Form FEMA Form FF-104-F FEMA Form FF-104-F Project Application for COVID-19
Public Assistance Program
FF-104-FY-22-241_Project Application for COVID_Final
Project Application for COVID-19
OMB: 1660-0017
D
EPARTMENT
OF HOMELAND SECURITY OMB
Control Number FF-104-FY-22-241
Federal Emergency Management Agency Expires Month Day, Year
PROJECT APPLICATION FOR COVID-19
Paperwork Burden Disclosure Notice Public reporting burden for this data collection is estimated to average 22 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form. This collection of information is required to obtain or retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right corner of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW., Washington, DC 20472, Paperwork Reduction Project (1660-0017) NOTE: Do not send your completed form to this address. |
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Privacy Act Statement The collection of this information is authorized by the Robert T. Stafford Disaster Relief and Emergency Assistance Act, §§ 402-403, 406-407, 417, 423, 427, 428, 502, and 705; 42 U.S.C. 5170a-b, 5172-73, 5184, 5189a, 5189e, 5189f, 5192, 5205; 44 C.F.R. § 206 Subpart G; and 2 C.F.R. § 200. This information is collected to provide assistance to eligible jurisdictions and organizations to facilitate the response to and recovery from a Presidentially-declared disaster or emergency, or to provide assistance for hazard mitigation measures during the recovery process. The disclosure of information on this form is voluntary; however, failure to provide the requested information may delay or prevent the agency from receiving funds from FEMA’s Public Assistance program. |
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Purpose and Applicability FEMA may provide funding to eligible Applicants for costs related to emergency protective measures conducted as a result of the COVID-19 pandemic. Emergency protective measures are activities conducted to address immediate threats to life, public health, and safety. Please contact the State, local, Tribal, or Territorial emergency management office for additional information. Recipients and Applicants should use PA Grants Portal to submit all documentation and information to FEMA. Questions are displayed in an intuitive manner to show the information and documentation needed based on answers provided. All signatures are official and legally binding. In general, this form collects work information related to a group of impacts, including:
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Section I – Project Application Information |
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Instructions: The Applicant must assign a unique title and number for each project application. This title and number may help the Applicant connect this project application to their accounting or other systems. Any documents attached to this project application should include the project application number and title. |
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Declaration
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Legal Name of Applicant: [system generated]
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FEMA PA ID: [system generated] |
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Project # [system generated] |
Applicant-Assigned Project # (optional) |
Project Title: |
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Section II – Scope of Work |
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Instructions: Applicants must complete this section and describe the activities that the Applicant conducted or will conduct in response to the COVID-19 Public Health Declaration. For certain applicable activities, Applicants must provide additional information in the Large Project Work and Environmental and Historic Preservation Surveys. |
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Please provide a brief description of the activities the Applicant conducted or will conduct in response to COVID-19. Please explain how these activities eliminate or lessen the immediate COVID-19 threat to public health and safety or address positive/presumed positive COVID-19 cases:
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Please select all the activities the Applicant conducted or will conduct: For information on COVID-19 disaster specific policies, see www.fema.gov/media-collection/public-assistance-disaster-specific-guidance-covid-19-declarations. Except where specifically stated otherwise in COVID-19 disaster specific policies, assistance is subject to PA Program requirements as defined in Version 3.1 of the Public Assistance Program and Policy Guide (PAPPG). Management, control, and reduction of immediate threats to public health and safety ☐ Dissemination of information to the public to provide health and safety warnings and guidance ☐ Emergency Operations Centers to coordinate COVID-19 response activities ☐ Interior facility disinfection ☐ Acquisition and installation of temporary physical barriers ☐ Mass casualty management (including storage of human remains or mass mortuary services) for COVID-19 remains1 ☐ Movement of equipment and supplies, including transportation and storage ☐ Purchase and distribution of food ☐ Law enforcement and/or security ☐ Non-congregate sheltering ☐ Medical Sheltering ☐ Technical assistance on emergency management ☐ Training (i.e. proper use of PPE, proper distribution and administration of vaccines) ☐ Other. Describe other management, control, and reduction of immediate threats to public health and safety:
Emergency Medical Care ☐ Purchase and distribution/use of medical supplies and equipment Includes PPE and vaccine administration and distribution measures ☐ Personal protective equipment (PPE) ☐ Surgical masks ☐ Face shields ☐ Face masks (FDA approved) ☐ Respirators ☐ Protective clothing (i.e. medical gowns) ☐ Protective eyewear ☐ Other. Describe other PPE: ☐ COVID-19 Vaccine storage, supplies, or equipment ☐ Coolers ☐ Freezers ☐ Temperature monitoring devices ☐ Portable vaccine storage units for transportation ☐ Emergency medical supplies used in the administration of the vaccine ☐ Sharps containers ☐ Equipment or supplies necessary for proper storage (i.e. dry ice) ☐ Equipment or supplies necessary for proper handling and administration of vaccines ☐ Equipment or supplies necessary for proper distribution or transportation ☐ Ventilators and products modified for use as ventilators ☐ Other. Describe other COVID-19 vaccine administration and distribution activities: ☐ Other. Describe other purchase and distribution/use of medical supplies & equipment: ☐ Provision of medical services Includes patient treatment, testing and vaccination measures in response to the COVID-19 Declaration. ☐ COVID-19 Diagnostic Testing ☐ Diagnosis to determine medical treatment ☐ Medical Treatment (i.e., FDA-approved monoclonal antibodies) ☐ Prescriptions ☐ Emergency medical transport ☐ Medical waste disposal ☐ Vaccine administration and distribution ☐ Other. Describe other provision of medical services. ☐ Expansion of medical facilities Includes the use of temporary medical facilities or expanded medical facilities when necessary to response to the COVID-19 Declaration. ☐ Expansion of capacity within an existing medical facility ☐ Community-based testing sites ☐ Vaccine storage ☐ Other. Describe other temporary or expanded medical facilities: Non-Congregate Sheltering (NCS) ☐ Isolation-related temporary sheltering ☐ Quarantine-related temporary sheltering ☐ High-risk population sheltering ☐ Healthcare worker and first responder temporary sheltering ☐ Household pet or assistance animal or service and assistance animals (HPSA) sheltered in support of individuals in NCS for purposes of isolation and quarantine or transferred from sheltering to acute medical setting for COVID-19 treatment. ☐ Other. Describe other sheltering: Other ☐ Other Activity. Describe other activities the Applicant conducted or will conduct:
