OST Self-Certification Eligibility Worksheet, Supplemental P

DRAFT

TEMPLATE; NOT INTENDED FOR EXECUTION WITHOUT MODIFICATION

Revised 2023-3-9

Award No.	Effective Date See No. 17 Below	Assistance Listings No. 20.939
Award To Unique Entity Id.: TIN No.:	Sponsoring Office U.S. Department of Transportation Federal Highway Administration Office of Safety 1200 New Jersey Avenue, SE HSSA-1, Mail Drop E71-117 Washington, DC 20590
Period of Performance Effective Date of Award –	Total Amount Federal Share: Recipient Share: Other Federal Funds: Other Funds: Total:		$0 $0 $0 $0 $0
Type of Agreement Grant	Authority Section 24112 of the Infrastructure Investment and Jobs Act (Pub. L. 117–58, November 15, 2021; also referred to as the “Bipartisan Infrastructure Law” or “BIL”)
Procurement Request No.	Federal Funds Obligated $0
Submit Payment Requests To See article 20.	Payment Office See article 20.
Accounting and Appropriations Data
Description of Project
RECIPIENT Signature of Person Authorized to Sign ___________________________________ Signature Date Name: Title:	FEDERAL HIGHWAY ADMINISTRATION Signature of Agreement Officer ______________________________________ Signature Date Name: Title: Agreement Officer

U.S. DEPARTMENT OF TRANSPORTATION

GRANT AGREEMENT UNDER THE
FISCAL YEAR 2022 SAFE STREETS AND ROADS FOR ALL GRANT PROGRAM

This agreement is between the [United States Department of Transportation (the “USDOT”)] [Federal Highway Administration (the “FHWA”) and the [insert full name of applicant] (the “Recipient”).

This agreement reflects the selection of the Recipient to receive a Safe Streets and Roads for All (“SS4A”) Grant for the [insert project name from the application].

The parties therefore agree to the following:

1. 
   General Terms and Conditions

   1. General Terms and Conditions.

(a) In this agreement, “General Terms and Conditions” means the content of the document titled “General Terms and Conditions Under the Fiscal Year 2022 Safe Streets and Roads for All Grant Program,” dated February 8, 2023, which is available at https://www.transportation.gov/grants/ss4a/grant-agreements. Articles 7–30 are in the General Terms and Conditions. The General Terms and Conditions are part of this agreement.

(b) The Recipient states that it has knowledge of the General Terms and Conditions. Recipient also states that it is required to comply with all applicable Federal laws and regulations including, but not limited to, the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (2 CFR part 200); National Environmental Policy Act (NEPA) (42 U.S.C. § 4321 et seq.); and Build America, Buy America Act (BIL, div. G §§ 70901-27).

(c) The Recipient acknowledges that the General Terms and Conditions impose obligations on the Recipient and that the Recipient’s non-compliance with the General Terms and Conditions may result in remedial action, termination of the SS4A Grant, disallowing costs incurred for the Project, requiring the Recipient to refund to the [FHWA] [USDOT] the SS4A Grant, and reporting the non-compliance in the Federal-government-wide integrity and performance system.

2. 
   Application, Project, and Award

   1. Application.

Application Title: [insert full title of submitted application]

Application Date: [insert the date in box 3 of the SF-424]

2. Award Amount.

SS4A Grant Amount: [$XXX]

3. Award Dates.

   Period of Performance End Date:

   [insert date]

4. Budget Period

Budget Period End Date: [insert date]

5. Action Plan Grant or Implementation Grant Designation.

Designation: [Action Plan] or [Implementation]

6. Federal Award Identification Number.

The Federal Award Identification Number is listed on page 1, line 1.

3. 
   Summary Project Information

   1. Summary of Project’s Statement of Work.

Drafting Instructions: Use OST’s description of the project.

