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pdfU.S. Department of Labor
Bureau of Labor Statistics
2 Massachusetts Ave., N.E.
Washington, D.C. 20212
DATE:
OSHS ADMINISTRATIVE MEMORANDUM NO. S-16
STATE AGENCIES PARTICIPATING IN THE SOII
STATE AGENCIES PARTICIPATING IN THE CFOI
BLS REGIONAL COMMISSIONERS
MEMORANDUM FOR:
FROM
:
JAY A. MOUSA
Associate Commissioner
Office of Field Operations
SUBJECT
:
Occupational Safety and Health Statistics (OSHS) Program
Cooperative Agreement Application Package for Fiscal Year 2017
I.
Purpose: The purpose of this memorandum is to transmit the fiscal year (FY) 2017 OSHS Cooperative
Agreement (CA) application package and provide information about the application process.
II.
Applicability: For the sake of simplicity, all state agencies will receive this package; therefore, we
have included the work statements for the Survey of Occupational Injuries and Illnesses (SOII) and
for the Census of Fatal Occupational Injuries (CFOI). 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.
III.
Office of Management and Budget (OMB) Paperwork Reduction Act Approval: The BLS received OMB
approval of a generic OSHS CA application package through May 31, 2018. 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.
IV.
Changes:
PART I. ADMINISTRATIVE REQUIREMENTS
Section H., Financial Reporting
The following statement has been added: “The BLS reserves the right to withhold
payment to a state agency if financial reports are delinquent.”
Section R., Data and Communications Safeguards
The reference to the OCWC support staff point of contact has been removed.
PART II. APPLICATION INSTRUCTIONS
Section C., Instructions for Completing Forms
C.5.
The instructions for completing the Disclosure of Lobbying Activities (SFLLL) form have been updated for the new OMB version (4040-0013).
PART III. APPLICATION MATERIALS
Disclosure of Lobbying Activities
The form has been replaced by the new OMB version (4040-0013) with the expiration
date of January 31, 2019.
OSHS COOPERATIVE AGREEMENT WORK STATEMENTS
ALL OSHS PROGRAM
Section C., Program Requirements Applicable to Both SOII and CFOI
C.1.
Language has been added to clarify the data publication dates for each of
the programs.
C.6.
The following sentence has been added to the paragraph outlining
attendance at conferences and meetings: “Should staff be unable to fulfill
any of these requirements, an appropriate level of funding will be
deobligated by the BLS.”
C.7.
The following sentence has been added to the paragraph outlining program
training: “BLS may deobligate funds if SGA staff does not attend these
required sessions.”
SURVEY OF OCCUPATIONAL INJURIES AND ILLNESSES
Section A., Program Activities
A.1.a.
The phrase “Summary and C&D” has been added to clarify the type of state
estimates to be reviewed.
A.2.d.
The statement has been amended to read: “Review state Summary and
C&D estimates, and advise the regional office of any concerns prior to the
publication of estimates.” The section referencing the number of
establishments and estimated number of cases has been removed.
CENSUS OF FATAL OCCUPATIONAL INJURIES
Section A., Program Activities
A.1.
The statement specifies the type of cases (“injury”) that shall be entered into
the CFOI Web application.
A.5.
The following sentence has been added: “The SGA will follow the new
timelines set forth in CFOI S-16-01 for a single release of CFOI data for
reference year 2015.”
Section B., Program Performance Requirements
B.1.
The following paragraph has been added: “All CFOI memoranda, manuals,
and other communications are for CFOI internal use only. They should not
be shared with any non-CFOI staff without prior approval of BLS.”
B.2.
The following sentence has been added: “States will follow the guidance set
forth in CFOI S-15-04 when they receive inquiries from outside requestors
for source documents collected for CFOI.”
V.
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) and also submitting
the BLS-OSHS2 Quarterly Financial Report to the BLS regional office.
E.
Only one signed original OSHS CA closeout package is required to be sent to the BLS.
Schedule:
Review and discussion with states on the 2017 CA .......................... July-August 2016
Draft 2017 CA application due in regional office (RO) ...................... To be set by RO
Final 2016 OSHS CA modifications for deobligations
due in national office ...................................................................... July 18, 2016
Final 2016 OSHS CA modifications for reobligations
due in national office ...................................................................... August 5, 2016
Final, signed 2017 CA application due in RO .................................... August 19, 2016
Effective date of 2017 CA ................................................................. October 1, 2016
Completed, signed 2017 CAs due in national office ......................... October 5, 2016
VII.
Clearance Required: Any variances to the 2017 CA work statements must be approved by the BLS
before the package is submitted in final.
VIII.
Action Required:
A.
Grantees are requested to observe the time frame for the submission of their draft and final
CA applications as specified above.
B.
Grantees are reminded that new obligations cannot be charged to the 2016 CA after
September 30, 2016, and that closeouts of the 2016 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.
D.
Grantees are requested to only use the most up-to-date forms when submitting their initial
CA application, any subsequent CA modifications, and their CA closeout. The most up-to-date
forms are included in this CA application and can be found on StateWeb.
IX.
Inquiries: Questions on any aspect of this memorandum may be directed to the appropriate BLS
regional office.
X.
Attachments: Occupational Safety and Health Statistics Program Cooperative Agreement
FY 2017 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 05/31/2018
TABLE OF CONTENTS
I. ADMINISTRATIVE REQUIREMENTS _______________________________________________ 1
A.
INTRODUCTION __________________________________________________________ 1
B.
AUTHORIZING LEGISLATION ________________________________________________ 1
C.
ELIGIBLE APPLICANTS _____________________________________________________ 1
D.
REGULATIONS AND REFERENCE DOCUMENTS __________________________________ 1
E.
PROGRAM FUNDING ______________________________________________________ 2
F.
CASH MANAGEMENT _____________________________________________________ 2
G.
COST GUIDELINES ________________________________________________________ 2
H.
FINANCIAL REPORTING ____________________________________________________ 3
I.
MONITORING____________________________________________________________ 3
J.
DEOBLIGATION OF UNDERUTILIZED FUNDS ____________________________________ 4
K.
PROGRAM VARIANCES ____________________________________________________ 4
L.
CHANGES TO THE COOPERATIVE AGREEMENT __________________________________ 4
M. EQUIPMENT ____________________________________________________________ 5
N.
PROCUREMENT __________________________________________________________ 6
O.
CLOSEOUTS AND AUDITS __________________________________________________ 6
P.
RECORDS _______________________________________________________________ 7
Q.
CONFIDENTIALITY ________________________________________________________ 7
R.
DATA AND COMMUNICATIONS SAFEGUARDS _________________________________ 10
S.
DATA COLLECTION INTEGRITY ______________________________________________ 12
T.
CERTIFICATIONS_________________________________________________________ 12
U.
ASSURANCES ___________________________________________________________ 13
BLS-OSHS QUARTERLY FINANCIAL REPORT _______________________________________ 15
TRANSMITTAL AND CERTIFICATION FORM _______________________________________ 17
BLS-OSHS FINANCIAL RECONCILIATION WORKSHEET (FRW) TERMS DEFINED ____________ 19
BLS-OSHS PROPERTY LISTING ____________________________________________ 21
FEDERAL FINANCIAL REPORT ____________________________________________ 23
II. APPLICATION INSTRUCTIONS _________________________________________________ 25
A.