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Please select which of the following the Applicant used or will use to complete the activities reported above: ☐ Establishment of temporary facilities, including: ☐ Repurposing, renovating, or reusing existing facilities ☐ Placing prefabricated facilities on a site ☐ Constructing new temporary medical or sheltering facilities ☐ Staging resources at an undeveloped site ☐ Meals associated with sheltering ☐ Purchase of equipment or supplies (equipment and supplies are subject to disposition requirements) ☐ Purchase of personal protective equipment (PPE) ☐ Purchase of face masks ☐ Purchase of land or buildings (real property purchased or leased is subject to PA disposition requirements) ☐ Temperature scanning in facilities where reported activities were performed
Please
provide information for each COVID-19 vaccination site as
vaccine administration activities were reported above. COVID-19 Vaccination Sites Type of site: _______ Site name: Site location: Number of COVID-19 vaccines administered: _______ Select: Per day, per week or total. Number COVID-19 vaccination administration sites supported [auto-generated] |
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Please select where the activities reported above, other than COVID-19 vaccine administration, were or will be conducted: ☐ Jurisdiction-wide ☐ Geographic area(s) Please provide a list of counties, towns or other geographic area(s). ☐ Specific sites
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Section III – Cost and Work Status Information Instructions: Applicants must complete this section and provide the costs of the COVID-19 Declaration activities reported in Section II. Applicants must also complete Schedule A, B, C, or EZ as instructed below to estimate a project cost. |
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Does the Applicant have insurance that might cover any activities reported in Section II? ☐ Yes, the Applicant anticipates receiving a payment from its insurance carrier ☐ Yes, the Applicant has already received a payment from its insurance carrier ☐ Uncertain if the Applicant will be receiving proceeds from insurance carrier ☐ No, insurance funding is unavailable or was denied If either “yes” is checked above, provide the insurance policy and include insurance proceeds must be included as a deduction in the cost schedules. See FEMA’s Coronavirus (COVID-19) Pandemic: Medical Care Eligible for Public Assistance (Interim) (Version 2) and Public Assistance Policy on Insurance. What is the total project cost after all reductions including insurance deductions? Approximate Cost $: Has the Applicant started any of the work activities claimed on this project application? An Applicant may not request funding for activities conducted prior to January 20, 2020, the beginning of the COVID-19 incident period. This question should be answered once to describe all the activities claimed on this project (i.e. the earliest start date and the latest end date). If FEMA’s eligibility criteria for certain activities are limited to specific time periods, FEMA will ask for the time period that a particular activity was or will be conducted. ☐ Yes. Date Started: MM/DD/YYYY Has the Applicant completed all of the work claimed on this project application? ☐ Yes Date Completed: MM/DD/YYYY ☐ No Projected End Date: MM/DD/YYYY or ☐ Unsure ☐ No Projected Start Date: MM/DD/YYYY Projected Completion Date: MM/DD/YYYY or ☐ Unsure Request Expedited Funding An Applicant may request approval for expedited funding from the Recipient and FEMA if they have an immediate need for funding to continue life-saving emergency protective measures. If approved, the Applicant will be awarded 50% of the FEMA-confirmed project cost based on initial documentation. However, the Applicant will then be required to provide all information, including all documentation to support actual incurred costs, to support the initial 50% of funding before receiving any additional funding. Applicants will be required to return any funds that were not spent in compliance with the program’s terms and conditions. In general, Applicants who have never received FEMA Public Assistance funding and do not have significant experience with federal grant requirements should avoid expedited funding or, at a minimum, discuss expedited funding with their Recipient emergency management office prior to requesting expedited funding. Expedited funding is only available for activities completed during specific time periods. Does the Applicant want to request expedited funding? ☐ No ☐ Yes |
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It is important to know that upon submittal your project application becomes a legal document. The Recipient or FEMA may use external sources to verify the accuracy of the information you enter. It is a violation of Federal law to intentionally make false statements or hide information when applying for Public Assistance. This can carry severe criminal and civil penalties including a fine of up to $250,000, imprisonment, or both. (18 U.S.C. §§ 287, 1001, 1040, and 3571). ☐ I have read the statements above and understand that I will be required to certify these statements upon completion of my project application. |
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☐ Based upon your answers in Sections II and III, you will be prompted to complete a cost schedule and one or more work surveys upon creation of this Streamlined Project Application. |
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Section IV – Project Acknowledgements and Certifications |
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Instructions: If Applicant used external support to develop this Application, this section must be completed. |
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Did a consultant prepare this project application on behalf of the Applicant? ☐ No ☐ Yes. Please provide the following information and obtain the preparer’s signature. |
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Preparer’s Company or Firm Name |
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Preparer’s Company or Firm Address |
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By signing below, I certify all information provided in this project application is true and correct based on all information of which I have any knowledge. I understand that causing the Applicant to make false certification or statements or conceal any information in an attempt to obtain disaster aid is a violation of Federal laws, which carry severe criminal and civil penalties, including a fine of up to $250,000, imprisonment, or both (18 U.S.C. Part 287, 1001, 1040 and 3571). |
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Preparer’s Name |
Preparer’s Title |
Preparer’s Signature |
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Instructions: Applicants must complete this section to acknowledge their acceptance of Environmental and Historic Preservation compliance and documentation requirements. |
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Environmental and historic preservation compliance acknowledgement |
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In accordance with the Public Assistance Program and Policy Guide, the Applicant acknowledges that they are required to comply with applicable Federal, state, and local laws; must provide all documentation requested to allow FEMA to ensure project applications comply with Federal Environmental and Historic Preservation (EHP) laws, implementing regulations, and executive orders (EOs); and must comply with any EHP compliance conditions placed on the grant. |
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Documentation requirement acknowledgement |
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In accordance with 2 C.F.R. §200.333 as well as state and local record retention requirements, the Applicant acknowledges the requirement to maintain all documentation that supports this project application in its own files. This documentation will be required if the Applicant submits an appeal for additional funding, as well as in the case of any audits. |
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Applicant Authorized Representative |
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Signature |
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Instructions: Applicants must complete this section to certify that the activities and costs reported in this project application comply with applicable Federal, state, tribal, territorial, and local laws and regulations. |