2. Project’s Estimated Schedule.

Drafting Instructions: If the Grant is for an Action Plan or Supplemental Action Plan, complete the Action Plan Schedule and remove the Implementation Schedule. If the Grant is for an Implementation project, complete the Implementation Schedule and remove the “Action Plan Schedule,”

ACTION PLAN SCHEDULE

Milestone	Schedule Date
Planned Draft Action Plan Completion Date:	[INSERT DATE]
Planned Action Plan Completion Date:	[INSERT DATE]
Planned Action Plan Adoption Date:	[INSERT DATE]
Planned SS4A Final Report Date:	[INSERT DATE]

IMPLEMENTATION SCHEDULE INVOLVING CONSTRUCTION

Milestone	Schedule Date
Planned NEPA Completion Date:	[insert date]
Planned Construction Start Date	[insert date]
Planned Construction Substantial Completion and Open to Public Use Date:	[insert date]

IMPLEMENTATION SCHEDULE NON-CONSTRUCTION

Milestone	Schedule Date
Planned NEPA Completion Date:	[insert date]
Planned Activity Completion Date:	[insert date]

3. Project’s Estimated Costs.

(a) Eligible Project Costs

Eligible Project Costs
SS4A Grant Amount:	[$XXX]
Other Federal Funds:	[$XXX]
State Funds:	[$XXX]
Local Funds:	[$XXX]
In-Kind Match:	[$XXX]
Other Funds:	[$XXX]
Total Eligible Project Cost:	[$XXX]

(b) Supplemental Estimated Budget

[If this is an Action Plan Grant, delete the row for Construction.]

Cost Element	Federal Share	Non-Federal Share	Total Budget Amount
Direct Labor	$0.00	$0.00	$0.00
Fringe Benefits	$0.00	$0.00	$0.00
Travel	$0.00	$0.00	$0.00
Equipment	$0.00	$0.00	$0.00
Supplies	$0.00	$0.00	$0.00
Contractual/Consultant	$0.00	$0.00	$0.00
Construction	$0.00	$0.00	$0.00
Other	$0.00	$0.00	$0.00
Indirect Costs	$0.00	$0.00	$0.00
Total Budget	$0.00	$0.00	$0.00

(c) Cost Classification Table -Implementation Grants Only

Drafting Instructions: Utilize the descriptions from the SF-424c (https://www.grants.gov/forms/sf-424-family.html) to determine what cost goes in each row.

Cost Classification	Total Costs	Non-SS4A Previously Incurred Costs	Eligible Costs
Administrative and legal expenses
Land, structures, rights-of-way, appraisals, etc.
Relocation expenses and payments
Architectural and engineering fees
Other architectural and engineering fees
Project inspection fees
Site work
Demolition and removal
Construction
Equipment
Miscellaneous
Contingency
Project Total

[If no costs are anticipated in a category, remove the row from the table.]

4. 
   
   RECIPIENT Information

   1. Recipient’s Unique Entity Identifier.

[Reserved]

2. Recipient Contact(s).

[Insert information for the person designated as the official contact.]

[enter name]

[enter job title]

[enter organization]

[enter address]

[enter telephone]

[enter email address]

3. Recipient Key Personnel.

[Insert name of key personnel who will be responsible for completing the task. Add rows to identify as many key personnel as necessary]

Name	Title or Position
[Insert name]	[insert title]

4. USDOT Project Contact(s).

[enter name]

Safe Streets and Roads for All Program Manager

Federal Highway Administration

Office of Safety

HSSA-1, Mail Stop: E71-117

1200 New Jersey Avenue, S.E.

Washington, DC 20590

[enter telephone]

[enter email address]

and

[enter name]

Agreement Officer (AO)

Federal Highway Administration

Office of Acquisition and Grants Management

HCFA-33, Mail Stop E62-310

1200 New Jersey Avenue, S.E.

Washington, DC 20590

[enter telephone]

[enter email address]

and

[enter name]

Agreement Specialist (AS)

Office of Acquisition and Grants Management

HCFA-33, Mail Stop E62-204

1200 New Jersey Avenue, S.E.

Washington, DC 20590

[enter telephone]

[enter email]

and

[enter name]

Agreement Officer’s Representative (AOR)

[enter job title]

[enter office]

[enter address]

[enter telephone]

[email address]

and

[enter name]

[enter State] Division Office Point of Contact

[enter job title]

[enter address]

[enter telephone]

[email address]

5. 
   USDOT Administrative Information

   1. Office for Subaward and Contract Authorization.

USDOT Office for Subaward and Contract Authorization: FHWA Office of Acquisition and Grants Management

SUBAWARDS AND CONTRACTS APPROVAL

Note: See 2 CFR § 200.331, Subrecipient and contractor determinations, for definitions of subrecipient (who is awarded a subaward) versus contractor (who is awarded a contract).