GENERAL RESPONSIBILITIES _______________________________________________ 25
B.
APPLICATION PROCESS __________________________________________________ 25
C.
INSTRUCTIONS FOR COMPLETING FORMS ___________________________________ 26
III. APPLICATION MATERIALS ____________________________________________________ 41
APPLICATION FOR FEDERAL ASSISTANCE SF-424 ___________________________________ 43
INSTRUCTIONS FOR THE SF-424 ________________________________________________ 47
BUDGET INFORMATION – NON-CONSTRUCTION PROGRAMS _________________________ 49
INSTRUCTIONS FOR THE SF-424A _______________________________________________ 50
CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS _________________ 53
DISCLOSURE OF LOBBYING ACTIVITIES ___________________________________________ 55
BLS AGENT AGREEMENT ______________________________________________________ 57
BLS PRE-RELEASE ACCESS CERTIFICATION FORM ____________________________ 59
ALL OSHS PROGRAM __________________________________________________________ 63
SURVEY OF OCCUPATIONAL INJURIES AND ILLNESSES (SOII) FISCAL YEAR 2017_____________ 67
CENSUS OF FATAL OCCUPATIONAL INJURIES (CFOI) FISCAL YEAR 2017 ___________________ 71
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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 2 Part 2900 of the Code of Federal Regulations (hereinafter cited as 2 CFR 2900), Uniform
Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards;
3.
Title 2 Part 200 of the Code of Federal Regulations (hereinafter cited as 2 CFR 200), Uniform
Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards; and
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).
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.
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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 2 CFR 200.302) 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 2 CFR 200, Subpart E (Cost Principles). A
request for prior approval of certain costs, under the cost principles of 2 CFR 200, Subpart E, may be made by
means of a letter from the recipient organization to the BLS.
Indirect costs are defined as all costs incurred for a common or joint purpose benefiting more than one cost
objective, and not readily assigned to the cost objectives specifically benefited, without effort
disproportionate to the results achieved. 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 2 CFR 200, Subpart F (Audit Requirements) 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 2 CFR 200, Subpart E. 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. 2 CFR 200.420 through
200.475, provides full guidance regarding this requirement. Note that states with time and attendance
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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. The FFR is used to report cumulative Federal cash transactions (total cash received
and disbursed) and financial status information (Federal expenditures and unobligated balance) for each
program. The BLS-OSHS2 Quarterly Financial Report captures both quarterly and cumulative expenditures
for each program. The SGA’s quarterly and closeout reporting requirements are summarized below.
Quarterly Financial Reporting Requirements
•
BLS-OSHS2 – 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.
•
HHS-PMS FFR Federal Cash Transaction Report – State agencies must complete item 10 (lines a – c) 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.
•
The BLS reserves the right to withhold payment to a state agency if financial reports are delinquent.
Closeout Financial Reporting Requirements
State agencies should use the Transmittal and Certification Form as a checklist to ensure all required forms
are included in the closeout package submitted to the regional office.
• BLS-OSHS2 – State agencies must submit the BLS-OSHS2 Quarterly Financial Report to the regional office
as part of the closeout package.
• Hardcopy FFR – State agencies must complete item 10 (lines d – k) and item 11 (lines a – f) of the FFR
annually and submit it to the regional office as part of the closeout package. HHS-PMS does not have
the functionality to report all sections of the FFR for the BLS (only item 10 a – c). Therefore, item 10
(lines d – k) and item 11 (lines a – f) of the FFR must be completed on paper and submitted to the
appropriate regional office as part of the closeout documentation. A copy of the FFR is included at the
end of the Administrative Requirements Section and also can be found here:
http://www.grants.gov/web/grants/forms/post-award-reporting-forms.html
I.
MONITORING
The BLS will review the financial reports from the SGAs to monitor fund utilization and identify potential overor 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 2 CFR 200.328(e), the BLS may also conduct periodic on-site reviews to ensure the adequacy of
the SGA's financial management systems.
In accordance with 2 CFR 200.328, SGAs are responsible for managing the day-to-day operations of grantsupported activities and monitoring their performance under the agreement to assure compliance with
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applicable Federal requirements and to assure that performance goals are being met. Also per 2 CFR
200.328(e), 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:
L.
1.
Background of the problem;
2.
Performance during the previous period, such as the previous survey year for the SOII 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.
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.
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2.
Programmatic Changes
Programmatic changes that require BLS prior written approval include:
3.
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.
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 and with the provisions of the All OSHS Program Work Statement.
When disposing of equipment, which includes printers, hard drives must be properly sanitized. The state may
choose to ship the equipment back to BLS for disposal. Title to equipment purchased with cooperative
agreement funds shall vest upon acquisition in the SGA. However, the BLS, per 2 CFR 200.313(a), 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 2
CFR 200.313(a)(1)-(3). Pursuant to those standards, specifically, 2 CFR 200.313(a)(1), the BLS reserves the
right to transfer title of any Automated Data Processing (ADP) equipment, purchased with cooperative
5
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 2 CFR 200.313a)(1)-(3). The SGA will maintain an inventory of BLS-owned and state-owned
equipment used for the OSHS program and respond promptly to BLS requests for information about its
location, operating status, and condition. The SGA will adhere to BLS security requirements regarding all
computer equipment as outlined in program memoranda.
N.
PROCUREMENT
The provisions of 2 CFR 200.317 – 200.326, Procurement Standards, 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:
2.
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.
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 2 CFR 200.343, regarding
closeout, and 2 CFR 200, Subpart F (Audit Requirements), 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 (BLSOSHS2); the Financial Reconciliation Worksheet (FRW); the SF-425 Federal Financial Report (FFR) item 10
(lines d – k) and item 11 (lines a – f); and the Property Listing (where applicable). The BLS-specific forms are
included as part of this Cooperative Agreement Application and located on StateWeb. As required by OMB,
closeout packages are due no later than 90 calendar days after the end of the Cooperative Agreement period.
If SGAs are not able to make this deadline they 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 regional office grants staff 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.
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P.
RECORDS
1.
Retention
Records will be retained in accordance with 2 CFR 200.333 – 200.337, Record Retention and Access.
Generally, the SGA will retain all records pertinent to the agreement, including financial records and
supporting documents for a period of three years from the date of the final expenditure report. States
will retain the hard copy forms (Survey of Occupational Injuries and Illnesses (SOII) and Census of Fatal
Occupational Injuries (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 SOII 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 BLS State 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.
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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.
3.
4.
Pre-release information such as official estimates and other official statistical products prior
to the official BLS release of the national data.
State’s Confidentiality Responsibility
a.
The state agency agrees to use respondent identifiable information for statistical purposes only.
b.
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 been approved for access to BLS pre-release information as certified by the
BLS State Cooperating Representative.
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 SOII and CFOI) prior to its
execution in accordance with BLS requirements. The BLS State 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 authorized by the BLS to receive access to respondent identifiable information for
work on the activities directly 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.
