HomeMy WebLinkAbout850941.tiff ,. OMB Approval No.0348-0006
2. APPLI- a NUMBER 3. STATE a.NUMBER
FEDERAL ASSISTANCE AIi S CATION
1. TYPE CATION IDENTi-NAL — !
OF ❑ NOTICE OF INTENT(OPTIONAL) IDENTi- b.DATE F!£R b. DATE
SUBMISSION FIER Year NOM:TO BE ASSIGNED Yeo- rts«rh :ley
(M_ark tip. D PIREAPPUCATIOP! Asstarrao
�'�`t` Dl APPLICATION 19 85 06 03 BY STATE ,a I
Leave
Blank
W
4. LEGAL APPLICANT/REClPtENT 5. EMPLOYER IDENTIFICATION NUMBS,•(EiN),
aAppIl ntName . Weld County Division of Human Resources _
b.Organization U t . Head Start Program 6.
c.Street/P.O. Box . P. 0. Box 1805 PRO- a. NUMBER LY-1 3 V 16 1 0 10l
d.City . Greeley ..03,,,t1 Weld GRAM
f.State . Colorado 9 ZIP Cods. 80632 (From CFtDA) ____ VitiLTIPLE O
h_CC91blif.,1 Person(Name Walter J. Speckman, Executive Director b. TITLE Migrant Head Start/ i
e relepho eNa) • (303) 3537_05,40 Day Care
I- 7. TITLE OF APPLICANT'S PROJECT(Use IV of this form to provide a summary description Of the 8. TYPE 8s�OF APPLICANT/RECIPIENTixo4 ) e—+aw,cv, `n-Cans.gay ge,n t tr°igo".M
c•-a.6seor, t--My,Far hxae rv:txv-
1985 - Weld County Migrant Head Start/Day Care Program E.,°^ ,lya.
Direr o ^.prlate krT I DI
9. AREA OF PROJECT IMPACT(Names of cider.counties,states,etc) 10.ESTIMATED NUMBER 11. TYPE OF ASSISTANCE
• OF PERSONS BENMMNG �°'k cyst 's`
Weld and Adams County 200 , .,,
pria:�.q(� P L 1
•
12. PROPOSED FUNDING 13 CONGRESSIONAL DISTRICTS OF:
14. TYPE OF APPLICATION
A—eM.c C-AMsbn -.4K..xe,:z7oet
308 899 ` a .W
APPLICANT b. PROJECT D— nerd 0—Corn-talon �
a FEDERAL : s oo Ewer cF.-,opkrr Ore, t1 l
b.APPLICANT 61,779 .00 4 County-Wide 17.TYPE OF CHANGE(For tk o,14e)
-. A—kiaww Dodos F--Oahu(Spxf.4j?:
c.STATE .00 15. PROJECT START 16. PROJECT �D
Year month day
DATE DURATION
d.LOCAL .00 E--cancesato.
OTHER _ 29, 500.00 I 19 85 06. _ 17 __5..__ Months
Err&
a. 18. DATE DUE TO Year month day giet9Mr3s(s/ 1�—I
f. Total s 400,178 -000 FEDERAL AGENCY m 19 85. 06 03
19. FEDERAL AGENCY TO RECEIVE REQUEST Administration for Children Youth and Families 20.EXISIIFG AEE N e� T
a ORGANIZATIONAL UNIT(IF APPROPRIATE) b.ADMINISTRATIVE CONTACT(IF KNOWN)
C. ADDRESS 21. REMARKS ADDED
I
r-i Veg.__ j] No_---
22. To the best of my knowledge and be4ef• a YES,THIS NOTICE OF INTENT/PREAPPUCATION/APPLICATION WAS MADE AVAILABLE TO THE STATE
g, THE data in this preappllcatian/appBcation EXECUTIVE ORDER 12372 PROCESS FOR REVIEW ON:
APPLICANT are true and corrsct,ns document ent has
ES
been Oil authorzed by the 2eYerrdreg
F THAT body of the secant and the apg cant DATE
will comply with theattachedsssurance? b. NO,PROGRAM IS NOT COVERED BY EO. 12372 O -_
if the assistance is approved. OR PROGRAM HAS NOT BEEN SELECTED BY STATE FOR REVIEW ❑
6 23. a. TYPED NAME AND TITLE b. SIGNATURE
CERTIFYING ING Jacqueline Johnson, Chairman
CERT
SEiNTATIVE Board of Commissioners
24. APPLICA- Year month day 25. FEDERAL APPLICATION IDEhT.1._ TION MBER 26. E ERAL GRANT IDENTIFICATION
TION
