Form OSHS CA OSHS CA 2013 OSHS Cooperative Agreement

U .S. Department of Labor Bureau of Labor Statistics

2 Massachusetts Ave., N.E.

Washington, D.C. 20212

[insert date]

OSHS ADMINISTRATIVE MEMORANDUM NO. S-xx-x

MEMORANDUM FOR: STATE AGENCIES PARTICIPATING IN THE SOII
STATE AGENCIES PARTICIPATING IN THE CFOI
BLS REGIONAL COMMISSIONERS

FROM : JAY A. MOUSA

Associate Commissioner
Office of Field Operations

SUBJECT : Occupational Safety and Health Statistics (OSHS) Program
Cooperative Agreement Application Package for 2013

1. Purpose: The purpose of this memorandum is to transmit the 2013 OSHS Cooperative Agreement (CA) application package and provide information about the application process.

2. 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 or the Survey) and for the Census of Fatal Occupational Injuries (CFOI). We realize, however, that not all State agencies participate in both the SOII and CFOI. Your regional office will be contacting you with follow-up information.

3. Office of Management and Budget (OMB) Paperwork Reduction Act Approval: The BLS received OMB approval of a generic OSHS CA application package through XXXX-XX-XXXX. Under this approval, 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. The approval number for this decision is 1220-0149.

4. Changes: Along with some routine updates of reference dates, editorial updates, and clarifying changes, we have made other, more significant changes that affect the CA. These are described below, organized by Part and Section of the CA.

5. PART I. ADMINISTRATIVE REQUIREMENTS

Section O., Closeouts and Audits

Updates have been made to this section to clarify the forms included in the closeout package. The following sentences have been added to paragraph 2: The forms to be included in the closeout package are; the Transmittal and Certification Form (TCF); the Quarterly Financial Report (BLS-OSHS2); the Financial Reconciliation Worksheet (FRW); the SF-425 Federal Financial Report (FFR); and the Property Listing (where applicable). The BLS specific forms are included as part of this Cooperative Agreement Application.

Section Q., Confidentiality

The changes in this section create the distinction between the two types of confidential information governed by this section: respondent identifiable information and pre-release information.  Additionally, they remove specific references to Commissioner’s Orders, as the relevant clauses from these Orders are included in the application.  Furthermore, individuals with access to pre-release information, but not respondent identifiable information, will be required to sign non-disclosure agreements following the new instructions incorporated in the cooperative agreement.

Q.1. The following sentences have been added: 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 Bureau’s ability to carry out its duties.

The following sentences have been deleted: In addition, BLS policy on confidentiality is stated in Commissioner’s Order No. 1-06, “Confidential Nature of BLS Statistical Data," dated September 21, 2006. This Order applies 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 Bureau’s ability to carry out its duties.

Q.2. For items (i.-v.) the following subtitle has been added: Respondent Identifiable Information (Protected by CIPSEA). Additionally, for item (iii.) “unless it has been separately identified as coming from a public source” has been added.

For item (vi.) the following subtitle has been added: Pre-release Information (Protected by Federal Policies).

Q.3.b. The first sentence has been reordered and the following sentence has been added: Authorized persons are State employees designated as “authorized agents” of the BLS (defined in section 4) or State employees that have signed a non-disclosure agreement permitting access to pre-release information.

Q.4.d. All references to “confidential” information have been changed to “respondent identifiable” information.

Q.4.e. The phrase “BLS program data” has been changed to “information.”

Q.5.a. The phrase “confidential” information has been changed to “respondent identifiable” information.

Q.5.b. The following has been added to the sentence: in the case of respondent identifiable information.

Q.6.a. The phrase “Commissioner’s Order 1-06” has been replaced with “this cooperative agreement.”

Q.6.j. The phrase “confidential” information has been changed to “respondent identifiable” information.

Section S., Data Collection Integrity

The changes in this section remove specific references to Commissioner’s Orders, as the relevant clauses from the orders are included in the application, but the orders themselves are not.

Para. 1 The following has been deleted: 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.

Para. 2 The phrase “Commissioner’s Order 3-91” has been replaced with “This requirement.”

Para. 5 The phrase “integrity policy” has been replaced with “requirements set above.”

New Forms - The following forms have been added to the Cooperative Agreement (CA) application because they are to be included in the closeout package to end the work and financial transactions on a CA for each fiscal year.

The Transmittal and Certification Form (TCF)

OSHS Financial Reconciliation Worksheet (FRW)

OSHS Property Listing

PART II. APPLICATION INSTRUCTIONS

Section C., Instructions for Completing Forms

C.1. The instructions have been completely updated to coincide with the new SF-424 format.

C.7. The instructions for the new BLS Non-Disclosure Agreement (NDA) have been added.

PART III. APPLICATION MATERIALS

SF-424 The old form has been replaced with the most up-to-date version, which includes a new format and new data elements, as well as, corresponding new instructions.

BLS NDA A BLS Non-Disclosure Agreement has been added to the application package.

OSHS COOPERATIVE AGREEMENT WORK STATEMENTS

ALL OSHS PROGRAM COMPONENTS

Section C., Program Requirements Applicable to Both SOII and CFOI

C.1. Para. 4 Language has been updated to include the option of submitting Word or PDF versions in lieu of three hard copy reports.

C.5. Para 4 The first sentence has been replaced with: “The SGA shall exercise reasonable care in handling and operating the hardware in a manner consistent with its design and intended use. The BLS will provide maintenance and repair of BLS purchased hardware.”

C.6. The following sentence has been added: The SGA shall inform the BLS Regional Office in writing if no SGA staff will attend an annual conference providing the reason the SGA is unable to attend.

SURVEY OF OCCUPATIONAL INJURIES AND ILLNESSES

All dates have been updated.

Section A., Program Activities

A.2. The phrase “and cases” has been added to the first sentence.

A.2.a The breakout has been consolidated to incorporate private and public sector establishments and cases.

A.3.a. The phrase “sampling frame” has been added.

Section C., Full-Time Equivalent Employees

C. The title “Employee Years” has been changed to “Full-Time Equivalent Employees.”

CENSUS OF FATAL OCCUPATIONAL INJURIES

Section A., Program Activities

A.3. The phrase “CFOI program manual” has been changed to “CFOI manual, the CFOI-Web User Guide and technical memoranda”

A.4. The phrase “CFOI program manual” has been changed to “CFOI manual.”

A.6. The phrase “CFOI program” has been changed to “CFOI.”

Section B., Program Performance Requirements

B.1. The phrase “system user guide” has been added to the first sentence and the dates have been updated.

B.2.Para.3 The phrase “CFOI program” has been changed to “CFOI.”

B.2.Para.4 The language has been updated to identify the types of information that will be kept in confidence to the extent of the law.

B.2.Para.5 The phrase “and from the CFOI operating sytem” has been deleted from the last sentence.

B.2.Para.6 The phrase “CFOI program” has been changed to “CFOI,” and the last sentence has been deleted and replaced with “The SGA will implement changes, initiated with the 2011 CFOI data, to identify which source documents are confidential and whether data for nine key variables come from a public or confidential source (see CFOI Technical Memo S-12-01).”

B.2.Para.7 The paragraph has been deleted and replaced with language making sure the SGA is aware of the new disclosure requirements, and how they will affect published CFOI data.

Section C., Research Files

C. Data Item 4. The phrase “NAICS 2007 beginning with RY 2009” has been added.

C. The following has been added at the end of the section: Note that there may be additional elements included in the RY 2011 research file that were first introduced in RY 2011. These include contractor, contractor industry, contractor ownership, actual contractor industry, and others.

Section D., Full-Time Equivalent Employees

D. The title “Employee Years” has been changed to “Full-Time Equivalent Employees.”

VI. Key Administrative Provisions:

A. When submitting the final, signed cooperative agreement application, only one signed original and two photocopies 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.

B. 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.

C. 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.

D. 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 the Federal Financial Report (FFR).

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

VII. Schedule:

Review and discussion with States on the 2013 CA July-August 2012

Draft 2013 CA application due in regional office (RO) To be set by RO

Final 2012 OSHS CA modifications for deobligations

due in national office July 23, 2012

Final 2012 OSHS CA modifications for reobligations

due in national office August 10, 2012

Final, signed 2013 CA application due in RO August 10, 2012

Completed, signed 2013 CAs due in national office August 31, 2012

Effective date of 2013 CA October 1, 2012

VIII. Clearance Required: Any variances to the 2013 CA work statements must be approved by the BLS before the package is submitted in final.