Note: Recipients with a procurement system deemed approved and accepted by the Government or by the AO are exempt from the requirements of this clause. See 2 CFR 200.317 through 200.327.

Note: This clause is only applicable to Action Plan Grants.

Unless described in the application and funded in the approved award, the Recipient must obtain prior written approval from the AO for the subaward, transfer, or contracting out of any work under this award above the Simplified Acquisition Threshold. This provision does not apply to the acquisition of supplies, material, equipment, or general support services. Approval of each subaward or contract is contingent upon the Recipient’s submittal of a written fair and reasonable price determination, and approval by the AO for each proposed contractor/sub-recipient. Consent to enter into subawards or contracts will be issued through written notification from the AO or a formal amendment to the Agreement.

The following subawards and contracts are currently approved under the Agreement by the AO. This list does not include supplies, material, equipment, or general support services which are exempt from the pre-approval requirements of this clause.

(Fill in at award or by amendment)

5.2 Reimbursement Requests

(a) The Recipient may request reimbursement of costs incurred in the performance of this agreement if those costs do not exceed the funds available under section 2.2 and are allowable under the applicable cost provisions of 2 C.F.R. Part 200, Subpart E. The Recipient shall not request reimbursement more frequently than monthly.

(b) The Recipient shall use the DELPHI eInvoicing System to submit requests for reimbursement to the payment office. When requesting reimbursement of costs incurred or credit for cost share incurred, the Recipient shall electronically submit supporting cost detail with the SF 271 (Outlay Report and Request for Reimbursement for Construction Programs) to clearly document all costs incurred.

(c) The Recipient’s supporting cost detail shall include a detailed breakout of all costs incurred, including direct labor, indirect costs, other direct costs, travel, etc., and the Recipient shall identify the Federal share and the Recipient’s share of costs. If the Recipient does not provide sufficient detail in a request for reimbursement, the AO may withhold processing that request until the Recipient provides sufficient detail.

(d) The USDOT shall not reimburse costs unless the Agreement Officer’s Representative (the “AOR”) reviews and approves the costs to ensure that progress on this agreement is sufficient to substantiate payment.

(e) The USDOT may waive the requirement that the Recipient use the DELPHI eInvoicing System. The Recipient may obtain waiver request forms on the DELPHI eInvoicing website (http://www.dot.gov/cfo/delphi-einvoicing-system.html) or by contacting the AO. A Recipient who seeks a waiver shall explain why they are unable to use or access the Internet to register and enter payment requests and send a waiver request to

Director of the Office of Financial Management

US Department of Transportation,

Office of Financial Management B-30, Room W93-431

1200 New Jersey Avenue SE

Washington DC 20590-0001

or

[email protected].

If the USDOT grants the Recipient a waiver, the Recipient shall submit SF 271s directly to:

DOT/FAA

P.O. Box 268865

Oklahoma City, OK 73125-8865

Attn: [INSERT NAME]

(f) The requirements set forth in these terms and conditions supersede previous financial invoicing requirements for Recipients.

6. 
   Special Grant Terms

6.1 SS4A funds must be expended within five years after the grant agreement is executed and DOT obligates the funds, which is the budget period end date in section 10.3 of the Terms and Conditions and section [wherever the date it is in this agreement].

6.2 The Recipient acknowledges that the [Action Plan] [Supplemental Action Plan] will be made publicly available, and the Recipient agrees that it will publish the final [Action Plan] [Supplemental Action Plan] on a publicly available website.