State employees may not have access to pre-release information, unless they are designated as
“authorized agents” of the BLS (as described in section 4.b.) or they have been approved for access
to pre-release information as certified by the BLS State Cooperating Representative. A copy of the
certification form is included as part of the application materials in Part III.
d.
The BLS may revoke an agent agreement or revoke an individual’s access to pre-release
information at any time and without advance notice.
e.
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.
f.
The state agency agrees to recertify on an annual basis through the BLS State Cooperating
Representative that state employees approved for access to only pre-release information have
been provided the “Conditions for Handling BLS Pre-Release Information” (included as part of the
application materials in Part II) and have indicated their understanding and acceptance of those
conditions. State employees approved for access to only pre-release information are not required
to take the annual confidentiality training referenced in section 4.e.
8
5.
6.
g.
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.
h.
State agencies agree to prohibit remote access to confidential information from offsite locations
without prior written approval from the Grant Officer.
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 or those individuals approved for access to only pre-release information 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 (in the case of respondent identifiable information), approved individual (in the case
of pre-release information), 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.
Use of Contractors
a.
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.
b.
Contractor officers and employees must adhere to CIPSEA and all applicable Federal laws regarding
the handling of all respondent identifiable information and also must adhere to the BLS
confidentiality policy as stated in this cooperative agreement with regard to access to all
confidential information;
9
c.
Access to respondent identifiable 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;
d.
Access to pre-release information must be limited to contractor officers and employees who have
been designated agents by the BLS or approved for access to only pre-release information as
certified by the BLS State Cooperating Representative;
e.
Reliability of personnel;
f.
No subcontracting permitted;
g.
Right of inspection of contractor facilities;
h.
Physically secure work site and computer/communications environment;
i.
Exclusive storage facilities for confidential information;
j.
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;
k.
Right of termination for failure to comply with security requirements;
l.
Right to review outputs produced from respondent identifiable information prior to release or
publication;
m. Return or destruction of confidential information upon termination of the contract; and
n.
R.
Contractor shall not, by action or inaction, do anything to cause the state to violate the terms of
this cooperative agreement.
DATA AND COMMUNICATIONS SAFEGUARDS
1.
This section of the cooperative agreement has been developed to establish a management agreement
between the BLS and state offices. The BLS and state offices, when referred to collectively in this
section, will be referred to as the “parties.” The data and communication systems covered in this
section are the BLS LAN/WAN system owned by the BLS state-owned personal computers, whether
they are provided by the BLS or purchased directly 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.
10
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
202-691-5950
[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 pointof-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:
12.
a.
Any breach or suspected breach of security, or
b.
Any disclosure of the confidential information not authorized by this cooperative agreement.
All OSHS-related electronic communications (email) that contain confidential information will be
transmitted using the BLS (“bls.gov”) mail server. If email is sent from one BLS-provisioned email
account to another BLS-provisioned email account no additional email encryption measures are
needed. If email will be transmitted using non-BLS provisioned accounts, users will encrypt the data in
an attachment using a FIPS 140-2-validated method. For example, FIPS 140-2 approves as encryption
the password protecting of Word or Excel attachments as long as they can be saved with the file
11
extension of .docx or .xlsx. respectively.
http://csrc.nist.gov/groups/STM.
S.
More information on FIPS 140-2 can be found at
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 the OSHS program with the data
collection requirements set out 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 nonfinancial 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
12
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 2 CFR 200.206, 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
13
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 2 CFR 200, Subpart F (Audit Requirements).
9.
Will comply with all applicable requirements of all other Federal laws, executive orders regulations
and policies governing this program.
14
BLS-OSHS QUARTERLY FINANCIAL REPORT BLS-OSHS2
OMB Approval No. 1220-0149; Expires 05-31-2018
State Grant Agency: ________________________________ Cooperative Agreement No.: ___________________ Reporting Period Ending: _______________
SECTION A – FINANCIAL ACTIVITY SUMMARY
Grant Program
Function
or Activity
(a)
Catalog of Federal
Domestic Assistance
Number
(b)
1.
Expenditures for the Quarter
Federal
(c)
Cumulative Expenditures
Non-Federal
(d)
Federal
(e)
Non-Federal
(f)
Total
(g)
$
$
$
$
$
$
$
$
$
$
2.
3.
4.
5. TOTALS
SECTION B -- TOTAL EXPENDITURES BY BUDGET CATEGORY FOR THE CURRENT QUARTER
GRANT PROGRAM, FUNCTION, OR ACTIVITY
TOTAL
6. Object Class Categories
(1)
(2)
(3)
(4)
(5)
a. Personnel
$
$
$
$
$
k. TOTALS (sum of 6i and 6j)
$
$
$
$
$
7. Program Income
$
$
$
$
$
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
CERTIFICATION: I certify that to the best of my knowledge and belief the information provided above is accurate and complete, and was obtained from agency accounting records.
Authorized Signature: _________________________________________________________________________________________
Authorized for Local Reproduction
15
Date: _______________________________
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., SOII 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., SOII 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 take 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.
16
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: 05-31-2018
State Grant
Agency (SGA):
Check, or write in, the appropriate boxes:
SOII
CA#:
CFOI
Other
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 [Item 10 (lines d – k) and
item 11 (lines a – f)]
BLS-OSHS2 Quarterly Financial Report
Property Listing (if applicable)
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:
(type/print)
Title:
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:
17
[this page intentionally left blank]
18
U.S. DEPARTMENT OF LABOR
BUREAU OF LABOR STATISTICS
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.
State Grant Agency (SGA):
Date:
CA #:
CA Period: From:
SOII
CFOI
FUND LEDGER CODE:
1. Cumulative Disbursements
2. Payments
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
19
To:
OTHER
OMB No. 1220-0149
Approval Expires 05-31-2018
OSHS FINANCIAL RECONCILIATION WORKSHEET (FRW) TERMS DEFINED
Line 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 Financial Reconciliation Worksheet:
•
applicable credits, refunds and rebates;
•
outstanding advances and prepaid expenses; and
•
other cash adjustments.
Line 2. Payments:
The amount of cash drawn down against HHS-PMS or checks received.
Line 3. Difference:
The amount of Payments/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
o
•
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
o
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
o
The amount of cash available for the payment of obligations.
Line 4. Total Obligational Authority:
The amount of funds that the SGA is allowed to obligate against a specific program ( i.e., CFOI, SOII, etc.).
Line 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 (Payments).
Line 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).
Line 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.
20
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.
State Grant Agency (SGA):
Date:
CA #:
Item No.
Identification
No.
CA Period: From:
Description
OMB No. 1220-0149
Approval Expires 05-31-2018
Location
Acquisition
Date
Remarks:
BLS OSHS Property Listing
21
To:
Condition
Code
Unit
Quantity
Unit Acquisition
Cost Federal
Non-Federal
Total Cost
Instructions for Completing the Property Listing
The Property Listing is required by 2 CFR 200.312. 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.
i.
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.