IX. Action Required:

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

B. Grantees are reminded that new obligations cannot be charged to the 2012 CA after September 30, 2012, and that closeouts of the 2012 CA are due to the regional offices 90 days after the end of the fiscal year.

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

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

XI. Attachments: Occupational Safety and Health Statistics Program 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 XX/XX/XXXX

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TABLE OF CONTENTS

I. ADMINISTRATIVE REQUIREMENTS I-1

A. INTRODUCTION I-1

B. AUTHORIZING LEGISLATION I-1

C. ELIGIBLE APPLICANTS I-1

D. REGULATIONS AND REFERENCE DOCUMENTS I-1

E. PROGRAM FUNDING I-2

F. CASH MANAGEMENT I-2

G. COST GUIDELINES I-2

H. FINANCIAL REPORTING I-3

I. MONITORING I-3

J. DEOBLIGATION OF UNDERUTILIZED FUNDS I-3

K. PROGRAM VARIANCES I-3

L. CHANGES TO THE COOPERATIVE AGREEMENT I-4

1. Budget Changes I-4

2. Programmatic Changes I-4

3. Obtaining Prior Approval I-4

4. BLS-Initiated Budget Changes I-5

M. EQUIPMENT I-5

N. PROCUREMENT I-5

1. Forms and Survey Material I-5

2. Subcontracting I-6

O. CLOSEOUTS AND AUDITS I-6

P. RECORDS I-6

1. Retention I-6

2. Disposal I-6

Q. CONFIDENTIALITY I-6

R. DATA AND COMMUNICATIONS SAFEGUARDS I-9

S. DATA COLLECTION INTEGRITY I-10

T. CERTIFICATIONS I-11

1. Debarment, Suspension, and Other Responsibility Matters I-11

2. Drug-Free Workplace Requirements I-11

3. Lobbying Activities I-11

U. ASSURANCE I-11

ATTACHMENTS I-14

1. BLS-OSHS Quarterly Reporting Form I-14

2. Instructions for BLS-OSHS Quarterly Reporting Form I-15

3. Transmittal and Certification Form I-16

4. OSHS Financial Reconciliation Worksheet I-18

5. Instructions for OSHS Financial Reconciliation Worksheet I-19

6. Property Listing Form I-20

7. Instructions for Property Listing Form I-21

II. APPLICATION INSTRUCTIONS II-1

A. GENERAL RESPONSIBILITIES II-1

B. APPLICATION PROCESS II-1

C. INSTRUCTIONS FOR COMPLETING FORMS II-2

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

2. Certification Regarding Debarment, Suspension, and Other Responsibility Matters II-4

3. Drug-Free Workplace Certification II-7

4. Certification Regarding Lobbying Activities II-9

5. Disclosure Of Lobbying Activities (SF‑LLL) II-10

6. BLS Agent Agreement II-12

7. BLS Non-Disclosure Agreement II-12

8. Budget Information - Non-Construction Programs (SF-424A) II-13

9. Work Statements II-14

III. APPLICATION MATERIALS III-1

A. APPLICATION FOR FEDERAL ASSISTANCE (SF-424)

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

C. CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS

D. DISCLOSURE OF LOBBYING ACTIVITIES (SF-LLL)

E DISCLOSURE OF LOBBYING ACTIVITIES (SF-LLL-A)

F. BLS AGENT AGREEMENT

G. BLS NON-DISCLOSURE AGREEMENT

H. WORK STATEMENTS

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.

B. 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."

C. 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.”

D. 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;

2. 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;

3. 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;

4. 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

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

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.

E. 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.

F. CASH MANAGEMENT

Cash advances to qualified SGAs will be made under the Department of Health and Human Services Payment 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.

G. COST GUIDELINES

Allowable costs are determined in accordance with the provisions of OMB Circular A-87. A request for prior approval of certain costs, under the cost principles of OMB Circular A-87, may be made by means of a letter from the recipient organization to the BLS.

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.

For employees whose time charges are levied solely against a single Federal award or cost objective (i.e., any or all of the OSHS data series covered under this cooperative agreement), the State grantee must certify at least semi-annually that the work being charged for relates exclusively to that award. OMB Circular A-87, Attachment B (Selected Items of Cost), provides full guidance regarding this requirement. Note that States with time and attendance systems that account for employees’ time at the project code level on a weekly, bi-weekly, or monthly basis are already in compliance with this requirement.

H. 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 SF-425 Federal Financial Report (FFR) and the BLS-OSHS2 Quarterly Financial Report. State agencies must complete the SF-272 portion of the FFR each quarter at HHS-PMS within 30 days from the end of the fiscal quarter, after which the system will close until the end of the following fiscal quarter.

State agencies must submit the BLS-OSHS2 Quarterly Financial Report to the regional office within 30 days after the end of each quarter. The regional office will then enter this information into the DOL eGrants System. In addition, State agencies also must complete the SF-269 portion of the FFR annually and submit it to the regional office as part of the closeout package. (The Financial Status Report [SF-269 portion of the FFR], is not required quarterly, but is required as part of the SGA’s closeout package. The SF-269 portion of the FFR cannot be submitted in the Payment Management System.)

I. MONITORING

The BLS will review the financial reports from the SGAs to monitor fund utilization and identify potential over- or under-spending. The primary objectives of financial monitoring are 1) to ensure that program objectives are met; 2) prevent significant imbalances of funds at the end of the fiscal year; and 3) to 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.

J. DEOBLIGATION OF UNDERUTILIZED FUNDS

To obtain maximum benefits from the funds available, each grant will be reviewed by the BLS during the third and fourth quarters 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, but BLS will unilaterally deobligate underutilized funds when the amount and the purpose to which those funds would be re-directed warrant it. Usually, deobligation of funds will be accomplished through a 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.

K. 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. The State agency must also submit a Variance Request Form to the BLS regional office for review before it is sent to the BLS national office for approval. The approved variance should be shown in the appropriate section for the work statement to which it applies. All program variances must be approved by the BLS national office prior to the CA being signed. If the SGA failed during the previous period to meet agreed-upon work requirements 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 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:

1. Background of the problem;

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

3. Proposed performance; and

4. 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.

L. CHANGES TO THE COOPERATIVE AGREEMENT

1. Budget Changes

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

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

b. Cumulative transfers among cost categories that exceed or are expected to exceed 10 percent of the current total approved program budget, whenever the total funded by the BLS is greater than $100,000.

2. Programmatic Changes

Programmatic changes that require BLS prior written approval include:

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

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

c. Need to extend the period of availability of funds.

3. 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;

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

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

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.

m. 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 Automated Data Processing (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.

N. PROCUREMENT

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

1. Forms and Survey Material

The State will obtain 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;

b. State-originated solicitation and prenotification letters to employers;

c. State-originated survey verification forms and letters; and

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

2. 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.

O. 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. The forms to be included in the closeout package are; the Transmittal and Certification Form (TCF); the Quarterly Financial Report (BLS-OSHS2); the Financial Reconciliation Worksheet (FRW); the SF-425 Federal Financial Report (FFR); and the Property Listing (where applicable). The BLS specific forms are included as part of this Cooperative Agreement Application. 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. Final closeouts must reflect that there are not any outstanding resources on order or accruals remaining at the time of submission. In addition, cash drawdowns in HHS-PMS should equal total expenses for the fiscal year.

P. 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 BLS computer systems. States shall also retain any electronic version of the forms received through email 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.

2. 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.

Q. CONFIDENTIALITY

1. Federal Guidelines

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 Bureau’s ability to carry out its duties. The Confidential Information Protection and Statistical Efficiency Act (CIPSEA) of 2002 (Title 5 of Public Law 107-347) safeguards the confidentiality of respondent identifiable information acquired for exclusively statistical purposes under a pledge of confidentiality controlling access to and uses of such information. BLS officers, employees, and agents are subject to CIPSEA and other Federal laws governing confidentiality.

2. Description of Confidential Information

For the purposes of this cooperative agreement “confidential information” includes:

Respondent Identifiable Information (Protected by CIPSEA)

i. All names, addresses, and other information about an establishment from which data are requested.

ii. All identifiable respondent submissions.

iii. Information in administrative files that has been commingled with confidential information, unless it has been separately identified as coming from a public source.

iv. Disclosure avoidance parameters applied to published data, unless otherwise specified by the BLS.

v. 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.

Pre-release Information (Protected by Federal Policies)

vi. Pre-release information such as official estimates and other official statistical products prior to the official BLS release of the national data.