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I certify the following: |
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General Certifications |
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As required by Title 44 Code of Federal Regulations (C.F.R.) §§ 206.223 and 206.225 and in accordance with the Public Assistance Program and Policy Guide (PAPPG), the Emergency Protective Measures described in this project were or are:
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Any activity claimed must have been performed or is being performed at the direction of or pursuant to guidance of state, local, tribal, or territorial public health officials (such as an executive order or other official order signed by a public health official). Work and costs are claimed in accordance with the following PA policy and guidance documents:
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If any activity was or will be occurring on private property: For each property, the Applicant (A) had or has a legal basis and authority to conduct the activities; and (B) completed or will complete the following actions for each property for which supporting documentation will be maintained: (i) obtained a right-of-entry, (ii) signed an agreement with the property owner to indemnify and hold harmless the Federal Government, and (iii) made efforts to identify any known insurance proceeds for the same activities. |
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Cost Certifications |
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As required by 44 C.F.R. § 206.228 and 2 C.F.R. Part 200 and in accordance with the PAPPG, the costs for which the Applicant is claiming reimbursement were or are:
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As required by the Stafford Act § 312, 42 U.S. Code § 5155, and 2 C.F.R. §200.406 and in accordance with the PAPPG, the Applicant has either:
If claiming contract costs: The Applicant complied with federal, Recipient, and Applicant procurement requirements. If claiming equipment costs: The Applicant complied with all FEMA policies regarding equipment rates in accordance with the PAPPG. If claiming labor costs: The Applicant complied with all FEMA policies regarding labor in accordance with the PAPPG. |
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Certification That Benefits Will Not Be Duplicated |
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Has the Applicant applied for any funding for COVID-19 from any other federal program? An Applicant may request funding from other programs but may not receive funding for the same costs from multiple programs. ☐ No ☐ Yes. Please list other programs:
If yes, has the Applicant applied for any funding from any other federal program for the activities reported in Section II? ☐ No ☐ Yes, but the other federal program has not yet approved the funding. The Applicant must inform FEMA if funding is approved and either (a) withdraw the FEMA project application for any non-obligated subaward or (b) request to close the subaward and return withdrawn funding for any obligated subaward. ☐ Yes, but the other federal program has conclusively denied the funding. Please attach denial. I certify that the specific activities and costs in this project application were not requested from another funding source or, if they were requested, that other source has not yet approved the funding. Further, I certify that if the Applicant does receive funding for the specific activities and costs in this project application, I must notify the Recipient and FEMA, and funding will be reconciled to eliminate duplication. |
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Applicant Authorized Representative |
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Signature |
Project Application Signature |
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It is important to know that upon submittal your project application becomes a legal document. The Recipient or FEMA may use external sources to verify the accuracy of the information you enter. It is a violation of Federal law to intentionally makes false statements or hide information when applying for Public Assistance. This can carry severe criminal and civil penalties including a fine of up to $250,000, imprisonment, or both. (18 U.S.C. §§ 287, 1001, 1040, and 3571). I certify that all information I have provided regarding the project application is true and correct to the best of my knowledge. I understand that, if I intentionally make false statements or conceal any information in an attempt to obtain Public Assistance, it is a violation of Federal laws, which carry severe criminal and civil penalties. |
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Applicant Authorized Representative |
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Please ensure that you have completed all schedules and surveys applicable to the activities you performed. |
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Large Project Work Survey |
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Are all activities being claimed on this project only being performed by the Applicant as a result of the COVID-19 Declaration? ☐ Yes. ☐ No. Please explain: Is the Applicant legally responsible for performing the activities being claimed on this project? ☐ Yes, the Applicant is a government organization and the state’s, tribe’s, or territory’s constitution or laws delegate jurisdictional powers to the Applicant. ☐ Yes, the Applicant is a PNP organization that owns and/or operates an eligible facility, as defined in Title 44 of the Code of Federal Regulations (44 C.F.R.) §§206.222(b), 206.223(b). ☐ Yes, the Applicant is a PNP organization that owns and/or operates medical facilities, as defined in Title 44 of the Code of Federal Regulations (44 C.F.R.) §206.221(e)(5). ☐ Yes, a statute, order, contract, articles of incorporation, charter, or other legal document makes the Applicant responsible to conduct the activities for the general public. Please attach and describe how the Applicant has legal responsibility: ☐ Yes, for other reasons. Please attach supporting documentation and describe: ☐ No. Please describe how the Applicant is eligible for funding: Please describe how the activities being claimed on this project address an immediate threat to life, public health, or safety:
Did
or will any of the activities reported in Section II require
access to residential private property? ☐ No. ☐ Yes. Please identify and describe the activities taking place on private property: For activities that involve the creation of a new program, please describe or attach the internal control plan the Applicant executed or will execute to ensure costs incurred remain reasonable in accordance with 2 C.F.R. Part 200, the FEMA Public Assistance Program and Policy Guide, and applicable Recipient and Applicant requirements:
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Only costs in excess of current operating costs are eligible, disinfection of closed facilities is generally not eligible, and disinfection must be necessary to protect public health and safety. When did or will the activities start and end? Activities started ______ (MM/DD/YY) and completed _______ (MM/DD/YY). Describe the activities conducted: Please provide documentation to support that these activities and costs are above and beyond routine cleaning and maintenance. Is the facility being re-opened? ☐ No ☐ Yes. Was the facility being used in the 7 days prior to disinfection? No Yes Facility disinfection is not eligible for facilities that were closed and unoccupied for seven or more days before disinfection. The CDC's Cleaning and Disinfection Guidance for Reopening states: "If your workplace, school, or business has been unoccupied for 7 days or more, it will only need your normal routine cleaning to reopen the area". Was facility disinfection performed at the direction of or pursuant to guidance from a public health official. ☐ Yes ☐ No. Was there a suspected or confirmed COVID-19case in the facility? No Yes For which emergency protective measures was the interior facility disinfection necessary? Select all that apply.
