such confidential information for any other purpose.
4. We, the parties, understand and agree that the activities performed by and any outputs produced by the Agent
under this agreement are subject to review upon request by the assigned BLS Regional Commissioner or any other
BLS official that the BLS designates for verification that the activities are statistical in nature and that outputs do not
contain respondent-identifying data.
5. We, the parties, understand and agree that the Agent will not be an employee of the United States for any purpose
and will not receive compensation or payment of any kind from the BLS or the Government in connection with the
Agent's activities under this agreement or any other agreements between the BLS and the State agency. Neither this
agreement nor any agreement between the BLS and the State agency provide any right of access to BLS information.
The parties also understand and agree that the BLS may decline to give the Agent access to information and/or to
terminate this agreement at any time, without notice. The parties agree that neither this agreement, nor any
termination thereof will result in any legal liability by the BLS or the Government; however, termination will not affect
the Agent's continuing obligation to safeguard all confidential data, and it will not affect any license granted to the
Government pursuant to section 6.
6. We, the parties, understand and agree that for the purposes of the copyright laws any product developed under this
agreement is in the public domain and is therefore not subject to copyright protection. However, it is also understood
that confidential information remains fully protected from improper disclosure and use as provided by law and this
agreement.
7. I, [Name of Agent], will notify the BLS if I should no longer be affiliated with the State agency or of any change of
status with the State agency.
8. I, [Name of Agent], fully understand my responsibilities to protect confidential information. I will comply with all
security requirements and will avoid all improper use or disclosure of confidential information. I understand that under
Section 513 of CIPSEA, the penalty for a knowing and willful disclosure of confidential information is a class E felony
with a fine of not more than $250,000 or imprisonment for not more than 5 years, or both.

[Name of Agent]
[Title]
[Name of Organization]

[Name of BLS Official]
Regional Commissioner
Bureau of Labor Statistics

_________________
Date

[this page intentionally left blank]

OSHS COOPERATIVE AGREEMENT
WORK STATEMENTS

The BLS uses the attached "check-the-box" work statements in lieu of requiring long, written program narratives to
accompany the Cooperative Agreement application. OMB Circular A-102 states that agencies should generally
include a request for a program narrative statement that is based on instructions provided in the circular. The
instructions include: objectives and need for assistance, results or benefits expected, approach, and geographic
location.
The work statements are considered forms for purposes of OMB's Paperwork Reduction Act approval process. As
such, an estimate of the time required to complete the form must be provided and those affected by the forms must
be afforded the opportunity to comment on the estimates or any other aspect of the form. Rather than place the
required language on each of the work statements that follow, estimates are provided below. Each estimate of time
required to complete a work statement assumes that no variances will be needed. The work statements and the
estimated times to complete them are:
All Programs
Annual Survey
CFOI

25 minutes
50 minutes
45 minutes

We estimate that it will take an average of two (2) hours to complete these forms, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the information. If you have any comments on the estimates or the forms, send them to the Bureau of
Labor Statistics, Division of Financial Planning and Management (1220-0079), 2 Massachusetts Avenue, NE,
Washington, D.C. 20212-0001. You are not required to respond to the collection of information unless it displays a
currently valid OMB control number.

[this page intentionally left blank]

Work Statement

State

CA Number

_____

W9J_________

ALL OSHS PROGRAMS
Agree To
Comply
(Check Box)

ADMINISTRATIVE REQUIREMENTS/ASSURANCES

The SGA shall adhere to all terms and conditions specified in Part I, Administrative Requirements,
including the Assurances. By agreeing to comply here, the SGA is relieved of attaching the
Assurances (Standard Form 424C) to its application. No variances will be accepted for this
requirement.

SUBMISSION OF FINANCIAL REPORTS

The SGA shall complete and submit the PMS-272, Federal Cash Transactions Report, according to
Health and Human Services Payment Management System (HHS-PMS) instructions. The
BLS-OSHS2, Quarterly Financial Report, shall be completed and submitted to the BLS regional
office within 30 days of the completion of the reporting period and sent to the BLS, Washington.
(The Financial Status Report [SF-269], is not required quarterly, but is required as part of the SGA's
closeout package.)