3. State’s Confidentiality Responsibility

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

2. The State agency agrees that pre-release information such as official estimates and other statistical products will be accessible only to authorized persons and will not be disclosed or used in an unauthorized manner before the official BLS release of the national data. Authorized persons are State employees designated as “authorized agents” of the BLS (defined in section 4) or State employees that have signed a non-disclosure agreement permitting access to pre-release information.

4. Access to Confidential Information

a. The State agency agrees to assign BLS State Cooperating Representative(s) for the OSHS program components 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.

b. 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 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.

c. The State agency agrees to administer annual confidentiality training as provided by the BLS to all State employees designated as agents to carry out work under this cooperative agreement.

d. The State agency will assure that there will be no access to respondent identifiable 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 respondent identifiable information for any purpose other than a BLS-approved statistical purpose. The BLS may require the submission of any output(s) produced from respondent identifiable 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.

e. State agencies agree to prohibit remote access to confidential information from offsite locations without prior written approval from the Grant Officer.

5. Data Sharing

a. The State agency agrees to obtain BLS approval prior to using the respondent identifiable 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.

b. 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 in the case of respondent identifiable information written consent has been obtained from the respondent prior to disclosure in conformance with BLS policies regarding informed consent procedures.

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

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

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

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

6. Use of Contractors

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 this cooperative agreement;

b. 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 and have completed confidentiality training in advance;

c. Reliability of personnel;

d. No subcontracting permitted;

e. Right of inspection of contractor facilities;

f. Physically secure work site and computer/communications environment;

g. Exclusive storage facilities for confidential information;

h. 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;

i. Right of termination for failure to comply with security requirements;

j. Right to review outputs produced from respondent identifiable information prior to release or publication;

k. Return or destruction of confidential information upon termination of the contract; and

l. Contractor shall not, by action or inaction, do anything to cause the State to violate the terms of this cooperative agreement.

R. DATA and communications safeguards

1. This cooperative agreement has been developed to establish a management agreement between the Bureau of Labor Statistics and State offices. The Bureau of Labor Statistics and State offices, when referred to collectively in this section, will be described as the “parties.” The systems that are the subject of this agreement are the BLS LAN/WAN system owned by the Bureau of Labor Statistics and State personal computers, provided by the BLS and owned by each State. No computers used for the OSHS program to access OSHS systems or BLS
email shall be attached to any State network.

2. This agreement between the parties allows for exchanges of information between State offices using BLS-provided equipment and information systems owned, operated, and processed at the Bureau of Labor Statistics as required or allowed by The Department of Labor Computer Security Handbook (CSH) and The Department of Labor Manual Series-9 as well as other federal statutes, regulations, and policies that may apply.

3. The BLS LAN/WAN and the OSHS computers in the State are connected to one another using VPN connections via DSL, or other mutually acceptable means.

4. The core of the BLS network resides on the ground floor of the Postal Square Building (2 Massachusetts Avenue, NE, Washington, DC); however, it extends to several regional offices, Regional Outstation Collection Center’s (ROCC) and State offices throughout the country.

The State agency office location information is maintained by the BLS regional offices.

5. The parties agree to maintain open lines of communication between designated staff.

The BLS regional office staff will coordinate all communications between the BLS national office and State partners, except for when technical staff needs to communicate directly with one another to resolve security or connectivity issues.

The parties agree to designate and provide contacts to support the management and operation of the OSHS resources.

The BLS point of contact for security or connectivity emergencies is:

LANWAN Support Staff or OCWC Help Support Staff

202-691-5950 202-691-6125

[email protected]

6. In the event of a disaster, technical staff for the resources experiencing the disaster will immediately notify their designated counterparts, via the BLS regional office contacts, that a disaster has occurred and describe the contingency operations undertaken or to be undertaken to avoid a disruption.

7. The parties agree to provide notification, via the BLS regional office contacts, of any changes in point-of-contact information.

8. Both parties agree to implement safeguards to prevent unauthorized access by electronic or physical means to confidential information.

9. The BLS reserves the right to make unannounced inspections of SGA facilities to determine compliance with confidentiality and security requirements.

10. In the event of grant termination, or at an earlier time if required by the BLS, all confidential information 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 BLS permission, be destroyed. The State agency's failure to surrender or destroy such materials promptly or the State agency's conversion of such materials to a use not authorized by this CA may be a violation of 18 USC Section 641.

11. The State agency agrees to notify the BLS regional office immediately upon discovering:

1. Any breach or suspected breach of security, or

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

12. All OSHS-related electronic communications (email) that contain confidential information will be transmitted using the BLS (“bls.gov”) mail server.

s. DATA COLLECTION INTEGRITY

"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."

This requirement 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 program with the data collection requirements set above, 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.

T. 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 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.

3. 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.

U. 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.

2. 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.

3. 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.

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

5. 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).

6. 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.

7. 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.

8. 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.”

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

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B LS-OSHS QUARTERLY FINANCIAL REPORT BLS-OSHS2 OMB Approval No. 1220-0149; Expires xx-xx-xxxx State Grant Agency: ________________________________ Cooperative Agreement No.: ___________________ Reporting Period Ending: _______________
SECTION A – FINANCIAL ACTIVITY SUMMARY
Grant Program	Catalog of Federal	Expenditures for the Quarter		Cumulative Expenditures
Function	Domestic Assistance
or Activity	Number	Federal	Non-Federal	Federal	Non-Federal	Total
(a)	(b)	(c)	(d)	(e)	(f)	(g)
1.		$	$	$	$	$
2.
3.
4.
5. TOTALS		$	$	$	$	$

section b -- total expenditures by budget category for the current quarter

		GRANT PROGRAM, FUNCTION, OR ACTIVITY				TOTAL
6. Object Class Categories		(1)	(2)	(3)	(4)	(5)
a. Personnel		$	$	$	$	$
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: _________________________________________________________________________________________ Date: _______________________________

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. Your response is required to obtain or retain benefits under 29 USC 673. 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., Room 4135, 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.

BUREAU OF LABOR STATISTICS

U.S. DEPARTMENT OF LABOR

TRANSMITTAL AND CERTIFICATION FORM

FOR OSHS COOPERATIVE AGREEMENT CLOSEOUT DOCUMENTS

We estimate that it will take an average of 5-10 minutes 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. Your response is required to obtain or retain benefits under 29 USC 673. If you have any comments regarding these estimates or any other aspect of this form, including suggestions for reducing this burden, send them to the Bureau of Labor Statistics, Division of Financial Planning and Management (1220-0149), 2 Massachusetts Avenue, NE, Room 4135, Washington, DC 20212-0001. You are not required to respond to the collection of information unless it displays a currently valid OMB control number.

OMB No. 1220-0149 Approval Expires: xx-xx-xxxx

State Grant Agency (SGA):

Check, or write in, the appropriate boxes:

SOII

CFOI

Other

CA#:

CA Period From:

To:

The following documents are being submitted for the closeout of the cooperative agreement indicated above.

(Check the appropriate boxes.)

Document Name

OSHS Financial Reconciliation Worksheet

SF-425 Federal Financial Report (the SF-269 portion)

BLS-OSHS Quarterly Financial Report

Property Listing (if applicable)

Health and Human Services Payment Management

System (HHS-PMS) FCO Report

Other (Specify)

_________________

"I certify, to the best of my knowledge and belief, that all information on this form is correct and complete. Further, all information on all documents that accompany and constitute the cooperative agreement closeout package are correct and complete. Finally, I certify, to the best of my knowledge and belief, that all program objectives, as delineated in the cooperative agreement work statement(s), have been met."

SGA Representative:

Title:

(type/print)

Authorized Signature:

Date:

FOR THE BLS USE ONLY

Date Received in RO:

Received by:

Date Received in OFO:

Received by:

Date Received in DFPM:

Received by:

Approved by (Analyst, BGFM):

Date:

Remarks:

[this page intentionally left blank]

BUREAU OF LABOR STATISTICS

U.S. DEPARTMENT OF LABOR

BLS OSHS FINANCIAL RECONCILIATION WORKSHEET (FRW)

We estimate that it will take an average of 20-30 minutes 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. Your response is required to obtain or retain benefits under 29 USC 673. If you have any comments regarding these estimates or any other aspect of this form, including suggestions for reducing this burden, send them to the Bureau of Labor Statistics, Division of Financial Planning and Management (1220-0149), 2 Massachusetts Avenue, NE, Room 4135, Washington, DC 20212-0001. You are not required to respond to the collection of information unless it displays a currently valid OMB control number.

