HomeMy WebLinkAbout20042460.tiff RESOLUTION
RE: APPROVE APPLICATION FOR FEDERAL ASSISTANCE FOR HEAD START CHANGE
OF SCOPE AND AUTHORIZE CHAIR TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS,the Board has been presented with an Application for Federal Assistance for
Head Start Change of Scope between the County of Weld, State of Colorado, by and through the
Board of County Commissioners of Weld County,on behalf of the Department of Human Services,
Family Educational Network of Weld County, and the United States Department of Health and
Human Services,commencing January 1,2004,and ending December 31,2004,with further terms
and conditions being as stated in said application, and
WHEREAS,after review,the Board deems it advisable to approve said application, a copy
of which is attached hereto and incorporated herein by reference.
NOW,THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that the Application for Federal Assistance for Head Start Change of Scope
between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Department of Human Services, Family
Educational Network of Weld County, and the United States Department of Health and Human
Services be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said application.
The above and foregoing Resolution was,on motion duly made and seconded,adopted by
the following vote on the 18th day of August, A.D., 2004, nunc pro tunc January 1, 2004.
]E,L® BOARD OF COUNTY COMMISSIONERS
WE COUNTY, COLORADO
1861 t 121.14 ,
Robert D. Masden, Chair
u Clerk to the Board
William H. Je , Pro-Tem
BY: , . 4-�
Deputy Clerk to the Board
M. ile (�'
AP OV D AS TO i \
David E. Long
unty A orn�e
Gla
Date of signature: ///0S
2004-2460
a
MEMORANDUM
frDATE: August 10, 2004
milkTO: Board of County Commissioners I�
FROM: Walt Speckman, Executive Director �V
COLORADO SUBJECT: Head Start Change of Scope
Enclosed for Board approval is Change of Scope between the Family Educational Network of
Weld County Head Start Program, School District RE-9 (Ft. Lupton School District) and ACY.
FENWC was approached by School District RE-9 to expand the scope of its current partnership.
In addition to one Head Start classroom (2 sessions), the District currently serves preschool
children in eleven (11) sessions in its two elementary schools.
The District RE-9 is proposing to extend all class sessions to 3 YZ hours, Tuesday through
Friday. Hire additional aides (lunch aides) to assist in its classrooms, per FENWC model,
mingle all preschool and Head Start children throughout the 13 sessions. Incorporate the Head
Start model in all classrooms, in accordance with the Performance Standards.
The District RE-9 will continue to provide classroom space and transportation to FENWC at no
cost. In addition, the District will pay for a half-time Center Director to be added to the half-time
Center Director currently funded by FENWC and provide office apace and telephone service.
This change of scope does not require any changes in the current FENWC budget. School
District RE-9 through the District's General Fund will fund the addition of a half-time Center
Director.
The term of this Change of Scope is for the school year 2004-2005.
If you have any questions please contact Janet Flaugher, Director, @ 353-3800, ext. 3340.
2004-2460
APPLICATION FOR 2.DATE SUBMITTED: Applicant Identifier 08CH0019
FEDERAL ASSISTANCE
1.TYPE OF SUBMISSION 3.DATE RECEIVED BY STATE: State Application Identifier
Application Preapplicafion
Construction ri Construction 4.DATE RECEIVED BY FEDERAL AGENCY Federal Identifier 08CH0019
71Non-Construction n Non-Construction
5.APPLICANT INFORMATION
Legal Name: Weld County Division of Human Services Organizational Unit: Family Educational Network of Weld County
Address(give city,county,state,and zip code) Name and telephone number of the person to be contacted on matters involving
1551 North 17th Avenue this
P.O.Box 1805 Walt Speckman (970)353-3800
Greeley,CO 80632 Weld Executive Director,WCDHS
6. EMPLOYER IDENTIFICATION NUMBER(EIN) 7.TYPE OF APPLICANT(enter appropriate letter in box) B
8 1 4 am. 6 0 0 0 8 1 3 A.State H.Independent School Dist.