RECEIVED 19 -
27. ACTION TAKEN 128. FUNDING Year month day 30- Year monr,k .4;t,
STARTING
< O S. AWARDED 29. ACTION DATEr 19 DATE 19
6 ❑ b. REJECTED a. FEDERAL $ .00�31. CONTACT FOR ADDITIONAL INFORMA- 32. yea....month date
LL O c. RETURNED FOR TION(Name and Telephone number) ENDING
I < AMENDMENT b. APPLICANT .00 DATE 19
g 0 d. RETURNED FOR c. STATE - .00 33. REMARKS ADDED
5 w E.O. 12372 SUBMISSION
v is< BY APPLICANT TO d. LOCAL .00
STATE
O e. DEFERRED e. OTHER .00
O f. WITHDRAWN I. TOTAL S .00 1 Yes Li No
NSN 7540-01-008-8162 424-103 '-''•"''•'.??s.ir RP4 424.^•AGE 1 (Rev.4-84)
PREVIOUS EDITION a no.'C •4 1 -:-+ OMB Cfrmt.Tr A-102
IS NOT USABLE ' i '•: //'L-6IgY
PART III - BUDGET INFORMATION
'SECTION A-BUDGET SUMMARY
Grant Program, Federal Estimated Unobligated Funds New or Revised Budget
Function
or Activity Catalog No. Federal Non-Federal Federal Non-Federal Total
(a) (b) (c) (d) (e) (0 (g)
1. PA 23 $ $ $ 281 ,922 ,$ 56.384 $ 338
2 PA 26 _ ___ 26,977 5,395 32,37?
3.
4. ---
5. TOTALS .$ $ $ 308,899 $ 61,779 ,678
SECTION B- BUDGET CATEGORIES
6. Object Class Categories -Grant Program, Function or Activity ^ -� -
Total
PA 23 (2) PA 26 13pJUTR/USDA (4) j5)
a. Personnel $ 189,577 $ 12,470 $ (12,320) $ $ 202,047
b. Fringe Benefits 31,405 1,621 _ (1 ,602) 33,026 j
I
c. Travel 2,600 _ (-0-) 2,600
. d. Equipment 2,886 (-0-) 2 886
e. Supplies 13,000 ------ ------------- (-U-) 13 000
f. Contractual 6,140 10,000 (-0-) 16,140
9. Construction
(-o-) o
h. Other 39,200 (15,578) 39,200
i. Total Direct Charges
j. Indirect Charges
k. TOTALS $ 281,922 i$ 26,977 $ (29,500) $ $ 308,899 ___
7. Program Income $ _I$ $ $ $
-- On NO.0348000
SECTION C- NON-FEDERAL RESOURCES
(aJGrait Praararn (b)APPLICANT (C)STATE (d)OTHER SOURCES (e)TOTALS
8. PA 23 $ 56,384 $ $ $ 56_3a4
9. PA 26 5,395 5,395
10.
11.
12. TOTALS ��$ 61 ,779 $ $ $ 61,779
SECTION D-FORECASTED CASH NEEDS
'Total for 1st Year 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
13. Federal $ 3D8,R99 $ -A- $ 102,q5.6 i$ 2QCQ133 $ -Q-
14. Non-Federal . 61,779 -0- 20,593 41,186 -0-
15. TOTAL :$ 370,678. $ -0- $123,559 $ 247,119 $ -0-
SECTION E-BUDGET ESTIMATES OF FEDERAL FUNDS NEEDED FOR BALANCE OF THE PROJECT
FUTURE FUNDING PERIODS EARS
(a)Grant Program (b) FIRST (C)SECOND • (d)THIRD (e) FOURTH
16. PA 23 $ 342,678
17.
_28,326 a9,742 31,229 32 790
18.
19. —_
20. TOTALS $ 324,344 $. 340,561 $ 357,589 $ 68
SECTION F-OTHER BUDGET INFORMATION •
(Attach Additional Sheets If Necessary)
21. Direct Charges:
22. Indirect Charges:
23. Remarks:
PART IV PROGRAM NARRATIVE (Attach per instruction)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ASSURANCE OF COMPLIANCE WITH SECTION 504 OF THE
REHABILITATION ACT OF 1973,AS AMENDED
The undersigned(hereinafter called the "recipient") HEREBY AGREES THAT it will comply with section 504 of the Re-
habilitation Act of 1973,as amended (29 U.S.C. 794),all requirements imposed by the applicable HHS regulation(45 C.F.R.