BLS OSHS Property Listing
22
Federal Financial Report
(Follow form Instructions)
23
OMB Number: 4040-0014
Expiration Date: 01/31/2019
11. Indirect Expense
a. Type
b. Rate
c. Period From
Period To
e. Amount
Charged
d. Base
f. Federal Share
g. Totals:
12. Remarks: Attach any explanations deemed necessary or information required by Federal sponsoring agency in compliance with governing legislation:
13. Certification: By signing this report, I certify that it is true, complete, and accurate to the best of my knowledge. I am aware that any false,
fictitious, or fraudulent information may subject me to criminal, civil or administrative penalties. (U.S. Code, Title 18, section 1001)
a. Name and Title of Authorized Certifying Official
Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
Title:
b. Signature of Authorized Certifying Official
c. Telephone (Area code, number and extension)
d. Email Address
e. Date Report Submitted
14. Agency use only:
Standard Form 425
24
II. APPLICATION INSTRUCTIONS
A.
GENERAL RESPONSIBILITIES
The cooperating SGA 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:
B.
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, and, once issued, notifying the SGA of its obligational
authority under the Cooperative Agreement.
APPLICATION PROCESS
The SGA is requested to submit a copy of a draft application, which may, at the state's option, be submitted
without the original signature of the duly authorized representative of the SGA. The draft application will
consist of the following application materials:
1.
Application for Federal Assistance (SF-424);
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, email 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 state agency’s authorized representative 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, along with the BLS Agent
Agreement for BLS State Cooperating Representatives and the BLS Pre-Release Access Certification Form,
when applicable.
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, verify that the correct Cooperative Agreement
number is used, and, finding no outstanding issues, the BLS Regional Commissioner, as Grant Officer, will
25
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.
a.
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.
26
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 14 digit
CA number (ex. OS-20318-17-75-J-25) as follows:
1st through 2nd digits – Program identifier; “OS” is used for OSHS
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--2017
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 “17” for 2017.
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” for 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, Bureau of Labor Statistics”
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 114th Congress can be found online at
http://www.census.gov/geo/maps-data/maps/reference-cd114.html.
27
2.
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, 10/01/16 and 09/30/17 for Federal
fiscal year 2017.
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.
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.
28
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 lowertier 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.
29
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.
2.
c.
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.
Where the prospective primary participant is unable to certify to any of the statements
in this certification, such prospective participant shall attach an explanation to this
application/proposal.
Instructions--Lower-Tier Covered Transactions
1.
By signing and submitting this proposal, the prospective lower-tier participant is providing
the certification set out below.
2.
The certification in this clause is a material representation of fact upon which reliance was
placed when this transaction was entered into. If it is later determined that the
prospective lower-tier participant knowingly rendered an erroneous certification, in
addition to other remedies available to the Federal Government, the department or
agency with which this transaction originated may pursue available remedies, including
suspension and/or debarment.
3.
The prospective lower-tier participant shall provide immediate written notice to the
person to whom this proposal is submitted if at any time the prospective lower-tier
participant learns its certification was erroneous when submitted or has become
erroneous by reason of changed circumstances.
4.
The terms "covered transaction," "debarred," "suspended," "ineligible," "lower-tier
covered transaction," "participant," "person," "primary covered transaction," "principal,"
"proposal," and "voluntarily excluded," as used in this clause, have the meanings set out
in the Definitions and Coverage sections of the rules implementing Executive Order 12549
30
[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.
d.
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 lowertier 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.
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.
31
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
32
not on the grantee's payroll; or employees of subrecipients or subcontractors in covered
workplaces).
b.
Certification Regarding Drug-Free Workplace Requirements
1.
2.
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).
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.
33
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
of Lobbying Activities," 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. 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.
34
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. 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.
11.
The certifying official shall sign and date the form, print his/her name, title, and telephone
number.
35
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.
7.
Instructions
1.
Each BLS 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 BLS State 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
BLS State 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 BLS 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 BLS 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.
BLS Pre-Release Access Certification Form
a.
General Guidelines
The purpose of the BLS Certification Form is for the BLS State Cooperating Representative to
certify that persons with advance access to BLS pre-release information are aware of their
responsibilities for ensuring compliance with BLS confidentiality policies regarding handling of
pre-release information. This agreement is intended for signature by the BLS State Cooperating
Representative only to certify that the individuals listed in the attachment to the certification
form are authorized to have advance access to BLS pre-release information and have indicated
their understanding and acceptance of the conditions for access to BLS pre-release information.
36
b.
8.
Instructions
1.
Each BLS 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. This list will serve as attachment A of
the Pre-release Access Certification Form.
2.
Each individual named on the list above must be fully informed of their responsibilities
and obligations for handling BLS pre-release information either in writing or verbally. The
document entitled, “Conditions for Handling Pre-release Information,” can be used for
this purpose.
3.
The BLS State Cooperating Representative is responsible for forwarding to their
respective BLS regional office the list of individuals authorized advance access to BLS prerelease information and the signed Pre-release Access Certification Form.
4.
The BLS regional office is responsible for maintaining on file the signed original copies of
all Certification Forms from their respective SGAs.
5.
The BLS Pre-release Access Certification Form signed by the BLS State Cooperating
Representative is in effect so long as the list of authorized persons is accurate. A new
certification must be made each time a new individual is added to the list of authorized
persons. The new individual should be appended to the list and the list should be recertified. At the time of modification, individuals who no longer need-to-know this
information should be dropped from the list.
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 in whole dollar amounts. 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 (e.g. SOII or
CFOI) on the lines in column (a) and "17.005" (the catalog number) in the corresponding
lines of column (b).
Lines 1-4, Columns (c) through (g): The first and third paragraphs of the standard
instructions apply.
37
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).
Please use separate columns for Federal and nonfederal if budgeted cost categories
matching differs.
Lines 6a-6h: Enter totals for the object class categories for each program activity.
Line 6j: The correct reference for determining indirect charges is 2 CFR 200, Subpart E
(Cost Principles).
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 2 CFR
200, Subpart E (Cost Principles) 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.
38
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.
39
d.
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.
e.
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.
40
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 Pre-Release Access Certification Form
•
Work Statements
41
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42
OMB Number: 4040-0004
Expiration Date: 08/31/2016
Application for Federal Assistance SF-424
*1. Type of Submission:
*2. Type of Application
Preapplication
New
Application
Continuation
Changed/Corrected Application
Revision
3. Date Received :
* If Revision, select appropriate letter(s)
*Other (Specify)
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:
43
OMB Number: 4040-0004
Expiration Date: 08/31/2016
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:
44
OMB Number: 4040-0004
Expiration Date: 08/31/2016
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 18, 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:
*Date Signed:
*Signature of Authorized Representative:
* 22a. Typed Name of BLS Grant Officer:
b. Title:
d. Signature of BLS Grant Officer:
Regional Commissioner
c. Telephone Number:
e. Date Signed:
45
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46
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
1.
Entry:
Item
Entry:
Type of Submission: (Required): Select one type of submission in
accordance with agency instructions.
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.
•
•
•
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.
•
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.
4.
Applicant Identifier: Enter the entity identifier assigned by the Federal
agency, if any, or applicant’s control number, if applicable.
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.
5a
Federal Entity Identifier: Enter the number assigned to your
organization by the Federal agency, if any.
16.
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.
