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Home My WebLink AboutchecklistPHS a161-1 (7)00) time 25 CHECKLIST Public Burden Statement: Public reporting burden of this collection of information is estimated to average 4 - 50 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number, Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, OMB Approval No. 0920.0428 Clearance Officer, 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0428). Do not send the completed form to this address. NOTE TO APPLICANT: This form must be completed and submitted with the original of your application. Be sure to cornplete both sides of this form. Check the appropriate boxes and prcrvlde the information requested. This form should be attached as the last page of the signed original of the application. This page is reserved for PHS staff use only. Noncompeting Competing Type of Application: ® NEW ❑ Continuation ❑ Continuation ❑ Supplemental PART A: The following checklist is provided to assure that proper signatures, assurances, and certifications have been submitted. NOT 1. Proper Signature and Date for item 18 on SF 424 (FACE PAGE) 2. Proper Signature and Date on PHS-5161-1 "Certifications" page. 3. Proper Signature and Date on appropriate "Assurances" page, i.e., SF-4248 (Non -Construction Programs) or SF-424D (Construction Programs) 4. If your organization currently has on file with DHHS the following assurances, please identify which have been filed by indicating the date of such filing on the line provided. (All four have been consolidated into a single form, HHS Form 690) El Civil Rights Assurance (45 CFR Bo) ® Assurance Concerning the Handicapped (45 CFR 84) El Assurance Concerning Sex Discrimination (45 CFR 86) El Assurance Concerning Age Discrimination (45 CFR 90 & 45 CFR 91) 5. Human Subjects Certification, when applicable (45 CFR 46) ® ❑ Included Applicable PART B: This part is provided to assure that pertinent information has been addressed and included in the application. NOT YES Applicable 1. Has a Public Health System Impact Statement for the proposed program/project been completed and distributed as required? 0 ❑ 2. Has the appropriate box been checked for item # 16 on the SF-424 (FACE PAGE) regarding intergovernmental review under E.O. 12372 ? (45 CFR Part 100) 3. Has the entire proposed project period been identified in item # 13 of the FACE PAGE? 4. Have biographical sketch(es) with job description(s) been attached, when required ® ❑ 5. Has the "Budget Information" page, SF-424A (Non -Construction Programs) or SF-424C (Construction Programs), been completed and included? 6. Has the 12 month detailed budget been provided? ® ❑ 7. Has the budget for the entire proposed project period with sufficient detail been provided? ® 0 8. For a Supplemental application, does the detailed budget address only the additional funds requested? ❑ ID 9. For Competing Continuation and Supplemental applications, has a progress report been included? ❑ LEI PART C: In the spaces provided below, please provide the requested information. Business Official to be notified if an award is to be made. program Director/Project Director/Principal investigator designated to direct the proposed project or program. Name Allie Grande Name Dr. Donald Rosenberg Title Grants Manager Organization Miami -Dade Fire Rescue Address 9300 NW 41st Street Email Address grandea@rniarnidade.gov Telephone Number 786-331-4653 Fax Number 786-331-5259 APPLICANT ORGANIZATION'S 12-DIGIT DHHS EIN (Italready assigned) Title Medical Director Organization Address Miami -Dade Fire Rescue E-mail Address Telephone Number 786-331-5000 Fax Number 786-331-5259 SOCIAL SECURITY NUMBER HIGHEST DEGREE EARNED MD (OVER) IPHS-.,161-1 (7/00) Page 26 PART D: A private, nonprofit organization must include evidence of its nonprofit status with the application. Any of the following is acceptable evidence. Check the appropriate box or complete the "Previously Filed" section, whichever is applicable. ❑ (a) A reference to the organization's listing in the Internal Revenue Service's (IRS) most recent list of tax-exempt organizations described in section 501 (c)(3) of the IRS Code. ❑ (b) A copy of a currently valid Internal Revenue Service Tax exemption certificate. ❑ (c) A statement from a State taxing body, State Attorney General, or other appropriate State official certifying that the applicant organization has a nonprofit status and that none of the net earnings accrue to any private shareholders or individuals. A certified copy of the organization's certificate of incorporation or similar document if it clearly establishes the nonprofit status of the organization. Any of the above proof for a State or national parent organization, and a statement signed by the parent organization that the applicant organization is a local nonprofit affiliate. if an applicant has evidence of current nonprofit status on file with an agency of PHS, it will not be necessary to file similar papers again, but the place and date of filing must be indicated. Previously Filed with: (Agency) Federal Emergency Management Agency on (Date) 1/1/03 INVENTIONS If this is an application for continued support, include: (1) the report of inventions conceived or reduced to practice required by the terms and conditions of the grant; or (2) a list of inventions already reported, or (3) a negative certification. EXECUTIVE ORDER 12372 Effective September 30, 1983, Executive Order 12372 (Intergovernmental Review of Federal Programs) directed OMB to abolish OMB Circular A-95 and establish a new process for consulting with State and local elected officials on proposed Federal financial assistance. The Department of Health and Human Services implemented the Executive Order through regulations at 45 CFR Part 100 (Inter -governmental Review of Department of Health and Human Services Programs and Activities). The objectives of the Executive Order are to (1) increase State flexibility to design a consultation process and select the programs it wishes to review, (2) increase the ability of State and local elected officials to influence Federal decisions and (3) compel Federal officials to be responsive to State concerns, or explain the reasons. The regulations at 45 CFR Part 100 were published in the Federal Register on June 24, 1983, along with a notice identifying the Department's programs that are subject to the provisions of Executive Order 12372. Information regarding PHS programs subject to Executive Order 12372 is also available from the appropriate awarding office. States participating in this program establish State Single Points of Contact (SPOCs) to coordinate and manage the review and comment an proposed Federal financial assistance. Applicants should contact the Governor's office for information regarding the SPOC, programs selected for review, and the consultation (review) process designed by their State, Applicants are to certify on the face page of the SF-424 (attached) whether the request is for a program covered under Executive Order 12372 and, where appropriate, whether the State has been given an opportunity to comment.