Explain how facility disinfection was necessary to support the activities selected:
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3. ACQUISITION AND INSTALLATION OF TEMPORARY PHYSICAL BARRIERS |
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When did or will the activities start and end? Activities started ______ (MM/DD/YY) and completed _______ (MM/DD/YY).
Describe the activities conducted:
For which emergency protective measures was acquisition/installation necessary? Select all that apply.
Explain how acquisition/installation was necessary to support the selected activities:
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4. MOVEMENT (TRANSPORTATION AND/OR STORAGE) OF EQUIPMENT AND SUPPLIES |
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When did or will the activities start and end? Activities started ______ (MM/DD/YY) and completed _______ (MM/DD/YY).
Please describe the resources the Applicant moved or will move:
Please describe the activities that were or will be conducted using the moved resources:
For which emergency protective measures was movement necessary? Select all that apply.
Explain how movement was necessary to support the selected activities: |
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5. PURCHASE AND DISTRIBUTION OF FOOD |
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When did or will purchase and distribution of food start and end? Activities started ______ (MM/DD/YY) and completed _______ (MM/DD/YY).
Please select and describe the work necessary to purchase and distribute food: ☐ Purchasing and packaging. Please describe the work necessary for purchasing and packaging: ☐ Acquiring distribution and storage space. Please describe the work necessary for acquiring distribution and storage space: ☐ Delivery and distribution. Please describe the work necessary for delivery and distribution: ☐ Other. Please describe the other necessary work:
Did or will the Applicant distribute food to for-profit entities? ☐ No ☐ Yes. Please describe how the Applicant will seek reimbursement for the fair market value of the food:
Did or will the Applicant enter into a formal agreement or contract for the provision of food through a private organization? ☐ No ☐ Yes. Please ensure contract costs are captured and associated questions answered in Schedule B or C as applicable.
If the purchase and distribution involved food, how is food security negatively impacted, making food distribution necessary to protect public health and safety? Please select all that apply. ☐ Reduced mobility of those in need due to government-imposed restrictions, including “stay-at-home” orders, which prevent certain populations from accessing food ☐ Marked increase or atypical demand for feeding resources ☐ Disruptions to the typical food supply chain within the a given jurisdiction ☐ Other. Please describe the other impacts:
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6. SECURITY AND LAW ENFORCEMENT |
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When did or will the activities start and end? Activities started ______ (MM/DD/YY) and completed _______ (MM/DD/YY). Describe the activities conducted:
For which emergency protective measures was security or law enforcement necessary? Select all that apply.
Explain why security or law enforcement was necessary to support the selected activities
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Please provide approximate quantities and total costs for each type of equipment or supply being claimed on this project:
For which emergency protective measures was the PPE necessary? Select all that apply.
Explain how the PPE or other medical supplies are or were necessary to perform the selected activities:
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8. PURCHASE OF EQUIPMENT OR SUPPLIES |
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Did or will the Applicant purchase equipment or supplies with a total cost of greater than $5,000?
(Tribal, local, and non-profit entities only) Does the Applicant anticipate any piece of equipment they purchased will have fair market value of greater than $5,000 after its use for federal projects concludes?
(State- and Territory Applicants only) Did the Applicant dispose of equipment in accordance with state or territorial laws and procedures?
Did or will the Applicant distribute supplies or equipment to for-profit entities?
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9. NON-CONGREGATE SHELTERING |
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When did or will the non-congregate sheltering activities start and end? Activities started ______ (MM/DD/YY) and completed _______ (MM/DD/YY). Please describe how the non-congregate sheltering was or is directly related to the COVID-19 Declaration: Please describe how non-congregate sheltering was or is being conducted in accordance with standards and order or directive mandated by public health officials including social distancing measures: What manner was non-congregate sheltering conducted? ☐ Hotel and motel accommodations ☐ Other. Please describe how non-congregate sheltering was accomplished: Did the Applicant receive prior approval for non-congregate sheltering from FEMA? ☐ Yes. Please attach your request, all supporting documentation, and a copy of the FEMA approval. ☐ No. This activity requires the FEMA approval. Please submit a request through the Recipient directly to the FEMA Regional Administrator. For more information on these requirements, see Coronavirus (COVID-19) Pandemic: Non-Congregate Sheltering - FAQ .