Part 84),and all guidelines and interpretations issued pursuant thereto.
Pursuant to § 84.5(a) of the regulation [45 C.F.R. 84.5(a)], the recipient gives this Assurance in consideration of and for the
purpose of obtaining any and all federal grants,loans,contracts(except procurement contracts and contracts of insurance
or guaranty), property,discounts,or other federal financial assistance extended by the Department of Health and Human
Services after the date of this Assurance,including payments or other assistance made after such date on applications for
federal financial assistance that were approved before such date. The recipient recognizes and agrees that such federal financial
assistance will be extended in reliance on the representations and agreements made in this Assurance and that the United
States will have the right to enforce this Assurance through lawful means.This Assurance is binding on the recipient,its
successors, transferees,and assignees,and the person or persons whose signatures appear below are authorized to sign this
Assurance on behalf of the recipient.
This Assurance obligates the recipient for the period during which federal financial assistance is extended to it by the De-
partment of Health and Human Services or,where the assistance is in the form of real or personal property,for the period
provided for in § 84.5(6)of the regulation [45 C.F.R.84.5(b)]
•
The recipient: (Check (a)or(b)] •
a. ( ) employs fewer than fifteen persons;
A73
b. ( X ) employs fifteen or more persons and,pursuant to § 84.7(a)of the regulation [45 C.F.R.84.7(a)],has
A74 designated the following person(s)to coordinate its efforts to comply with the HHS regulation:
Weld County Commissioners
Name of Designee(s) —Type or Print
Cl2 C42
Weld County Division of Human Resourct=s P.Q,�ox_1$95
Name of Recipient —Type or Print Street Address or P.O.Box
Al2 A41 A42 A71
84-6000813 Greeley
(IRS)Employer Identification Number City
Al All 812 B41
B1 B11 Colorado 80632
Cl CII State Zip
842 B71
I certify that the above information is complete and correct to the best of my knowledge.
06/03/85
Date S gnatur nd Title o A thorized Official
B72 B77 Jacqueline Johnson, Chairman
Weld County Board of Commissioners
If there has been a change in name or ownership within the last year,please PRINT the former name below:
NOTE: The 'A'.`B',and 'C' followed by numbers are for computer use. Please disregard.
PLEASE RETURN ORIGINAL TO: Office for Civil Rights, Room 5627/B North Building, 330 Independence Avenue,N
Washington.D.C. 20201.
RETURN COPY TO: Grants Management Office
HDS GRANTS MANAGEMENT
HHS-641 (10!821 REV.
ASSURANCE OF COMPLIANCE WITH THE DEPARTMENT OF
HEALTH AND HUMAN SERVICES REGULATION UNDER
TITLE VI OF THE CIVIL RIGHTS ACT OF 1964
Weld Coun y Commissioners/Division of Human (hereinafter called the "Applicant")
(Name of Agdgg ij)rce5
HEREBY AGREES THAT it will comply with title VI of the Civil Rights Act of 1964 (P.L. 88-352)
and all requirements imposed by or pursuant to the Regulation of the Department of Health and
Human Services (45 CFR Part 80) issued pursuant to that title, to the end that, in accordance with
title VI of that Act and the Regulation, no person in the United States shall, on the ground of race,
color, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise
subjected to discrimination under any program or activity for which the Applicant receives Federal
financial assistance from the Department; and HEREBY GIVES ASSURANCE THAT it will imme-
diately take any measures necessary to effectuate this agreement.
If any real property or structure thereon is provided or improved with the aid of Federal financial
assistance extended to the Applicant by the Department, this assurance shall obligate the Applicant, or
in the case of any transfer of such property, any transferee, for the period during which the real
property or structure is used for a purpose for which the Federal financial assistance is extended or for
another purpose involving the provision of similar services or benefits. If any personal property is so
provided, this assurance shall obligate the Applicant for the period during which it retains ownership
or possession of the property. In all other cases, this assurance shall obligate the Applicant for the
period during which the Federal financial assistance is extended to it by the Department.
THIS ASSURANCE is given in consideration of and for the purpose of obtaining any and all Federal
grants, loans, contracts, property, discounts or other Federal financial assistance extended after the
date hereof to the Applicant by the Department, including installment payments after such date on
account of applications for Federal financial assistance which were approved before such date. The
Applicant recognizes and agrees that such Federal financial assistance will be extended in reliance on
the representations and agreements made in this assurance, and that the United States shall have the
right to seek judicial enforcement of this assurance. This assurance is binding on the Applicant, its
successors, transferees, and assignees, and the person or persons whose signatures appear below are
authorized to sign this assurance on behalf of the Applicant.