B.County I.State Controlled Institution of Higher Leaming
8.TYPE OF APPLICATION C.Municipal J.Private University
D.Township K.Indian Tribe
New 7 Continuation X Revision E.Interstate L.Individual
F.Intennunicipal M.Profit Organization
If Revision,enter appropriate letter(s)in box(es): ID El G.Special Distncl N.Other(specify)
A.Increase Award B.Decrease Award C.Increase Duration 9.NAME OF FEDERAL AGENCY
D.Decrease Duration Other(specify: Change of Scope USDHHS/ACF/ACYF/Head Start
10.CATALOG OF FEDERAL DOMESTIC 9 13 • 6 0 0 11.DESCRIPTIVE TITLE OF APPLICANTS PROJECT:
ASSISTANCE NUMBER: 1 PY2004
TITLE:Head Start PA22 Head Start Basic Grant
Continuation Application
Change of Scope
12.AREAS AFFECTED BY PROJECT
Weld County,Colorado
13.PROPOSED PROJECT: 14.CONGRESSIONAL DISTRICTS OF:
Start Date Ending Date a Applicant 4 b.Project 4
1/01/2004 12/31/2004
15. ESTIMATED FUNDING 16.IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE ORDER 12372 PROCESS?
a. YES THIS PREAPPLICATION/APPLICATION WAS MADE AVAILABLE TO THE STATE
a Federal $ 2,732,977 .00 EXECUTIVE ORDER 12372 PROCESS FOR REVIEW ON
b Applicant $ 683,245.00 DATE
c State $ .00 b NO n PROGRAM IS NOT COVERED BY E.O.12372
d Local $ .00 n OR PROGRAM HAS NOT BEEN SELECTED BY STATE FOR REVIEW
e Other $ .00
17.IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT?
f Program Income $ .00 n It I�
Yes If"Yes,"attach an explanation. No
g Total $ 3,416,222.00
18.TO THE BEST OF MY KNOWLEDGE AND BELIEF,ALL DATA IN THIS APPLICATION ARE TRUE AND CORRECT. THE DOCUMENT HAS BEEN DULY AUTHORIZED
BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED
a Typed Name of Authorized Representative b Title c Telephone number
Robert Masden Chair,Weld Co.Board of Co.Commissioners (970)356-4000
b Signature of Authorized Representative th
e Date Signed
AUG 1 8 2004
PROGRAM NARRATIVE
The Family Educational Network of Weld County (FENWC) is committed to providing
low-income children and families with a developmentally appropriate, comprehensive
program to promote self-esteem, and social competence and help children experience
educational success. For children to develop high self-esteem and be successful in school
it is important that our program partner in a collaborative effort with K-12 school
institutions to create optimal transitional opportunities for both children and parents.
These opportunities include the development of a sense of belonging and bonding,
continuity of services, broadening of experiences, a smooth transition from preschool to
kindergarten, scaffolding of curricular scope and sequence and ongoing positive
involvement with a diverse population.
The partnerships that FENWC endeavors to create focus on optimizing services,
coordinating care and broadening the social and experiential base for children and
families. These collaborative efforts simplify family/child entry into systems, increase
the range of services available to families, ensure continuity of care from prenatal to
preschool and develop comprehension, acuity and confidence for operating within
cultural and social systems. These cooperative efforts allow for the Head Start Program
to meet the individual health, socio-cultural and educational needs of its families while
assisting them to successfully transition into the mainstream
A recent partnership with Fort Lupton School District RE-9 has afforded Head Start the
occasion to provide services to thirty (30) eligible children. In that current agreement,
curricular activities have been coordinated with the District's early childhood program.
In addition, the District has provided FENWC with classroom space and transportation at
no cost. FENWC families, FENWC staff and the District have registered great
satisfaction with the collaborative efforts.
CHANGE OF SCOPE
FENWC has been approached by School District RE-9 to expand the scope of its current
partnership. In addition to one Head Start classroom (2 sessions), the District currently
serves preschool children in eleven (11) sessions in its two elementary schools (2
classrooms at one school and 3 at the other). Children attend for 21/2 hours daily. Head
Start operates (from one additional classroom) a morning and an afternoon session for
31/2 hours Tuesday through Friday.