Are the non-congregate sheltering activities completed? ☐ No ☐ Yes. The Applicant needs to provide sufficient documentation to establish eligibility, including the following information:
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11. PURCHASE OF LAND OR BUILDINGS |
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Did or will the Applicant acquire or improve any real property? FEMA defines real property as “land, including land improvements, structures, and appurtenances thereto.” Real property acquired with FEMA funds is subject to specific disposition and reporting requirements. ☐ No ☐ Yes. The Applicant must obtain specific disposition instructions from FEMA. The Applicant should work through their Recipient to obtain specific instructions when the acquired or improved property is no longer needed for the original authorized purpose. |
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12. PURCHASE OF FACE MASKS |
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When did or will the activities start and end? Activities started ______ (MM/DD/YY) and completed _______ (MM/DD/YY). Which emergency protective measures are or were the face masks necessary to perform? Select all that apply.
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13. TEMPERATURE SCANNING |
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When did or will the activities start and end? Activities started ______ (MM/DD/YY) and completed _______ (MM/DD/YY) In what types of facilities were the activities conducted? Which emergency protective measures were being conducted in the facility? Select all that apply:
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14. EMERGENCY MEDICAL CARE |
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FEMA will provide assistance for medical care provided under COVID-19 declarations to improve the abilities of communities to effectively respond to the COVID-19 Public Health Emergency. Coronavirus (COVID-19) Pandemic: Medical Care Eligible for Public Assistance (Interim) (Version 2) defines the framework, policy details, and requirements for determining the eligibility of medical care under the Public Assistance program to ensure consistent and appropriate implementation across all COVID-19 emergency and major disaster declarations. Except where specifically stated otherwise in this policy, assistance is subject to PA Program requirements as defined in Version 3.1 of the Public Assistance Program and Policy Guide. When did or will the medical care activities start and end? Activities started ______ (MM/DD/YY) and completed _______ (MM/DD/YY). Please select the facility types where the medical care activities were or will be conducted. Select all that apply. ☐ Primary Medical Care Facility ☐ Temporary and Expanded Medical Care What clinical care was provided? ☐ Emergency medical transport related to COVID-19 ☐ Triage and medically necessary tests and diagnosis related to COVID-19 ☐ Medical treatment of COVID-19 patients ☐ Medical treatment of non-COVID-19 patients ☐ Prescription costs related to COVID-19 treatments Was or is all clinical care being claimed on this project directly related to emergency and inpatient clinical care for COVID-19 patients? ☐ Yes ☐ No. Please describe how the work or activities are eligible for funding: _______________ Please describe how the Applicant has and will continue to pursue payment from private insurance, Medicaid, Medicare, or any other source of funding. At no time will FEMA request or accept any Personally Identifiable Information related to the medical care of individual COVID-19 patients. |
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Environmental and Historic Preservation Survey |
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Instructions: Applicants must complete this schedule if any of the following COVID-19 Declaration activities are reported in Section II: |
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For additional information on EHP requirements, see the Environmental and Historic Preservation (EHP) and Emergency Protective Measures for COVID-19 Fact Sheet and the Floodplain Considerations for Temporary Critical Facilities Fact Sheet. |
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Please describe the staging activities: Provide Latitude and Longitude coordinates for each site. |
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Please describe activities related to the storage or treatment of human remains or mass mortuary services: Please select the locations where the activities reported above were or will be conducted: ☐ Jurisdiction-wide ☐ Geographic area(s) Please provide a list of counties, towns or other geographic area(s). ☐ Specific sites
Did Applicant have to handle burial for any unidentified/unclaimed human remains ☐ No ☐ Yes. Please provide detailed explanation of any work or costs being claimed:
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What is the intended method of disposal? ☐ Using an existing licensed disposal site ☐ Creating a new landfill disposal site ☐ Creating a new incinerator disposal site
Provide Latitude and Longitude coordinates for each site (decimal degrees with six decimal places). |
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What type of activities occurred or will occur? ☐ Use of high-powered fogging, misting, or spraying equipment ☐ Use of EPA-registered disinfectants products ☐ Other. Please describe the other activity that has occurred or will occur
Provide the GPS coordinates for each site.
Where did or will the disinfection activity occur? ☐ Interior (Disinfection of countertops, floors, walls, etc.). Please provide location within the facility that the disinfection activities took place or will take place: ☐ Exterior (Disinfection of interior components conducted outside the facility). Based on the Center for Disease Control Guidance - Reopening Guidance for Cleaning and Disinfecting Public Spaces, Workplaces, Businesses, Schools, and Homes, disinfection of exterior components (i.e. located outside of a building) is ineligible. Please provide location outside the facility that the disinfection activities took place or will take place
Did exterior activities result in wastewater runoff? ☐ Yes. Please provide runoff disposal method/location: ☐ No ☐ Unsure. Please describe why you are unsure:
Was or were disinfectant, sanitizing, or decontamination products disposed of according to Manufacturer Guidance and Environmental Regulations? ☐ Yes ☐ No. Please describe how products were disposed: ☐ Unsure. Please describe how products were disposed:
Has there been any coordination with any regulatory agencies? ☐ Yes. Please select the relevant agencies: ☐ Environmental Protection Agency (EPA) ☐ State, Local or Tribal Agency ☐ Other. Please list Agency: _____________________ Please attach documentation of coordination with Regulatory Agencies. ☐ No |
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Expedited Funding (Schedule A) |
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Instructions: The Applicant must complete this section if requesting expedited funding in Section III of the project application. Expedited funding is only available if the total net cost for the request is greater than or equal to [insert threshold applicable for the declaration]. |
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Please explain why there is an immediate need for funding: |
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Please select the time-period for which the Applicant is requesting expedited funding for the activities being claimed on this project. Start Date: ____________ (MM/DD/YY) Designated Time-Period: ☐ 30 days ☐ 60 days ☐ 90 days ☐ Another time-period: __________ Days |
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Please describe how the activities being claimed on this project address an immediate threat to life, public health, or safety: |
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Please select the reason why the activities being claimed on this project are the legal responsibility of the Applicant: ☐ The Applicant is a government organization and the state’s, tribe’s, or territory’s constitution or laws delegate jurisdictional powers to the Applicant. ☐ The Applicant is a PNP organization that owns and/or operates medical facilities, as defined in Title 44 of the Code of Federal Regulations (44 C.F.R.) §206.221(e)(5). ☐ A statute, order, contract, articles of incorporation, charter, or other legal document makes the Applicant responsible to conduct the activities for the general public. Please explain: ☐ For other reasons. Please explain: |
