Form DOT F 4502 DOT F 4502 DOT SBTRC Field Office Quarterly Report Form

	U.S. Department of Transportation Small Business Transportation Resource Center Regional Field Office Quarterly Report Form			OMB Control Number: 2105-0554 Expiration Date: 01/31/2012 Form DOT F 4502
Public Burden Statement A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2105-0554. Public reporting for this collection of information is estimated to be approximately 3 hours per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, U.S. Department of Transportation, Room W57-463, 1200 New Jersey Ave, SE, Washington, D.C. 20590.
Organization Name:			Current Period of Performance:		Reporting Period:
Inquiries: No. of Inquires Via Phone, Email, or Fax, or Social Media: No. of Web-Site Hits:		Inquiry Activity Narrative:
Clients: New Intake Forms: Total No. of Clients:		Client Activity Narrative:
Counseling Activity: No. of New Appointments: Total Counseling Hours:		Counseling Activity Narrative:
Other Assistance: No. of DBE Workshops Hosted: No of One-On-One Matchmaking Events Hosted: Other (Explain in the Narrative):		Other Assistance Narrative:
Client Demographics: No. of DBEs Served: No. of Other Certified Businesses Served: No. of Non-Certified Business Served:		Client Demographics Narrative:

Rev. 4/12 OPI: Office of Small and Disadvantaged Business Utilization

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	U.S. Department of Transportation Small Business Transportation Resource Center Regional Field Office Quarterly Report Form		OMB Control Number: 2105-0554 Expiration Date: 01/31/2012 Form DOT F 4502
“Targeted” Database: No. of Businesses:		“Targeted” Database Narrative:
Outreach: No. of Events Attended as a Panelist: No. of Events Attended as an Exhibitor: No. of Events Attended in Another Capacity:		Outreach Narrative:
Credit & Lending Assistance: No. of STLP Workshops: No. of Complete STLP Applications Submitted: No. of New Participating Lenders: No. of Non-STLP Applications for Credit Submitted (Explain in the Narrative):		Credit & Lending Assistance Narrative:
Bonding Assistance: No. of BEP Participants that Either Obtained Increased Bonding Capacity or Access to Bonding (Provide Breakdown By Event in the Narrative): No. of BAP Applications Submitted (Upon Inception):		Bonding Assistance Narrative:

Rev. 4/12 OPI: Office of Small and Disadvantaged Business Utilization

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	U.S. Department of Transportation Small Business Transportation Resource Center Regional Field Office Quarterly Report Form		OMB Control Number: 2105-0554 Expiration Date: 01/31/2012 Form DOT F 4502
Women and Girls Program: No. of Internship Opportunities Created: No. of New Participating Institutions of Education: Total No. of Participating Institutions of Education Offering Course Credit:		Women and Girls Program Narrative:
DOT Grantees/Recipients: No. of Meetings with DOT Grantees/Recipients (Provide Detail in Narrative):		DOT Grantees/Recipients Narrative:
Planning Committee: No. of Meetings of the Planning Committee (Provide Detail in Narrative)		Planning Committee Narrative:
General Report Narrative (Attach Additional Pages as Necessary):

Rev. 4/12 OPI: Office of Small and Disadvantaged Business Utilization

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General Instructions

Purpose of Form

Use form Regional Field Office Quarterly Report Form, OMB Control Number 2105-0554 to submit the Quarterly Progress Report required by the Cooperative Agreement award to operate a U.S. Department of Transportation (DOT), Office of the Secretary, Office of Small and Disadvantaged Utilization (OSDBU), Regional Field Office Small Business Transportation Center (SBTRC).

How do I Obtain Assistance?

Direct assistance will be delivered by the DOT OSDBU Regional Assistance Division (RAD). Contact the Manager, Regional Assistance Division at the telephone or email address provided in the Cooperative Agreement.

When Must I Submit?

Quarterly Progress Reports are due every three months, with the first report due three (3) months after date on which both parties execute the Cooperative Agreement award. Quarterly Progress Reports must be submitted on the Regional Field Office Quarterly Report Form by the fifth (5^th) day of the month after the end of a quarter.

How Do I Submit?

Email your form to the Manager, Regional Assistance Division to the address provided in the SBTRC’s Cooperative Agreement. The form may be submitted

Specific Instructions

All entries on the form are mandatory. Print or type all entries on the Form, OMB Control Number 2105-0554. The form is an electronically fillable form. We strongly suggest SBTRCs utilize the electronically fillable form to complete the form entries. Illegible forms may cause unnecessary requests for additional information or clarification. Follow the instructions for each line to expedite processing and to avoid unnecessary requests for additional information.

Line 1. Organization Name. Enter the full legal name of the organization awarded the Cooperative Agreement.