District RE-9 is proposing the following:
1. Extend all of class sessions to 31/2 hours, Tuesday through Friday with
Monday becoming a day for home visits, staff in-service, lesson planning,
etc.,
2. Hire additional aides (lunch aides) to assist in its classrooms,per FENWC's
model,
3. Mingle all preschool and Head Start children throughout the 13 sessions,
4. Incorporate the Head Start model in all classrooms, in accordance with the
Performance Standards,
5. Require that all District preschool staff attend Head Start staff meetings, staff
development activities and pre and in-service trainings, and
6. Require that preschool staff follow all Head Start protocols and complete all
Head Start paperwork.
RE-9 will continue to provide classroom space and transportation to FENWC at no cost.
In addition, the District will pay for a half-time Center Director to be added to the half-
time Center Director currently funded by FENWC and provide office space and
telephone service for that individual. The Center Director will be FENWC's employee,
whose performance will be evaluated by FENWC. The District will provide training to
the Center Director on District protocols and support from the Preschool Coordinator.
In concert with FENWC, the District will develop a salary and benefits schedule for
preschool staff that parallels Head Start's, and will require that all district preschool staff
hired meet Head Start requirements. The District's Preschool Coordinator, the FENWC
Center Director and the FENWC Education Team will collaborate in performance
evaluations of the District's preschool staff. The FENWC Education Team and the
Center Director will collaborate in performance evaluations of the Head Start staff.
FENWC will provide pre-service training once a year and monthly in-service training to
the fifteen (15) District preschool staff(five teachers, five teacher assistants and 5 lunch
aides). Because these training opportunities are already in place for current FENWC
staff, the only cost incurred will be in supplies..
The District will continue to provide developmentally appropriate, literacy and
numeracy-based curriculum materials and supplies to all classrooms.. FENWC will
continue to provide the same level of materials and supplies as it has per prior agreement.
FENWC would like to proceed with this change of scope for school year 2004-5. It is
our belief that this collaborative effort will positively impact the educational success of
our children and strengthen our families as well as positively impact the school district in
general. Parent Policy council has expressed its support for the expansion of this
collaborative effort (see attached). The Governing Body concurs. FENWC is requesting
that this change be approved by ACF for school year 2004-2005.
BUDGET NARRATIVE
This change of scope does not require any changes in the current FENWC budget. The
addition of a half-time Center Director will be funded by School Dist RE-9 through the
District's General Fund.
BUDGET INFORMTION -Non-Construction Programs OMB Approval No.0348-0044
SECTION A•BUDGETSUMMARY-r.. ;
Grant Program Catalog of Federal Estimated Unobligated Funds New or Revised Budget
Function Domestic Assistance
or Activity Number Federal Non-Federal Federal Non-Federal Total
(a) (b) (c) (d) (e) (f) (g)
1.Program Operation 93.600 $2,693,425 $673,357 $3,366,782
2.T&TA 93.600 $39,552 $9,888 $49,440
3.
4.
5. Totals $2,732,977 $683,245 $3,416,222
17 z,. SECTION B BUDGET CATEGORIES`
GRANT PROGRAM,FUNCTION OR ACTIVITY Total
6.Object Class Categories (1) Program Operation (2) T&TA (3) (4) (5)
a.Personnel $1,269,954 $1,269,954
b.Fringe Benefits $340,304 $340,304
c.Travel $7,000 $8,500 $15,500
d.Equipment
e. Supplies $106,166 $106,166
f.Contractual $205,000 $205,000
g.Construction
h.Other $765,001 $31,052 $796,053
i Total Direct Charges(sum of 6a-6h) $2,693,425 $39,552 $2,732,977
j.Indirect Costs
k.TOTALS(sum of 6a-6j) $2,693,425 $39,552 $2,732,977
7.Program Income
Authorized for Local Reproduction Standard Form 424A(Rev.7-97)
Prescribed by OMB Circular A-102
08CH0019 / 0 2004 Weld County Division of Human Services Basic HS Grant Application
C,-NON-FEDEIiAL:RESOURCES , ;- . •# .. �`�� ._�Y�' r`_tir
(a)Grant Program (b)Applicant (c)State (d)Other Sources (e)TOTALS
8. NFS $683,245 $683,245
9.