Date Received by State: Leave this field blank. This date will be
assigned by the state, if applicable.
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 SF424 Project/Performance Site Location(s) Form. Attach an
additional list of program/project congressional districts, if
needed.
17.
Proposed Project Start and End Dates: (Required) Enter the
proposed start date and end date of the project.
2.
•
•
•
•
•
•
6.
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.
b. Employer/Taxpayer Number (EIN/TIN): (Required): Enter the
Employer or Taxpayer Identification Number (EIN or TIN) as assigned by
47
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.
19.
Is Application Subject to Review by State Under Executive
Order 12372 Process?
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).
e. Organizational Unit: Enter the name of the primary organizational
unit, department or division, if applicable that will undertake the
assistance activity.
(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
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.
9.
Type of Applicant: (Required) Select up to three applicants
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
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
M.
N.
O.
P.
Q.
R.
S.
T.
U.
V.
W.
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)
48
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.
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.)
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. 4040-0006
Expiration Date 1/31/2019
BUDGET INFORMATION -- Non-Construction Programs
SECTION A – BUDGET SUMMARY
Grant Program
Function
Or Activity
(a)
Catalog of Federal
Domestic Assistance
Number
(b)
Estimated Unobligated Funds
Federal
(c)
1.
New or Revised Budget
Non-Federal
(d)
$
Federal
(e)
$
Non-Federal
(f)
$
Total
(g)
$
$
2.
3.
4.
5. TOTALS
$
$
$
$
$
GRANT PROGRAM, FUNCTION, OR ACTIVITY
(1)
(2)
(3)
$
$
$
(4)
$
TOTAL
(5)
$
k. TOTALS (sum of 6i and 6j)
$
$
$
$
$
7. Program Income
$
$
$
$
$
SECTION B -- BUDGET CATEGORIES
6. Object Class Categories
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
Authorized for Local Reproduction
49
Standard Form 424A (Rev. 7-97)
Prescribed by OMB (2 CFR 200) page 1
INSTRUCTIONS FOR THE SF-424A
General Instructions
Lines 1-4, Columns (c) through (g) (continued)
This form is designed so that application can be made
for funds from one or more grant programs. In
preparing the budget, adhere to any existing Federal
grantor agency guidelines which prescribe how and
whether budgeted amounts should be separately
shown for different functions or activities within the
program. For some programs, grantor agencies may
require budgets to be separately shown by function or
activity. For other programs, grantor agencies may
require a breakdown by function or activity. Sections
A, B, C, and D should include budget estimates for
the whole project except when applying for assistance
which requires Federal authorization in annual or
other funding period increments. In the latter case,
Sections A, B, C, and D should provide the budget for
the first budget period (usually a year) and Section E
should present the need for Federal assistance in the
subsequent budget periods. All applications should
contain a breakdown by the object class categories
show on Lines a-k of Section B.
For continuing grant program applications, submit
these forms before the end of each funding period as
required by the grantor agency. Enter in Columns (c)
and (d) the estimated amounts of funds which will
remain unobligated at the end of the grant funding
period only if the Federal Grantor agency instructions
provide for this. Otherwise, leave these columns
blank. Enter in columns (e) and (f) the amounts of
funds needed for the upcoming period. The
amount(s) in Column (g) should be the sum of
amounts in Columns (e) and (f).
Section A. Budget Summary
For supplemental grants and changes to existing
grants, do not use Columns (c) and (d). Enter in
Column (e) the amount of the increase or decrease of
Federal funds and enter in Column (f) the amount of
the increase or decrease of non-Federal funds. In
Column (g), enter the new total budgeted amount
(Federal and non-Federal) which includes the total
previous authorized budgeted amounts plus or minus,
as appropriate, the amounts shown in Columns (e)
and (f). The amount(s) in Column (g) should not
equal the sum of amounts in Columns (e) and (f).
Lines 1-4, Columns (a) and (b)
Line 5 - Show the totals for all columns used.
For applications pertaining to a single Federal grant
program (Federal Domestic Assistance Catalog
number) and not requiring a functional or activity
breakdown, enter on Line 1 under Column (a) the
Catalog program title and the Catalog number in
Column (b). For applications pertaining to a single
program requiring budget amounts by multiple
functions or activities, enter the name of each activity
or function on each line in Column (a), and enter the
Catalog number in Column (b). For applications
pertaining to multiple programs where none of the
programs require a breakdown by function or activity,
enter the Catalog program title on each line in
Column (a) and the respective Catalog number on
each line in Column (b).
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).
Section B. Budget Categories
In the column headings (1) through (4), enter the titles
of the same programs, functions, and activities shown
on Lines 1-4, Column (a), Section A. When
additional sheets are prepared for Section A, provide
similar column headings on each sheet. For each
program, function or activity, fill in the total
requirements for funds (both Federal and nonFederal) by object class categories.
Lines 6a- i - Show the totals of Lines 6a to 6h in each
column.
Line 6j - Show the amount of indirect cost.
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)
50
SECTION C -- NON-FEDERAL RESOURCES
(a) Grant Program
(b) Applicant
8.
(c) State
(d) Other Sources
(e) TOTALS
$
$
$
$
$
$
$
$
9.
10.
11.
12. TOTALS (sum of lines 8 and 11)
SECTION D – FORECASTED CASH NEEDS
Total for 1st Year
13. Federal
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
$
$
$
$
$
$
$
$
$
$
14. Non-Federal
15. TOTALS (sum of lines 13 and 14)
SECTION E -- BUDGET ESTIMATES OF FEDERAL FUNDS NEEDED FOR BALANCE OF THE PROJECT
(a) Grant Program
16.
FUTURE FUNDING PERIODS (years)
(c) Second
(d) Third
(b) First
(e) Fourth
$
$
$
$
$
$
$
$
17.
18.
19.
20. TOTALS (sum of lines 16 - 19)
21. Direct Charges:
SECTION F -- OTHER BUDGET INFORMATION
(Attach Additional Sheets if Necessary)
22. Indirect Charges:
23. Remarks
Authorized for Local Reproduction
51
Standard Form 424A (Rev. 7-97)
Prescribed by OMB (2 CFR 200) Page 2
INSTRUCTIONS FOR THE SF-424A (continued)
Line 7 - Enter the estimated amount of income, if
any, expected to be generated from this project. Do
not add or subtract this amount from the total project
amount. Show under the program narrative statement
the nature and source of income. The estimated
amount of program income may be considered by the
Federal grantor agency in determining the total
amount of the grant.
Line 14 - Enter the amount of cash from all other
sources needed by quarter during the first fiscal year.
Section C. Non-Federal Resources
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.
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 15 - Enter the totals of amounts on Lines 13 and
14.
Section E. Budget Estimates of Federal Funds
Needed for Balance of the Project
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)
52
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: ___________________________________________________________________
53
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54
DISCLOSURE OF LOBBYING ACTIVITIES
Approved by OMB
Complete this form to disclose lobbying activities pursuant to 31 U.S.C.1352
Review Public Burden Disclosure Statement
1. * Type of Federal Action:
b.