Weld County Commissioners
Dated 06/03/85 Weld County Division of Human Resources
(Applicant)
(P.-sident, airman of B ar.,or comparable
authorized official)
Jacqueline Johnson, Chairman
P.O. Box 1805 Weld County Board of Commissioners
Greeley, Colorado 80632
(Applicant's mailing ad±'ess)
PLEASE RETURN ORIGINAL TO: Office of Civil Rights
Room 5627/B North Building
330 Independence Ave., N.W.
Washington, D.C. 20201
RE 1 URN COPY TO: GRANTS MANAGEMENT OFFICE
HDS GRANTS MANAGEMENT
HHS-441 (10/82) Rev. GPO 894-600
CERTIFICATION OF HEAD START
ADMINISTRATIVE COSTS
We Weld County Commissioners - Weld County Division of Human. Resources , have reviewed
Name re Grantee)
45 CFR Part 1301.32 and certify that the development and administrative costs to administer the
Weld County Division of Hyman Resources PlicrrantHead Start Program for the program year
fNa sner.,nnrat
s•
June 37, 1985 through October 75_ 1985 will not exceed 15.percent of $ 308,899.00
(total Federal and non-Federal costs for program accounts 22 through 26).
Documents substantiating administrative costs are available in our files for review by auditor and
Office of Human Development Services/Health and Human Services Personnel.
pn � _ 06/03/85
Sign , Certifying Official Date
cqueline Johnson, Chairman
Weld County Board of Commissioners
YIDS GRANTS MANAGEMENT
DEPARTMENT OF HEALTH AND HUMAN SERVICES ® GRANT O CONTRACT O FELLOW ❑OTHER
PROTECTION OF HUMAN SUBJECTS O NEW O RENEWAL 0 CONTINUATION
ASSURANCE/CERTIFICATION/DECLARATION APPLICATION IDENTIFICATION NUMBER(if known)
IXl ORIGINAL ❑ FOLLOWUP 0 REVISION
STATEMENT OF POLICY Safeguarding the rights and welfare of subjects at risk in activities supported under grants and contracts from DAMS is
primarily the responsibility of the institution which receives or is accountable to DHHS for the funds awarded for the support of the activity.In
order to provide for the adequate discharge of this institutional responsibility,it is the policy of DHHS that no activity involving human subje:is to
be supported by DBMS grants or contracts shall be undertaken unless the Institutional Review Board has reviewed and approved such activity,and
the institution has submitted to DHHSa certification of such review and approval,in accordance with the requirements of Public Law 93-348,as
implemented by Part 46 of Tito 45 of the Code of Federal Regulations,as amended,(45 CFR 46).Administration of the DIMS policy and regula-
tion is the responsiibility(of the Office for Protection from Research Risks,National Institutes of Health,Bethesda,MD 20205.
I..RTITTLE d- OF PROPOSAL OR ACTIrant VITY d Start/Ray Care
Walter J. Speckman, Executive Director
2. PRINCIPAL INVESTIGATOR/ACTIVITY DIRECTOR/FELLOW
3. DECLARATION THAT HUMAN SUBJECTS EITHER WOULD OR WOULD NOT BE INVOLVED
D A. NO INDIVIDUALS WHO MIGHT'BE CONSIDERED HUMAN SUBJECTS,S,INCLUDING THOSE FROM WHOM ORGANS,TISSUES..
FLUIDS,OR OTHER MATERIALS WOULD BE DERIVED,OR WHO COULD BE IDENTIFIED BY PERSONAL DATA,WOULD BE
INVOLVED IN THE PROPOSED ACTIVITY.(IF NO HUMAN SUBJECTS WOULD BE INVOLVED,CHECK THIS BOX AND FRO-
rrpp�� I CEED TO ITEM 7.PROPOSALS DETERMINED BY THE AGENCY TO INVOLVE HUMAN SUBJECTS WILL BE RETURNED.)