[____]

PROGRAM REQUIREMENTS APPLICABLE TO BOTH SOII AND CFOI
1.

PUBLICATION OF DATA
The SGA shall publish data produced under this cooperative agreement. The SGA
should coordinate its publications with the BLS regional office. Three copies of any
publication produced by the State with cooperative agreement funds will be provided to
the BLS Regional Office (who will forward two copies to the Office of Safety, Health,
and Working Conditions) within ten days of publication. If a web site is used for
publication, the State should provide BLS with the URL address.

[____]

RESEARCH PROPOSALS
States are encouraged to prepare research papers on the validity, usefulness, and
efficiency of SOII and/or CFOI data in State surveillance projects. The SGA will submit
a proposal for the research paper to the BLS. If the proposal is approved, the BLS will
match the SGA funding and the SGA and the BLS will modify the cooperative
agreement to add funding and incorporate the approved proposal as part of the statement
of work. The SGA will then complete the report and submit three copies to the BLS
Regional Office (two of which will be forwarded to the Office of Safety, Health, and
Working Conditions) within 12 months of the start date established in the proposal. The
BLS may publish such research papers in its publications.

All Programs--1

[____]

Work Statement

State

CA Number

_____

W9J_________
Agree To
Comply
(Check Box)

PROGRAM REQUIREMENTS APPLICABLE TO BOTH SOII AND CFOI (CONTINUED)
3.

OSHS COMPUTER SYSTEMS
The SGA shall use the OSHS computer systems as specified in the program manuals,
instructions, administrative and technical memorandum to capture, edit, process,
transmit, review, and publish data from the SOII or CFOI.

[____]

The SGA shall follow instructions regarding the installation and deployment of any
updates to the operating systems.

[____]

OSHS COMPUTER EQUIPMENT
The SGA shall manage computer equipment (which includes personal computers,
monitors, keyboards, mice, and printers, as well as routers, hubs, and print servers)
supplied by BLS or purchased by the State for the OSHS programs in accordance with
BLS rules and procedures, including the submittal of the Property Listing at closeout if
required.

[____]

To preserve security and data integrity, the SGA shall ensure that the equipment
(including telecommunications lines) provided by BLS or the State for the programs
governed by this agreement shall only be used by authorized State personnel and only for
the BLS Occupational Safety and Health Statistics programs. Any other proposed use
requires written permission of the BLS regional office.

[____]

In the event the equipment is no longer needed, the SGA shall request disposition
instructions from the BLS. No disposition instructions are required in cases when the
title of equipment has been transferred to the SGA.

[____]

The SGA shall maintain the hardware in working order. In the event maintenance is
needed the hardware must be back in working order within three (3) workdays.

[____]

ATTENDANCE AT CONFERENCES
The SGA shall be represented at the BLS/State annual conference on occupational
fatalities and nonfatal occupational injuries and illnesses. Senior management of the
Survey of Occupational Injuries and Illnesses and the Census of Fatal Occupational
Injuries for the SGA shall be represented at the BLS State managers’ roundtable
meetings, if scheduled. These meetings provide critical policy information, operational
instructions, and training to SGA staff and are an essential requirement of the CA.

[____]

PROGRAM TRAINING
SGA staff shall participate in scheduled BLS training.

All Programs--2

[____]

Work Statement

EXPLANATION OF VARIANCE

(Attach additional pages if needed)

All Programs--3

State

CA Number

_____

W9J_________

[this page intentionally left blank]

Work Statement

State

CA Number

_____

W9J_________

SURVEY OF OCCUPATIONAL INJURIES AND ILLNESSES
FISCAL YEAR 2007
Agree To
Comply
(Check Box)

PROGRAM ACTIVITIES
1.

FOR REFERENCE YEAR 2005:
The SGA shall by the dates specified in technical memoranda:
a.

Complete review of State estimates; and

[____]

Complete the coding of the collected cases using the OSHS coding procedures.

[____]

The SGA shall publish survey results.

