HHS-5161-1 Checklist

HHS-5161-1

OMB Approval No. 0990-0317
Expiration Date: 8/31/2010

CHECKLIST
NOTE TO APPLICANT: This form must be completed and submitted with the original of your application. Be sure to complete each page of this form.
Check the appropriate boxes and provide the information requested. This form should be attached as the last pages of the signed original of the application.
Type of Application:

New

Noncompeting Continuation

Competing Continuation

Supplemental

PART A: The following checklist is provided to assure that proper signatures, assurances, and
Included
certifications have been submitted.
1. Proper Signature and Date on the SF 424 (FACE PAGE) ...................
2. If your organization currently has on file with HHS the following assurances, please identify which have been filed by
indicating the date of such filing on the line provided. (All four have been consolidated into a single form, HHS 690)

NOT Applicable

Civil Rights Assurance (45 CFR 80) ...........................................
Assurance Concerning the Handicapped (45 CFR 84) .................
Assurance Concerning Sex Discrimination (45 CFR 86) ..............
Assurance Concerning Age Discrimination (45 CFR 90 & 45 CFR 91) ...........................................
3. Human Subjects Certification, when applicable (45 CFR 46) .....................................
PART B: This part is provided to assure that pertinent information has been addressed and
included in the application.

YES

NOT Applicable

1. Has a Public Health System Impact Statement for the proposed program/project been completed and distributed
as required? ...............................................................
2. Has the appropriate box been checked on the SF-424 (FACE PAGE) regarding intergovernmental review under
E.O. 12372 ? (45 CFR Part 100) ...............
3. Has the entire proposed project period been identified on the SF-424 (FACE PAGE)?..................
4. Have biographical sketch(es) with job description(s) been provided, when required?..............
5. Has the "Budget Information" page, SF-424A (Non-Construction Programs) or SF-424C (Construction Programs),
been completed and included? ............................
6. Has the 12 month narrative budget justification been provided? ......................................................
7. Has the budget for the entire proposed project period with sufficient detail been provided? ...................
8. For a Supplemental application, does the narrative budget justification address only the additional funds requested?
9. For Competing Continuation and Supplemental applications, has a progress report been included?
PART C: In the spaces provided below, please provide the requested information.
Business Official to be notified if an award is to be made
Prefix:

First Name:

Middle Name:

Last Name:

Suffix:

Title:
Organization:
Street1:
Street2:
City:
ZIP / Postal Code:

State:

ZIP / Postal Code4:

E-mail Address:
Telephone Number:

Fax Number:

Program Director/Project Director/Principal Investigator designated to direct the proposed project or program.
Prefix:

First Name:

Middle Name:

Last Name:

Suffix:

Title:
Organization:
Street1:
Street2:
City:
State:

ZIP / Postal Code:

ZIP / Postal Code4:

E-mail Address:
Telephone Number:

Fax Number:
HHS Checklist (08-2007)

HHS-5161-1 (08/2007)
PART D: A private, nonprofit organization must include evidence of its nonprofit status with the application. Any of the following is acceptable
evidence. Check the appropriate box or complete the "Previously Filed" section, whichever is applicable.
(a) A reference to the organization's listing in the Internal Revenue Service's (IRS) most recent list of tax-exempt organizations described in section
501(c)(3) of the IRS Code.
(b) A copy of a currently valid Internal Revenue Service Tax exemption certificate.
(c) A statement from a State taxing body, State Attorney General, or other appropriate State official certifying that the applicant organization has a
nonprofit status and that none of the net earnings accrue to any private shareholders or individuals.
(d) A certified copy of the organization's certificate of incorporation or similar document if it clearly establishes the nonprofit status of the organization.
(e) Any of the above proof for a State or national parent organization, and a statement signed by the parent organization that the applicant
organization is a local nonprofit affiliate.
If an applicant has evidence of current nonprofit status on file with an agency of HHS, it will not be necessary to file similar papers again, but the
place and date of filing must be indicated.
Previously Filed with: (Agency)

on (Date)

INVENTIONS
If this is an application for continued support, include: (1) the report of inventions conceived or reduced to practice required by the terms and conditions of
the grant; or (2) a list of inventions already reported, or (3) a negative certification.