6.3 The Recipient demonstrates compliance with civil rights obligations and nondiscrimination laws, including Titles VI of the Civil Rights Act of 1964, the Americans with Disabilities Act (ADA), and Section 504 of the Rehabilitation Act, and accompanying regulations. Recipients of Federal transportation funding will also be required to comply fully with regulations and guidance for the ADA, Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and all other civil rights requirements.

6.4 There are no other special grant requirements for this [award] [project].

Attachment A
Performance Measurement Information

Study Area: [Insert description of area to be studied]

Baseline Measurement Date: [insert date]

Baseline Report Date: [insert date]

Table 1: Performance Measure Table

Measure	Category and Description	Measurement Frequency
Safety Performance [for Implementation Grants]	Fatalities: Total annual fatalities in the project location(s)	Annually and at the end of the period of performance
Safety Performance [for Implementation Grants]	Serious Injuries: Total annual serious injuries in the project location(s) [if available]	Annually and at the end of the period of performance
Safety Performance [for Implementation Grants]	Crashes by Road User Category: Total annual crashes in the project location(s) broken out by types of roadway users involved (e.g., pedestrians, bicyclists, motorcyclist, passenger vehicle occupant, commercial vehicle occupant)	Annually and at the end of the period of performance
Equity	Percent of Funds to Underserved Communities: Funding amount (of total project amount) benefitting underserved communities, as defined by USDOT	End of period of performance
Costs	Project Costs: Quantification of the cost of each eligible project carried out using the grant	End of period of performance
Outcomes and Benefits [for Implementation Grants]	Quantitative Project Benefits: Quantification of evidence-based projects or strategies implemented (e.g., miles of sidewalks installed, number of pedestrian crossings upgraded, etc.)	End of period of performance
Outcomes and Benefits [for Implementation Grants]	Qualitative Project Benefits: Qualitative description of evidence-based projects or strategies implemented (e.g., narrative descriptions, testimonials, high-quality before and after photos, etc.)	End of period of performance
Outcomes and Benefits [for Implementation Grants]	Project Location(s): GIS/geo coordinate information identifying specific project location(s)	End of period of performance
Lessons Learned and Recommendations	Lessons Learned and Recommendations: Description of lessons learned and any recommendations relating to future projects of strategies to prevent death and serious injury on roads and streets.	End of period of performance

Attachment B
Changes from Application

Instructions for completing attachment B: Describe all material differences between the scope, schedule, and budget described in the application and the scope, schedule, and budget described in Article 3. The purpose of this attachment B is to document the differences clearly and accurately in scope, schedule, and budget to establish the parties’ knowledge and acceptance of those differences. See section 10.1.

Scope:

Schedule:

Budget:

The table below provides a summary comparison of the project budget.

Fund Source	Application		Section 3.3
	$	%	$	%
Previously Incurred Costs (Non-Eligible Project Costs)
Federal Funds
Non-Federal Funds
Total Previously Incurred Costs
Future Eligible Project Costs
SS4AFunds
Other Federal Funds
Non-Federal Funds
Total Future Eligible Project Costs
Total Project Costs

Attachment C
Racial Equity and Barriers to Opportunity

1. Efforts to Improve Racial Equity and Reduce Barriers to Opportunity.

The Recipient states that rows marked with “X” in the following table are accurate:

	A racial equity impact analysis has been completed for the Project. (Identify a report on that analysis or, if no report was produced, describe the analysis and its results in the supporting narrative below.)
	The Recipient or a project partner has adopted an equity and inclusion program/plan or has otherwise instituted equity-focused policies related to project procurement, material sourcing, construction, inspection, hiring, or other activities designed to ensure racial equity in the overall delivery and implementation of the Project. (Identify the relevant programs, plans, or policies in the supporting narrative below.)
	The Project includes physical-barrier-mitigating land bridges, caps, lids, linear parks, and multimodal mobility investments that either redress past barriers to opportunity or that proactively create new connections and opportunities for underserved communities that are underserved by transportation. (Identify the relevant investments in the supporting narrative below.)
	The Project includes new or improved walking, biking, and rolling access for individuals with disabilities, especially access that reverses the disproportional impacts of crashes on people of color and mitigates neighborhood bifurcation. (Identify the new or improved access in the supporting narrative below.)
	The Project includes new or improved freight access to underserved communities to increase access to goods and job opportunities for those underserved communities. (Identify the new or improved access in the supporting narrative below.)
	The Recipient has taken other actions related to the Project to improve racial equity and reduce barriers to opportunity, as described in the supporting narrative below.
	The Recipient has not yet taken actions related to the Project to improve racial equity and reduce barriers to opportunity but, before beginning construction of the project, will take relevant actions described in the supporting narrative below
	The Recipient has not taken actions related to the Project to improve racial equity and reduce barriers to opportunity and will not take those actions under this award.