[____]

The means to publish these results will be: (Please check format[s] below.)

Report

[____]

Press Release

[____]

Web Site
(list URL, if known now): __________________

[____]

Other
(Describe): ______________________________

[____]

FOR REFERENCE YEAR 2006:
The SGA shall:
[____]
a.

Collect the 2006 survey by the dates specified in the program manuals and technical
memoranda.

Edit and clarify the 2006 survey data as specified in the program manuals and
technical memoranda.

[____]

Code the collected cases according to the OSHS coding procedures by the dates
specified in technical memoranda.

[____]

Review State estimates.

[____]

SOII--1

Work Statement

State

CA Number

_____

W9J_________
Agree To
Comply
(Check Box)

PROGRAM ACTIVITIES (CONTINUED)
2.

FOR REFERENCE YEAR 2006 (CONTINUED):
The estimated number of units in the Survey for reference year 2006 will be:
a.

Private sector:
establishments

_________________

cases

_________________

b. Public sector:

establishments

_________________

cases

_________________

FOR REFERENCE YEAR 2007
The SGA shall, by the dates specified in the program manuals and technical memoranda:

Review and refine the 2007 sample units.

[____]

Pre-notify employers who have not been notified by the contract printer/mailer to
keep occupational injury and illness records.

[____]

PROGRAM PERFORMANCE REQUIREMENTS
1.

The SGA shall follow the procedures and timetables described in the OSHS program
manuals and technical memoranda in the performance of work under this agreement,
unless the SGA has received written approval from the BLS regional office.

[____]

The SGA shall use the survey forms provided by the BLS, unless the SGA has received
written approval from the BLS regional office. Because the BLS is concerned that SGA
forms designed to improve survey response may bias the data provided by respondents,
all such forms are required to have BLS regional office review and approval.

[____]

EMPLOYEE YEARS:

______________________

SOII--2

Work Statement

State

CA Number

_____

W9J_________

BLS STATE COOPERATING REPRESENTATIVE:
Name
________________________________________________________________________
Title
________________________________________________________________________
Address
________________________________________________________________________

________________________________________________________________________

________________________________________________________________________
Telephone
________________________________________________________________________

EXPLANATION OF VARIANCES

(Attach additional pages if needed)

SOII--3

[this page intentionally left blank]

Work Statement

State

CA Number

_____

W9J_________

CENSUS OF FATAL OCCUPATIONAL INJURIES (CFOI)
FISCAL YEAR 2007
Agree To
Comply
(Check Box)

PROGRAM ACTIVITIES
1.

DEVELOP AND MAINTAIN DATA SOURCES IDENTIFYING OCCUPATIONAL FATALITIES
The SGA shall make formal arrangements to obtain the following source documents as
well as amendments to these reports to identify occupational fatalities:
a.
b.
c.

death certificates with the "injury at work" box marked "Yes";
State workers' compensation fatality reports;
other fatality reports available to the SGA, such as news reports, medical
examiner records, autopsy reports, motor vehicle fatality reports, etc.

The BLS shall have access to source documents for data quality control purposes.
2.

[____]

VERIFY WORK-RELATEDNESS
The SGA will substantiate work-related injury fatalities, whenever possible, by at least
two independent source documents. The SGA shall attempt to obtain a substantiating
source document or conduct a mail follow-back when only one source document
identifies the fatal injury as work-related or when work relationship cannot be
determined from the available source materials. For any fatalities for which work
relationship could not be substantiated before the end of the data collection period, the
BLS, in consultation with the State and regional office, will determine whether these
fatalities are in scope for CFOI.

[____]

The SGA shall enter all fatal occupational illnesses identified on death certificates with
the "at work" box marked "yes" in the CFOI operating system, but is not required to
substantiate the work-relatedness of illness fatalities with two source documents.

[____]

CODE FATALITY DATA
The SGA shall code fatalities using information from the various source documents.
Data elements to be coded are listed in the CFOI program manual. States shall minimize
the use of "unknown" codes.