OMB No. 1220-0149 Approval Expires xx-xx-xxxx

State Grant Agency (SGA):

Date:

CA #:

CA Period: From:

To:

SOII

CFOI

OTHER

FUND LEDGER CODE:

1. Cumulative Disbursements

2. Charged Advance

3. Difference

4. Total Obligational Authority

5. Unused Obligational Authority

6. Revised Obligational Authority

7.

Total Unused Obligational Authority from this page:

BLS OSHS FRW

OSHS FINANCIAL RECONCILIATION WORKSHEET (FRW) TERMS DEFINED

1. Cumulative Disbursements:

The amount shown should represent cumulative cash disbursements through the obligations incurred during the CA period that were paid out prior to the completion of the Reconciliation Worksheet:

• applicable credits, refunds and rebates;

• outstanding advances and prepaid expenses; and

• other cash adjustments.

This figure is comparable to the FCO DISBURSED column found in the HHS-PMS FCO report.

2. Charged Advance:

The amount of cash drawn down against HHS-PMS or checks received.

This figure is comparable to the CHG-ADV column found in the HHS-PMS FCO report.

3. Difference:

The amount of Charged Advances/draw downs (Line 2), subtracted from reported expenses in Line 1. If the balance is greater, or less than zero, the closeout cannot take place until the SGA fully updates their last quarter’s FFR to properly match their draw downs.

When the Difference (Line 3) is greater than zero, there are either:

• Resources on Order

  • The amount of those goods or services that is obligated, but not yet delivered by the vendor. Does not include: personal services, personnel benefits, most nonpersonal services line items and any items included as an “Accrual.”

• Accruals

  • The amount of those goods received, services rendered, expenses incurred, and assets acquired, but for which payments have not yet been made.

When the Difference (Line 3) is less than zero there is:

• Cash on Hand

  • The amount of cash available for the payment of obligations.

4. Total Obligational Authority:

The amount of funds that the SGA is allowed to obligate against a specific program ( i.e., CFOI, SOII, etc.).

This figure is comparable to the FUTURE AUTH column found in the HHS-PMS FCO report.

5. Unused Obligational Authority:

The amount of funds that the SGA did not obligate against a specific program. This sum should equal Line 4 (Total Obligational Authority) minus Line 2 (Charged Advance).

6. Revised Obligational Authority:

The actual amount of funds used during the fiscal year. This sum should equal Line 4 (Total Obligational Authority) minus Line 5 (Unused Obligational Authority).

7. Total Unused Obligational Authority from this page:

Represents all Unused Obligational Authority summed across all programs, which illustrates the total amount of funds that will be deobligated from the CA.

BUREAU OF LABOR STATISTICS				U.S. DEPARTMENT OF LABOR
BLS OSHS PROPERTY LISTING
(BLS-Owned Property ONLY--NOT Property Procured with Cooperative Agreement Funds)
We estimate that it will take an average of 20-30 minutes 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. Your response is required to obtain or retain benefits under 29 USC 673. If you have any comments regarding these estimates or any other aspect of this form, including suggestions for reducing this burden, send them to the Bureau of Labor Statistics, Division of Financial Planning and Management (1220-0149), 2 Massachusetts Avenue, NE, Room 4135, Washington, DC 20212-0001. You are not required to respond to the collection of information unless it displays a currently valid OMB control number.									OMB No. 1220-0149 Approval Expires xx-xx-xxxx
	State Grant Agency (SGA):						Date:
	CA #:		CA Period: From:				To:
Item No.	Identification No.	Description	Location	Acquisition Date	Condition Code	Unit	Quantity	Unit Acquisition Cost Federal Non-Federal		Total Cost
Remarks:

BLS OSHS Property Listing

Instructions for Completing the Property Listing

The Property Listing is required by 29 CFR 97.50(b)(5). SGAs shall submit, as part of the final closeout package, a complete listing of all BLS-owned property for which it is responsible. BLS‑owned property is distinct from property purchased with CA funds; an inventory of property purchased with CA funds is not required.

The Property Listing need not be submitted for a partial closeout.

Please read the instructions below before completing the form.

1. Enter the complete SGA name, CA number, and date in the spaces provided at the top of the form.

2. For each item of property, enter the following information in the appropriate column.

a. Item #: Enter property items in numerical sequence, i.e., 1, 2, 3, etc.

b. Identification #: Enter an identification number such as the Federal stock number, manufacturer's serial number, or other identifying number.

c. Description: Describe the property, e.g., IBM PC-XT.

d. Location: If different from the SESA address, enter the location of the property.

e. Date of Acquisition: Date on which the SESA assumed responsibility for the property.

f. Condition Code: Enter the condition code corresponding to the condition descriptions provided in the attached list; e.g., property that can be described as "Used-Good" receives a condition code of "4".

g. Unit: Enter the unit, e.g., "ea" for each, "dz" for dozen, "st" for set, etc.

h. Quantity: Enter the number of units.

1. Unit Acquisition Cost, Total Cost: Leave blank; these columns will be completed by BLS.

Condition Codes

1 Unused-Good Unused property that is usable without repairs and identical or interchangeable with new items from normal supply sources.

2 Unused-Fair Unused property that is usable without repairs, but is deteriorated or damaged to the extent that utility is somewhat impaired.

3 Unused-Poor Unused property that is usable without repairs, but is considerably deteriorated or damaged. Enough utility remains to classify the property better than salvage.

4 Used-Good Used property that is usable without repairs, and most of its useful life remains.

5 Used-Fair Used property that is usable without repairs, but somewhat worn or deteriorated and may soon require repairs.

6 Used-Poor Used property that may be used without repairs, but is considerably worn or deteriorated to the degree that remaining utility is limited or major repairs will soon be required.

7 Repairs required-Good Required repairs are minor and should not exceed 15 percent of original acquisition cost.

8 Repairs required-Fair Required repairs are considerable and are estimated to range from 16 to 40 percent of original acquisition cost.

9 Repairs required-Poor Required repairs are major because property is badly damaged, worn, or deteriorated, and are estimated to range from 41 to 65 percent of original acquisition cost.

X Salvage Property has some value in excess of its basic material content, but repair or rehabilitation to use for the originally intended purpose is clearly impractical. Repair for any use would exceed 65 percent of the original acquisition cost.

S Scrap Material that has no value except for its basic material content.

II. APPLICATION INSTRUCTIONS

A. GENERAL RESPONSIBILITIES

The cooperating State agency is responsible for:

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

2. Verifying all items in the package for accuracy, reasonableness, and consistency with past budgets.

The BLS is responsible for:

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

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

3. 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.

B. 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);

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

3. 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 two photocopies 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 22, which has been modified by the BLS to provide space for this purpose. The original will be sent to the BLS Washington, Office of Field Operations. One copy of the executed agreement with the original 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.

The BLS is working to make its application available for electronic submission via www.Grants.gov. Although electronic submission is not available at this time, 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.

C. INSTRUCTIONS FOR COMPLETING FORMS

1. Application for Federal Assistance (SF‑424)

General Guidelines

The SF‑424 is an OMB‑approved standard form and is required as a face sheet for applications submitted for Federal assistance. The SF‑424 requests important information, including total estimated funding and the time period of the funded activities. The highlights below are followed by step‑by‑step instructions for completing the form. Please ensure that the SF‑424 is filled out completely and accurately and that it is signed and dated by the State agency's authorized representative. Failure to do so may result in delayed processing of the CA.

Item 2: Type of Application – Must be completed. The initial application for funding should be treated as a "New" (A) agreement; any modification to the CA after the beginning of the period of activity should be treated as a "Revision” (C). “Continuation” (B) does not apply to BLS CAs.

Item 17: Proposed Project – Project start and ending dates must be consistent with the dates entered on the BIF and in the work statements. The start and ending dates for base programs will always be October 1 and September 30, respectively.

Item 21: Only the State agency’s authorized representative(s) may sign and date the form.

1. Instructions for SF‑424, Application for Federal Assistance

State agencies will follow the instructions below in completing the SF‑424. Instructions are organized by and refer to the Item No. on the SF-424.