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Please select the resources necessary to complete the activities being claimed on this project. For each resource selected, please provide the cost or other information FEMA can use to estimate the cost. |
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☐ Contracts |
Costs $ |
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Please enter the total cost of contracts and provide copies of the request for proposals, bid documents or signed contracts. If contracts are not available, please provide a unit price estimate and the basis for the unit prices (for example, historic price documentation, or vendor quotes). |
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☐ Labor Including the Applicant’s own staff, mutual aid, prison labor, or National Guard. If using Emergency Management Assistance Compact (EMAC), please upload the following documents:
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Costs $ |
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Please enter the total costs of labor and provide a copy of the calculation. If not available, please provide the following in an attached list:
Which of the following types of labor is the Applicant claiming for the activities claimed on this project? ☐ Applicant’s Own Staff (Force Account Labor). Please provide labor pay policy (documentation must cover each employee type used, for example, part time, full time, temporary). ☐ Budgeted Employees Overtime Costs $ ☐ Unbudgeted Employees Straight Time Costs $ Overtime Costs $ Please refer to the table below for more information on the definitions and eligibility of labor costs for Emergency Work.
☐ Mutual aid Total Costs $ Please provide written mutual aid agreement. ☐ Prison labor Total Costs $ ☐ National Guard Total Costs $ ☐ Other Total Costs $ Please describe other type of labor: |
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☐ Equipment Including applicant owned, purchased, or rented. |
Costs $ |
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Which of the following types of equipment costs is the Applicant claiming for the activities claimed in this project? ☐ Applicant owned equipment costs $ Please provide the following (attach a list if necessary):
☐ Purchased equipment costs $ ☐ Rented equipment costs $ |
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☐☐ Materials and Supplies |
Costs $ |
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Please enter the total cost of materials and supplies and provide the following (attach a list if necessary): • Amount of materials and supplies, by type: • Purchase or stock replenishment cost: How did the Applicant acquire the materials or supplies? ☐ From stock Total Costs $ ☐ Purchased Total Costs $ |
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☐ Other Costs Including other eligible expenses not listed above. |
Costs $ |
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☐ Travel costs Total Costs $ ☐ Meals and incidentals costs Total Costs $ ☐ Miscellaneous costs Total Costs $ Please provide high-level information which can substantiate costs: |
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GROSS COST Please add together costs of contracts, labor, equipment, materials and other costs. |
Gross Cost $ |
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3. DEDUCTIONS |
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Please select the credits available to offset costs of activities being claimed on this project. For each selected, please provide the deduction or other information FEMA can use to estimate the deduction. |
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☐ Insurance Proceeds |
Deductions $ |
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Please enter the actual or anticipated insurance proceeds covered under the Applicant’s Insurance policy. This does not include payment from patient insurance; for that, continue to medical payments below. (More Info) FEMA cannot provide funding that duplicates insurance proceeds. FEMA requires the Applicant to take reasonable efforts to pursue claims to recover insurance proceeds that the Applicant is entitled to receive from its insurer(s). See FEMA’s Public Assistance Policy on Insurance. |
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☐ Medical Payments |
Deductions $ |
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Please enter the total amount of medical payments received or expected from for-profit entities, Medicare, Medicaid, or a pre-existing private payment agreement. |
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☐ Other Funding Sources. |
Deductions $ |
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Please enter the total amount of proceeds or payments received or expected from another source for the same work claimed in this project application.
Which of the following additional funding sources is the Applicant reporting? ☐ Other Federal Awards Total Deductions $ Please describe Other Federal Award funding sources: ☐ Non-Federal Grants and Cash Donations Total Deductions $ Please describe Non-Federal Grants and Cash Donations: ☐ Third-Party Liability Proceeds Total Deductions $ Please describe Third-party Liability Proceeds:
|
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NET COST Please subtract all proceed deductions from the subtotal. |
Net Cost $ |
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☐ You have completed this schedule. Return to Section IV to certify and sign this project application. |
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Completed Work Costs (Schedule B) |
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Instructions: Applicants must complete this schedule if the Applicant (1) has completed the activities reported in Section II, (2) has documentation available to support the actual costs, and (3) the cost of the activities is over [insert threshold applicable for the declaration]. |
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PROJECT COST & COST ELIGIBILITY |
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Please select the resources necessary to complete the activities being claimed on this project. For each resource selected, please provide the cost and requested information. (More Info) For each resource selected, please provide the cost and requested information. |
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☐ Contracts |
Costs $ |
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Please enter the completed cost of contracts. If no contracts-related costs are complete, enter 0. To calculate the total cost, complete the Contract Information section in this project application. Please also provide:
Contract Information ☐ Name of Contractor ☐ Contractor EIN ☐ Contract Award Date ☐ Contract Start Date ☐ Contract End Date ☐ Was the contract awarded through a competitive bidding process? ☐ No. If not competitively bid, please provide justification: ☐ Only available from a single source ☐ FEMA authorized ☐ Recipient authorized ☐ Inadequate competition ☐ Other. Describe other justification: ☐ Yes ☐ Type of Contract ☐ Fixed price ☐ Cost-reimbursement ☐ Time and materials ☐ Cost-plus % of cost ☐ Other ☐ Scope of Contact: For example, construction of temporary facility or emergency medical transport. ☐ Total Contract Award: $ ☐ Amount requested for funding on this project application: $ |
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☐ Labor Including the Applicant’s own staff, mutual aid, prison labor, or National Guard. |
Total Cost $ |
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Please complete FEMA Form 009-0-123 Force Account Labor Summary and FEMA Form 009-0-128 Applicants Benefit Calculation Worksheet or provide all information contained in these FEMA templates therein. Which of the following types of labor is the Applicant claiming for the activities claimed on this project? ☐ Applicant’s Own Staff (Force Account Labor) Please provide labor pay policy (documentation must cover each employee type used, for example part time, full time, and temporary). ☐ Budgeted Employees Overtime Cost $ ☐ Unbudgeted Employees Straight time Cost $ Overtime Cost $
Please refer to the table below for more information on the definitions and eligibility of labor costs for Emergency Work:
☒ Mutual aid Total Cost $ ☐ Prison labor Total Cost $ ☐ National Guard Total Cost $ ☐ Other Total Cost $ Please describe other type of labor: Please also provide:
|
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☐ Equipment Including applicant owned, purchased, or rented. |
Total Cost $ |
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Please enter the total cost of equipment. To calculate the total cost, complete FEMA Form 009-0-127 Force Account Equipment Summary and FEMA Form 009-0-125 Rented Equipment Summary Record or provide all information contained therein.