2. * Status of Federal Action:
4040-0013
3. * Report Type:
a. contract
a. bid/offer/application
a. initial filing
grant
b. initial award
b. material change
c. cooperative agreement
c. post-award
d. loan
e. loan guarantee
f. loan insurance
4. Name and Address of Reporting Entity:
Prime
SubAwardee
* Name
* Street 1
Street 2
* City
State
Zip
Congressional District, if known:
5. If Reporting Entity in No.4 is Subawardee, Enter Name and Address of Prime:
* Name
* Street 1
Street 2
* City
State
Zip
Congressional District, if known:
6. * Federal Department/Agency:
7. * Federal Program Name/Description:
CFDA Number, if applicable:
8. Federal Action Number, if known:
9. Award Amount, if known:
$
10. a. Name and Address of Lobbying Registrant:
Prefix
Middle Name
* First Name
* Last Name
Suffix
* Street 1
Street 2
* City
Zip
State
b. Individual Performing Services (including address if different from No. 10a)
Prefix
Middle Name
* First Name
* Last Name
Suffix
* Street 1
Street 2
* City
11.
State
Zip
Information requested through this form is authorized by title 31 U.S.C. section 1352. This disclosure of lobbying activities is a material representation of fact upon which reliance
was placed by the tier above when the transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information will be reported to
the Congress semi-annually and will be available for public inspection. Any person who fails to file the required disclosure shall be subject to a civil penalty of not less than
$10,000 and not more than $100,000 for each such failure.
* Signature:
*Name:
Prefix
* First Name
Middle Name
* Last Name
Title:
Suffix
Telephone No.:
Date:
Authorized for Local Reproduction
Standard Form - LLL (Rev. 7-97)
Federal Use Only:
55
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56
BLS AGENT AGREEMENT
FOR OSHS FEDERAL-STATE PROGRAM
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 CIPSEA, 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]
[Title]
[Name of Organization]
[Name of BLS Official]
Regional Commissioner
Bureau of Labor Statistics
_________________
Date
_________________
Date
57
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58
Bureau of Labor Statistics Pre-Release Access Certification Form
I, [Name], Cooperating Representative for the State of [Name of state], do hereby certify that all of the individuals
listed in Attachment A of this certification form are authorized to have advance access to Bureau of Labor Statistics
(BLS) pre-release information. I certify that the individuals listed in Attachment A have been fully informed of their
responsibilities and obligations in handling and maintaining the confidentiality of pre-release information prior to
its set time for release. I further certify that each of the individuals listed in Attachment A have indicated their
understanding and acceptance of the conditions for access to BLS pre-release information.
__________________________________________
[Name]
BLS State Cooperating Representative
[Name of state]
_______________
Date
59
CONDITIONS FOR HANDLING BLS PRE-RELEASE INFORMATION
PURPOSE. The purpose of this document is to inform individuals 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 Statistical Policy Directive No. 4, “Release and Dissemination of
Statistical Products Produced by Federal Statistical Agencies,” (73 FR 12622-12626). BLS pre-release information
includes statistics and analyses that have not yet officially been released to the public. BLS pre-release information
is deemed confidential until made available to the public through the official, scheduled release. Individuals
granted 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 release.
Acknowledging the requirements contained within this document only provides the individual accepting these
handling conditions with access to BLS pre-release information; acknowledgment does not authorize access to
respondent identifiable information.
Individuals granted access to BLS pre-release information must acknowledge acceptance of the conditions
presented in this document. Individuals will be deemed to have acknowledged the conditions presented below
through reading or listening to the requirements and accepting the conditions through a written or verbal
affirmation provided to the BLS State OSHS Cooperating Representative.
•
•
•
•
•
•
Individuals will not release BLS 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 approved individuals with a need-to-know who have acknowledged acceptance
of the conditions for handling BLS pre-release information as presented in this document or previously
have signed a BLS agent agreement.
Individuals will store BLS pre-release information in a manner that ensures unauthorized persons cannot
view or otherwise gain access to the BLS pre-release information.
Individuals will not remove BLS pre-release information from state government facilities.
Individuals acknowledge that BLS pre-release information may only be provided to authorized persons.
Should a question arise about whether an individual is an authorized person, or should the need arise to
provide BLS pre-release information to additional individuals who have not previously acknowledged
acceptance of these conditions, or should any questions arise regarding the appropriate handling of this
information, then individuals will first contact the BLS before taking any action with the BLS pre-release
information.
Individuals with access to any BLS pre-release information must not use the information for personal gain.
Individuals will notify the BLS immediately upon discovering any actual or perceived unauthorized
disclosure of the BLS pre-release information.
60
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. 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
SOII
CFOI
25 minutes
50 minutes
45 minutes
We estimate that it will take an average of two (2) hours to complete these forms, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the information. If you have any comments on the estimates or the forms, send them to the Bureau of
Labor Statistics, Division of Financial Planning and Management (1220-0149), 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.
61
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62
Work Statement
State
CA Number
____
OS-___________-17-75-J-______
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.
[____]
Quarterly Financial Reporting Requirements
BLS-OSHS2 – State agencies must submit the BLS-OSHS2 Quarterly Financial Report to the regional
office within 30 days after the end of the each quarter.
[____]
HHS-PMS FFR Federal Cash Transaction Report – State agencies must complete item 10 (lines a –
c) 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.
[____]
Closeout Financial Reporting Requirements
C.
BLS-OSHS2 – State agencies must submit the BLS-OSHS2 Quarterly Financial Report to the regional
office as part of the closeout package.
[____]
Hardcopy FFR – State agencies must complete item 10 (lines d – k) and item 11 (lines a – f) of the
FFR annually and submit it to the regional office as part of the closeout package. HHS-PMS does
not have the functionality to report all sections of the FFR for the BLS (only item 10a – c).
Therefore, item 10 (lines d – k) and item 11 (lines a – f) of the FFR must be completed on paper
and submitted to the appropriate regional office as part of the closeout documentation.
[____]
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 provided by the BLS OSHS program at the time of
the corresponding National news release, no additional BLS validation is needed. The SGA
may use other approved systems to obtain data for publishing including: Case and
Demographics system, and CFOI Web. These data must be validated by the regional or
national office.
63
[____]
Work Statement
C.
State
CA Number
____
OS-___________-17-75-J-______
PROGRAM REQUIREMENTS APPLICABLE TO BOTH SOII AND CFOI (CONTINUED)
2.
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.
[____]
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 Office of Field Operations, Division of Cooperative
Survey Programs). 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. For SOII, with the exception of top-line state totals that may be published as part
of the national data releases and the data products associated with the release, the BLS will
normally provide the SGA a minimum of ten business days after each release in which to
publish their data prior to the BLS making the state data available to the public. If the end of
the ten-day period falls on a holiday, the BLS reserves the right to publish state data one
business day before the holiday. For CFOI, full state data will be published by the BLS on the
same day that national data are released.
[____]
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.
Agree To
Comply
(Check
Box)
[____]
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.
64
[____]
Work Statement
C.
State
CA Number
____
OS-___________-17-75-J-______
PROGRAM REQUIREMENTS APPLICABLE TO BOTH SOII AND CFOI (CONTINUED)
The SGA shall follow instructions regarding the installation and deployment of any updates
to the operating systems.