1.	Type of Submission—Check the box labeled “Application.”
	Type of Application—Select one type of application in accordance with the following definitions: New – An application that is being submitted to an agency for the first time. Continuation – Does not apply to BLS CAs. Revision – Any modification to the CA after the beginning period of activity. If a revision, enter the appropriate letter(s). More than one may be selected. If "Other" is selected, please specify in text box provided. A. Increase Award D. Decrease Duration B. Decrease Award E. Other (specify) C. Increase Duration
3.	Date Received—Leave blank. The appropriate regional office will complete this.
4.	Applicant Identifier—This box is optional.
5a.	Federal Entity Identifier—Leave blank.
5b.	Federal Award Identifier— (i.e., Cooperate Agreement Number)—Enter the ten digit CA number (ex. OS-20318-13-75-J-25) as follows: 1st through 2nd digits – Program identifier; “OS” is used for LMI 3rd through 7th digits – Each fiscal year the DOL eGrants system randomly selects and assigns a sequence of 5 digits for each State Agency. (See attachment--2013 Occupational Safety and Health Statistics Cooperative Agreement Document Numbers for assigned State Agency DOL eGrants system number.) 8th through 9th digits – Represents the fiscal year “13” for 2013. 10th through 11th digits – Type of Federal assistance document; “75” denotes CA. 12th digit – Is a Federal agency identifier. “J” is used for the BLS. 13th through 14th digits – Applicable FIPS code for the State, e.g., “01”Alabama, “23” for Maine, and “48” for Texas, etc.
6.	Date Received by State—This box is optional.
7.	State Application Identifier—This box is optional.
8.	Applicant Information—Enter (a) legal name of the State agency, (b) employer or taxpayer identification number (EIN or TIN) as assigned by the Internal Revenue Service, (c) the organization’s DUNS number (received from Dun and Bradstreet), (d) enter the complete address of the State agency, (e) name of the primary organizational unit, department or division that will undertake the assistance activity (for example, “OSHS Division”), and (f) Name and contact information of person to be contacted on matters involving this application.
9.	Type of Applicant 1—Enter “State Government” in the field provided.
10.	Name of Federal Agency—Enter “Department of Labor”
11.	Catalog of Federal Domestic Assistance Number—Enter “17.005”; CFDA Title: “Occupational Safety and Health Statistics”
12.	Funding Opportunity Number—Leave blank.
13.	Competition Identification Number—Leave blank.
14.	Areas Affected by Project (Cities, Counties, States, etc.)—Enter the name of the State or territory that will benefit from the project.
15.	Descriptive Title of Applicant’s Project—For the initial application, enter "BLS Occupational Safety and Health Statistics, pursuant to Sec. 24 of the Occupational Safety and Health Act of 1970, and equivalent State laws.”
16.	Congressional Districts of —(a) Enter the applicant’s three digit congressional district and (b) Enter “all” to signify that the scope for the OSHS program is statewide. Maps depicting congressional districts of the 112th Congress can be found online at http://nationalatlas.gov/printable/congress.html.
17.	Proposed Project Start and End Dates—Enter “10/01/XX” and “09/30/XX” where XX is the year in which the Federal fiscal year begins followed by the next calendar year when the Federal fiscal year ends. For example, 10/01/12 and 09/30/13 for Federal fiscal year 2013.
18.	Estimated Funding—Enter the amount of Federal assistance requested. If the purpose of this application is to change an existing award (2), enter only the amount of increase or decrease. For decreases, enclose the amount in parentheses. If the amount is the net result of several increases and/or decreases, attach a separate page to break out the amount by Fund Ledger Code.
18 a.	Federal—Enter the amount of Federal assistance requested.
18 b.	Applicant—Enter the amount of funds provided by the SGA.
18 c.	State—Leave blank.
18 d.	Local—Leave blank.
18 e.	Other—Leave blank.
18 f.	Program Income—Leave blank.
18 g.	TOTAL—Will automatically calculate based on information in 18a and 18b.
19.	E.O. 12372 Review—The OSHS program is not subject to review; box 19c is checked “Program is not covered by E.O. 12372.”
20.	Delinquent on Federal Debt—Check Yes or No; if Yes, include an explanation on an additional page. Categories of debt include, but are not limited to, delinquent audit disallowances, loans and taxes. [Note: This question applies to the State agency applying for Federal assistance, not to the authorized representative who signs the application for the State agency.]
21.	Authorized Representative—To be signed and dated by the authorized representative of the applicant organization. Enter the first and last name, prefix, middle name, suffix, title, telephone number, email, and fax number. This authorized representative must also sign and date the application. By signing, the signatory is making the certification set forth on the form.
22.	Grant Officer Signature—Leave these boxes blank. The BLS Grant Officer will provide his (a) name, (b) title, (c) telephone number, (d) signature, and (e) date signed. Note that this item has been added by the BLS. It does not appear on the electronic version of this form available at the OMB website.

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

a. Instructions--Primary Covered Transactions

(1) By signing and submitting this application or grant agreement, the prospective primary participant is providing the certification set out below (see paragraph b.).

(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’s 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 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.

b. 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:

(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.

(2) 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.

c. 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.

(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) 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.

(8) 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.

(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.

d. 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.

3. 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.

(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 contendere) 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).

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

(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).

(2) 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.

4. 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.).

b. 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.

(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 meets the above criteria.

b. 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 recipient is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants.

(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.

6. 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.

b. 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 the confidential information protection provisions of the Confidential Information Protection and Statistical Efficiency Act of 2002.

(5) State designees must review and sign the BLS Agent Agreement 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.

(8) The BLS Agent Agreement form signed by the State designee is effective until the State designee resigns or is terminated.

(9) The SGA will promptly notify the BLS regional office when a State designee is no longer working on the OSHS program.

7. BLS Non-Disclosure Agreement

1. General Guidelines

The purpose of the BLS Non-Disclosure Agreement (NDA) is to inform persons with advance access to BLS pre-release information of their responsibilities for ensuring compliance with BLS confidentiality policies regarding handling of pre-release information. This agreement is intended for signature by persons authorized only to have advance access to pre-release information. Individuals who have signed a BLS Agent Agreement are not required to sign the Non-disclosure Agreement prior to accessing pre-release information.

2. Instructions

1. Each State Cooperating Representative should provide the BLS with a list of individuals with a need to see pre-release information, including the name, State government affiliation, and title of each individual.

2. Each individual named on the list above must review the BLS NDA and sign the agreement.

3. The State Cooperating Representative is responsible for forwarding to their respective BLS regional office all signed NDAs.

4. The BLS regional office is responsible for maintaining on file the signed original copies of all BLS NDAs received from their respective SGAs.

5. The BLS NDA form signed by the State designee is effective until the State designee no longer has a need for pre-release information.

8. 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.

b. Specific Instructions

Section A. Budget Summary

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-6h: 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.

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.

9. Work Statements

The work statements are the core documents in the application. They describe the work to be performed and list major deliverables and/or milestones. 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.

b. 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.

c. Explanation of 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. The State agency must also submit a Variance Request Form to the BLS regional office for review before it is sent to the BLS national office for approval. The approved variance should be shown in the appropriate section for the work statement to which it applies. All program variances must be approved by the BLS national office prior to the CA being signed.. 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.

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.

4. 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.

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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

• BLS Non-disclosure Agreement

• Work Statements

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Application for Federal Assistance SF-424
*1. Type of Submission: Preapplication Application Changed/Corrected Application		*2. Type of Application New Continuation Revision					* If Revision, select appropriate letter(s)
							*Other (Specify)      
3. Date Received : 4. Applicant Identifier:            
5a. Federal Entity Identifier:      						*5b. Federal Award Identifier:      
State Use Only:
6. Date Received by State:      			7. State Application Identifier:      
8. APPLICANT INFORMATION:
*a. Legal Name:      
*b. Employer/Taxpayer Identification Number (EIN/TIN):      						*c. Organizational DUNS:      
d. Address:
*Street 1:      
Street 2:      
*City:      
County:      
*State:      
Province:      
*Country:      
*Zip / Postal Code      
e. Organizational Unit:
Department Name:      						Division Name:      
f. Name and contact information of person to be contacted on matters involving this application:
Prefix:       *First Name:      
Middle Name:      
*Last Name:      
Suffix:      
Title:      
Organizational Affiliation:      
Application for Federal Assistance SF-424
*Telephone Number:       Fax Number:      
*Email:      
*9. Type of Applicant 1: Select Applicant Type:
Type of Applicant 2: Select Applicant Type:
Type of Applicant 3: Select Applicant Type:
*Other (Specify)      
*10. Name of Federal Agency:      
11. Catalog of Federal Domestic Assistance Number:       CFDA Title:      
*12. Funding Opportunity Number:       *Title:      
13. Competition Identification Number:       Title:      
14. Areas Affected by Project (Cities, Counties, States, etc.):      
*15. Descriptive Title of Applicant’s Project:      
16. Congressional Districts Of: *a. Applicant:       *b. Program/Project:      
Application for Federal Assistance SF-424
17. Proposed Project: *a. Start Date:       *b. End Date:      
18. Estimated Funding ($):
*a. Federal	     
*b. Applicant	     
*c. State	     
*d. Local	     
*e. Other	     
*f. Program Income	     
*g. TOTAL	     
*19. Is Application Subject to Review By State Under Executive Order 12372 Process? a. This application was made available to the State under the Executive Order 12372 Process for review on       b. Program is subject to E.O. 12372 but has not been selected by the State for review. c. Program is not covered by E. O. 12372
*20. Is the Applicant Delinquent On Any Federal Debt? (If “Yes”, provide explanation.) Yes No
21. *By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. (U. S. Code, Title 218, Section 1001) ** I AGREE ** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency specific instructions
Authorized Representative:
Prefix:       *First Name:       Middle Name:       *Last Name:       Suffix:      
*Title:      
*Telephone Number:      								Fax Number:      
* Email:      
*Signature of Authorized Representative:									*Date Signed:
* 22a. Typed Name of BLS Grant Officer:      					b. Title: Regional Commissioner				c. Telephone Number:      
d. Signature of BLS Grant Officer:									e. Date Signed:

