PRS Specific Checklist(Tribal)

OMB No. 0581-0326

Appendix B:

Application Form - Tribal Seafood Processors Pandemic Response and Safety Grant Program

Instructions: Column A provides the outcomes and activities funded by the Tribal Seafood Processors Pandemic Safety and Response Grant Program. The funding request to offset costs associated with the outcomes and activities is entered in column B.

A: Eligible Outcomes and Activities	B: Funding Request
Implement workplace safety measures to protect workers against COVID-19 Provide personal protective equipment, thermometers, cleaning supplies, sanitizer, or hand washing stations Installation and purchase of air filters or new signage	[Enter $ Amount]
Implement market pivots to protect workers against COVID–19 Develop and implement online sales platforms Utilize online or print materials to communicate market pivots Transition from restaurant or food service to retail markets, including costs associated with shifting from fresh to frozen products (building cold storage, purchasing new packaging, or implementing new distribution methods)	[Enter $ Amount]
Retrofit facilities for worker and consumer safety to protect against COVID–19 Installation and purchase of protective barriers made of plexiglass or plastic sheeting, walk up windows, heat lamps/heaters, fans, tents, propane, weights, tables, chairs and lighting Installing new production or processing equipment required to increase social distancing	[Enter $ Amount]
Provide additional transportation options to maintain social distancing and worker and consumer safety to protect against COVID-19 Secure additional transportation services for workers Offer new delivery routes or distribution services	[Enter $ Amount]
Provide worker housing that protects workers against COVID-19 Secure additional housing resources/services to maintain social distancing, allow for mandatory quarantining of newly arrived seasonal employees, or isolation of exposed employees	[Enter $ Amount]
Provide health services to protect workers against COVID-19 Offer or enable vaccinations, testing, or healthcare treatment of infected employees, including any paid leave due to COVID-19 infection.	[Enter $ Amount]
Total Funding Request (This amount must be between $100,000 and $250,000)	[Auto Sum]

By submitting this application, I attest that:

• Between January 27, 2020 and December 31, 2021, my entity has implemented and/or plans to implement the activity or activities selected below, and the funding amount requested in my application reflects the fair market value of the goods and services associated with the selected activity or activities and the corresponding outcome(s).

• No other Federal funds were used to cover the cost of the activity or activities selected below.

• I certify that the statements herein are true, complete, and accurate to the best of my knowledge. I also 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 2018, Section 1001)

Pandemic Response and Safety Grant Program

Assistance Listing Number: 10.181