Agree To
Comply
(Check
Box)
[____]
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.
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. The SGA agrees to comply with program memoranda
outlining computer security procedures.
[____]
[____]
5. OSHS Computer Equipment
Typically, BLS provides the SGA with the computer equipment necessary for conducting OSHS
program activities. The SGA may, however, purchase its own equipment, but must first
contact the regional office to ensure compatibility with other OSHS equipment and with
OSHS computer systems.
[____]
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.
The SGA will submit the BLS OSHS Property Listing at closeout, if required.
[____]
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.
[____]
In the event the equipment used to process BLS data, 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. However, the SGA must
ensure that any information categorized as confidential or sensitive by the BLS be removed
from the equipment before disposition. The SGA may choose to ship the equipment to BLS
for sanitization and disposal after obtaining instructions from the BLS.
65
[____]
Work Statement
C.
State
CA Number
____
OS-___________-17-75-J-______
PROGRAM REQUIREMENTS APPLICABLE TO BOTH SOII AND CFOI (CONTINUED)
Agree To
Comply
(Check
Box)
6. Attendance at Conferences and Meetings
The SGA shall be represented at the BLS/state annual training conference on both the fatal
occupational injuries 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. Should staff be unable to fulfill any of these
requirements, an appropriate level of funding will be deobligated by the BLS.
[____]
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. BLS may deobligate funds if SGA staff does not attend these
required sessions.
D.
EXPLANATION OF VARIANCES
(Attach additional pages if needed)
66
[____]
Work Statement
State
CA Number
____
OS-___________-17-75-J-______
SURVEY OF OCCUPATIONAL INJURIES AND ILLNESSES (SOII)
FISCAL YEAR 2017
A.
Agree To
Comply
(Check Box)
PROGRAM ACTIVITIES
1.
For Reference Year 2015:
The SGA shall by the dates specified in technical memoranda:
a.
Complete review of state Summary and C&D estimates; and
[____]
b.
The SGA shall publish survey results.
[____]
The means to publish these results will be: (Please check format[s] below.)
2.
o
Report
[____]
o
News Release
[____]
o
Web Site
(list URL, if known now): __________________
[____]
o
Other
(Describe): ______________________________
[____]
For Reference Year 2016:
The SGA shall:
a.
Collect the survey by the dates specified in the program manuals and technical
memoranda. The collection targets are based on “survey rates” rather than
response rates.
b.
Edit and clarify the survey data as specified in the program manuals and technical
memoranda.
[____]
c.
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.
[____]
d.
Review state Summary and C&D estimates, and advise the regional office of any
concerns prior to the publication of estimates.
[____]
67
[____]
Work Statement
A.
.
State
CA Number
____
OS-___________-17-75-J-______
Agree To
Comply
(Check Box)
PROGRAM ACTIVITIES (CONTINUED)
3.
For Reference Year 2017:
The SGA shall, by the dates specified in the program manuals and technical
memoranda:
4.
a.
Review and refine the sample units.
[____]
b.
Pre-notify employers who have not been notified by the contract
printer/mailer to keep occupational injury and illness records.
[____]
For Reference Year 2018:
The SGA shall, by the dates specified in the program manuals and technical
memoranda:
B.
a.
Review and refine the target estimation industries (TEIs).
[____]
b.
Review and refine the sampling frame.
[____]
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.
[____]
68
Work Statement
State
CA Number
____
OS-___________-17-75-J-______
C.
FULL-TIME EQUIVALENT EMPLOYEES WORKING ON THE SURVEY OF OCCUPATIONAL INJURIES
AND ILLNESSES:
______________________
D.
BLS STATE COOPERATING REPRESENTATIVE:
Name
________________________________________________________________________
Title
________________________________________________________________________
Address
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Telephone
________________________________________________________________________
Email Address
________________________________________________________________________
E.
EXPLANATION OF VARIANCES
(Attach additional pages if needed)
69
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70
Work Statement
State
CA Number
____
OS-___________-17-75-J-______
CENSUS OF FATAL OCCUPATIONAL INJURIES (CFOI)
FISCAL YEAR 2017
A.
PROGRAM ACTIVITIES
1.
Agree To
Comply
(Check Box)
Develop and Maintain Data Sources Identifying Occupational Fatalities
The SGA shall make formal arrangements to obtain the following source documents
as well as amendments to these reports to identify occupational fatalities:
a.
b.
c.
2.
3.
[____]
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 injury cases from
those sources into the CFOI Web application.
[____]
The BLS shall have access to source documents for data quality control purposes.
[____]
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 fatal occupational illnesses consistent with the guidance set forth
in CFOI Technical Memo S-13-03.
[____]
The SGA shall specify reasons for scope determinations on questionable cases in the
state comments field.
[____]
Code Fatality Data
The SGA shall code fatalities using information from the various source documents.
Data elements to be coded are listed in the CFOI Program Guide, the CFOI Web User
Guide, and technical memoranda. States shall minimize the use of “unknown” codes.
71
[____]
Work Statement
A.
State
CA Number
____
OS-___________-17-75-J-______
Agree To
Comply
(Check Box)
PROGRAM ACTIVITIES (CONTINUED)
4.
5.
6.
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-up and data clarification, the SGA shall use the guidelines, solicitation letter,
and OMB-approved questionnaire provided by BLS unless the SGA has received prior
written approval from the BLS regional office.
[____]
Enter Data in a Timely Manner
The SGA will identify, verify, code, and enter current reference year cases into the CFOI
Web application by the dates specified in the CFOI timetable and technical memoranda.
[____]
The SGA will set review flags as specified in the CFOI Web User’s Guide 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 Web application by the dates
specified in the technical memoranda.
[____]
The SGA will follow the new timelines set forth in CFOI S-16-01 for a single release of
CFOI data for reference year 2015.
[____]
Process Fatality Reports for Out-of-State Cases
The SGA shall be responsible for processing fatality reports for persons fatally injured
and/or deceased 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.
[____]
72
Work Statement
A.
State
CA Number
____
OS-___________-17-75-J-______
Agree To
Comply
(Check Box)
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.)
B.
o
Report
[____]
o
News Release
[____]
o
Web Site
(list URL, if known now): __________________
[____]
o
Other
(Describe): _____________________________
[____]
PROGRAM PERFORMANCE REQUIREMENTS
1.
2.
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 2015, 2016, and 2017.
[____]
States shall use the OMB-approved questionnaire for follow-back.
[____]
All CFOI memoranda, manuals, and other communications are for CFOI internal use
only. They should not be shared with any non-CFOI staff without prior approval of
BLS.
[____]
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.
[____]
73
Work Statement
State
CA Number
____
OS-___________-17-75-J-______
B. PROGRAM PERFORMANCE REQUIREMENTS (CONTINUED)
2.
Confidentiality (CONTINUED)
Agree To
Comply
(Check
Box)
Data collected by state agencies will be used only in the CFOI unless the SGA and data
sources agree to other arrangements. States will follow the guidance set forth in
CFOI S-15-04 when they receive inquiries from outside requestors for source
documents collected for CFOI.