EXECUTIVE ORDER 12372
Effective September 30, 1983, Executive Order 12372
(Intergovernmental Review of Federal Programs) directed OMB to
abolish OMB Circular A-95 and establish a new process for consulting
with State and local elected officials on proposed Federal financial
assistance. The Department of Health and Human Services
implemented the Executive Order through regulations at 45 CFR Part
100 (Inter-governmental Review of Department of Health and Human
Services Programs and Activities). The objectives of the Executive
Order are to (1) increase State flexibility to design a consultation
process and select the programs it wishes to review, (2) increase the
ability of State and local elected officials to influence Federal decisions
and (3) compel Federal officials to be responsive to State concerns, or
explain the reasons.

Department’s programs that are subject to the provisions of Executive Order
12372. Information regarding HHS programs subject to Executive Order
12372 is also available from the appropriate awarding office.
States participating in this program establish State Single Points of Contact
(SPOCs) to coordinate and manage the review and comment on proposed
Federal financial assistance. Applicants should contact the Governor’s office
for information regarding the SPOC, programs selected for review, and the
consultation (review) process designed by their State.
Applicants are to certify on the face page of the SF-424 (attached) whether
the request is for a program covered under Executive Order 12372 and,
where appropriate, whether the State has been given an opportunity to
comment.

The regulations at 45 CFR Part 100 were published in the Federal
Register on June 24, 1983, along with a notice identifying the
BY SIGNING THE FACE PAGE OF THIS APPLICATION, THE APPLICANT ORGANIZATION CERTIFIES THAT THE STATEMENTS IN THIS
APPLICATION ARE TRUE, COMPLETE, AND ACCURATE TO THE BEST OF THE SIGNER’S KNOWLEDGE, AND THE ORGANIZATION ACCEPTS
THE OBLIGATION TO COMPLY WITH U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES’ TERMS AND CONDITIONS IF AN AWARD IS
MADE AS A RESULT OF THE APPLICATION. THE SIGNER IS ALSO AWARE THAT ANY FALSE, FICTITIOUS, OR FRAUDULENT STATEMENTS
OR CLAIMS MAY SUBJECT THE SIGNER TO CRIMINAL, CIVIL, OR ADMINISTRATIVE PENALTIES.
THE FOLLOWING ASSURANCES/CERTIFICATIONS ARE MADE AND VERIFIED BY THE SIGNATURE OF THE OFFICIAL SIGNING FOR THE
APPLICANT ORGANIZATION ON THE FACE PAGE OF THE APPLICATION:
Civil Rights – Title VI of the Civil Rights Act of 1964 (P.L. 88-352), as amended, and all the requirements imposed by or pursuant to
the HHS regulation (45 CFR part 80).
Handicapped Individuals – Section 504 of the Rehabilitation Act of 1973 (P.L. 93-112), as amended, and all requirements imposed by
or pursuant to the HHS regulation (45 CFR part 84).
Sex Discrimination – Title IX of the Educational Amendments of 1972 (P.L. 92-318), as amended, and all requirements imposed by or
pursuant to the HHS regulation (45 CFR part 86).
Age Discrimination – The Age Discrimination Act of 1975 (P.L. 94-135), as amended, and all requirements imposed by or pursuant to
the HHS regulation (45 CFR part 91).
Debarment and Suspension – Title 2 CFR part 376.
Certification Regarding Drug-Free Workplace Requirements – Title 45 CFR part 82.
Certification Regarding Lobbying – Title 32, United States Code, Section 1352 and all requirements imposed by or pursuant to the
HHS regulation (45 CFR part 93).
Environmental Tobacco Smoke – Public Law 103-227.
Program Fraud Civil Remedies Act (PFCRA)
HHS Checklist (08-2007)