2. Supporting Narrative.

[ Insert supporting text, as described in the table above. ]

Attachment D
Climate Change and Environmental Justice Impacts

1. Consideration of Climate Change and Environmental Justice Impacts.

The Recipient states that rows marked with “X” in the following table are accurate:

	The Project directly supports a Local/Regional/State Climate Action Plan that results in lower greenhouse gas emissions. (Identify the plan in the supporting narrative below.)
	The Project directly supports a Local/Regional/State Equitable Development Plan that results in lower greenhouse gas emissions. (Identify the plan in the supporting narrative below.)
	The Project directly supports a Local/Regional/State Energy Baseline Study that results in lower greenhouse gas emissions. (Identify the plan in the supporting narrative below.)
	The Recipient or a project partner used environmental justice tools, such as the EJSCREEN, to minimize adverse impacts of the Project on environmental justice communities. (Identify the tool(s) in the supporting narrative below.)
	The Project supports a modal shift in freight or passenger movement to reduce emissions or reduce induced travel demand. (Describe that shift in the supporting narrative below.)
	The Project utilizes demand management strategies to reduce congestion, induced travel demand, and greenhouse gas emissions. (Describe those strategies in the supporting narrative below.)
	The Project incorporates electrification infrastructure, zero-emission vehicle infrastructure, or both. (Describe the incorporated infrastructure in the supporting narrative below.)
	The Project supports the installation of electric vehicle charging stations. (Describe that support in the supporting narrative below.)
	The Project promotes energy efficiency. (Describe how in the supporting narrative below.)
	The Project serves the renewable energy supply chain. (Describe how in the supporting narrative below.)
	The Project improves disaster preparedness and resiliency (Describe how in the supporting narrative below.)
	The Project avoids adverse environmental impacts to air or water quality, wetlands, and endangered species, such as through reduction in Clean Air Act criteria pollutants and greenhouse gases, improved stormwater management, or improved habitat connectivity. (Describe how in the supporting narrative below.)
	The Project repairs existing dilapidated or idle infrastructure that is currently causing environmental harm. (Describe that infrastructure in the supporting narrative below.)
	The Project supports or incorporates the construction of energy- and location-efficient buildings. (Describe how in the supporting narrative below.)
	The Project includes recycling of materials, use of materials known to reduce or reverse carbon emissions, or both. (Describe the materials in the supporting narrative below.)
	The Recipient has taken other actions to consider climate change and environmental justice impacts of the Project, as described in the supporting narrative below.
	The Recipient has not yet taken actions to consider climate change and environmental justice impacts of the Project but, before beginning construction of the Project, will take relevant actions described in the supporting narrative below.
	The Recipient has not taken actions to consider climate change and environmental justice impacts of the Project and will not take those actions under this award.

2. Supporting Narrative.

[ Insert supporting text, as described in the table above. ]

attachment e
Labor and WorkFORCE

1. Efforts to Support Good-Paying Jobs and Strong Labor Standards

The Recipient states that rows marked with “X” in the following table are accurate:

