Child Passenger Safety Seat Program

OMB Control No. 1076-0190
Expiration Date XX/XX/XX

United States Department of the Interior
BUREAU OF INDIAN AFFAIRS

Instructions for Completion of BIA Indian Highway Safety Program
Child Passenger Safety Seat Program Grant
The Highway Safety Act of 1966, U.S.C. Title 23, Section 402, provides U.S. Department of
Transportation funding to assist Indian Tribes in implementing traffic safety projects. These
projects are designed to reduce the high number of traffic crashes and their resulting fatalities,
injuries and property damage within Indian communities.
Tribes can apply for the Child Passenger Safety Seat Program grant with this application.
Complete the application in its entirety; do not leave any blank spaces/fields.
The BIA Indian Highway Safety Program is performance-based and data driven. The problem
statement will need to justify the Tribes need for a child passenger safety seat program. All
applications must contain measurable targets and performance measures, and be justified by data.
Insufficient data to justify a need for a CPS program will significantly reduce the possibility
of funding for the Tribe.
These 402 funds are intended to supplement an existing traffic safety program on the reservation.
Indian Highway Safety Program grants are funded in the form of reimbursements. Tribes must
first expend their funds and submit documentation for reimbursement consideration each month.
Monthly report and financial reports (requests for reimbursement) are required. 2 CFR 225
Appendix B.12 and 2 CRF Part 200.434 Contributions and Donations do not allow indirect costs
to be applied to the reimbursement of car seats and car seat shipping costs.
A Tribal Resolution and approved Indirect Cost Rate letter must be submitted with the
application.
Please contact the Indian Highway Safety Program at (505)563-3139 to inquire about BIA IHSP
Grant Writing Training.
Grant applications are due by May 1 of the current year for the next fiscal year award. Grant
applications and attachments can be e-mailed to [email protected] or
submitted by mail to:
Bureau of Indian Affairs
Office of Justice Services
Indian Highway Safety Program
1001 Indian School Road NW, Suite 251
Albuquerque, New Mexico 87104

1

OMB Control No. 1076-0190
Expiration Date XX/XX/XX

Bureau of Indian Affairs
Office of Justice Services - Indian Highway Safety Program
Child Passenger Safety Seat Program Grant Instructions
Select Grant Type:
CPS Grant is 1 year funding and Mobilization Grant is 1 type funding during the grant year.
FISCAL GRANT YEAR APPLYING FOR:
Indicate the grant year the application is being submitted for.
Example: FY2025 (this grant year cycle begins October 1, 2024 - September 30, 2025)
SECTION A: General Information
Tribes Information:
Fill in all boxes. Complete information for the federally recognized tribe applying for the
grant.
Person Completing the Form:
Provide the name, title, Office/Department, Phone and Fax number along with an e-mail
address, etc… of the person completing the application. This information is essential if
questions arise regarding the application and missing documents.
Tribal Grant Coordinator:
Complete the fields for the Tribal Grant Coordinator. Provide the name, title, telephone
number, Office/Department, Phone and Fax number, address, along with an e-mail. The
Tribal Grant Coordinator is responsible for grant administration and is the main point of
contact.
Grant History:
In these fields please indicate if the Tribe has received federal funding from the BIA IHSP,
other federal agencies, or state(s) focused in traffic safety.
Reservation Information:
Provide reservation population and estimated births.
Problem Identification: (Problem Statement)
Provide information to justify the tribe’s financial need for a child passenger safety seat
(CPS) program. Motor-vehicle crash data involving children on tribal lands can also be used
to assit in justifying the need for a CPS program.
Problem Countermeasures:
Check the boxes to indicate if the tribe has a Child Safety Seat Law; if yes, is it primary or
secondary.
Check the appropriate box if a child safety seat survey was conducted to determine a usage
rate. If yes, provide the date.
If an assessment was not conducted explain how the usage rates were determined.
CPS grant awards require a certified CPS Technician on staff. Check the appropriate box
and provide the name of the Lead CPS Tech, to be available if not on staff, and how
training is conducted and how CPS events are publicized.
2

OMB Control No. 1076-0190
Expiration
ExpirationDate
DateXX/XX/XX
11/30/2024

SECTION C: Targets
Provide an estimated number of car seat clinics to be held, seats to be distributed and inspected,
along with hand out to be distributed.
SECTION D: Budget
All costs in this section should be reasonable and necessary and related directly to the proposed
project. Estimate the number and total cost of car seats, supplies and equipment needed to
execute the grant.
SECTION E: Travel & Training
The grant can cover registration fees for Child Protection Seat training and travel expenses and
CPS conferences. Provide an estimated of CPS travel and training cost in this section.
Budget Line Item Grand Totals:
The grant totals calculated from the previous pages will automatically appear on this page.
SECTION F: Terms, Conditions and Responsibilities
Each condition MUST be initialed. Applications received without initials, signature and date
will not be considered for funding. Do not leave any fields in the form blank.
Questions regarding the grant application can be e-mailed to the BIA Indian Highway Safety
Program at: [email protected] or call (505)563-3139.

