Form FEMA Form 080-5 FEMA Form 080-5 Activity Specific Questions for Fire Prevention and Safe

O.M.B. No. 1660-0054

FF 080-5

PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this form is estimated to average 2 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting the form. You are not required to respond to this collection of information unless it displays a valid OMB control number.  Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (1660-0054) NOTE: Do not send your completed form to this address.

Activity Specific Questions for Fire Prevention and Safety Applicants

Department of Homeland Security has established a help desk to assist you during the application period. Technical assistance with completion of the application will be available by phone on our toll free hotline at (866) 274-0960 during the following hours:

• Monday through Friday from 8:00 am to 4:30 pm EST

In addition to the toll free hotline (866-274-0960) applicants can e-mail questions to [email protected].

There are two activities that can be funded under this offering: The Fire Prevention and Safety activity and the Firefighter Safety Research and Development activity. Fire departments are eligible to receive assistance only in the Fire Prevention and Safety activity. Private and public nonprofit organizations are eligible to apply in both the Fire Prevention and Safety activity and Firefighter Safety Research and Development activity.

1. Fire Prevention and Safety activity. The applicant can describe up to three “projects” to address their strategic risk based on FP&S needs.

2. Firefighter Safety and Research and Development activity. The purpose of this funding activity is to improve Firefighter health and life safety through research and development projects.

For more information about this program, visit www.firegrantsupport.com

Firegrants Office

(866) 274 – 0960

(866) 274 – 0942 Fax

Overview

The Fire Prevention and Safety grants provide funding for an array of prevention activities aimed at protecting the health and safety of the public and firefighting personnel. Grant funds are available to fire departments as well as national, state, local, or regional organizations that specialize in prevention activities.

Please provide information about the preparer of this application below and indicate if the person listed is the appropriate person to be contacted regarding the matters of this application.

Note: Fields marked with an * are required.

Preparer Information
Prefix
* First Name
Middle Initial
* Last Name
* Organization Name
* Address 1
Address 2
* City
* State
* Zip
* Business Phone	Ext.
Home Phone
Mobile Phone/Pager
* Email
* Is there a grant-writing fee associated with the preparation of this request?		○ Yes ○ No
If you answered yes above, what is the fee?		$ (whole dollar amounts only)

* Are you the person to be contacted on matters involving this application? ○ Yes ○ No

If yes, please specify: ○ Primary Contact ○ Alternate Contact

Contact Information

Two contacts are required for each application. In addition to yourself, please provide one additional point of contact for this application.

Note: Fields marked with an * are required.

Primary Contact Information
* Title
Prefix (check one)	○ Dr. ○ Mr. ○ Mrs. ○ Ms. ○ N/A
* First Name
Middle Initial
* Last Name
* Business Phone (e.g. 123-456-7890)	Ext.
* Home Phone (e.g. 123-456-7890)	Ext.
Mobile Phone/Pager (e.g. 123-456-7890)
Fax (e.g. 123-456-7890)
* Email (e.g. [email protected])

Alternate Contact Information
* Title
Prefix (check one)	○ Dr. ○ Mr. ○ Mrs. ○ Ms. ○ N/A
* First Name
Middle Initial
* Last Name
* Business Phone (e.g. 123-456-7890)	Ext.
* Home Phone (e.g. 123-456-7890)	Ext.
Mobile Phone/Pager (e.g. 123-456-7890)
Fax (e.g. 123-456-7890)
* Email (e.g. [email protected])

Applicant Information

Please complete the following information regarding your department.

Note: Fields marked with an * are required.

* Organization Name
* Type of Applicant (select one)	○ County ○ Fire Department ○ Independent School District ○ Indian Tribe ○ Individual ○ Municipal ○ National ○ Non-Profit ○ Private University ○ Profit ○ Regional ○ State ○ State controlled institute of higher learning ○ Town/Township ○ Other (please explain)
If other, please enter the type of Applicant
* Are you a Fire Department?	○ Yes ○ No
If yes, what type of department do you represent?	○ Career ○ Paid on Call ○ All Volunteer ○ Combination
If you answered combination, above, what is the percentage of career members in your organization?
* Are you a non-fire based EMS?	○ Yes ○ No
* Type of community served?	○ Rural ○ Urban ○ Suburban ○ N/A
* Employer Identification Number (e.g. 12-3456789)
* What is your DUNS Number? (call 1-866-705-5711 to get a DUNS number)
* Please describe your organization and/or community that you serve. (limited to 4,000 characters)
* Please describe your organization’s need for Federal financial assistance. (limited to 4,000 characters)