CFOI--1

[____]

Work Statement

State

CA Number

_____

W9J_________
Agree To
Comply
(Check Box)

PROGRAM ACTIVITIES (CONTINUED)
4.

CONDUCT FOLLOW-BACK AND DATA CLARIFICATION
The SGA will follow-up by mail or telephone when required data elements are missing
or inconsistent between source documents.

[____]

For follow-back and data clarification, the SGA shall use the guidelines, solicitation
letter, and OMB-approved questionnaire found in the CFOI program manual and
technical memoranda, unless the SGA has received prior written approval from the BLS
Regional Office.

[____]

ENTER DATA IN A TIMELY MANNER
The SGA will identify, verify, code, and enter current reference year cases into the CFOI
operating system by the dates specified in the CFOI manual and technical memoranda.

[____]

The SGA will set review flags as specified in the manual and technical memoranda.

[____]

The SGA will code all cases occurring in the first quarter of the reference year by
December of that reference year.

[____]

The SGA will promptly enter updates or additions to cases for the prior reference year
into the CFOI operating system prior to the dates specified in the technical memoranda.

[____]

PROCESS OUT-OF-STATE FATALITY REPORTS
The SGA shall be responsible for processing fatality reports for persons deceased or
fatally injured in that State.

[____]

The SGA is required to exchange information with SGAs in other States in the CFOI
program (abiding by the confidentiality requirements of the source agencies) to facilitate
the receipt and processing of fatality data to ensure that data on all fatal occupational
injuries are captured and published by State of incident.

[____]

PUBLISH DATA
The SGA shall publish CFOI results.

[____]

The means to publish these results will be: (Please check format[s] below.)
o

Report

[____]

Press Release

[____]

Web Site
(list URL, if known now): __________________

[____]

Other
(Describe): _____________________________

[____]

CFOI--2

Work Statement

State

CA Number

_____

W9J_________

Agree To
Comply
(Check Box)

PROGRAM PERFORMANCE REQUIREMENTS
1.

BLS INSTRUCTIONS, TIME SCHEDULES AND OMB-APPROVED QUESTIONNAIRE
The SGA shall follow the methods, technical instructions and time schedules described
in the program manual, technical memoranda and other communications in the
performance of work under this agreement for reference years 2005, 2006, and 2007.

[____]

States shall use the OMB-approved questionnaire for follow-back.

[____]

CONFIDENTIALITY
Source documents acquired by the SGA for the purposes of this cooperative agreement
are considered State records and should be handled by the SGA in accordance with its
written agreements with the State agencies that supply the source documents and in
accordance with State law. Data collected on the CFOI-1 form and all information
incorporated into the CFOI operating system will be used by the Bureau of Labor
Statistics for exclusively statistical purposes and will be held in confidence to the full
extent permitted by Federal law. Only BLS officers, employees, and agents will have
access to the confidential information. The BLS and SGA employees designated as
Agents of the BLS shall abide by the Confidential Information Protection and Statistical
Efficiency Act and all other applicable Federal laws governing confidentiality and by the
confidentiality provisions in Part I, Section Q of this cooperative agreement in handling
data from the CFOI-1 form and in handling data from the CFOI operating system.

[____]

The SGA shall work with the BLS to resolve any inconsistencies between the work
statement and confidentiality requirements of the source data agencies. Restrictions on
the use of data provided by a State agency should be listed in the section entitled,
Explanation of Variances.

[____]

Data collected by State agencies will be used only in the CFOI program unless the SGA
and data sources agree to other arrangements.

[____]

The SGA shall ensure that published CFOI results are in accordance with the BLS Data
Confidentiality provisions included in the CFOI program manual and technical
memoranda and in accordance with the SGA’s written agreement with the State agencies
that supply source documents.

[____]

RETENTION OF RECORDS
All records shall be retained for a period of at least one year after submitting the final
data file for the reference year, unless otherwise specified in the variances to this work
statement. States are encouraged to retain source documents for as long as they are
needed in State-specific research projects.

