Form 3045-0010 NCCC Service Project Application

OMB Control No. 3045-0010, Exp. XX/XX/20XX

AMERICORPS NATIONAL CIVILIAN COMMUNITY CORPS (NCCC) SERVICE PROJECT APPLICATION

INTERNAL USE ONLY:

Project Title:

Project Number:

State:

Focus Area:

APD:

Select one: Rural Urban Suburban Wilderness

Select one: New Sponsor Returning Sponsor

APPLICATION INFORMATION

1

Organization Name

Mailing Address

City

State

ZIP

Office Telephone

Ext.

Secondary Sponsor Organization Name

Mailing Address

City

State

ZIP

Office Telephone

Ext.

2

EIN

Secondary Sponsor EIN

3

Organization Type

Community-Based Nonprofit Organization Federal Government Tribal Nation Local Government or Municipality Nonprofit National School State Government

4

Authorized Representative

Organizational Title

Phone Number

Ext.

Email Address

5

Project Site Supervisor

Organizational Title

Phone Number

Ext.

Email Address

PROJECT INFORMATION

6

Estimated Completion Time (Weeks)

Project Start Date

Flexible

Fixed

Project End Date

Flexible

Fixed

PROJECT FOCUS AREAS AND OBJECTIVES
7	Primary Area of Community Need	Energy Conservation Environmental Stewardship and Conservation Infrastructure Improvement Natural and Other Disasters Urban and Rural Development
8	Secondary Area of Community Need	Energy Conservation Environmental Stewardship and Conservation Infrastructure Improvement Natural and Other Disasters Urban and Rural Development
	Disaster Type (if applicable)	Preparedness Mitigation Readiness Recovery Not Applicable
9	Project Objectives	Access to Care Alleviate Poverty At-Risk Ecosystems Advance racial equity Awareness and Stewardship Mitigate the impacts of the Covid-19 pandemic Capacity Building and Leverage and other public health crises Community Support Reduce greenhouse gas Energy Efficiency emissions Support Conserve lands and waters and adapt to Disaster Assistance Provided changing climate. Education Expand educational and economic opportunity Financial Literacy Service to undeserved Housing individuals and communities Inclusion of People with Disabilities

AREAS SERVED BY THE PROJECT
10	State or Territory			City or County
	State or Territory			City or County
	State or Territory			City or County
	State or Territory			City or County
OTHER
11	Organization Goals Relevant to the Project	1
		2
		3
12	Are there any required permits or zoning variances for this project?				Yes	No
	If ‘Yes,’ please list the specific permits or zoning variances required and state whether you have secured them. Though not required at the time of application, proof of permits may be requested at a later date.
13	Is your organization currently funded wholly or in part by AmeriCorps?				Yes	No
	If ‘Yes,’ is the proposed project funded by an AmeriCorps State and National grant or any AmeriCorps VISTA resources?
	If ‘Yes,’ to either of the above questions, please provide detailed information concerning the funding source and utilization of those funds.
14	Will the proposed service replace any of your organization’s current or projected staff or contracted labor?				Yes	No
15	Could this project be impacted by inclement weather?				Yes	No