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* What is the permanent resident population of your Primary/First-Due Response Area or jurisdiction served? (whole numbers only)
Headquarters Physical Address
* Physical Address 1
Physical Address 2
* City
* State
* Zip
○ Mailing Address is the same as Headquarters Physical Address
* Mailing Address 1
Mailing Address 2
* City
* State
* Zip
Account Information
* Type of bank account	○ Checking ○ Savings
* Bank routing number - 9 digit number on the bottom left hand corner of your check	(numbers only, no dashes)
* Your account number	(numbers only, no dashes)
Additional Information
* This fiscal year, are you receiving Federal funding from any other grant program for the same purpose for which you are applying for this grant?	○ Yes ○No
* This fiscal year, are you receiving Federal funding from any other grant program regardless of purpose?	○ Yes ○ No
* Is the applicant delinquent on any federal debt?	○ Yes ○ No
If you answered yes to any of the additional questions above, please provide an explanation in the space provided below (attach additional sheet if necessary):

Budget Object Class Definitions

The following definitions will allow you to complete your budget items appropriately.

Construction	The creation of a new structure or any modification of the footprint or profile of an existing structure. Changes or renovations to an existing structure that do not change the footprint or profile of the structure but exceeds either $10,000 or 50 percent of the value of that structure, is also considered major construction. Changes or alterations or modifications of an existing structure that does not exceed either $10,000 or 50 percent of the value of the structure and does not involve a change in the footprint or profile of the structure.
Contractual	The costs in this area should cover any contracts that you issue that are not already covered under equipment or supplies. For example, the costs incurred if you hire a grant writer or a contractor to handle your Fire Prevention Program.
Equipment	"Equipment" means an article of nonexpendable, tangible personal property having a useful life of more than one year and an acquisition cost which equals or exceeds the lesser of (a) the capitalization level established by the organization for the financial statement purposes, or (b) $5000.
Fringe Benefits	Fringe benefits in the form of regular compensation paid to employees during periods of authorized absences from the job, such as vacation leave, sick leave, military leave, and the like, are allowable, provided such costs are absorbed by all organization activities in proportion to the relative amount of time or effort actually devoted to each. Fringe benefits in the form of employer contributions or expenses for social security, employee insurance, workmen's compensation insurance, pension plan costs, and the like, are allowable, provided such benefits are granted in accordance with established written organization policies. Such benefits whether treated as indirect costs or as direct costs, shall be distributed to particular awards and other activities in a manner consistent with the pattern of benefits accruing to the individuals or group of employees whose salaries and wages are chargeable to such awards and other activities.
Indirect Charges	These costs are allowed but you must have a Federally approved indirect cost rate agreement.
Other	This area is for a cost that will not fit into the other areas, (e.g. administrative costs). If you put a cost in this category you must describe it in your program.
Personnel	The costs in this area will cover personnel costs within your department, if they are allowed. (The program narrative should list the Employee Title, hours x hourly rate.)
Supplies	The costs of materials and supplies necessary to carry out an award are allowable. Such costs should be charged at their actual prices after deducting all cash discounts, trade discounts, rebates, and allowances received by the organization. Incoming transportation charges may be a proper part of material cost. Materials and supplies charged as a direct cost should include only the materials and supplies actually used for the performance of the contract or grant, and due credit should be given for any excess materials or supplies retained, or returned to vendors.
Travel	The costs in this area are for any allowed travel, example airfare, mileage, lodging, etc. The rates must be in accordance with your written department policy and cannot exceed the government-authorized rates.

Request Information

Activity Selection

Please use this section to select the award program for which you want to apply.

* 1. Select one of the choices listed below. You can apply for a maximum of 3 projects within an activity.
Activity Name	Eligibility
○ Fire Prevention and Safety (continue to page 7)	All organizations are eligible for projects in this area.
○ Fire Prevention and Safety and Research and Development (continue to page 7)	You may apply for as many as three projects within each area. Fire and EMS Departments may not apply for projects in this area.
○ Research and Development (please skip to page 12)	Fire and EMS Departments may not apply for projects in this area.

