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###### Department of Health and Human Services

###### Administration for Children and Families 

          - [Program Announcement No. FV03-2004] 

# AGENCY:

Family and Youth Services Bureau, Administration on Children, Youth and Families (ACYF) and the Office of Community Services (OCS), Administration for Children and Families (ACF), Department of Health and Human Services (HHS). 

# ACTION:

Notice of the availability of funds to State domestic violence coalitions for grants to carry out family violence intervention and prevention activities. 

# SUMMARY:

This instruction governs the proposed award of fiscal year (FY) 2004 formula grants under the Family Violence Prevention and Services Act (FVPSA) to private non-profit State domestic violence coalitions. The purpose of these grants is to assist in the conduct of activities to promote domestic violence intervention and prevention and to increase public awareness of domestic violence issues. 

This announcement sets forth the application requirements, the application process, and other administrative and fiscal requirements for grants in fiscal year (FY) 2004. 

# DATES:

Applications for FY 2004 State domestic violence coalition grant awards meeting the criteria specified in this instruction must be received no later than February 20, 2003. 

# ADDRESSES:

Applications should be sent to, Family and Youth Services Bureau, Administration for Children, Youth, and Families, Administration for Children and Families, Attention: William D. Riley, 330 C Street, SW., Room 2117, Washington, DC, 20447. 

# FOR FURTHER INFORMATION CONTACT:

                        William D. Riley at (202) 401-5529 or e-mail at                         *WRiley@acf.hhs.gov*, or Sunni Knight at (202) 401-5319 or e-mail at                         *GKnight@acf.hhs.gov*.                     

# SUPPLEMENTARY INFORMATION:

This notice for family violence prevention and services grants to State domestic violence coalitions serves two purposes. The first is to confirm a Federal commitment to reducing family and intimate partner violence and the second purpose is to urge States, localities, cities, and the private sector to become involved in State and local planning towards an integrated service delivery approach. 

## Annual State Domestic Violence Coalition Grantee Conference 

The annual grantee conference is a training and technical assistance activity. Attendance at these activities is mandatory. Family Violence Prevention and Services Act (FVPSA) funds may also be used to support attendance and participation. A subsequent Program Instruction will advise State Coalition administrators of the date, time, and location of their grantee conference. 

## Client Confidentiality 

FVPSA programs must establish or implement policies and protocols for maintaining the safety and confidentiality of the adult victims and their children of domestic violence, sexual assault, and stalking. It is essential that the confidentiality of individuals receiving FVPSA services be protected. Consequently, when providing statistical data on program activities, individual identifiers of client records will not be used (section 303(a)(2)(E)). 

## Stop Family Violence Postal Stamp 

The U.S. Postal Service was directed by the “Stamp Out Domestic Violence Act of 2001” (the Act), Pub. L. 107-67, to make available a “semipostal” stamp to provide funding for domestic violence programs. Funds raised in connection with sales of the stamp, less reasonable costs, will be transferred to the U.S. Department of Health and Human Services in accordance with the Act for support of services to children and youth affected by domestic violence. It is projected that initial revenues will be received during the third quarter of FY 2004. Subsequent to the receipt of the stamp proceeds, a program announcement will be issued providing guidance and information on the process and requirements for awards to programs providing services to children and youth. 

## State Coalition Grant Application Requirements 

This section includes application requirements for family violence prevention and services grants for state domestic violence coalitions and is organized as follows: 

## Application Requirements

A. Legislative Authority 

B. Background 

C. Eligibility 

D. Funds Available 

E. Expenditure Period 

F. Reporting Requirements 

G. Application Requirements 

H. Paperwork Reduction Act 

I. Executive Order 12372

J. Certifications 

### A. Legislative Authority 

                    Title III of the Child Abuse Amendments of 1984, (Pub. L. 98-457, 42 U.S.C. 10401,                     *et seq.*) is entitled the “Family Violence Prevention and Services Act” (the Act). The Act was first implemented in FY 1986, was reauthorized and amended in 1992 by Public Law 102-295, was amended and reauthorized for fiscal years 1996 through 2000 by Public Law 103-322, the Violence Crime Control and Law Enforcement Act of 1994 by Public Law 104-235, the Child Abuse Prevention and Treatment Act Amendment of 1996, and in 2000 by the Victims of Trafficking and Violence Protection Act (Pub. L. 106-386, 10/28/2000). The Act was most recently amended by the “Keeping Children and Families Safe Act of 2003” (Pub. L.108-36).                 