10.
11.
12. TOTAL(sum of tines 8-11) $683,245 $683,245
-.;t.,ECT� �
SION
Total for 1st Year 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
13. Federal $2,732,977 $683,244 $683,244 $683,244 $683,245
14. Non-Federal $683,245 $170,811 $170,811 $170,811 $170,812
15. TOTAL(sum of lines 13-14) $3,416,222 $854,055 $854,055 $854,055 $854,057
.. y ,: .. .-• w '4MIF, .. ;:- a .^ w -w::t r:sadsrid'�35^v, '� �'. a ,a;sM.:i....i ;y,
,„. " SECTION I ET ESTIMATES OF FEDERAL�'FUNDS NEEDED FORBALA�NCE OF THEPROJECT r �
FUTURE FUNDING PERIODS(Years)
(a)Grant Program
(b)First (c)Second (d)Third (e)Fourth
16.
17.
18.
19.
20. TOTAL(sum of lines 16-19)
•
:-... .,TION F. OTHER BUDGET INFORMATION �- .. . .
21 Direct Charges: $2,732,977 22. Indirect Charges:
23. Remarks:
Authorized for Local Reproduction
Standard Form 424A(Rev.7-97)Page2
08CH0019 / 0 2004 Weld County Division of Human Services Basic HS Grant Application
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
COMPENDIUM OF REQUIRED CERTIFICATIONS AND ASSURANCES
SF 4248
ASSURANCES - NON-CONSTRUCTION PROGRAMS
Note: Certain of these assurances may not be applicable to your project or program. If you have
questions, please contact the awarding agency. Further, certain Federal awarding agencies may require
applicants to certify to additional assurances. If such is the case, you will be notified.
As the duly authorized representative of the applicant, I certify that the applicant:
1. Has the legal authority to apply for Federal assistance, and the institutional, managerial and financial
capability(including funds sufficient to pay the non-Federal share of project costs) to ensure proper
planning, management and completion of the project described in this application.
2. Will give the awarding agency, the Comptroller General of the United States, and if appropriate, the
State, through any authorized representative, access to and the right to examine all records, books,
papers, or documents related to the award; and will establish a proper accounting system in accordance
with generally accepted accounting standards or agency directives.
3. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes
or presents the appearance of personal or organizational conflict of interest, or personal gain.
4. Will initiate and complete the work within the applicable time frame after receipt of approval of the
awarding agency.
5. Will comply with the intergovernmental Personnel Act of 1970 (42 U.S.C. 4278-4763) relating to
prescribed standards for merit systems for programs funded under one of the nineteen statutes or
regulations specified in Appendix A of OPM=s Standards for a Merit System of Personnel Administration
(5 CFR 900, Subpart F).
6. Will comply with all Federal statutes relating to non-discrimination. These include but are not limited to:
(a) Title VI of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits discrimination on the bases of
race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended(20 U.S.C.
1681-1683, and 1685-1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the
Rehabilitation Act of 1973, as amended(29 U.S.C. 794), which prohibits discrimination on the basis of
handicaps; (d) the Age Discrimination Act of 1975, as amended(42 U.S.C. 6101-6107), which prohibits
discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255), as
amended, relating to non-discrimination on the basis of drug abuse; (t) the Comprehensive Alcohol Abuse
and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as amended, relating
to non-discrimination on the bases of alcohol abuse or alcoholism; (g) 523 and 527 of the Public Health
Service Act of 1912 (42 U.S.C. 290 dd-3 and 290 ee-3), as amended, relating to confidentiality of the
alcohol and drug abuse patient records; (h) Title VII of the Civil Rights Act of 1968 (42 U.S.C. 3601 et
seq.), as amended, relating to non-discrimination in the sale, rental or financing of housing; (I) any other
non-discrimination provisions in the specific statute(s) under which application for Federal assistance is
being made; and(j) the requirements of any other non-discrimination statute(s) which may apply to the
application.