L_J B. HUMAN SUBJECTS WOULD BE INVOLVED IN THE PROPOSED ACTIVITY AS EITHER:❑ NONE OF THE FOLLOWING,OR
INCLUDING:t) MINORS.Q FETUSES,❑ ABORTUSES,❑ PREGNANT WOMEN,0 PRISONERS,❑ MENTALLY
RETARDED.❑ MENTALLY DISABLED.UNDER SECTION 6.COOPERATING INSTITUTIONS,ON REVERSE OF THIS FORM,
GIVE NAME OF INSTITUTION AND NAME AND ADDRESS OF OFFICIAL(S)AUTHORIZING ACCESS TO ANY SUBJECTS IN
FACILITIES NOT UNDER DIRECT CONTROL OF THE APPLICANT OR OFFERING INSTITUTION.
4. DECLARATION OF ASSURANCE STATUS/CERTIFICATION OF REVIEW
O A. THIS INSTITUTION HAS NOT PREVIOUSLY FILED AN ASSURANCE AND ASSURANCE IMPLEMENTING PROCEDURES FOR
THE PROTECTION OF HUMAN SUBJECTS WITH THE DHHS THAT APPLIES TO THIS APPLICATION OR ACTIVITY.ASSUR-
ANCE IS HEREBY GIVEN THAT THIS INSTITUTION WILL COMPLY WITH REQUIREMENTS OF WINS Regulation 45 CFR 46,
THAT IT HAS ESTABLISHED AN INSTITUTIONAL REVIEW BOARD FOR THE PROTECTION OF HUMAN SUBJECTS AND,
WHEN REQUESTED.WILL SUBMIT TO DHHS DOCUMENTATION AND CERTIFICATION OF SUCH REVIEWS AND PROCE-
DURES AS MAY BE REQUIRED FOR IMPLEMENTATION OF THIS ASSURANCE FOR THE PROPOSED PROJECTOR ACTIVITY.
® B. THIS INSTITUTION HAS AN APPROVED GENERAL ASSURANCE(DHHS ASSURANCE NUMBER )OR AN AC-
TIVE SPECIAL ASSURANCE FOR THIS ONGOING ACTIVITY,ON FILE WITH DHHS.THE SIGNER CERTIFIES THAT ALL
ACTIVITIES IN THIS APPLICATION PROPOSING TO INVOLVE HUMAN SUBJECTS HAVE BEEN REVIEWED AND APPROVED
BY THIS INSTITUTION'S INSTITUTIONAL REVIEW BOARD IN A CONVENED MEETING ON THE DATE CF 06�(A3. 85.IN
ACCORDANCE WITH THE REQUIREMENTS OF THE Code of Federal Regulations on Protection of Human Subjects 45 C R 46).
THIS CERTIFICATION INCLUDES.WHEN APPLICABLE,REQUIREMENTS FOR CERTIFYING FDA STATUS FOR EACH IN-
VESTIGATIONAL NEW DRUG TO BE USED(SEE REVERSE SIDE OF THIS FORM).
THE INSTITUTIONAL REVIEW BOARD HAS DETERMINED,AND THE INSTITUTIONAL OFFICIAL SIGNING BELOW CONCURS THAT:
EITHER HUMAN SUBJECTS WILL NOT BE AT RISK; OR❑ HUMAN SUBJECTS WILL BE AT RISK.
6.AND 6. SEE REVERSE SIDE
Weld County Division of Human Resources - Head Start Program
7. NAME AND ADDRESS OF INSTITUTION
Walter J. Speckman. Fxecutive Director
8. TI LE F INST TUTIONAL OFFICIAL TELEPHONE NUMBER
(303) 353-0540
G TURE INSTITUTIONAL OFFICIAL - DATE
06/03/85
HHS-596(Rev.5-80)
ENCLOSE THIS FORM WITH THE PROPOSAL OR RETURN IT TO REQUESTING AGENCY.
5. INVESTIGATIONAL NEW DRUGS-ADDITIONAL CERTIFICATION REQUIREMENT
SECTION 46.17 OF TITLE 45 OF THE Code of Federal Regulations states, "Where an organization is required to prepare or to submit a cer-
tification...and the proposal involves an investigational new drug within the meaning of The Food,Drug,and Cosmetic Act,the drus shall
be identified in the certification together with a statement that the 30-day delay required by 21 CFR 130.3(a)(2)has elapsed and the Food and
Drug Administration has not,prior to expiration of such 30-day interval.requested that the sponsor continue to withhold or to restrict use of
the drug in human subjects;or that the Food and Drug Administration has waived the 30.day delay requirement;provided,however,that in
those cases in which the 30day delay interval has neither expired nor been waived,a statement shall be forwarded to DIMS upon such expira-
tion or upon receipt of a waiver.No certification shall be considered acceptable until such statement has been received."