### B. Background 

Section 311 of the Act authorizes the Secretary to award grants to statewide private non-profit State domestic violence coalitions to conduct activities to promote domestic violence intervention and prevention and to increase public awareness of domestic violence issues. 

### C. Eligibility 

To be eligible for grants under this program announcement, an organization shall be a statewide private non-profit domestic violence coalition meeting the following criteria: 

(1) The membership of the coalition includes representatives from a majority of the programs for victims of domestic violence operating within the State (a State domestic violence coalition may include representatives of Indian Tribes and Tribal organizations as defined in the Indian Self-Determination and Education Assistance Act); 

(2) The Board membership of the coalition is representative of such programs; 

(3) The purpose of the coalition is to provide services, community education, and technical assistance to domestic violence programs in order to establish and maintain shelter and related services for victims of domestic violence and their children; and 

(4) In the application submitted by the coalition for the grant, the coalition provides assurances satisfactory to the Secretary that the coalition: 

(A) Has actively sought and encouraged the participation of law enforcement agencies and other legal or judicial entities in the preparation of the application; and 

                    (B) will actively seek and encourage the participation of such entities in the                           ( print page 5167)                        activities carried out with the grant (section 311(5)(A)).                 

#### Additional Information on Eligibility 

                    All applications must have a Dun and Bradstreet Number (DUNS). A DUNS number will be required for every application for a new or renewal/continuation of an award under formula, entitlement and block grant programs. A DUNS number may be acquired at no cost by calling the dedicated toll-free DUNS number request line at 1-866-705-5711 or a number may be requested on-line at                     *http://www.dnb.com.*

                    Private, non-profit organizations are encouraged to submit with their applications the survey located under “Grant Related Documents and Forms” titled “Survey for Private, Non-Profit Grant Applicants.” The forms are located on the web at                     *http://www.acf.hhs.gov/​programs/​ofs/​forms.htm.*

### D. Funds Available 

The Department will make ten percent of the Family Violence Prevention and Services Act appropriation available for grants to State domestic violence coalitions. One grant each will be available for the State domestic violence coalitions of the 50 states, the Commonwealth of Puerto Rico, and the District of Columbia. The Coalitions of the U.S. Territories (Guam, U.S. Virgin Islands, Northern Mariana Islands, American Samoa, and Trust Territory of the Pacific Islands) are also eligible for domestic violence coalition grant awards. 

### E. Expenditure Period 

                    The FVPSA funds may be used for expenditures after October 1 of each fiscal year for which they are granted and will be available for expenditure through September 30 of the following fiscal year,                     *i.e.*, FY 2004 funds may be used for expenditures from October 1, 2003 through September 30, 2005. Funds will be available for obligation through October 1, 2004.                 

### F. Reporting Requirements 

The State domestic violence coalition grantee must submit an annual report of activities describing the coordination, training and technical assistance, needs assessment, and comprehensive planning activities carried out. Additionally, the coalition must report on the public information and education services provided; the activities conducted in conjunction with judicial and law enforcement agencies; the actions conducted in conjunction with other agencies such as the state child welfare agency; and any other activities undertaken under this grant award. The annual report also must provide an assessment of the effectiveness of the grant-supported activities. 

                    The annual report is due 90 days after the end of the fiscal year in which the grant is awarded,                     *i.e.*, December 30. The final program report is due 90 days after the end of the two-year expenditure period.                 

The State domestic violence coalition grantees must also submit an annual financial report, Standard form 269(SF-269). A financial report is due 90 days after the end of the fiscal year in which the grant is awarded. 

### G. Application Requirements 

The State domestic violence coalition application must be signed by the Executive Director of the Coalition or the official designated as responsible for the administration of the grant. The application must contain the following information: 

We have cited each requirement to the specific section of the law. 

1. A description of the process and anticipated outcomes of utilizing these federal funds to work with local domestic violence programs and providers of direct services to encourage appropriate responses to domestic violence within the State, including— 

Training and technical assistance for local programs and managers working the field: 

(a) Planning and conducting State needs assessments and planning for comprehensive services; 

(b) Serving as an information clearinghouse and resource center for the State; and 

(c) Collaborating with other governmental systems that affect battered women (section 311(a)(1)). 

2. A description of the public education campaign regarding domestic violence to be conducted by the coalition through the use of public service announcements and informative materials that are designed for print media; billboards; public transit advertising; electronic broadcast media; and other forms of information dissemination that inform the public about domestic violence, including information aimed at underserved racial, ethnic or language-minority populations (Section 311(a)(4)). 

