CPS Annual Report Form

Project Number:

Tribe:

Grant Award:

Amount Expended:

If grant funds were not fully expended explain why: (REQUIRED) § 1300.35

attach an additional page if needed

PERFORMANCE MEASURES
Targets can be found under Section Three: Targets in the FY2018 Project Agreement

To conduct a minimum of

CPS fitting stations.

Was performance target achieved?
To distribute a minimum of

Select One

If no, how many were conducted?

car seats, to include infant, convertible, booster seats, etc.…

Was performance target achieved?
To provide a minimum of
installation and use of seats).

Select One

If no, how many were distributed?

CPS trainings to Tribal community members (hands on proper

Was performance target achieved?
To provide a minimum of

Select One

If no, how many were provided?

CPS brochures and handouts to community members.

Was performance target achieved?

Select One

If no, how many were handed out?

If targets were not achieved explain why: (REQUIRED) § 1300.35

attach an additional page if needed

OMB Control No. 1076-0190
Expiration Date ##/##/####

Project Number:

Tribe:
CAR SEAT AWARDS

Total number of:
Car Seats

# Awarded

# Purchased

Total Cost

Distributed Remaining

Select One
Select One
Select One
Select One
Select One

0
0
0
0
0
0
0

Other:
Other:

If car seats were purchased and not distributed provide a plan with dates and locations for future distribution events.

OCCUPANT PROTECTION & CHILD PASSENGER SAFETY (CPS)
Does the Tribe have a Safety Belt Law?

Select One

If yes, is the safety belt law:

Select One

Effective date of safety belt law:

Does the Tribe have a CPS law?

Select One

Effective date of CPS law:

How many Tribal CPS Technicians are on staff?
List Certified Tribal CPS Technician:
Name:

Title:

Name:

Title:
OCCUPANT PROTECTION & CHILD PASSENGER SAFETY (CPS)

List CPS event/clinic dates and locations held within the community in FY18
Date

(attach additional page if needed)

Location

CPS Tech. Name

OCCUPANT PROTECTION & CHILD PASSENGER SAFETY (CPS) (Continued)
Did the CPS grant program partner with other departments to conduct CPS activities? Select One
If yes, which departments did they partner with?
CHECK POINTS/ MOBILIZATIONS
Did the CPS Grant Program Participate in check points?

Select One

If yes, how many?

Did the CPS Grant Program participate in any of the checkpoint mobilizations listed below? Select One
(Check the mobilizations the grant program participated in below)

Don't Shatter the Dream:

Were seats distributed: Select One

If yes, how many?

Click It or Ticket:

Were seats distributed: Select One

If yes, how many?

Drive Sober or Get Pulled Over: Were seats distributed: Select One

If yes, how many?
OMB Control No. 1076-0190
Expiration Date ##/##/####

18

18

Project Number:

Tribe:
EQUIPMENT

# Awarded

Equipment Awarded

# Purchased

Total Cost

Select One
Select One
Select One
Select One
Select One

Other:
Other:
HIGHLIGHTS & ACHIEVEMENTS
1. What are the CPS grant programs highlights for the FY2018 grant year?
(BIA IHSP highly encourages grant programs to submit photos if available) Attach an additional page if needed

2. What are the grant programs achievements within the FY2018 grant year?
(BIA IHSP highly encourages grant programs to submit photos if available) Attach an additional page if needed

Project Coordinator Signature

Date

Project Coordinator (Print Name)
OMB Control No. 1076-0190
Expiration Date ##/##/####

Paperwork Reduction Act Statement: We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) for the BIA
Indian Highway Safety Program (IHSP) to fulfill the data obligations of 23 CFR 1300.11. Your response is voluntary and we will not share the results
publicly. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid OMB
Control Number. OMB has reviewed and approved this survey and assigned OMB Control Number 1076-0190, which expires ##/##/####.
Estimated Burden Statement: We estimate the application will take you 300 minutes to complete, including time to read instructions, gather
information, and complete and submit the application. You may submit comments on any aspect of this information collection to the Information
Collection Clearance Officer, Office of Regulatory Affairs & Collaborative Action—Indian Affairs (RACA), U.S. Department of the Interior, 1849 C
Street NW, Mail Stop 4660, Washington, DC 20240.

OMB Control No. 1076-0190
Expiration Date ##/##/####