Which of the following types of equipment costs is the Applicant claiming for the activities being claimed in this project? ☐ Applicant Owned Owned Equipment Cost $ ☐ Purchased Purchased Equipment Cost $ ☐ Rented Rented Equipment Cost $
What was the basis of the rate used in the equipment summary? Please select all that apply. ☐ FEMA’s Schedule of Equipment Rates ☐ Applicant’s Equipment Rates ☐ State, Territorial, or Tribal Rates |
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☐ Materials and Supplies |
Total Cost $ |
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Please enter the total cost of materials and supplies. (More Info) To calculate the total cost, complete FEMA Form 009-0-124 Materials Summary Record or provide all information contained therein.
How did the Applicant acquire the materials or supplies? ☐ From stock Total Cost $ ☐ Purchased Total Cost $ |
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☐ Other Costs Including other eligible expenses not listed above. |
Total Cost $ |
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Please enter the total cost. Please also provide invoices or receipts. If claiming travel expenses, please provide a travel policy. ☐ Travel Costs Total Cost $ ☐ Meals and Incidentals Costs Total Cost$ ☐ Miscellaneous Costs Total Cost $ Please provide high-level information which can substantiate costs: |
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GROSS COST Please add together costs of contracts, labor, equipment, materials and other costs. |
Gross Cost $ |
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DEDUCTIONS |
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Please select the credits available to offset costs of activities being claimed on this project. For each selected, please provide the deduction or other information FEMA can use to estimate the deduction. |
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☐ Insurance Proceeds |
Deductions $ |
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Please enter the actual or anticipated insurance proceeds covered under the Applicant’s Insurance policy. This does not include payment from patient insurance; for that, continue to medical payments below.
|
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☐ Salvage Value |
Deductions $ |
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Please enter the total salvage value of purchased equipment and supplies (if greater than $5,000) and answer additional questions in the Large Project Eligibility Survey. |
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☐ Medical Payments |
Deductions $ |
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Please enter the total amount of medical payments received or expected from for-profit entities, Medicare, Medicaid, or a pre-existing private payment agreement. |
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☐ Other Funding Sources. |
Deductions $ |
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Please enter the total amount of proceeds or payments received or expected from another source for the same work claimed on this project application. ☐ Other Federal Awards Deductions $ Please describe Other Federal Award funding sources: ☐ Non-Federal Grants and Cash Donations Deductions $ Please describe Non-Federal Grants and Cash Donations funding sources: ☐ Third-Party Liability Proceeds Deductions $ Please describe Third-Party Liability Proceeds funding sources: |
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NET COST Please subtract all proceed deductions from the subtotal. |
Net Cost $ |
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You have completed this schedule. |
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Large Project In-Progress Costs (Schedule C) |
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Instructions: Applicants must complete this schedule if the Applicant (1) has not started or is in the process of completing the activities reported in Section II and (2) the cost of the activities reported in Section II is over [insert threshold applicable for the declaration]. |
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BUDGET ESTIMATE |
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Please attach an itemized budget estimate created using standard procedures the Applicant would use absent federal funding.
What is the basis for the Applicant’s cost estimate? Select all that apply. ☐ Extrapolation of completed costs ☐ Historical unit costs ☐ Average costs for similar work in the area ☐ Published unit costs from national cost estimating database ☐ Contractor or vendor quotes ☐ FEMA Schedule of Equipment Rates ☐ Other. Describe the other bases for estimate:
|
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PROJECT COST & COST ELIGIBILITY |
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Please select the resources necessary to complete the activities being claimed on this project. For each resource selected, please provide the cost incurred to date and estimated future costs. Please also provide the other requested information. |
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DEDUCTIONS |
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Please select the credits available to offset costs of activities being claimed on this project. For each selected, please provide the deduction or the estimate of future deductions. |
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Please enter actual or anticipated insurance proceeds covered under the Applicant’s Insurance policy. This does not include payment from patient insurance; for that, continue to medical payments below. |
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Please enter the total amount of medical payments received or expected from for-profit entities, Medicare, Medicaid, or a pre-existing private payment agreement.
|
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Please enter the total amount of other goods and services provided to for-profit entities or any other proceeds or payments received or expected. |
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NET COST Please subtract all proceed deductions from the subtotal. |
Net Cost $ |
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You have completed this schedule. |
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Small Project Costs (Schedule EZ) |
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Instructions: Applicants must complete this schedule if the total project cost is less than [insert threshold applicable for the declaration] and provide the costs of the activities reported in Section II. |
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Please attach an itemized budget estimate.