3. The anticipated outcomes and a description of planned grant activities to be conducted in conjunction with judicial and law enforcement agencies concerning appropriate responses to domestic violence cases and an examination of related issues. 

4. The anticipated outcomes and a description of planned grant activities to be conducted in conjunction with Family Law Judges, Criminal Court Judges, Child Protective Services agencies, Child Welfare agencies, Family Preservation and Support Service agencies, and children's advocates to develop appropriate responses to child custody and visitation issues in domestic violence cases and in cases where domestic violence and child abuse are both present. The anticipated outcomes and a description of other activities in support of the general purpose of furthering domestic violence intervention and prevention (section 311(a)). 

5. The following documentation will certify the status of the domestic violence coalition and must be included in the grant application: 

(a) A description of the procedures developed between the State domestic violence agency and the Statewide coalition that allow for implementation of the following cooperative activities: 

(i) the participation of the State domestic violence coalition in the planning and monitoring of the distribution of grants and grant funds provided in the State (section 311(a)(5); and 

(ii) the participation of the State domestic violence coalition in compliance activities regarding the State's family violence prevention and services program grantees (section 303 (a)(C)). 

(b) Unless already on file at HHS, a copy of a currently valid 501(c)(3) certification letter from the Internal Revenue Service stating private non-profit status; or a copy of the applicant's listing in the Internal Revenue's Services (IRS) most recent list of tax-exempt organizations described in section 501(c)(3) of the IRS code; or 

(c) A copy of the articles of incorporation bearing the seal of the State in which the corporation or association is domiciled; 

(d) A current list of the organizations operating programs for victims of domestic violence programs in the State and the applicant coalition's current membership list by organization; 

(e) A list of the applicant coalition's current Board of Directors, with each individual's organizational affiliation and the Chairperson identified; 

                    (f) A copy of the resume of any coalition or contractual staff to be supported by funds from this grant and/or a statement of requirements for staff or consultants to be hired under this grant; and                           ( print page 5168)    

(g) A budget narrative which clearly describes the planned expenditure of funds under this grant. 

6. Required Documentation and Assurances (included in the application as an appendix).

(a) The applicant coalition must provide documentation in the form of support letters, memoranda of agreement, or jointly signed statements, that the coalition: 

(i) Has actively sought and encouraged the participation of law enforcement agencies and other legal or judicial organizations in the preparation of the grant application (section 311(b)(4)(A)); and 

(ii) Will actively seek and encourage the participation of such organizations in grant funded activities (section 311(b)(4)(B)). 

(b) The applicant coalition must provide a signed statement that the coalition will not use grant funds, directly or indirectly, to influence the issuance, amendment, or revocation of any executive order or similar legal document by any Federal, State or local agency, or to undertake to influence the passage or defeat of any legislation by the Congress, or any State or local legislative body, or State proposals by initiative petition, except that the representatives of the State Domestic Violence Coalition may testify or make other appropriate communications except: 

(c) When formally requested to do so by a legislative body, a committee, or a member of such organization (section 311(d)(1)); or in connection with legislation or appropriations directly affecting the activities of the State domestic violence coalition or any member of the coalition (section 311(d)(2)). 

The applicant coalition must provide a signed statement that the State domestic violence coalition will prohibit discrimination on the basis of age, handicap, sex, race, color, national origin or religion (section 307). 

*Additional Forms:*                     Private, non-profit organizations may submit with their applications the additional survey located under “Grant Related Documents and Forms” titled “Survey for Private, Non-Profit Grant Applicants” at                     *http://www.acf.hhs.gov/​programs/​ofs/​form.htm.*

### H. Paperwork Reduction Act 

This program announcement contains information collection requirements in sections (F) and (G). We estimate that all of the information requirements for this program will take each grantee approximately 6 hours to complete. As there are 53 projected grantees, the total number of hours annually will be 318. In accordance with the Act, the application requirements contained in this notice have been approved by OMB under control number 0970-0062. 

### I. Executive Order 12372

This program is covered under Executive Order 12372, “Intergovernmental Review of Federal Programs” for State plan consolidation and simplification only—45 CFR 100.12. The review and comment provisions of the Executive Order and Part 100 do not apply. 

### J. Certifications 

Applicants must comply with the required certifications found at the Appendices: 

                    1.                     *The Anti-Lobbying Certification and Disclosure Form*                     must be signed and submitted with the application. If applicable, a Standard Form LLL, which discloses lobbying payments must be signed and submitted.                 