	If ‘Yes,’ do you have sufficient alternate project work opportunities for at least 25% of the project time for the team should there be inclement weather?
	Please list examples of inclement weather plans that make up 25% of project time.
16	AmeriCorps conducts history checks on all members which consists of fingerprint-based FBI criminal history search and a check of the National Sex Offender Public Website (NSOPW.org). Will your organization conduct additional background checks?	Yes	No
	If ‘Yes,’ please specify what additional background checks are required and how these requirements will be satisfied. If an organization requires additional background checks for AmeriCorps NCCC members, the organization is responsible for fees associated with the background checks and completing background checks prior to or at the start of the project.
17	Does this project include possible exposure of AmeriCorps NCCC members to asbestos, lead paint, hazardous waste, mold, or any other safety hazards?*	Yes	No
18	Will members be required to work with potentially hazardous chemicals such as solvents, acids, pesticides, herbicides, adhesives, etc.?*	Yes	No
	Are there any current or recent (within the last five years) environmental hazards that campus staff should be aware of near the service and/or lodging sites? Examples could include but are not limited to: tap water that is undrinkable or not recommended to drink, chemical or hazardous waste spills, mine blowouts impacting waterways/groundwater, chemical weapon storage locations, or oil spills.	Yes	No
19	Are there any health or environmental conditions that might preclude an AmeriCorps NCCC member from fully participating based on project location or project conditions?*	Yes	No
*Selection of ‘Yes’ to this question does not preclude your organization from receiving an AmeriCorps NCCC team. You will need to further explain any hazards or conditions in the Safety and Security Narrative (Question 30).

Continue onto next page

LOCATIONS
20	Location of Service #1				Primary Site?			Yes	No
	Organization
	Projected Start Date			Projected End Date
	Street Address
	Address Line 2
	County		City		State				ZIP
	Accessible for people with disabilities?	Yes	No
	Site Supervisor Name
	Organizational Title
	Email Address				Phone Number
	Location of Service #2				Primary Site?			Yes	No
	Organization
	Projected Start Date			Projected End Date
	Street Address
	Address Line 2
	County		City		State				ZIP
	Accessible for people with disabilities?	Yes	No
	Site Supervisor Name
	Organizational Title
	Email Address				Phone Number
	Location of Service #3				Primary Site?			Yes			No
	Organization
	Projected Start Date			Projected End Date
	Street Address
	Address Line 2
	County		City		State				ZIP
	Accessible for people with disabilities?	Yes	No
	Site Supervisor Name
	Organizational Title
	Email Address				Phone Number
*For projects with more than three site locations, please include an attachment with the information required above for each additional location.

LODGING SITE #1

21

Lodging Provider

Anticipated Arrival Date

Anticipated Departure Date

Type of Lodging

Apartment or Condo Hotel Armory Military Facility Bed and Breakfast NCCC Campus Cabin Recreational Vehicle Campsite School Room or Classroom Trailer Church or Other Faith- Summer Camp Based Organization Vacant Home Community Center Volunteer Housing Dorm Yurt Short Term Rental Other Hostel

Lodging Category

Community or Faith-Based Local Government or Organization Municipality Federal Government Military Indian Tribe National Nonprofit Organization Institute of Higher Education National or State Park

Other

Street Address

Address Line 2

County

State

ZIP

Accessible for people with disabilities?

Yes

No

Beds provided?

Yes

No

Number of sleeping spaces available?

If you’ve selected Yes, is it accessible for:

Hearing

Vision

Mobility- Partially Accessible

Mobility-Fully Accesible

Other

Showers on site?

Yes

No

Laundry on site?

Yes

No

Wi-Fi access on site?

Yes

No

Full Kitchen(including stove and fridge) on site?

Yes

No

If no full kitchen, are meals provided?

Yes

No

If no full kitchen, microwave on site?

Yes

No

22	LODGING SITE #1 Continued
	Lodging Contact Name
	Phone number		Email Address
	If lodging is not currently move-in ready? If lodging is not currently move-in ready, when will it be ready by (include date) Please explain.
	Please use the space provided below to address the requested information for the Lodging Narrative in the AmeriCorps NCCC Project Concept Form & Service Project Application Instructions.

NARRATIVES
Please refer to the NCCC Service Project Application instructions guide for full details on requirements for each section.
23	Executive Summary (Include Secondary Sponsor and Organizational Capacity)

24	Project Design (Include Secondary Sponsor)

25	Project Management and Training (Include Secondary Sponsor)

26	Recruitment

27	Member Development (Include Secondary Sponsor)

28	Strengthening Communities (Include Secondary Sponsor)

29	Safety and Security

30	Tools and Equipment

1

How did you hear about AmeriCorps NCCC?