	The Recipient demonstrate, to the full extent possible consistent with the law, an effort to create good-paying jobs with the free and fair choice to join a union and incorporation of high labor standards. (Identify the relevant agreements and describe the scope of activities they cover in the supporting narrative below.)
	The Recipient or a project partner has adopted the use of local and economic hiring preferences in the overall delivery and implementation of the Project. (Describe the relevant provisions in the supporting narrative below.)
	The Recipient or a project partner has adopted the use of registered apprenticeships in the overall delivery and implementation of the Project. (Describe the use of registered apprenticeship in the supporting narrative below.)
	The Recipient or a project partner will provide training and placement programs for underrepresented workers in the overall delivery and implementation of the Project. (Describe the training programs in the supporting narrative below.)
	The Recipient or a project partner will support free and fair choice to join a union in the overall delivery and implementation of the Project by investing in workforce development services offered by labor-management training partnerships or setting expectations for contractors to develop labor-management training programs. (Describe the workforce development services offered by labor-management training partnerships in the supporting narrative below.)
	The Recipient or a project partner will provide supportive services and cash assistance to address systemic barriers to employment to be able to participate and thrive in training and employment, including childcare, emergency cash assistance for items such as tools, work clothing, application fees and other costs of apprenticeship or required pre-employment training, transportation and travel to training and work sites, and services aimed at helping to retain underrepresented groups like mentoring, support groups, and peer networking. (Describe the supportive services and/or cash assistance provided to trainees and employees in the supporting narrative below.)
	The Recipient or a project partner has documented agreements or ordinances in place to hire from certain workforce programs that serve underrepresented groups. (Identify the relevant agreements and describe the scope of activities they cover in the supporting narrative below.)
	The Recipient or a project partner participates in a State/Regional/Local comprehensive plan to promote equal opportunity, including removing barriers to hire and preventing harassment on work sites, and that plan demonstrates action to create an inclusive environment with a commitment to equal opportunity, including: affirmative efforts to remove barriers to equal employment opportunity above and beyond complying with Federal law; proactive partnerships with the U.S. Department of Labor’s Office of Federal Contract Compliance Programs to promote compliance with EO 11246 Equal Employment Opportunity requirements and meet the requirements as outlined in the Notice of Funding Opportunity to make good faith efforts to meet the goals of 6.9 percent of construction project hours being performed by women and goals that vary based on geography for construction work hours and for work being performed by people of color; no discriminatory use of criminal background screens and affirmative steps to recruit and include those with former justice involvement, in accordance with the Fair Chance Act and equal opportunity requirements; efforts to prevent harassment based on race, color, religion, sex, sexual orientation, gender identity, and national origin; training on anti-harassment and third-party reporting procedures covering employees and contractors; and maintaining robust anti-retaliation measures covering employees and contractors. (Describe the equal opportunity plan in the supporting narrative below.)
	The Recipient has taken other actions related to the Project to create good-paying jobs with the free and fair choice to join a union and incorporate strong labor standards. (Describe those actions in the supporting narrative below.)
	The Recipient has not yet taken actions related to the Project to create good-paying jobs with the free and fair choice to join a union and incorporate strong labor standards but, before beginning construction of the project, will take relevant actions described in the supporting narrative below.
	The Recipient has not taken actions related to the Project to improving good-paying jobs and strong labor standards and will not take those actions under this award.

2. Supporting Narrative.

[ Insert supporting text, as described in the table above. ]

ATTACHMENT F

CRITICAL INFRASTRUCTURE SECURITY AND RESILIENCE

1. Efforts to strengthen the Security and Resilience of Critical Infrastructure against both Physical and Cyber Threats.

The Recipient states that rows marked with “X” in the following table are accurate:

	The Recipient demonstrates, prior to the signing of this agreement, effort to consider and address physical and cyber security risks relevant to the transportation mode and type and scale of the activities.
	The Recipient appropriately considered and addressed physical and cyber security and resilience in the planning, design and oversight of the project, as determined by the Department and the Department of Homeland Security.
	The Recipient complies with 2 CFR 200.216 and the prohibition on certain telecommunications and video surveillance services or equipment.
	For projects in floodplains: The Recipient appropriately considered whether the project was upgraded consistent with the Federal Flood Risk Management Standard, to the extent consistent with current law, in Executive Order 14030, Climate-Related Financial Risk (86 FR 27967), and Executive Order 13690, Establishing a Federal Flood Risk Management Standard and a Process for Further Solicit and Considering Stakeholder Input (80 FR 6425).

2. Supporting Narrative.

[Insert supporting text as described in the table above.]

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