If the activities are complete, you will be required to attach the following summary records based on the resources necessary to complete the activities selected in the Project Cost step. ☐ FEMA Form 009-0-123 Force Account Labor Summary ☐ FEMA Form 009-0-128 Applicants Benefit Calculation Worksheet ☐ FEMA Form 009-0-127 Force Account Equipment Summary ☐ FEMA Form 009-0-125 Rented Equipment Summary Record ☐ FEMA Form 009-0-124 Materials Summary Record
What is the basis for the estimate? Select all that apply. ☐ Extrapolation of completed costs ☐ Historical unit costs ☐ Average costs for similar work in the area ☐ Published unit costs from national cost estimating database ☐ Contractor or vendor quotes ☐ FEMA Schedule of Equipment Rates ☐ Other. Describe the other basis for estimate:
|
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|
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Please select the resources necessary to complete the activities being claimed on this project. For each resource selected, please provide the cost incurred to date and estimated future costs. Please also provide the other requested information. |
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☐ Contracts |
Completed Costs $ |
+ |
Future Costs $ |
= |
Total Costs $ |
||||||||||||||||||||||||||||||
Please enter the cost of contracts from your estimate.
|
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☐ Labor Including the Applicant’s own staff, mutual aid, prison labor, or National Guard. |
Completed Costs $ |
+ |
Future Costs $ |
= |
Total Costs $ |
||||||||||||||||||||||||||||||
Which of the following types of labor is the Applicant claiming for the activities claimed on this project? ☐ Applicant’s own staff (Force Account Labor). ☐ Budgeted Employees Overtime Completed Costs $ Overtime Future Costs $ ☐ Unbudgeted Employees Straight Time Completed Costs $ Straight Time Future Costs $ Overtime Completed Costs $ Overtime Future Costs $ Please enter the completed and estimated Straight time and Overtime cost of labor above. Please refer to the table below for more information on the definitions and eligibility of labor costs for Emergency Work:
☐ Mutual aid Completed Costs $ Future Costs $ ☐ Prison labor Completed Costs $ Future Costs $ ☐ National Guard Completed Costs $ Future Costs $ ☐ Other. Please describe other type of labor: Completed Costs $ Future Costs $
|
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Equipment Please enter the total cost of equipment from your estimate. |
Completed Costs $ |
+ |
Future Costs $ |
= |
Total Costs $ |
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Which of the following types of equipment costs is the Applicant claiming for the activities in this project? ☐ Applicant Owned Completed Costs $ Future Costs $ ☐ Purchased Completed Costs $ Future Costs $ ☐ Rented Completed Costs $ Future Costs $
|
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☐ Materials and Supplies Please enter the total cost of materials and supplies from your estimate. |
Completed Costs $ |
+ |
Future Costs $ |
= |
Total Costs $ |
||||||||||||||||||||||||||||||
How did or will the Applicant acquire the materials or supplies? ☐ From stock Completed Costs $ Future Costs $ ☐ Purchased Completed Costs $ Future Costs $
|
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☐ Other costs Including other eligible expenses not listed above. |
Completed Costs $ |
+ |
Future Costs $ |
= |
Total Costs $ |
||||||||||||||||||||||||||||||
☐ Travel costs. Completed Costs $ Future Costs $ ☐ Meals and incidentals costs. Completed Costs $ Future Costs $ ☐ Miscellaneous costs. Completed Costs $ Future Costs $ Please provide high-level information which can substantiate costs:
|
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GROSS COST Please add together costs of contracts, labor, equipment, materials and other costs. |
Gross Cost $ |
||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||
Please select the credits available to offset costs of activities reported in Section II. For each selected, please provide the deduction. |
|||||||||||||||||||||||||||||||||||
☐☐ Insurance Proceeds |
Deductions $ |
||||||||||||||||||||||||||||||||||
Please enter the actual or anticipated insurance proceeds covered under the Applicant’s Insurance policy. This does not include payment from patient insurance; for that, continue to medical payments below.
|
|||||||||||||||||||||||||||||||||||
☐☐ Salvage Value |
Deductions $ |
||||||||||||||||||||||||||||||||||
Please enter the total salvage value of purchased equipment and supplies (if greater than $5,000).
|
|||||||||||||||||||||||||||||||||||
☐☐ Medical Payments |
Deductions $ |
||||||||||||||||||||||||||||||||||
Please enter the total amount of medical payments received or expected from for-profit entities, Medicare, Medicaid, or a pre-existing private payment agreement. |
|||||||||||||||||||||||||||||||||||
☐ Other Funding Sources |
Deductions $ |
||||||||||||||||||||||||||||||||||
Please enter the total amount of proceeds or payments received or expected from another source for the same work claimed in this project application.
Which of the following additional funding sources is the Applicant reporting? ☐ Other Federal Awards Completed Deductions $ Future Deductions $ Please describe Other Federal Award funding sources: ☐ Non-Federal Grants and Cash Donations Completed Deductions $ Future Deductions $ Please describe Non-Federal Grants and Cash Donations: ☐ Third-Party Liability Proceeds Completed Deductions $ Future Deductions $ Please describe Third-Party Liability Proceeds:
|
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NET COST Please subtract all proceed deductions from the subtotal. |
Net Cost $ |
||||||||||||||||||||||||||||||||||
You have completed this schedule. |
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1 (More Info) For information on COVID-19-related fatality management see COVID-19 Fatality Management Resources.
FEMA
Form FF-104-FY-22-241
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | [email protected] |
| File Modified | 0000-00-00 |
| File Created | 2023-11-03 |
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