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INSTRUCTIONS FOR THE SF-424

This is a standard form required for use as a cover sheet for submission of pre-applications and applications and related information under discretionary programs. Some of the items are required and some are optional at the discretion of the applicant or the Federal agency (agency). Required fields on the form are identified with an asterisk (*) and are also specified as “Required” in the instructions below. In addition to these instructions, applicants must consult agency instructions to determine other specific requirements.

Item	Entry:		Item	Entry:
1.	Type of Submission: (Required): Select one type of submission in accordance with agency instructions. Pre-application Application Changed/Corrected Application – Check if this submission is to change or correct a previously submitted application. Unless requested by the agency, applicants may not use this to submit changes after the closing date.		10.	Name Of Federal Agency: (Required) Enter the name of the Federal agency from which assistance is being requested with this application.
			11.	Catalog Of Federal Domestic Assistance Number/Title: Enter the Catalog of Federal Domestic Assistance number and title of the program under which assistance is requested, as found in the program announcement, if applicable.
2.	Type of Application: (Required) Select one type of application in accordance with agency instructions. New – An application that is being submitted to an agency for the first time. Continuation - An extension for an additional funding/budget period for a project with a projected completion date. This can include renewals. Revision - Any change in the Federal government’s financial obligation or contingent liability from an existing obligation. If a revision, enter the appropriate letter(s). More than one may be selected. If "Other" is selected, please specify in text box provided. A. Increase Award B. Decrease Award C. Increase Duration D. Decrease Duration E. Other (Specify)		12.	Funding Opportunity Number/Title: (Required) Enter the Funding Opportunity Number and title of the opportunity under which assistance is requested, as found in the program announcement.
			13.	Competition Identification Number/Title: Enter the Competition Identification Number and title of the competition under which assistance is requested, if applicable.
			14.	Areas Affected By Project: This data element is intended for use only by programs for which the area(s) affected are likely to be different than the places(s) of performance reported on the SF-424 Project/Performance Site Location(s) Form. Add attachment to enter additional areas if needed.
3.	Date Received: Leave this field blank. This date will be assigned by the Federal agency.		15.	Descriptive Title of Applicant’s Project: (Required) Enter a brief descriptive title of the project. If appropriate, attach a map showing project location (e.g., construction or real property projects). For pre-applications, attach a summary description of the project.
4.	Applicant Identifier: Enter the entity identifier assigned by the Federal agency, if any, or applicant’s control number, if applicable.
5a	Federal Entity Identifier: Enter the number assigned to your organization by the Federal agency, if any.		16.	Congressional Districts Of: 16a. (Required) Enter the applicant’s congressional district. 16b. Enter all district(s) affected by the program or project. Enter in the format: 2 characters State Abbreviation – 3 characters District Number, e.g., CA-005 for California 5th district, CA-012 for California 12th district, NC-103 for North Carolina’s 103rd district. If all congressional districts in a state are affected, enter “all” for the district number, e.g., MD-all for all congressional districts in Maryland. If nationwide, i.e. all districts within all states are affected, enter US-all. If the program/project is outside the US, enter 00-000. This optional data element is intended for use only by programs for which the area(s) affected are likely to be different than the places(s) of performance reported on the SF-424 Project/Performance Site Location(s) Form. Attach an additional list of program/project congressional districts, if needed.
5b.	Federal Award Identifier: For new applications leave blank. For a continuation or revision to an existing award, enter the previously assigned Federal award identifier number. If a changed/corrected application, enter the Federal Identifier in accordance with agency instructions.
6.	Date Received by State: Leave this field blank. This date will be assigned by the State, if applicable.
7.	State Application Identifier: Leave this field blank. This identifier will be assigned by the State, if applicable.
8.	Applicant Information: Enter the following in accordance with agency instructions: a. Legal Name: (Required): Enter the legal name of applicant that will undertake the assistance activity. This is the name that the organization has registered with the Central Contractor Registry (CCR). Information on registering with CCR may be obtained by visiting www.Grants.gov.
			17.	Proposed Project Start and End Dates: (Required) Enter the proposed start date and end date of the project.
	b. Employer/Taxpayer Number (EIN/TIN): (Required): Enter the Employer or Taxpayer Identification Number (EIN or TIN) as assigned by the Internal Revenue Service. If your organization is not in the US, enter 44-4444444.
			18.	Estimated Funding: (Required) Enter the 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.
	c. Organizational DUNS: (Required) Enter the organization’s DUNS or DUNS+4 number received from Dun and Bradstreet. Information on obtaining a DUNS number may be obtained by visiting www.Grants.gov.
	d. Address: Enter address: Street 1 (Required), city (Required), County/Parish, State (Required, if country is US), Province, Country (Required), 9-digit zip/postal code (Required, if country is US).
			19.	Is Application Subject to Review by State Under Executive Order 12372 Process? (Required) Applicants should contact the State Single Point of Contact (SPOC) for Federal Executive Order 12372 to determine whether the application is subject to the State intergovernmental review process. Select the appropriate box. If “a.” is selected, enter the date the application was submitted to the State
	e. Organizational Unit: Enter the name of the primary organizational unit, department or division, if applicable that will undertake the assistance activity.
	f. Name and contact information of person to be contacted on matters involving this application: Enter the first and last name (Required); prefix, middle name, suffix, title. Enter organizational affiliation if affiliated with an organization other than that in 7.a. Telephone number and email (Required); fax number.
			20.	Is the Applicant Delinquent on any Federal Debt? (Required) Select the appropriate box. This question applies to the applicant organization, not the person who signs as the authorized representative. Categories of federal debt include; but may not be limited to: delinquent audit disallowances, loans and taxes. If yes, include an explanation in an attachment.
9.	Type of Applicant: (Required) Select up to three applicant type(s) in accordance with agency instructions.		21.	Authorized Representative: To be signed and dated by the authorized representative of the applicant organization. Enter the first and last name (Required); prefix, middle name, suffix. Enter title, telephone number, email (Required); and fax number. A copy of the governing body’s authorization for you to sign this application as the 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.)
	State Government County Government City or Township Government Special District Government Regional Organization U.S. Territory or Possession Independent School District Public/State Controlled Institution of Higher Education Indian/Native American Tribal Government (Federally Recognized) Indian/Native American Tribal Government (Other than Federally Recognized) Indian/Native American Tribally Designated Organization Public/Indian Housing Authority	Nonprofit Private Institution of Higher Education Individual For-Profit Organization (Other than Small Business) Small Business Hispanic-serving Institution Historically Black Colleges and Universities (HBCUs) Tribally Controlled Colleges and Universities (TCCUs) Alaska Native and Native Hawaiian Serving Institutions Non-US Entity Other (specify)
			22.	Item added to the 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 18.g.

OMB Approval No. 0348-0044

BUDGET INFORMATION -- Non-Construction Programs
SECTION A – BUDGET SUMMARY
Grant Program	Catalog of Federal	Estimated Unobligated Funds		New or Revised Budget
Function	Domestic Assistance
Or Activity	Number	Federal	Non-Federal	Federal	Non-Federal	Total
(a)	(b)	(c)	(d)	(e)	(f)	(g)
1.		$	$	$	$	$
2.
3.
4.
5. TOTALS		$	$	$	$	$

section b -- BUDGET CATEGORIES

		GRANT PROGRAM, FUNCTION, OR ACTIVITY				TOTAL
6. Object Class Categories		(1)	(2)	(3)	(4)	(5)
a. Personnel		$	$	$	$	$
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

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.