CFOI--3

[____]

Work Statement

State

CA Number

_____

W9J_________

Agree To
Comply
(Check Box)

RESEARCH FILES
The BLS will release to researchers under a Letter of Agreement a national research file with
personal, company, State, and county identifiers deleted. The purpose of the letter of
agreement, which is signed by the BLS Assistant Commissioner of Safety and Health Statistics
and the requesting organization official, is to ensure that users comply with the pledge of
confidentiality made to data sources by the BLS and the SGA.
The BLS intends to provide a CFOI research file to the Occupational Safety and Health
Administration (OSHA) Office of Research and Evaluations under a Memorandum of
Understanding that includes an additional data element. This data elements will identify
whether the fatality occurred in a State that has an OSHA approved State OSH plan or not.
The BLS intends to provide a CFOI research file to the National Institute of Occupational
Safety and Health (NIOSH) under a Memorandum of Understanding that includes additional
data elements. These data elements are: State codes, date of birth, date of death, actual age,
death certificate identification number, and narrative industry and occupation information.
The SGA authorizes the BLS to provide, upon request, research files of State-specific data to
designated agents of the BLS under Letters of Agreement that contain confidentiality
requirements that protect the data from unauthorized use or disclosure. States that receive
requests for research files of State-specific data shall forward the requests to the BLS for
consideration along with a letter from the BLS cooperating representative indicating approval
of the release of State-specific data. The BLS reserves the right to deny any request for access
to confidential data. The BLS will accommodate requests depending upon the statistical
purpose and technical merit of the requests and upon SGA authorization to provide access to
the State-specific data. (If a State does not check the box, then BLS must go to that State
on a case-by-case basis for approval to release State-specific data. In such a case, the
BLS would require a letter from the BLS cooperating representative indicating approval
of the release of State-specific data.)

CFOI--4

[____]

Work Statement

State

CA Number

_____

W9J_________

RESEARCH FILES (CONTINUED)
The BLS will include the following data elements on the CFOI fatal injury research file:

1.
2.
3.
4.

Reference year
Race
Gender
Industry (Standard Industrial Classification Manual, 1987 Edition; North
American Industry Classification System, U.S. 2002-beginning with RY 2003)
5. Ownership (Federal, State or local government; private)
6. Occupation (1990 Census of Population Occupational Classification
System; Standard Occupational Classification, 2000-beginning with RY 2003)
7. Employee status (wage and salary, self-employed)
8. Nature of injury (1992 BLS Occupational Injury and Illness
Classification Structures [OIICS])
9. Part of Body (1992 BLS OIICS)
10. Source of injury (1992 BLS OIICS)
11. Secondary source of injury (1992 BLS OIICS)
12. Event or exposure (1992 BLS OIICS)
13. Worker activity (at the time of incident)
14. Hispanic origin
15. Location type (farm, street, mine, etc.)
16. Geographic code (four Bureau of the Census regions)
17. Age group
18. Date of injury (day of the week, month, and year)
19. Date of death (number of days from date of injury)
20. Medical complications code (embolisms, infections, etc.)
21. Born in foreign country (continent of birth)
22. Establishment size (based on employment)
23. Length of time with employer
24. Time of incident (to the nearest hour)
25. How the injury occurred (narrative description)
Additional data elements for the NIOSH research file:
26. State codes
27. Actual age
28. Date of birth
29. Date of death
30. Death certificate identification number
31. Narrative industry and occupation information
(1999 and subsequent years)

Additional data element for the OSHA research file:
32. State Plan State indicator

CFOI--5

Work Statement

EMPLOYEE YEARS: ____________________

BLS STATE COOPERATING REPRESENTATIVE:

State

CA Number

_____

W9J_________

Name
________________________________________________________________________
Title
________________________________________________________________________
Address
________________________________________________________________________

________________________________________________________________________

________________________________________________________________________
Telephone
________________________________________________________________________

EXPLANATION OF VARIANCES

(Attach additional pages if needed)