Request Details – Fire Prevention and Safety

Note: You may apply for up to three programs. For each program, attach an additional sheet. You must answer all of the project specific questions and specify at least one budget item. The cost figures you provide do not have to be firm quotes from your vendors, but they should be estimated based on research of current prices (i.e., check with at least two vendors for your estimates) before you list your estimated costs. Only whole dollar amounts should be provided (no cents please). You are limited to three projects however many budget items can be requested to support the project.

Note: Fields marked with an * are required.

Fire Prevention and Safety
* 1. Project: (select one)
○ Arson Detection/Prevention ○ Burn Research/Prevention ○ Code Development/Enforcement ○ Firefighter Safety ○ General Prevention/Awareness ○ Juvenile Firesetter Program ○ Media/PR Campaign ○ Multi-Hazard Prevention Programs ○ Props/Trailers/Safety Village ○ Smoke Alarm Campaign ○ Targeted Mitigation Program ○ Wildland Fire Mitigation ○ Other
* If you selected other, above, please specify
* 2. Who is the target audience for the planned project?	○ Children under 14 ○ Adults over 65 ○ Firefighters ○ High risk group ○ Other (explain) _____________________
* 3. What is your estimated size of the target audience? (whole numbers only)
* How was this target audience determined?	○ Formal Assessment ○ Informal Assessment ○ Will Be Conducting Assessment ○ None of the above
Briefly describe method used (required if selected other than “None of the above” above)

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* 4. Does your proposal include partnerships? (i.e. Fire Departments, community organizations or national/state/local organizations)	○ Yes ○ No
If you answered Yes to question 4 above, please specify the partner(s):
* 5. Will your organization periodically evaluate the project’s impact on the community?	○ Yes ○ No
If you answered Yes to question 5 above, please specify:
* 6. Is it the applicant's intention to continue delivering this program after the grant year?	○ Yes ○ No
*7. In the space provided below, please provide a brief synopsis of the proposed project: (limited to 800 characters)
*8. In the space provided below, please explain the experience you have in managing the type of project you are proposing: (limited to 800 characters)

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*9. The narrative portion of the application should contain supporting information that allows for evaluation of this project. If you are applying for a grant in the Fire Prevention and Safety Activity, your Narrative Statement must address the following:

• A description of the vulnerability or risk that will be addressed with this project. Provide information regarding the determination of the vulnerability/risk and the targeted audience.

• A brief description of the implementation plan and methods that are to be used to reach the target audience, and how the applicant will carry out the plan.

• An explanation of any partnerships with other organizations or groups that would enhance the development or delivery of the project. (if additional space is needed to support the response from question #4 above)

• A discussion of how an evaluation of the effectiveness of the project and measurable goals are incorporated into the project or program. (if additional space is needed to support the response from question #5 above)

• If the program will be sustained beyond the grant performance period, list how this may be accomplished. (if additional space is needed to support the response from question #6 above)

• Describe the relationship of the benefits derived from the project as compared with the costs incurred directly through the delivery of the project. The costs associated with the project must be reasonable for the target audience.

• If requesting props – include specific goals, measurable results, and details on the frequency to which the prop will be utilized. Applicants should include information indicative of the various outreach efforts that will be conducted and/or the number of people reached through the proposed campaign.

• Include any further information you feel the reviewers may need to provide you with a fair and comprehensive evaluation.

Keep in mind that the evaluation of your application will also be based on a clear understanding of your proposal, your ability to meet the objectives of the program, and your probability of successfully delivering your project to the population targeted. You need to fully explain how the funds will be used to accomplish the goals of your project. To that end be sure to include descriptions/justification for all budgeted items - items not justified may be disallowed.

Your narrative may not exceed five pages of text. You may either type your project narrative in the space provided below or create the text in your word processing system and attach the pages. Images are not allowed.

Request Details – Budget item – Fire Prevention and Safety

Please provide the following information about the program you want funded. You must have at least one budget item for each program.

Note: For each budget item, attach an additional sheet.

Note: Fields marked with an * are required.

* Item:
Select Object Class: (see next page 6 for definitions)	○ Personnel ○ Fringe Benefits ○ Travel ○ Equipment ○ Supplies ○ Contractual ○ Construction ○ Indirect Charges ○ Other
If you selected “Other” above, please specify:
* Number of units: (whole number only)
* Cost per unit: (whole dollar amounts only)	$
Description The space to the right can be used to provide further clarification on the costs (i.e. personnel costs: number of hours/rate/staff; or meeting costs: number of meetings/days/attendees). Budget justification should be included in the project narrative.