Section A. Budget Summary

Lines 1-4, Columns (a) and (b)

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).

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).

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

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).

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).

Line 5 - Show the totals for all columns used.

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 non-Federal) 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.

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	(c) State	(d) Other Sources	(e) TOTALS
8.		$	$	$	$
9.
10.
11.
12. TOTALS (sum of lines 8 and 11)		$	$	$	$
SECTION D – FORECASTED CASH NEEDS
	Total for 1st Year	1st Quarter	2nd Quarter	3rd Quarter	4th Quarter
13. Federal	$	$	$	$	$
14. Non-Federal
15. TOTALS (sum of lines 13 and 14)	$	$	$	$	$
SECTION E -- BUDGET ESTIMATES OF FEDERAL FUNDS NEEDED FOR BALANCE OF THE PROJECT
		FUTURE FUNDING PERIODS (years)
(a) Grant Program		(b) First	(c) Second	(d) Third	(e) Fourth
16.		$	$	$	$
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.

Section C. Non-Federal Resources

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.

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

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

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.

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.

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

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

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.

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

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.

Section F. Other Budget Information

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.

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 Drug-Free 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: ___________________________________________________________________

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DISCLOSURE OF LOBBYING ACTIVITIES

CONTINUATION SHEET

Reporting Entity:_______________________________________________________

Page ________ of ________

Authorized for Local Reproduction Standard Form - LLL - A

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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, 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 (or affirm) 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. Confidential information includes confidential respondent identifiable data protected from unauthorized use or disclosure under CIPSEA, including the disclosure avoidance parameters applied to published data. Confidential information also includes pre-release information such as official estimates and other official statistical products prior to the official BLS release of the corresponding national data.

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], understand that the State agency or I 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] Date

[Title]

[Name of Organization]

  _________________

[Name of BLS Official] Date

Regional Commissioner

Bureau of Labor Statistics

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BLS NON-DISCLOSURE AGREEMENT FOR PRE-RELEASE ECONOMIC INFORMATION

PURPOSE. The purpose of this agreement is to inform persons who will have access to Bureau of Labor Statistics (BLS) pre-release information of their responsibility for adhering to the confidentiality policies of the BLS. This is in accordance with Office of Management and Budget Directive No. 4, “Release and Dissemination of Statistical Products by Federal Statistical Agencies,” (73 FR 12622-12626). Pre-release information are statistics and analyses deemed confidential information that have not yet officially been released to the public. Individuals granted advanced access to BLS pre-release information are responsible for ensuring that the pre-release information they have access to are not further disseminated or used in any unauthorized manner before their official date and time of release. This agreement does not authorize access to respondent identifiable information.

By signing this non-disclosure agreement, I agree to adhere to the following provisions.

• I will not release pre-release information to anyone not authorized to have access to this information prior to the scheduled release of the information to the public. Authorized persons include authorized BLS staff and non-BLS approved individuals with a need-to-know who have signed this non-disclosure agreement or a BLS agent agreement.

• I will store pre-release information in a manner that ensures unauthorized persons cannot view or otherwise gain access to the pre-release information.

• I will not remove pre-release information from the authorized State facility to which it was provided without prior approval from the BLS.

• I understand that pre-release information may only be provided to those BLS approved individuals with a need–to-know who have previously signed a non-disclosure agreement or an agent agreement. Should a question arise about whether an individual is an authorized person, should the need arise to provide pre-release information to additional individuals who have not previously signed non-disclosure agreements, or should any questions arise regarding the appropriate handling of this information, then I will first contact the BLS before taking any action with the pre-release information.

• I will make no transactions for personal gain based on the pre-release information provided.

• I will notify the BLS immediately upon discovering any actual or perceived unauthorized disclosure of the pre-release information.

ACKNOWLEDGEMENT OF UNDERSTANDING OF RESPONSIBILITY
AND PLEDGE TO OBSERVE BLS CONFIDENTIALITY POLICY

I acknowledge that I have read the provisions above, and that I understand the importance of safeguarding confidential BLS information.

I fully understand that it is my responsibility not to disclose BLS pre-release economic information to any unauthorized person and not to use such information for personal financial gain.

I understand that failure to maintain the obligations stated within this agreement may result in loss of access to the data. Furthermore, I understand that use of the data for personal financial gain may be a violation of criminal law.

_________________________ _________________________ _____________
Printed Name Signature Date

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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 OSHS Program 25 minutes
Annual Survey 50 minutes
CFOI 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 (1220-0149), 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.

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ALL OSHS PROGRAM

Agree To
Comply
(Check Box)

A. ADMINISTRATIVE REQUIREMENTS/ASSURANCES

The State Grantee Agency (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.

[____]

B. SUBMISSION OF FINANCIAL REPORTS

The SGAs Financial Accounting System must be able to provide the financial information necessary to comply with audit requirements and to complete the SF-425 Federal Financial Report (FFR) and the BLS-OSHS2 Quarterly Financial Report. State agencies must complete the SF-272 Financial Status Report portion of the FFR each quarter at HHS-PMS within 30 days from the end of the fiscal quarter, after which the system will close until the end of the following fiscal quarter.

[____]

State agencies must submit the BLS-OSHS2 Quarterly Financial Report to the regional office within 30 days after the end of each quarter. The regional office will then enter this information into eGrants. In addition, State agencies also must complete the SF-269 portion of the FFR annually and submit it to the regional office as part of the closeout package. The Financial Status Report [SF 269 portion of the FFR], is not required quarterly, but is required as part of the SGA’s closeout package. The SF-269 portion of the FFR cannot be submitted to the Payment Management System.)

[____]

C. PROGRAM REQUIREMENTS Applicable to BOTH SOII AND CFOI

1. PUBLICATION OF DATA The SGA is required to publish survey data that are validated by the BLS. If an SGA is using only the Profiles data tables and charts the BLS provides at the time of the corresponding National news release, no additional BLS validation is needed.	[____]
The SGA will obtain clearance from their BLS Regional Commissioner for any other reports for which any activity, collection, compilation, analysis and publication are funded under the grant.	[____]
The SGA will acknowledge the U.S. Department of Labor, BLS financial assistance when publishing data developed through the BLS-OSHS program.	[____]
C. PROGRAM REQUIREMENTS Applicable to BOTH SOII AND CFOI (cONTINUED)
	Agree To Comply Check (Box)
News releases, hard copy reports, and Internet web sites are considered publications for this purpose. If hard copies are published, the SGA will submit three copies to the BLS regional office (which will forward two copies to BLS-Washington). Electronic versions (Word or PDF) of hard copy reports may be submitted in lieu of three hardcopies. If a web site is used, the SGA will provide the URL address (which the RO will share with BLS-Washington).	[____]
The BLS reserves the right to publish State data from the OSHS programs funded under this agreement. Normally, the BLS will provide the SGA a ten-day period in which to publish State data prior to making them available to the public.	[____]
2. Research Proposals The SGA is 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.	[____]
3. OSHS Computer Systems The SGA shall use 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.	[____]
4. OSHS Computer security The SGA agrees to ensure that OSHS information technology resources will neither reside on nor be connected to State networks and that authorized State personnel who use OSHS resources will exercise due diligence to minimize security vulnerabilities.	[____]
C. PROGRAM REQUIREMENTS Applicable to BOTH SOII AND CFOI (Continued)
	Agree To Comply (Check Box)
5. 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 program 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 the BLS or the State for the program 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 exercise reasonable care in handling and operating the hardware in a manner consistent with its design and intended use. The BLS will provide maintenance and repair of BLS purchased hardware. In the event that assistance is required, the State will request such assistance from the BLS regional office within three (3) workdays.	[____]
6. 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 this CA. The SGA shall inform the BLS Regional Office in writing if no SGA staff will attend an annual conference providing the reason the SGA is unable to attend.		[____]
7. Program Training SGA staff shall participate in scheduled BLS training to ensure SGA staff understands the procedures, coding systems, and automated systems used in the BLS OSHS program. Such an understanding is critical to the quality and consistency of the OSHS data. Specific funding is provided for this activity.		[____]

D. EXPLANATION OF VARIANCES

(Attach additional pages if needed)