CFOI--6

OSHS COOPERATIVE AGREEMENT DOCUMENT NUMBERS

State Grantee
Alabama
Alabama
Alaska
Alaska
Arizona
Arizona
Arkansas
Arkansas
California
California
Colorado
Connecticut
Connecticut
Delaware
Delaware
Dist. of Columbia
Dist. of Columbia
Florida
Florida
Georgia
Georgia
Guam
Hawaii
Hawaii
Idaho
Illinois
Illinois
Indiana
Indiana
Iowa
Iowa
Kansas
Kansas
Kentucky
Kentucky
Louisiana
Louisiana
Maine
Maine
Maryland
Maryland
Massachusetts
Massachusetts
Michigan
Michigan
Minnesota
Minnesota
Mississippi
Missouri

Program
Survey
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
Survey
Survey
CFOI
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
CFOI
Survey

Document No.
CA No.
Suffix
W9J78101
7P
W9J78101
7Q
W9J78102
7P
W9J78102
7Q
W9J78104
7P
W9J78104
7Q
W9J78105
7P
W9J78105
7Q
W9J78106
7P
W9J78106
7Q
W9J78108
7Q
W9J78109
7P
W9J78109
7Q
W9J78110
7P
W9J78110
7Q
W9J78111
7P
W9J78111
7Q
W9J78112
7P
W9J78112
7Q
W9J78113
7P
W9J78113
7Q
W9J78166
7P
W9J78115
7P
W9J78115
7Q
W9J78116
7Q
W9J78117
7P
W9J78117
7Q
W9J78118
7P
W9J78118
7Q
W9J78119
7P
W9J78119
7Q
W9J78120
7P
W9J78120
7Q
W9J78121
7P
W9J78121
7Q
W9J78122
7P
W9J78122
7Q
W9J78123
7P
W9J78123
7Q
W9J78124
7P
W9J78124
7Q
W9J78125
7P
W9J78125
7Q
W9J78126
7P
W9J78126
7Q
W9J78127
7P
W9J78127
7Q
W9J78128
7Q
W9J78129
7P

State Grantee
Missouri
Montana
Montana
Nebraska
Nebraska
Nevada
Nevada
New Hampshire
New Jersey
New Jersey
New Mexico
New Mexico
New York
New York
New York
North Carolina
North Carolina
Ohio
Oklahoma
Oklahoma
Oregon
Oregon
Pennsylvania
Puerto Rico
Puerto Rico
Rhode Island
Rhode Island
South Carolina
South Carolina
Tennessee
Tennessee
Texas
Texas
Utah
Utah
Vermont
Vermont
Virgin Islands
Virgin Islands
Virginia
Virginia
Washington
Washington
West Virginia
West Virginia
Wisconsin
Wisconsin
Wyoming
Wyoming

Program
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
CFOI
Survey
CFOI
CFOI
Survey
CFOI
Survey
CFOI
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI
Survey
CFOI

Document No.
CA No.
Suffix
W9J78129
7Q
W9J78130
7P
W9J78130
7Q
W9J78131
7P
W9J78131
7Q
W9J78132
7P
W9J78132
7Q
W9J78133
7Q
W9J78134
7P
W9J78134
7Q
W9J78135
7P
W9J78135
7Q
W9J78136
7P
W9J78136
7Q
W9J78136
7R
W9J78137
7P
W9J78137
7Q
W9J78139
7Q
W9J78140
7P
W9J78140
7Q
W9J78141
7P
W9J78141
7Q
W9J78142
7Q
W9J78172
7P
W9J78172
7Q
W9J78144
7P
W9J78144
7Q
W9J78145
7P
W9J78145
7Q
W9J78147
7P
W9J78147
7Q
W9J78148
7P
W9J78148
7Q
W9J78149
7P
W9J78149
7Q
W9J78150
7P
W9J78150
7Q
W9J78178
7P
W9J78178
7Q
W9J78151
7P
W9J78151
7Q
W9J78153
7P
W9J78153
7Q
W9J78154
7P
W9J78154
7Q
W9J78155
7P
W9J78155
7Q
W9J78156
7P
W9J78156
7Q

File Type	application/pdf
File Title	Microsoft Word - admins0605 - FY07 CA.doc
Author	mccarthy_d
File Modified	2006-06-07
File Created	2006-06-07