INVESTIGATIONAL NEW DRUG CERTIFICATION
TO CERTIFY COMPLIANCE WITH FDA REQUIREMENTS FOR PROPOSED USE OF INVESTIGATIONAL NEW DRUGS IN ADDITION TO
CERTIFICATION OF INSTITUTIONAL REVIEW BOARD APPROVAL,THE FOLLOWING REPORT FORMAT SHOULD BE USED FOR
EACH IND: (ATTACH ADDITIONALIND CERTIFICATIONS AS NECESSARY),
I,
— INC FORMS FILED: D LJ FDA 1571, FDA 1572, FDA 1573
— NAME OF IND AND SPONSOR ._.
— DATE OF 30-DAY EXPIRATION OR FDA WAIVER
•
(FUTURE DATE REQUIRES FOLLOWUP REPORT TO AGENCY)
— FDA RESTRICTION
— SIGNATURE OF INVESTIGATOR - DATE
•
6. COOPERATING INSTITUTIONS-ADDITIONAL REPORTING REQUIREMENT ,I
SECTION 46.16 OF TITLE 45 OF THE Code of Federal Regulations IMPOSES SPECIAL REQUIREMENTS ON THE CONDUCT 07 STUDIES
OR ACTIVITIES IN WHICH THE GRANTEE OR PRIME CONTRACTOR OBTAINS ACCESS TO ALL OR SOME OF THE SUBJECTS
THROUGH COOPERATING INSTITUTIONS NOT UNDER ITS CONTROL. IN ORDER THAT THE DHHS BE FULLY INFORMED,THE
FOLLOWING REPORT IS REQUESTED WHEN APPLICABLE.
•
USE FOLLOWING REPORT FORMAT FOR EACH INSTITUTION OTHER THAN GRANTEE OR CONTRACTING INSTITUTION WITH
RESPONSIBILITY FOR HUMAN SUBJECTS PARTICIPATING IN THIS ACTIVITY: (ATTACH ADDITIONAL REPORT SHEETS AS
NECESSARY).
INSTITUTIONAL AUTHORIZATION FOR ACCESS TO SUBJECTS
— SUBJECTS: STATUS(WARDS, RESIDENTS, EMPLOYEES,PATIENTS,ETC.)
NUMBER AGE RANGE
NAME OF OFFICIAL(PLEASE PRINT)
TITLE TELEPHONE
NAME AND ADDRESS OF
COOPERATING INSTITUTION
— OFFICIAL SIGNATURE
NOTES: (e.g., report of modification in proposal as submitted to agency affecting'human subjects involvement)
•
HHS-596(Rev.5-80)(Back)
PART V
ASSURANCES
The Applicant hereby assures and certifies that he will comply with the regulations, policies, guidelines
and requirements, including 45 CFR Part 74, and OMB Circulars No. A-102 and A-110, as they relate
to the application,acceptance and use of Federal funds for this federally-assisted project.Also the Appli-
cant assures and certifies to the grant that:
1. It posers legal authority to apply for the 5. It will comply with the provisions of the Hatch
grant;that a resolution, motion or similar ac- Act which limit the political activity of
tion has been duly adopted or passed as an employees.
official act of the applicant's governing body,
authorizing the filing of the application, in- 6. It will comply with the minimum wage and
eluding all understandings and assurances maximum hours provisions of the Federal Fair
contained therein,and directing and authoriz- Labor Standards Act,as they apply to hospital
ing the person identified as the official and educational institution employees of
representative of the applicant to act in con- State and local governments.
nection with the application and to provide
such additional information as may be 7. It will establish safeguards to prohibit
required. employees from using their positions for a
purpose that is or gives the appearance of
2. It will comply with Title VI of the Civil Rights being motivated by a desire for private gain
Act of 1964(P.L. 88-352) and in accordance for themselves or others, particularly those
with Title VI of that Act, no person in the with whom they have family, business, or
United States shall, on the ground of race, other ties.
color,or national origin,be excluded from par-
ticipation in, be denied the benefits of, or be 8. It will give the sponsoring agency or the
otherwise subjected to discrimination under Comptroller General through any authorized,
any program or activity for which the appli- representative the access to and the right to
cant receives Federal financial assistance examine all records, books, papers, or
and will immediately take any measures documents related to the grant.
necessary to effectuate this agreement.