7. Will comply, or has already complies, with the requirements of Titles II and III of the Uniform Relocation
Assistance and Real Property Acquisition Policies Act of 1970(P.L. 91-646) which provide for fair and
equitable treatment of persons displaced or whose property is acquired as a result of Federal or Federally
assisted programs. These requirements apply to all interests in real property acquired for project
purposes regardless of Federal participation in purchases.
8. Will comply with the provisions of the Hatch Act(5 U.S.C. 1501-1508 and 7324-7328) which limit the
political activities of employees whose principal employment activities are funded in whole or in part with
Federal funds.
9. Will comply, as applicable, with the provisions of the Davis-Bacon Act(40 U.S.C. 276a to 276a-7), the
Copeland Act(40 U.S.C. 276c and 18 U.S.C. 874), and the Contract Work Hours and Safety Standards
Act(40 U.S.C. 327-333), regarding labor standards for Federally assisted construction subagreements.
10. Will comply, if applicable, with flood insurance purchase requirements of Section 102(a) of the Flood
Disaster Protection Act of 1973 (P.L. 93-234) which requires recipients in a special flood hazard area to
participate in the program and to purchase flood insurance if the total cost of insurable construction and
acquisition is$10,000 or more.
11. Will comply with environmental standards which may be prescribed pursuant to the following: (a)
institution of environmental quality control measures under the National Environmental Policy Act of 1969
(P.L. 91-190) and Executive Order(EO) 11514; (b) notification of violating facilities pursuant to 50 11738;
(c)protection of wetlands pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in
accordance with EO 11988; (e) assurance of project consistency with the approved State management
program developed under the Coastal Zone Management Act of 1972 (16 U.S.C. 1451 et seq.); (0
conformity of Federal actions to State (Clear Air) Implementation Plans under Section 176(c) of the Clear
Air Act of 1955, as amended(42 U.S.C. 7401 et seq.); (g) protection of underground sources of drinking
water under the Safe Drinking Water Act of 1974, as amended, (P.L. 93-523); and(h)protection of
endangered species under the Endangered Species Act of 1973, as amended, (P.L. 93-205)
12. Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C. 1271 et seq.) related to protecting
components or potential components of the national wild and scenic rivers system.
13. Will assist the awarding agency in assuring compliance with Section 106 of the National Historic
Preservation Act of 1966, as amended(16 U.S.C. 470), EO 11593(identification and protection of historic
properties), and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. 469a-1 et seq.).
14. Will comply with P.L. 93-348 regarding the protection of human subjects involved in research,
development, and related activities supported by this award of assistance.
15. Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as amended, 7 U.S.C. 2131
et seq.) pertaining to the care, handling, and treatment of warm blooded animals held for research,
teaching, or other activities supported by this award of assistance.
16. Will comply with the Lead-Based Paint Poisoning Prevention Act(42 U.S.C. 4801 et seq.) which
prohibits the use of lead based paint in the construction or rehabilitation of residence structures.
17. Will cause to be performed the required financial and compliance audits in accordance with the single
Audit Act of 1984.
18. Will comply with all applicable requirements of all other Federal laws, executive orders, regulations and
policies governing this program.
DRUG-FREE WORKPLACE REQUIREMENTS
GRANTEES OTHER THAN INDIVIDUALS
By signing and/or submitting this application or grant agreement, the grantee is providing the certification set
out below.
This certification is required by regulations implementing the Drug-Free Workplace Act of 1988, 45 CFR, Part
76, Subpart F. The regulations published in the January 31, 1989 Federal Register, require certification by
grantees that they will maintain a drug-free workplace. The certification set out below is a material
representation of fact upon which reliance will be placed when NHS determines to award the grant. False
certification or violation of the certification shall be grounds for suspension of payments, suspension or
termination of grants, or government-wide suspension or debarment.
Workplaces under grants, for grantees other than individuals, need not be identified on the certification. If
known, they may be identified in the grant application. If the grantee does not identify the workplaces at the
time of application, or upon award, if there is no application, the grantee must keep the identity of the
workplace(s) on file in its office and make the information available for Federal inspection. Failure to identify
all known workplaces constitutes a violation of the grantee's drug-free workplace requirements.