Line 2. Current Period of Performance. Enter the start date and the end date of the organization’s period of performance stated in the award of the Cooperative Agreement or the most recent Cooperative Agreement Amendment to exercise an option year.

Line 3. Reporting Period. Enter the number of the Quarter of the current period of performance for which the organization is reporting.

Line 4a. Inquiries; No. of Inquiries By Phone, Email, Fax, or Social Media. Enter the total number of inquiries via phone, email, fax, or other social media about the assistance provided by the SBTRC during the reporting period, whether or not the inquiry resulted in a request for services.

Line 4b. Inquiries; No. of Web-Site Hits. Enter the total number of hits on the web-site regarding the SBTRC program during the reporting period.

Line 4c. Inquiries; Inquiry Activity Narrative. Enter comments or any other report narrative the SBTRC wished to report on this topic. Attach additional pages as necessary.

Line 5a. Clients; New Intake Forms. Enter the total number of new Regional Office Intake Forms submitted during the reporting period. Attach a copy of the Regional Office Intake Forms to the Quarterly Progress Report submission.

Line 5b. Clients; Total No. of Clients. Enter the total number of clients that the SBTRC have provided services to or continues to provide services to. This number is cumulative over the life of the organization’s award(s) to operate as an SBTRC.

Line 5c. Clients; Client Activity Narrative. Enter comments or any other report narrative the SBTRC wished to report on this topic. Attach additional pages as necessary.

Line 6a. Counseling Activity; No. of New Appointments. Enter the total number of first-time counseling appointments with small and disadvantaged businesses that the SBTRC attended during the reporting period.

Line 6b. Counseling Activity; Total Counseling Hours. Enter the total number of counseling hours the SBTRC delivered during the reporting period.

Line 6c. Counseling Activity; Counseling Activity Narrative. Enter comments or any other report narrative the SBTRC wished to report on this topic. Attach additional pages as necessary.

Line 7a. Other Assistance; No. of DBE Workshops Hosted. Enter the number of DBE workshops the SBTRC hosted during the reporting period.

Line 7b. Other Assistance; One-On-One Matchmaking Events Hosted. Enter the number of One-On-One Matchmaking Events the SBTRC hosted during the reporting period.

Line 7c. Other Assistance; Other. Enter the number of other forms of assistance delivered by the SBTRC not accounted for in line 6 or elsewhere in Line 7 during the reporting period. Include a description of the services in Line 7d. Counseling Activity Narrative.

Line 7d. Other Assistance; Other Assistance Narrative. Include a description of the services reported in Line 7c. Enter comments or any other report narrative the SBTRC wished to report on this topic. Attach additional pages as necessary.

Line 8a. Client Demographics; No. of DBEs Served. Enter the total number of small and disadvantaged businesses that were certified DBEs that the SBTRC assisted during the reporting period.

Line 8b. Client Demographics; No. of Other Certified Businesses Served. Enter the total number of small and disadvantaged businesses that hold a small business certification, other than DBE, that the SBTRC assisted during the reporting period.

Line 8c. Client Demographics; No. of Non-Certified Businesses Served. Enter the total number of small and disadvantaged businesses that do not hold a small business certification that the SBTRC assisted during the reporting period.

Line 8d. Client Demographics; Client Demographics Narrative. Enter comments or any other report narrative the SBTRC wished to report on this topic. Attach additional pages as necessary.

Line 9a. “Targeted” Database; No. of Businesses. Enter the total number of businesses in the SBTRC’s “Targeted” Database required by the Cooperative Agreement. This is not the total number of SBTRC clients. This number is cumulative over the life of the organization’s award(s) to operate as an SBTRC. Businesses in the “Targeted” Database must have the capacity and capabilities, and are ready, willing and able to participate in transportation-related contracts and subcontracts immediately. This is the control group that must receive ample resources from the SBTRC, i.e., access to working capital, bonding assistance, business counseling, management assistance and direct referrals to DOT agencies at the state and local levels, and to prime contractors as effective subcontractor firms.

Line 9b. “Targeted” Database; “Targeted” Database Narrative. Enter comments or any other report narrative the SBTRC wished to report on this topic. Attach additional pages as necessary.

Line 10a. Outreach; No. of Events Attended as a Panelist. Enter the total number of conferences or other outreach events the SBTRC attended as a panelist during the reporting period. Line 10b. Outreach; No. of Events Attended as an Exhibitor. Enter the total number of conferences or other outreach events the SBTRC attended as an exhibitor during the reporting period.

Line 10c. Outreach; No. of Events Attended in Another Capacity. Enter the total number of conferences or other outreach events the SBTRC attended not otherwise reported in Line 10 during the reporting period.

Line 10d. Outreach; Outreach Narrative. Enter comments or any other report narrative the SBTRC wished to report on this topic. Attach additional pages as necessary.