ADDITIONAL QUESTIONS

I am an AmeriCorps NCCC alum

I am a past AmeriCorps NCCC Sponsor

I am a past AmeriCorps NCCC Staff member From an AmeriCorps NCCC alum

From an AmeriCorps NCCC Staff member From a current AmeriCorps NCCC member From an AmeriCorps Regional office.

From an AmeriCorps State or VISTA member

From a community partner

By email

On social media (e.g. Facebook, Twitter, Instragram, YouTube, LinkedIn.

On the AmeriCorps Website From a State Service Commission Other

Has your organization previously sponsored an AmeriCorps NCCC team?

2

If ‘Yes,’ how many teams have served with your organization?

Yes No

If ‘Yes,’ when did a team most recently serve with your organization?

Has your organization ever had a “Fee-for-

3 Service” arrangement with a Youth Corps or Conservation Corps program?

Yes ^No

If ‘Yes,’ AmeriCorps NCCC has effectively been used in past projects to augment and support existing Youth Corps partnerships with organizations. Please describe how you plan to utilize the AmeriCorps NCCC team with your existing partnership with the “Fee-for-Service” Corps.

4

IMPORTANT NOTICES SECTION

REQUIRED ATTACHMENTS: Supporting documentation is a critical component of the Service Project Application. The supporting materials requested below will help AmeriCorps NCCC Regional staff develop a better understanding of the proposed project during the application review process. Samples and templates are available from AmeriCorps NCCC Regional staff.

ON-SITE ORIENTATION: Please attach a comprehensive on-site orientation agenda to your application. This should include an overview of your organization and the project, introductions of the team to the staff of the sponsoring organization(s), tour of the work site(s) and the community, safety and security, and a lodging use overview.

TRAINING PLAN: Please attach a training plan outlining the training that AmeriCorps NCCC members will receive during the project. This plan should include tool training, safety training, and project specific training (e.g., positive youth development, tree identification, roofing instruction, etc.). If a variety of tasks have been proposed in the work plan, the training plan should identify how/when members will be trained to perform the task.

PROJECT WORK CALENDAR: Include a project work plan that outlines the schedule of work. The schedule will assist in planning where a team will perform work, which staff member will work with the team, the assigned task(s) for each work day and the number of AmeriCorps NCCC members it will take to complete each task. The work plan calendar is an essential part of demonstrating how the organization will provide at least 40 hours of work for each member of the team.

OPTIONAL ATTACHMENTS: The supporting materials requested below are OPTIONAL and will help AmeriCorps NCCC Regional staff develop a better understanding of the proposed project during the application review process.

LODGING PHOTOS: Please provide at least one clearly labeled photo of the proposed team lodging. Strong applications often include photos of team living quarters, kitchen and bath facilities and storage areas for personal belongings.

WORKSITE PHOTOS OR SUPPORTING DOCUMENTS: If feasible, clearly labeled photos of work site tasks, maps of service site locations (e.g. a camp map, trail system map, community housing map, etc.), or similar supporting documentation sometimes can help support the high level of detail you have provided in the Need Narrative and the Project Design Narrative.

ADDITIONAL PAPERWORK REQUIREMENTS: If the Service Project Application is approved and teams perform the service project, the project sponsor will be required to review and sign two additional documents: the Sponsor Agreement and the Project Completion Report. Sponsoring organizations will also be asked to complete a survey to capture their evaluation of their partnership with AmeriCorps NCCC.

SPONSOR AGREEMENT: Once the Service Project Application has been approved, a formal agreement (called a Sponsor Agreement) will be executed between the sponsoring organization and AmeriCorps NCCC, which will specify the roles, responsibilities, and contributions of both parties. This agreement must be signed by both parties before a team arrives to the project.

PROJECT COMPLETION REPORT: After the project is completed the project sponsor will be required to review, approve, and sign the AmeriCorps NCCC Project Completion Report, and return it to AmeriCorps NCCC regional campus staff within five (5) days of receipt.