[____]
The BLS, its employees, agents, and partner statistical agencies, will use the
information collected on the OMB-approved questionnaire (per the guidelines set
forth in CFOI S-15-02) and all information incorporated into the CFOI Web application
for statistical purposes only. Information collected using the OMB-approved
questionnaire 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 OMB-approved questionnaire.
[____]
The SGA shall ensure that published CFOI results are in accordance with the BLS Data
Confidentiality provisions included in the CFOI Program Guide 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 and S-15-03).
[____]
The SGA acknowledges the 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-12-01.) 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 CFOI Web application and Profiles and will be automatically applied
to publication tables run in these systems.
[____]
74
Work Statement
State
CA Number
____
OS-___________-17-75-J-______
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 state 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 State Cooperating Representative indicating approval
of the release of state-specific data.)
[____]
75
Work Statement
C.
State
CA Number
____
OS-___________-17-75-J-______
RESEARCH FILES (CONTINUED)
The BLS will include the following data elements on the CFOI fatal injury research file:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
Reference year
Race
Gender
Industry (North American Industry Classification System, U.S. [NAICS])
Ownership (Federal, state, local, foreign or other government; private)
Occupation (Standard Occupational Classification [SOC])
Employee status (wage and salary, self-employed, armed forces, etc.)
Nature of injury (BLS Occupational Injury and Illness Classification System [OIICS])
Part of Body (BLS OIICS)
Source of injury (BLS OIICS)
Secondary source of injury (BLS OIICS)
Event or exposure (BLS OIICS)
Worker activity (at the time of incident)
Hispanic origin
Location type (farm, street, mine, etc.)
Geographic code (four Bureau of the Census regions)
Age group
Date of injury (day of the week—Monday, Tuesday, etc., month, and year)
Date of death (number of days from date of injury)
Region (region of birth)
Establishment size (based on employment)
Length of time with employer
Time of incident (to the nearest hour)
How the injury occurred (narrative description)
Confined space (did the incident occur in a confined space)
Contractor (was the decedent a contractor)
Contractor industry (industry of the contracting firm)
Contractor ownership (ownership of the contracting firm)
Additional data elements for the NIOSH research file only:
29.
30.
31.
32.
33.
34.
State codes
Actual age
Date of birth
Date of death
Death certificate identification number
Narrative industry and occupation information (1999 and subsequent years)
Additional data element for the OSHA research file only:
35. State Plan indicator
76
Work Statement
State
CA Number
____
OS-___________-17-75-J-______
D.
FULL-TIME EQUIVALENT EMPLOYEES WORKING ON THE CENSUS OF FATAL OCCUPATIONAL
INJURIES: ____________________
E.
BLS STATE COOPERATING REPRESENTATIVE:
Name
Title
Address
________________________________________________________________________
________________________________________________________________________
______________________________ __________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Telephone
________________________________________________________________________
Email Address
________________________________________________________________________
F.
EXPLANATION OF VARIANCES
(Attach additional pages if needed)
77
[this page intentionally left blank]
78
FY 2017 OSHS COOPERATIVE AGREEMENT DOCUMENT NUMBERS
State Grantee
CA No.
Suffix
State Grantee
CA No.
Suffix
ALABAMA
OS-28262-17-75-J-01
17P/Q
NEVADA
OS-28231-17-75-J-32
17P/Q
ALASKA
OS-28224-17-75-J-02
17P/Q
NEW HAMPSHIRE
OS-28216-17-75-J-33
17Q
17P
ARIZONA
OS-28228-17-75-J-04
17P/Q
NEW JERSEY
OS-28274-17-75-J-34
ARKANSAS
OS-28246-17-75-J-05
17P/Q
NEW JERSEY
OS-28275-17-75-J-34
17Q
CALIFORNIA
OS-28227-17-75-J-06
17P/Q
NEW MEXICO
OS-28237-17-75-J-35
17P/Q
COLORADO
OS-28242-17-75-J-08
17Q
NEW YORK
OS-28219-17-75-J-36
17P
NEW YORK
OS-28286-17-75-J-36
17Q
17R
CONNECTICUT
OS-28220-17-75-J-09
17P/Q
DELAWARE
OS-28278-17-75-J-10
17P/Q
NEW YORK
OS-28289-17-75-J-36
DISTRICT OF COLUMBIA
OS-28271-17-75-J-11
17P/Q
NORTH CAROLINA
OS-28266-17-75-J-37
17P/Q
GEORGIA
OS-28263-17-75-J-13
17P/Q
OHIO
OS-28285-17-75-J-39
17Q
GUAM
OS-28290-17-75-J-66
17P/Q
OHIO
OS-28292-17-75-J-39
17P
OKLAHOMA
OS-28245-17-75-J-40
17Q
OREGON
OS-28233-17-75-J-41
17P/Q
HAWAII
OS-28229-17-75-J-15
17P/Q
IDAHO
OS-28230-17-75-J-16
17Q
ILLINOIS
OS-28281-17-75-J-17
17P/Q
PENNSYLVANIA
OS-28270-17-75-J-42
17P
INDIANA
OS-28280-17-75-J-18
17P/Q
PENNSYLVANIA
OS-28291-17-75-J-42
17Q
PUERTO RICO
OS-28269-17-75-J-72
17P/Q
17Q
IOWA
OS-28279-17-75-J-19
17P/Q
KANSAS
OS-28247-17-75-J-20
17P/Q
RHODE ISLAND
OS-28222-17-75-J-44
KENTUCKY
OS-28264-17-75-J-21
17P/Q
SOUTH CAROLINA
OS-28267-17-75-J-45
17P/Q
LOUISIANA
OS-28243-17-75-J-22
17P/Q
TENNESSEE
OS-28288-17-75-J-47
17P/Q
MAINE
OS-28223-17-75-J-23
17P/Q
TEXAS
OS-28239-17-75-J-48
17P/Q
17P/Q
MARYLAND
OS-28277-17-75-J-24
17P/Q
UTAH
OS-28238-17-75-J-49
MASSACHUSETTS
OS-28217-17-75-J-25
17P
VERMONT
OS-28221-17-75-J-50
17P/Q
MASSACHUSETTS
OS-28218-17-75-J-25
17Q
VIRGIN ISLANDS
OS-28268-17-75-J-78
17P/Q
MICHIGAN
OS-28283-17-75-J-26
17P/Q
VIRGINIA
OS-28273-17-75-J-51
17P/Q
WASHINGTON
OS-28234-17-75-J-53
17P/Q
17P
MINNESOTA
OS-28282-17-75-J-27
17P/Q
MISSISSIPPI
OS-28265-17-75-J-28
17Q
WEST VIRGINIA
OS-28272-17-75-J-54
MISSOURI
OS-28244-17-75-J-29
17P/Q
WISCONSIN
OS-28287-17-75-J-55
17P/Q
MONTANA
OS-28240-17-75-J-30
17P/Q
WYOMING
OS-28241-17-75-J-56
17P/Q
NEBRASKA
OS-28284-17-75-J-31
17P/Q
79
| File Type | application/pdf |
| Subject | 119 |
| Author | penn_j |
| File Modified | 2016-04-12 |
| File Created | 2016-04-12 |