The sum total of Line 10 should be the sum total of the Conference Summary reports submitted to DOT within five (5) days of the event during the reporting period.

Line 11a. Credit & Lending Assistance; No. of STLP Workshops. Enter the total number of Short Term Lending Program (STLP) Workshops the SBTRC delivered during the reporting period. Include the names of the Participating Lender(s) that participated in the workshops, if any.

Line 11b. Credit & Lending Assistance; No. of Complete STLP Applications Submitted. Enter the total number of complete STLP applications submitted to a Participating Lender, whether or not approved, where the SBTRC delivered some form of assistance, during the reporting period.

Line 11c. Credit & Lending Assistance; No. of New Participating Lenders. Enter the total number of new STLP Participating Lenders approved by the Director, where the SBTRC assisted DOT to obtain, during the reporting period.

Line 11d. Credit & Lending Assistance; No. of Non-STLP Applications for Credit. Enter the total number of complete Non-STLP credit applications submitted to any Lender, federally guaranteed or not, whether or not approved, where the SBTRC delivered some form of assistance, during the reporting period. Include a description in Line 11e. Credit & Lending Assistance Narrative.

Line 11e. Credit & Lending Assistance; Credit & Lending Assistance Narrative. Include a description of the services reported in Line 11d. Enter comments or any other report narrative the SBTRC wished to report on this topic. Attach additional pages as necessary.

Line 12a. Bonding Assistance; No. of BEP Participants that Obtained Either Increased Bonding Capacity or Access To Bonding. Enter the total number of Bonding Education Program (BEP) participants that obtained either increased bonding capacity or access to bonding during the reporting period. Count all of the businesses that obtained either an increase in bonding capacity or access to bonding capacity during the period, regardless of when the workshop(s) that the participant attended were held. Include a breakdown of the number by event in Line 12c. Bonding Assistance Narrative.

Line 12b. Bonding Assistance; No. of BAP Applications Submitted. Enter the total number of complete Bonding Assistance Program (BAP) applications submitted to a Participating Surety, whether or not approved, where the SBTRC delivered some form of assistance, during the reporting period. Leave blank if the BAP is not currently active.

Line 12c. Bonding Assistance; Bonding Assistance Narrative. Include a breakdown of the number by event reported in Line 12a. Enter comments or any other report narrative the SBTRC wished to report on this topic. Attach additional pages as necessary.

Line 13a. Women and Girls Program; No. of STLP Workshops. Enter the total number of internship opportunities created and filled during the reporting period, regardless of the internship start date.

Line 13b. Women and Girls Program; No. of New Participating Institutions of Education. Enter the total number of new Participating Institutions of Education added during the reporting period.

Line 13c. Women and Girls Program; Total No. of Participating Institutions of Education Offering Course Credit. Enter the total number of Participating Institutions of Education offering course credit. This number is cumulative over the life of the organization’s award(s) to operate as an SBTRC.

Line 13d. Women and Girls Program; Women and Girls Program Narrative. Enter comments or any other report narrative the SBTRC wished to report on this topic. Attach additional pages as necessary.

Line 14a. DOT Grantees/Recipients; No. of Meetings. Enter the total number of meetings with transportation agencies having received at least a dollar of funding during the reporting period. Include the name of the entities and the purpose of the meetings in Line 14b. DOT Grantees/Recipients Narrative.

Line 14b. DOT Grantees/Recipients; DOT Grantees/Recipients Narrative. Include a description of the meetings reported in Line 14a. Enter comments or any other report narrative the SBTRC wished to report on this topic. Attach additional pages as necessary.

Line 15a. Planning Committee; No. of Meetings of the Planning Committee. Enter the total number of meetings of the Planning Committee during the reporting period. Include a brief description of the topics discussed at the meeting(s) and any issues that DOT may need to be aware of in Line 15b.Planning Committee Narrative.

Line 15b. Planning Committee; Planning Committee Narrative. Include a description of the meetings reported in Line 15a. Enter comments or any other report narrative the SBTRC wished to report on this topic. Attach additional pages as necessary.

Line 16. General Report Narrative. Enter narrative as the SBTRC feels necessary to report their quarterly progress not otherwise reported in the form. Attach additional pages as necessary.

Privacy Act Statement

This notice is provided pursuant to the Privacy Act, 5 U.S.C. 552a(e)(3): The information on this form is solicited under the authority of Title 49 U.S.C. 332(b)(4)(7). The principal purpose for which the information is to be used by DOT to evaluate the performance of the SBTRC. Other possible routine uses of information are published in the Federal Register at 65 F.R. 19476 (April 11, 2000) under “Prefatory Statement of General Routine Uses.” Furnishing the information requested on this form is voluntary, but failure to provide all or part of the information may delay the formulation of an assistance plan and delivery of the required services.