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SURVEY OF OCCUPATIONAL INJURIES AND ILLNESSES
FISCAL YEAR 2013

Agree To
Comply
(Check Box)

A. PROGRAM ACTIVITIES

1. For Reference Year 2011:

The SGA shall by the dates specified in technical memoranda:
Complete review of State estimates; and			[____]
The SGA shall publish survey results.			[____]
The means to publish these results will be: (Please check format[s] below.)
Report	[____]
News Release	[____]
Web Site (list URL, if known now): __________________	[____]
Other (Describe): ______________________________	[____]

2. For Reference Year 2012:

The SGA shall: Collect the 2012 survey by the dates specified in the program manuals and technical memoranda. The collection targets are based on “survey rates” rather than response rates.	[____]
Edit and clarify the 2012 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. The target is based on concurrent coding for a percentage of completed surveys throughout collection.	[____]
Review State estimates.	[____]

Agree To
Comply
(Check Box)

A. PROGRAM ACTIVITIES (continued)

2. For Reference Year 2012 (Continued):

The number of units and estimated number of cases in the Survey for reference year 2012 will be:
Private and Public sector: Establishments _________________ Cases _________________

3. For Reference Year 2013

The SGA shall, by the dates specified in the program manuals and technical memoranda:
Review and refine the 2013 sampling frame units.	[____]
Pre-notify employers who have not been notified by the contract printer/mailer to keep occupational injury and illness records.	[____]

B. 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.	[____]
2. 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.	[____]

C. FULL-TIME EQUIVALENT EMPLOYEES: ______________________

D. BLS STATE COOPERATING REPRESENTATIVE:

Name
________________________________________________________________________

Title ________________________________________________________________________

Address
________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Telephone
________________________________________________________________________

E. EXPLANATION OF VARIANCES

(Attach additional pages if needed)

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CENSUS OF FATAL OCCUPATIONAL INJURIES (CFOI)
FISCAL YEAR 2013

Agree To
Comply
(Check Box)

A. 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: Death certificates with the “injury at work” box marked “Yes”; State workers' compensation fatality reports; and Other fatality reports available to the SGA, such as news reports, medical examiner records, autopsy reports, motor vehicle fatality reports, etc.	[____]
The SGA shall review all (Federal agency and other) source documents the BLS forwards or makes available to the SGA and shall enter all in-scope cases from those sources into the CFOI operating system.	[____]
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, using 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.	[____]
The SGA shall specify reasons for scope determinations on questionable cases in the comments field.	[____]

Agree To
Comply
(Check Box)

A. PROGRAM Activities (continued)

3. 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 manual, the CFOI-Web User Guide, and technical memoranda. States shall minimize the use of “unknown” codes.

[____]

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 manual and technical memoranda, unless the SGA has received prior written approval from the BLS regional office.	[____]

5. 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.	[____]
By December 31st of the reference year, the SGA will enter all cases occurring in the first quarter of the reference year and code them as fully as possible.	[____]
The SGA will promptly enter any newly-identified cases and/or updates or additions to existing cases for the prior reference year into the CFOI operating system by the dates specified in the technical memoranda.	[____]

6. 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 (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. The SGA will note the dissemination or receipt of information to/from another SGA in the State Comments field for the case.

[____]

Agree To
Comply
(Check Box)

A. PROGRAM Activities (continued)

7. Publish Data

The SGA shall publish CFOI results.			[____]
The means to publish these results will be: (Please check format[s] below.)
Report	[____]
News Release	[____]
Web Site (list URL, if known now): __________________	[____]
Other (Describe): _____________________________	[____]

B. 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, system user guide, technical memoranda and other communications in the performance of work under this agreement for reference years 2011, 2012, and 2013.	[____]
States shall use the OMB-approved questionnaire for follow-back.	[____]

2. 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.	[____]
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.	[____]

Agree To
Comply
(Check Box)

B. PROGRAM PerFORMANCE REQUIrEMENTS (CONTINUED)

2. Confidentiality (CONTINUED)

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

[____]

The BLS, its employees, agents, and partner statistical agencies, will use the information collected on the CFOI-1 form and all information incorporated into the CFOI operating system for statistical purposes only. Information collected using the CFOI-1 and information the States identify as coming from any confidential source will be held in confidence to the full extent permitted by law. In accordance with the Confidential Information Protection and Statistical Efficiency Act of 2002 (Title 5 of Public Law 107-347) and other applicable Federal laws, the information will not be disclosed in identifiable form without the informed consent of the respondent.

[____]

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.

[____]

The SGA shall ensure that published CFOI results are in accordance with the BLS Data Confidentiality provisions included in the CFOI manual and technical memoranda and in accordance with the SGA’s written agreement(s) with the State agencies that supply source documents. The SGA will implement changes, initiated with the 2011 CFOI data, to identify which source documents are confidential and whether data for nine key variables come from a public or confidential source (see CFOI Technical Memo S-12-01).

[____]

The SGA acknowledges the new disclosure avoidance parameters for published CFOI data for 2011 and future years and agrees to ensure that these parameters are used in publishing CFOI results. (See CFOI Technical Memo S-12-xx.) The CFOI measures to avoid disclosure of confidential data now rest on State identification of whether the data for nine key variables come from a confidential or public source. Application of the new parameters will allow BLS and its State partners to publish tabulations of data that come from public sources and, thereby, increase the number of detailed data cells that may be published. All historical data (2010 and earlier) and information for 2011 and subsequent years that the States mark as coming from confidential or proprietary sources will be subject to the publishability standards used in prior years (see Technical Memorandum S-02-03). These parameters are reflected in the CFOIWeb system and will be automatically applied to publication tables run in the system.

[____]

[____]

Agree To
Comply
(Check Box)

B. PROGRAM PerFORMANCE REQUIrEMENTS (CONTINUED)

3. 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.

[____]

C. 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 for Safety, Health and Working Conditions and a recipient 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 will 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 element identifies whether the fatality occurred in a State that has an OSHA-approved State OSH plan or not, but does not identify any particular State.	[____]
The BLS will provide a CFOI research file to the National Institute for 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.)	[____]

C. RESEARCH FILES (Continued)

The BLS will include the following data elements on the CFOI fatal injury research file*:

1. Reference year
2. Race
3. Gender
4. Industry (Standard Industrial Classification Manual; North American Industry Classification System,
U.S. [NAICS] beginning with RY 2003; NAICS 2007 beginning with RY 2009)
5. Ownership (Federal, State, local or other government; private)
6. Occupation (Census Bureau 1990 Occupational Classification System; Standard Occupational

Classification, 2000, beginning with RY 2003; SOC 2010, beginning with RY 2011)

7. Employee status (wage and salary, self-employed, armed forces, etc.)
8. Nature of injury (BLS Occupational Injury and Illness Classification System [OIICS]); OIICS,
version 2.0 beginning with RY 2011)

9. Part of Body (BLS OIICS; OIICS, version 2.0 beginning with RY 2011)
10. Source of injury (BLS OIICS; OIICS, version 2.0 beginning with RY 2011)
11. Secondary source of injury (BLS OIICS; OIICS, version 2.0 beginning with RY 2011)
12. Event or exposure (BLS OIICS; OIICS, version 2.0 beginning with RY 2011)
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—Monday, Tuesday, etc., month, and year)
19. Date of death (number of days from date of injury)
20. Born in foreign country (continent of birth)
21. Establishment size (based on employment)
22. Length of time with employer
23. Time of incident (to the nearest hour)
24. How the injury occurred (narrative description)

25. Usual lifetime industry code

26. Usual lifetime occupational code

Additional data elements for the NIOSH research file only:

27. State codes
28. Actual age
29. Date of birth
30. Date of death
31. Death certificate identification number
32. Narrative industry and occupation information (1999 and subsequent years)

Additional data element for the OSHA research file only:

33. State Plan indicator

*Note that there may be additional elements included in the RY 2011 research file that were first introduced in RY 2011. These include contractor, contractor industry, contractor ownership, actual contractor industry, and others.

D. FULL-TIME EQUIVALENT EMPLOYEES: ____________________

E. BLS STATE COOPERATING REPRESENTATIVE:

Name
________________________________________________________________________

Title
________________________________________________________________________

Address
______________________________ __________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Telephone
________________________________________________________________________

F. EXPLANATION OF VARIANCES

(Attach additional pages if needed)

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OSHS COOPERATIVE AGREEMENT document NUMBERS

*To be updated by BGFM prior to the beginning of FY 2013