                    2.                     *Certification Regarding Debarment:*                     The signature on the application by a coalition official responsible for the administration of the program attests to the applicant's intent to comply with the Debarment Certification. The Debarment Certification must be signed and submitted with the application.                 

                    3.                     *Certification Regarding Environmental Tobacco Smoke:*                     The signature on the application by a coalition official certifies that the applicant will comply with the requirements of the Pro-Children Act of 1994 (Act). The applicant further agrees that it will require the language of this certification be included in any standards which contain provisions for children's Services and that all grantees shall certify accordingly.                 

                    4.                     *Certification Regarding Drug-Free Workplace Requirements:*                     The signature on the application by a coalition official attests to the applicant's intent to comply with the Drug-Free Workplace requirements. The Drug Free Workplace Certification does not have to be returned with the application.                 

(Catalog of Federal Domestic Assistance Number 93.591, Family Violence Prevention and Services: Grants to State Domestic Violence Coalitions) 

Dated: January 24, 2004. 

Clarence Carter, 

Director, Office of Community Services, Administration for Children and Families. 

Appendices: Required Certifications: 

Anti-Lobbying and Disclosure; 

Regarding Debarment; 

Regarding Environmental Tobacco Smoke; and 

Drug-Free Workplace. 

# Appendix A

## Certification Regarding Lobbying 

### Certification for Contracts, Grants, Loans, and Cooperative Agreements 

The undersigned certifies, to the best of his or her knowledge and belief, that: 

(1) No Federal appropriated 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 an 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 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 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, subgrants, 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 file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. 

### Statement for Loan Guarantees and Loan Insurance 

The undersigned states, to the best of his or her knowledge and belief, that: 

If any funds have been paid or will be paid 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 this commitment providing for the United States to insure or guarantee a loan, the undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions. Submission of this statement is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. 
      ( print page 5169)    
Signature

Title

Organization

# Appendix B

## Certification Regarding Debarment, Suspension and Other Responsibility Matters 

### Certification Regarding Debarment, Suspension, and Other Responsibility Matters—Primary Covered Transactions 

#### Instructions for Certification 

1. By signing and submitting this proposal, the prospective primary participant is providing the certification set out below. 

2. The inability of a person to provide the certification required below will not necessarily result in denial of participation in this covered transaction. The prospective participant shall submit an explanation of why it cannot provide the certification set out below. The certification or explanation will be considered in connection with the department or agency's 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.

3. The certification in this clause is a material representation of fact upon which reliance was placed when the department or agency determined to enter into this transaction. If it is later determined that the prospective primary participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default. 

4. The prospective primary participant shall provide immediate written notice to the department or agency to which this proposal is submitted if at any time the prospective primary participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 

5. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order 12549. You may contact the department or agency to which this proposal is being submitted for assistance in obtaining a copy of those regulations. 

6. The prospective primary participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered tranaction with a person who is proposed for debarement under 48 CFR part 9, subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency entering into this transaction.

7. The prospective primary participant further agrees by submitting this proposal that it will include the clause title “Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Covered Transaction,” provided by the department or agency entering into this covered transaction, without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions. 

8. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not requied to, check the List of Parties Excluded from Federal Procurement and Nonprocurement Programs. 

9. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. 

10. Except for transactions authorized under paragraph 6 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default.

### Certification Regarding Debarment, Suspension, and Other Responsibility Matters—Primary Covered Transactions

(1) The prospective primary participant 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 by any Federal department or agency;

(b) Have not within a three-year period preceding this proposal been convicted of or had a civil judgment 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 statements, or receiving stolen property; 

(c) Are not presently indicted for 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 three-year period preceding this application/proposal had one or more public transactions (Federal, State or local) terminated for cause or default. 

(2) Where the prospective primary participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. 

### Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion—Lower Tier Covered Transactions 

#### Instructions for Certification 

1. By signing and submitting this proposal, the prospective lower tier participant is providing the certification set out below. 

2. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment. 

3. The prospective lower tier participant shall provide immediate written notice to the person to which this proposal is submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted or had become erroneous by reason of changed circumstances. 

4. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meaning set out in the Definitions and Coverage sections of rules implementing Executive Order 12549. You may contact the person to which this proposal is submitted for assistance in obtaining a copy of those regulations. 

5. The prospective lower tier participant agrees by submitting this proposal that, [[Page 33043]] should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency with which this transaction originated. 

6. The prospective lower tier participant further agrees by submitting this proposal that it will include this clause titled “Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion—Lower Tier Covered Transaction,” without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions. 