Workplace identifications must include the actual address of buildings (or parts of building) or other sites
where work under the grant takes place. Categorical descriptions may be used(e.g. all vehicles of a mass
transit authority of State highway department while in operation, State employees in each local unemployment
office, performers in concert halls or radio studios).
If the workplace identified to NHS changes during the performance of the grant, the grantee shall inform the
agency of the change(s), it previously identified the workplaces in question (see above).
Definitions of terms in the Nonprocurement Suspension and Debarment common rule and Drug-Free
Workplace common rule apply to this certification. Grantees'attention is called, in particular, to the following
definitions from these rules:
"Controlled substance"means a controlled substance in Schedules I through V of the Controlled Substances
Act (21 USC 812) and as further defined by regulations (21 CFR, 1308.11 through 1308.15). "Conviction"
means a finding of guilt(including a plea ofnolo contendere)or imposition of sentence, or both, by any judicial
body charged with the responsibility to determine violations of the Federal of State criminal drug statutes;
"Criminal drug statute"means a Federal or non-Federal criminal statute involving the manufacture, distribution,
dispensing use, or possession of any controlled substance; "Employee"means the employee of a grantee
directly engaged in the performance of work under a grant including: (i)All"direct charge"employees; (ii) all
"indirect charge"employees unless their impact of involvement is insignificant to the performance of the grant;
and(iii) temporary personnel and consultants who are directly engaged in the performance of work under the
grant and who are on the grantee's payroll. This definition does not include workers not on the payroll of the
grantee (e.g., volunteers, even if used to meet a matching requirement; consultants or independent
contractors not on the grantee's payroll; or employees of subrecipients or subcontractors in covered
workplaces).
The grantee certifies that it will provide a drug-free workplace by:
a) Publishing a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession or use of a controlled substance is prohibited in the grantee's
workplace and specifying the actions that will be taken against employees for violation of
such prohibition;
b) Establishing a drug-free awareness program to inform employees about:
(1) The dangers of drug abuse in the workplace;
(2) The grantee's policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, employee assistance programs; and
•
(4) The penalties that may be imposed upon employees for drug abuse violations
occurring in the workplace;
c) Making it a requirement that each employee to be engaged in the performance of the grant
be given a copy of be statement required by paragraph (a);
d) Notifying the employee in the statement required by paragraph (a) that as a condition of
employment under the grant, the employee will:
(1) Abide by the terms of the statement; and
(2) Notify the employer of any criminal drug statute conviction fora violation occurring in
the workplace no later than five days after such conviction;
e) Notifying the agency in writing within ten days after receiving notice under subparagraph
(d)(2), from an employee or otherwise receiving actual notice of such conviction. Employers
of convicted employees must provide notice, including position title, to every grant officer or
other designee on whose grant the convicted employee was working, unless the Federal
agency has designated a central point for the receipt of such notices. Notice shall include the
identification number(s) of each affected grant;
f) Taking one of the following actions within 30 days of receiving notice under subparagraph
(d)(2), with respect to any employee who is so convicted:
(1) Taking appropriate personnel action against such an employee, up to and including
termination, consistent with the requirements of the Rehabilitation Act of 1973, as
amended; or
(2) Requiring such employee to participate satisfactorily in a drug abuse assistance or
rehabilitation program approved for such purposes by a Federal, State, or local
health, law enforcement, or other appropriate agency.
g) Making a good faith effort to continue to maintain a drug-free workplace through
implementation of paragraphs (a) through (f).
CERTIFICATION REGARDING ENVIRONMENTAL TOBACCO SMOKE
Public Law 103-227, also known as the Pro-Children Act of 1994(Act),requires that smoking not be permitted
in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or
regularly for the provision of health, day care, early childhood development services, education or library
services to children under the age of 18, if the services are funded by Federal program either directly or
through State or local governments, by Federal grant, contract, loan, or loan guarantee. The law also applies
to children's services that are provided in indoor facilities that are constructed, operated, or maintained with
such Federal funds. The law does not apply to children's services provided in private residences;portions of
facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable
Federal funds in medicare of medicaid;or facilities where WIC coupons are redeemed. Failure to comply with
the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each
violation and/or the imposition of an administrative compliance order on the responsible entity.