9. It will comply with all requirements imposed
3. It will comply with Title VI of the Civil Rights by the Federal sponsoring agency concern-
Act of 1964 (42 USC 2000d) prohibiting ing special requirements of law, program re-
employment discrimination where (1)the quirements, and other administrative
primary purpose of a grant is to provide requirements.
employment or(2)discriminatory employment
practices will result in unequal treatment of 10. ft will insure that the facilities under its owner-
persons who are or should be benefiting from ship, lease or supervision which shall be
the grant-aided activity. utilized in the accomplishment of the project
are not listed on the Environmental Protec-
4. It will comply with requirements of the provi- tion Agency's(EPA)list of Violating Facilities
sions of the Uniform Relocation Assistance and that it will notify the Federal grantor
and Real Property Acquisition Act of 1970 agency of the receipt of any communication
(P.L. 91-646) which provides for fair and from the Director of the EPA Office of Federal
equitable treatment of persons displaced as Activities indicating that a facility to be used
a result of Federal and federally-assisted in the project is under consideration for listing
programs. by the EPA.
The phrase"Federal financial assistance"includes adverse effects (see 36 CFR Part 800.8) by
any form of loan, grant, guaranty, insurance pay- the activity and notifying the Federal grantor
ment, rebate,subsidy,disaster assistance loan or agency of the existence of any such proper-
grant,or any other form of direct or indirect Federal ties, and by (b)complying with all re-
assistance. quirements established by the Federal
grantor agency to avoid or mitigate adverse
11. It will comply with the flood insurance pur- effects upon such properties.
chase requirements of Section 102(a)of the
Flood Disaster Protection Act of 1973, Public 13. Applicants for the Administration for Native
Law 93-234, 87 Stat. 975, approved Decem- Americans Programs, hereby certify in ac-
ber 31, 1976. Section 102(a)requires,on and cordance with 45 CFR 1336.53,that the fintn-
after March 2, 1975,the purchase of flood in- cial assistance provided by the Office of
surance in communities where such in- Human Development Services for the spear
surance is available as a condition for the fled activities to be performed'elder this pre
receipt of any Federal financial assistance for gram, will be in addition to, and not in
construction or acquisition purposes for use substitution for, comparable a t vitias pro-
in any area that has been identified by the vided without Federal assistance.
Secretary of the Department of Housing and 14. It will comply with the Age Discrimination Act
Urban Development as an area having spe- of 1975 which provides that No person In the
cial flood hazards. - United States shall,on the basks of age be ex-
cluded from participation in, be denied the
12. It will assist the Federal grantor agency in its benefits of,or be subjected to discrimination
compliance with Section 106 of the National under, any program or activity for which the
Historic Preservation Act of 1966 as amended applicant receives Federal financial
(16 U.S.C.470),Executive Order 11593, and assistance.
the Archeological and Historic Preservation
Act of 1966 (16 U.S.C. 469a-1 et seq.) by 15. It will comply with Section 504 of the
(a)consulting with the State Historic Preser- Rehabilitation Act of 1973, as amended (29
vation Officer on the conduct of investiga- U.S.C.794),all requirements imposed by the
tions, as-necessary, to identify properties applicable HHS regulation (45 C.F.R. Part
listed in or eligible for inclusion in the National 84), and all guidelines and interpretations
Register of Historic Places that are subject to issued pursuant thereto.
•
Attachment B •
Concept Paper/Expenditure Authorization
Signature Page
Summer Youth Employment and Training Program
Type of Funds Title II-B
Time Period 10/01/84 to 09/30/85
SDA Weld County Division of Human Resources
P.O. Box 1805 _
Greeley, Colorado 80632
This agreement has been reviewed and approved by the following, and
will be incorporated as an expenditure authorization attachment to
the GJTO/SDA master contract. This signature page, when completed
,authorizes the funding for the program identified herein by GJTO.
•
�A Local Elected Official(s)
•
Chairman Jacqueline Johns 4/22/85
Title Name ) Signs. a Date
PIC - Chair
Chairman • M.J. Geile 4/22/85
U�'Title Name Si ature Date
GJTO Signature
Title Name Signature t.ThDate
Expenditure Authorization
Signature Page
Type of Funds Title II-A 6% Training and Technical Assistance
TY '84 Funds
Time Period: 01/01/85 to 04/15/85
SDA: Weld County Division tf`liuman Resources
P.O. Box 1805
Greeley, CO 80632
This agreement has been reviewed and approved by the following, and
will be incorporated as an expenditure authorization attachment to
the GJTO/SDA master contract. This signature page, when completed,
authorizes the funding for the program identified herein by GJTO.