Fire Prevention Budget

Please total the individual budget items on the previous pages.

Note: Fields marked with an * are required.

Budget Object Class
	Budget Amount
Personnel	$
Fringe Benefits	$
Travel	$
Equipment	$
Supplies	$
Contractual	$
Construction	$
Other	$
Indirect Charges	$
Indirect Cost Details
Agency Indirect Cost Agreement with
Indirect Cost Rate (whole numbers only)	%
Agreement Summary (attach an additional sheet if necessary)
Total Federal and Applicant Share
Federal Share	$
Applicant Share	$
Federal Rate Sharing (%)

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* Non-Federal Resources (The combined Non-Federal Resources must equal the Applicant Share)
a. Applicant: (whole dollar amounts only)	$
b. State: (whole dollar amounts only)	$
c. Local: (whole dollar amounts only)	$
d. Other Sources: (whole dollar amounts only)	$
If you entered a value in Other Sources other than zero (0), include your explanation below. You can use this space to provide information on the project, cost share match, or if you have an indirect cost agreement with a federal agency.
Total Budget	$

If you are a Fire Department/District or you are not applying for any projects under Research and Development, please go directly to page 19.

Request Details – Research and Development

Note: You may apply for up to three programs. For each program, attach an additional sheet. You must answer all of the project specific questions and specify at least one budget item. The cost figures you provide do not have to be firm quotes from your vendors, but they should be estimated based on research of current prices (i.e., check with at least two vendors for your estimates) before you list your estimated costs. Only whole dollar amounts should be provided (no cents please). You are limited to three projects however many budget items can be requested to support the project. Fire Departments/Districts are not eligible to apply in this area.

Note: Fields marked with an * are required.

Research and Development
* 1. Project:
* 2. Provide an abstract, that includes the following headings: Purpose and Objectives (with rationale), Study Design and Methods, Results (projected), and Conclusions (projected). (limited to 4000 characters)

Request Details – Budget item – Research and Development

Please provide the following information about the program you want funded. You must have at least one budget item for each program.

Note: For each budget item, attach an additional sheet.

Note: Fields marked with an * are required.

* Item:
Select Object Class: (see page 6 for definitions)	○ Personnel ○ Fringe Benefits ○ Travel ○ Equipment ○ Supplies ○ Contractual ○ Construction ○ Indirect Charges ○ Other
If you selected “Other” above, please specify:
* Number of units: (whole number only)
* Cost:	$ First 12-Month Period of Your Grant (required)
	$ Second 12-Month Period of Your Grant
	$ Third 12-Month Period of Your Grant
Description The space to the right can be used to provide further clarification on the costs (i.e. personnel costs: number of hours/rate/staff; or meeting costs: number of meetings/days/attendees). Budget justification should be included in the project narrative.

Research and Development Budget

Please total the individual budget items on the previous pages.

Note: Fields marked with an * are required.

Budget Object Class
	First 12-Month Period	Second 12-Month Period	Third 12-Month Period	Total
Personnel	$	$	$	$
Fringe Benefits	$	$	$	$
Travel	$	$	$	$
Equipment	$	$	$	$
Supplies	$	$	$	$
Contractual	$	$	$	$
Construction	$	$	$	$
Other	$	$	$	$
Indirect Charges	$	$	$	$
Indirect Cost Details
Agency Indirect Cost Agreement with
Indirect Cost Rate (whole numbers only)		%
Agreement Summary (attach an additional sheet if necessary)
Total Federal and Applicant Share
Federal Share		$
Applicant Share		$
Federal Rating Sharing (%)		100/1

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* Non-Federal Resources (The combined Non-Federal Resources must equal the Applicant Share)
a. Applicant: (whole dollar amounts only)	$
b. State: (whole dollar amounts only)	$
c. Local: (whole dollar amounts only)	$
d. Other Sources: (whole dollar amounts only)	$
If you entered a value in Other Sources other than zero (0), include your explanation below. You can use this space to provide information on the project, cost share match, or if you have an indirect cost agreement with a federal agency.
Total Budget	$