By signing this certification, the offeror/contractor(for acquisitions) or applicant/grantee (for grants) certifies
that the submitting organization will comply with the requirements of the Act and will not allow smoking within
any portion of any indoor facility used for the provision of services for children as defined by the Act.
The submitting organization agrees that it will require that the language of this certification be included in any
subawards which subrecipients shall certify accordingly.
CERTIFICATION REGARDING DEBARMENT, SUSPENSION AND OTHER
RESPONSIBILITY MATTERS - PRIMARY COVERED TRANSACTIONS
By signing and submitting this proposal, the applicant, defined as the primary participant in accordance with 45
CFR Part 76 certifies to the best of his or her knowledge and believe that it and its principals:
(a) are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily
excluded from covered transaction by any Federal Department or agency;
(b) have not within a 3-year period preceding this proposal been convicted or had a civil judgement
rendered against them for commission of fraud or a criminal offense in connection with obtaining,
attempting to obtain, or performing a public(Federal, State or local) transaction or contract under a
public transaction: violation of Federal or State antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false statement, or receiving
stolen property;
(c) are not presently indicted or otherwise criminally or civilly charged by a governmental entity(Federal,
State or local) with commission of any of the offenses enumerated in paragraph (1) (b) of this
certification; and
(d) have not within a 3-year period preceding this application/proposal had one or more public transaction
(Federal, State or local) terminated for cause or default.
The inability of a person to provide the certification required above will not necessarily result in denial of
participation in this covered transaction. If necessary, the prospective participant shall submit an explanation
of why it cannot provide the certification. The Department of Health and Human Services' (HHS)
determination whether to enter into this transaction. However, failure of the prospective primary participant to
furnish a certification or an explanation shall disqualify such person from participation in this transaction.
The prospective primary participant agrees that by submitting this proposal, it will include the clause entitled
"Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered
Transactions,"provided below without modification in all lower tier covered transactions.
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY
AND VOLUNTARY EXCLUSION - LOWER TIER COVERED TRANSACTIONS
(TO BE SUPPLIED TO LOWER TIER PARTICIPANTS)
By signing and submitting this lower tier proposal, the prospective lower tier participant, as defined in 45 CFR,
Part 76, certifies to the best of its knowledge and belief that it and its principals:
(a) are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from participation in this transaction by any Federal department or agency.
(b) where the prospective lower tier participant is unable to certify to any of the above, such prospective
participant shall attach an explanation to this proposal.
The prospective lower tier participant further agrees by submitting this proposal that it will include this clause
entitled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier
Covered Transactions,"without modification in all lower tier covered transactions and in all solicitations for
lower tier covered transactions.
CERTIFICATION REGARDING LOBBYING
FOR CONTRACTS, GRANTS, LOANS
AND COOPERATIVE AGREEMENTS
The undersigned certifies to the best of his or her knowledge and belief, that:
(1) No Federal appropriate funds have been paid or will be paid, by or on behalf of the undersigned, to
any person for influencing or attempting to influence an officer or employee of any agency, a member
of congress, an officer or employee of congress, or an employee of a member of congress in
connection with the awarding of any Federal contract, the making of any Federal grant, the making of
any Federal loan, the entering into of any cooperative agreement, and the extension, continuation,
renewal, amendment or modification of any Federal contract, grant, loan, or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person
influencing or attempting to influence an officer or employee or an agency, a member of congress, an
officer or employee of congress, or an employee of a member of congress in connection with this
Federal contract, grant, loan or cooperative agreement, the undersigned shall complete and submit
Standard Form LLL, "Disclosure Form to Report Lobbying,"in accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in the award
documents for all subawards at all tiers (including subcontracts, sub grants, and contracts under
grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose
accordingly.
This certification is a material representation of fact upon which reliance was placed when this transaction was
made or entered into. Submission of this certification is a prerequisite for making or entering into this
transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to me the required certification
shall be subject to a civil penalty or not less than S10,000 and not more than S100,000 for each such failure.
I hereby agree to the above certifications and assurances. •
Signature of Certifying Official Date
Title
Applicant Organization
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