3

OMB Control No. 1076-0190
Expiration Date XX/XX/XX

All Sections of the grant application should be completed; do not leave any blank fields. Blank fields could result in dis-qualification.

Select a grant type:

CPS Grant

Mobilization Grant Only

SECTION A: GENERAL INFORMATION

FISCIAL GRANT YEAR APPLYING FOR:

Tribe Name:
Tribal Leader Name:

Title:

Mailing Address:
City:

State:

Zip:

State:

Zip:

FedEx Address:
City:
Phone Number:

Fax Number:
SAM CAGE CODE:

SAM UEI:

DUNS:

PERSON COMPLETING THE APPLICATION:
Title:

Name:
Office/Department:

Fax Number:

Phone Number:
E-Mail Address:
TRIBAL GRANT COORDINATOR INFORMATION

If grant is awarded, please identify the Project Coordinator. (Person who will be responsible for grant administration)

Title:

Name:
Office/Department:
Mailing Address:
State:

City:

Zip:
Fax Number:

Phone Number:
E-Mail Address:
GRANT HISTORY:

Does the tribe have another traffic safety (focused) grant currently in place? (i.e. CDC, Indian Health, State, etc.):
Yes

No

If yes, please list the agencies:
RESERVATION INFORMATION:
Population:
Enter an estimate of the number of Native American children born in your service unit.

OMB Control No. 1076-0190
Expiration Date XX/XX/XX

PROBLEM IDENTIFICATION: Problem Statement: Provide information to justify the tribe’s financial
need for a child passenger safety seat program.

PROBLEM COUNTERMEASURES:
Does the Tribe have a child safety seat law?

Yes

No

If yes, is it:

Has the Tribe conducted a survey to determine child safety seat use rate?

Primary
Yes

Secondary
No

If yes, when was survey conducted?
If an assessment was not conducted, how will the usage rate be determined?

Does the tribe have a certified child protection seat technician?

Yes

No

If yes, provide Name of Lead CPS Technician and Agency:
SECTION C: TARGETS
The following information represents the targets which must be reported for child passenger safety seat grant
award. Indicate the number of Tribal events to be held. Please estimate the number at this time.
Number of car seat:
clinics to be held
to be distributed & inspected
training events to be conducted
brochures to be distributed

OMB Control No. 1076-0190
Expiration Date XX/XX/XX

SECTION D: BUDGET
Budgets must support the project being proposed. Federal guidelines requires costs to be reasonable and
necessary to carry out/or operate the grant. 2 CFR 225 Appendix B.12 and 2 CRF Part 200.434 Contributions
and Donations do not allow indirect costs to be applied to the reimbursement of car seats and car seat shipping
costs. Indirect Cost can be applied to other items if allowable in the negotiated rate.
Car Seats:
Estimate the total number of car seats needed.

Estimate the total cost of car seats needed.

Car Seat Equipment and Supplies:
Latch manuals, pool noodles, traffic cones, sandwich boards, portable canopies, car seat clinic signs and brochures.
Estimate the total cost of car seat equipment and supplies needed.
SECTION E: TRAVEL & TRAINING
The grant can cover CPS training and conference registration. Travel is a reimbursable expense under this grant
program. Provide an estimated budget to cover travel expenses if needed.
Estimate the amount of CPS training and travel expenses needed.
BUDGET LINE ITEM GRAND TOTALS:
Total Car Seats:
Total Equipment & Supply:
Total Training & Travel:
Indirect Cost Rate

%

Grand Total Budget:
SECTION F: CERTIFICATIONS AND ACKNOWLEDGEMENTS
Read and initial to acknowledge each condition in this section.
Tribe understands the BIA Indian Highway Safety Program is a REIMBURSABLE grant program. The
Tribe must expend their funds and seek reimbursement based upon an approved budget and application.
A current draft/approved Tribal Resolution is attached.
Approved Indirect Cost Rate letter is attached.
Tribes A-133 is current
I,

, do hereby state and affirm: I have authority to submit this application on
behalf of the Tribal government named herein. I further understand and affirm: I have obtained all necessary
approvals, and have discussed this application with the necessary and appropriate people.

Signature:

Date:

Name (Print):

Title:

OMB Control No. 1076-0190
Expiration Date XX/XX/XX

Paperwork Reduction Act Statement: We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) for
the BIA Indian Highway Safety Program (IHSP) to fulfill the data obligations of 23 CFR 1300.11. Your response is voluntary and we
will not share the results publicly. We may not conduct or sponsor and you are not required to respond to a collection of information
unless it displays a currently valid OMB Control Number. OMB has reviewed and approved this survey and assigned OMB Control
Number 1076-0190, which expires XX/XX/XXXX.
Estimated Burden Statement: We estimate the application will take you 240 minutes to complete, including time to read instructions,
gather information, and complete and submit the application. You may submit comments on any aspect of this information collection to
the Information Collection Clearance Officer, Office of Regulatory Affairs & Collaborative Action—Indian Affairs (RACA), U.S.
Department of the Interior, 1001 Indian School Road NW, Suite 229, Albuquerque, New Mexico 87104..