SURVEYS: Project sponsors, site supervisors, and secondary sponsors who have used the services of teams will be asked to complete surveys designed to provide AmeriCorps NCCC with feedback that will inform continuous improvement of services.

DISASTER/FIRE RESPONSE: AmeriCorps NCCC members and staff are part of the Federal Emergency Management Agency (FEMA) and American Red Cross National Disaster Response Network. In addition, AmeriCorps NCCC assists local, state, and national forest services with wildfire suppression. Potential project sponsors should note that in the event of a natural disaster or homeland security crisis, members may be recalled from projects to serve as part of the relief efforts. This could result in a decrease in the number of members assigned to your project, a delay in the deployment of a team, or cancellation of a project.

LIABILITY AND WORKERS' COMPENSATION CLAIMS: AmeriCorps is a self-insured federal agency that administers the AmeriCorps National Civilian Community Corps (NCCC) program. Consequently, AmeriCorps NCCC Corps Members, Team Leaders, and Federal employees of AmeriCorps are covered by the provisions of the Federal Tort Claims Act (liability claims) and the Federal Employees Compensation Act (workers’ compensation claims) 42 U.S.C.

§12620 (b) & (c). Accordingly, any injuries or property damage proximately caused by the negligence of an AmeriCorps NCCC Member, Team Leader, or AmeriCorps employee will be assumed by the United States Government, if it is determined that the negligent individual was acting within the scope of his/her official service activity or employment at the time of the potentially compensable event. Similarly, any on-the-job injuries received by an AmeriCorps member of the NCCC program or federal employee will be processed by AmeriCorps and the Department of Labor.

WAIVERS: No member of an AmeriCorps NCCC Team (including any Corps Member or Team Leader) shall sign any document provided by the Project Sponsor or any representative or employee of the Project Sponsor, including but not limited to: liability waivers, hold harmless agreements, indemnification agreements, or employment-related documents. In the event that a member of an AmeriCorps NCCC Team signs a document provided by the Project Sponsor or any representative or employee of the Project Sponsor, the signature on any such document shall have no force or effect of law. Neither the Team nor any Team Leader or Corps Member thereof, may legally bind the AmeriCorps NCCC Team or the AmeriCorps NCCC Program.

NON-DISCRIMINATION: A Project Sponsor receiving teams from AmeriCorps NCCC will comply with all federal statutes, including the National and Community Service Act of 1990, as amended, relating to nondiscrimination, which includes nondiscrimination on the basis of race, color, national origin, sex, age, disability, and in most instances, religion. AmeriCorps prohibits all forms of discrimination based on race, color, national origin, gender, age, religion, sexual orientation, disability, gender identity or expression, political affiliation, marital or parental status, or military service. All programs administered by, or receiving Federal assistance from AmeriCorps, must be free from all forms of harassment. Project sponsors will be required to sign an assurance of non-discrimination as part of the Sponsor Agreement.

SERVICE PROJECT LIMITATIONS: In the course of performing a service project, members cannot engage in any project assignments that involves direct fundraising, financial transactions, preparation of a grant application to AmeriCorps or to any other Federal agency, or any political or inherently religious activities.

SIGNATURE
The Service Project Application MUST be signed by the authorized representative of the sponsoring organization.
SIGNATURE	DATE

Paperwork Reduction Act Notice: Public reporting burden for this collection of information is estimated to average 8 hours per submission, including reviewing instructions, gathering and maintaining the data needed, and completing the form. Comments on the burden or content of this instrument may be sent to the Corporation for National and Community Service, 250 E Street, SW, Washington DC 20024 . The Corporation informs people who may respond to this collection of information that they are not required to respond to the collection of information unless the OMB control number and expiration date displayed on page 1 are current and valid. (See 5 C.F.R. 1320.5(b)(2)(i).)