SDA - Local Elected Official (s)
Chairman Jacqueline Johnson 03//8,6g,,'85
Ti'Tt e Name 'gnatur ate
PIC - Chairman
Chairman M.J. Geile 7P771 !�,� 03/07/85
litle Name Sign r Date
GJTO Signature
r� i A
Title Name Signature Date
Concept Paper/Expenditure Authorization
SDA: Weld County Division of Human Resources
P.O. Box 1805
Greeley, CO 80632
1. Title of Funds:
Title II-A 6% Training and Technical Assistance
TY '84 Funds
2. Period of Performance:
01/01/85 - 04/15/85
3. Scope of Work:
Funds will be used to program and create a magnetic tape to transfer
the Colorado Job Training Partnership Act (JTPA) Participant Record
from the Employment Opportunities Delivery System (EODS) to the
Colorado Management Information System (MIS). The tape will be
processed on a monthly basis and Weld County will therefore be a
member of the Colorado MIS. The availability of Weld County's data
will enable GJTO to monitor the Performance Standards of the SDA,
identify any problem areas and initiate corrective action procedures
so that the Performance Standard can be met.
4. Budget:
Total $1,500
5. Special Conditions:
None
6. Signature Page:
See Attached
Attachment 1
Contractor: Weld Cnunty SDA Title: Ty ` R4 6 T__It TA_
Address: LO, B0); 1_805 Contract dates: 1/1/25 to 5/t5L85
Greeley, Colorado _
80632
BUDGET SUM≥IARY
LINE ITEM ADMIN PARTICIPANT TRAINING TOTAL
PERSONNEL
OPERATING
EXPENSE
Magnetic
MIS - Tape Trans. $1,500 $1,500
OPERATING
EXPENSE TOTAL
TRAVEL
TRAVEL TOTAL
EQUIPMENT
•
TOTAL BUDGET $1,500 1,500^
Percent 100X X Z 100 X
JTPA Fiscal For 84-4
EXPENDITURE AUTHORIZATION
WELD COUNTY SERVICE DELIVERY AREA
A. Type of Funds:
$10,000 Technical Assistance
B. Performance Period:
September 10-11, 1984
C. Scope of Work:
The following product outline would provide for necessary steps
to accomplish this effort:
1. Products to be provided during the first year would include
the names and Social Security Numbers of all clients who
have participated in the Diverison Program for a period
beginning September 17, 1981 to June 30, 1984. This will
allow your office to provide statewide data comparisons on
the migration of these clients. Also, the Welfare Diver-
sion Program Operating Manual, which includes policies,
procedures, and forms, would be finalized for distribution.
2. Our office would structure a- conference on the Welfare
Diversion Program through the auspices of the Governor's
Job Training Office for agencies and Service Delivery
Areas. The applicability of the program design for Supple-
mental Security Insurance participants would be researched
and a county specific series of models presented at a
workshop prior to September 15 , 1984.
3. The three year evaluation of the 1115 Waiver request for
the Wefare Diversion Program will be completed as well as
the final and updated version of the Welfare Diversion
Program Operating Manual would be completed.
DA
• Contractor: ijsQ S
C Title: — h CV.) IDikt " -
Address: Contract dates: q/ioJ )to Jib �Lj
BUDGET SUMMARY
LINE ITEM ADMIN PARTICIPANT TRAINING TOTAL
•
PERSONNEL
OPERATING
EXPENSE
•
• •
•
OPERATING
• EXPENSE TOTAL pp0,0
0 C>oO.
•
TRAVEL
TRAVEL TOTAL
EQUIPMENT
• TOTAL BUDGET to oor,,o =QC)QL'e'
•
Percent
.)1 JTPA Fiscal Form 84-4
Concept Paper/Expenditure Authorization
Signature Page
Type of Funds 10,000 Technical Assistance
Time Period 9-10-84 to 9-11-84
SDA Weld County
Po Box 1805
Crccloy Co. , 60632
• This agreement has been reviewed and approved by the following, and
will be incorporated as an expenditure authorization attachment to
the GJTO/SDA master contract. This signature page, when completed
authorizes the funding for the program identified herein by GJTO.
SDA — Local Elected Official(s)
Chairman Jacqueline Johnson 2/6/85
Title Name natu Date
PIC - Chair 7/
Chairman M.J. "Mike" Geile 7/7A 46 2/5/85
Title Name Sinatdre Date
GJTO Signature
Title Name (ignatdre Date
•
Hello