                        7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or                               ( print page 5170)                            voluntarily excluded from covered transactions, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check the List of Parties Excluded from Federal Procurement and Nonprocurement Programs.                     

8. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. 

9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment. 

### Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion—Lower Tier Covered Transactions 

(1) The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency. 

(2) Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. 

## Certification Regarding Environmental Tobacco Smoke 

Public Law 103227, Part C Environmental Tobacco Smoke, also known as the Pro Children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor routinely owned or leased or contracted for by an entity and used routinely or regularly for provision of health, day care, education, or library services to children under the age of 18, if the services are funded by Federal programs either directly or through State or local governments, by Federal grant, contract, loan, or loan guarantee. The law does not apply to children's services provided in private residences, facilities funded solely by Medicare or Medicaid funds, and portions of facilities used for inpatient drug or alcohol treatment. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1000 per day and/or the imposition of an administrative compliance order on the responsible entity. By signing and submitting this application the applicant/grantee certifies that it will comply with the requirements of the Act. 

The applicant/grantee further agrees that it will require the language of this certification be included in any subawards which contain provisions for the children's services and that all subgrantees shall certify accordingly. 

# Appendix D 

## Certification Regarding Drug-Free Workplace Requirements 

The certification is required by the regulations implementing the Drug-Free Workplace Act of 1988: 45 CFR part 76, subpart F, sections 76.630(c) and (d)(2) and 76.645(a)(1) and (b) provide that a Federal agency may designate a central receipt point for STATE-WIDE AND STATE AGENCY-WIDE certifications, and for notification of criminal drug convictions. For the Department of Health and Human Services, the central point is: Division of Grants Management and Oversight, Office of Management and Acquisition, Department of Health and Human Services, Room 517-D, 200 Independence Avenue, SW Washington, DC 20201. 

### Certification Regarding Drug-Free Workplace Requirements (Instructions for Certification) 

1. By signing and/or submitting this application or grant agreement, the grantee is providing the certification set out below. 

2. The certification set out below is a material representation of fact upon which reliance is placed when the agency awards the grant. If it is later determined that the grantee knowingly rendered a false certification, or otherwise violates the requirements of the Drug-Free Workplace Act, the agency, in addition to any other remedies available to the Federal Government, may take action authorized under the Drug-Free Workplace Act. 

3. For grantees other than individuals, Alternate I applies. 

4. For grantees who are individuals, Alternate II applies. 

5. 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. 

                        6. Workplace identifications must include the actual address of buildings (or parts of buildings) or other sites where work under the grant takes place. Categorical descriptions may be used (                        *e.g.*, all vehicles of a mass transit authority or State highway department while in operation, State employees in each local unemployment office, performers in concert halls or radio studios).                     

7. If the workplace identified to the agency changes during the performance of the grant, the grantee shall inform the agency of the change(s), if it previously identified the workplaces in question (see paragraph five). 

8. 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 U.S.C. 812) and as further defined by regulation (21 CFR 1308.11 through 1308.15);

Conviction means a finding of guilt (including a plea of nolo contendere) or imposition of sentence, or both, by any judicial body charged with the responsibility to determine violations of the Federal or 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 or 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).                     

### Certification Regarding Drug-Free Workplace Requirements 

#### Alternate I. (Grantees Other Than Individuals) 

The grantee certifies that it will or will continue to 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 an ongoing 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, and 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 the 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 in writing of his or her conviction for a violation of a criminal                               ( print page 5171)                            drug statute occurring in the workplace no later than five calendar days after such conviction;                     

(e) Notifying the agency in writing, within ten calendar days after receiving notice under paragraph (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 activity 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 calendar days of receiving notice under paragraph (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), (b), (c), (d), (e) and (f). 

(B) The grantee may insert in the space provided below the site(s) for the performance of work done in connection with the specific grant: 

Place of Performance (Street address, city, county, state, zip code)

Check if there are workplaces on file that are not identified here. 

#### Alternate II. (Grantees Who Are Individuals) 

(a) The grantee certifies that, as a condition of the grant, he or she will not engage in the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance in conducting any activity with the grant; 

(b) If convicted of a criminal drug offense resulting from a violation occurring during the conduct of any grant activity, he or she will report the conviction, in writing, within 10 calendar days of the conviction, to every grant officer or other designee, unless the Federal agency designates a central point for the receipt of such notices. When notice is made to such a central point, it shall include the identification number(s) of each affected grant. 

[FR Doc. 04-2173 Filed 2-2-04; 8:45 am] 

BILLING CODE 4184-01-P