## DISCLOSURE OF LOBBYING ACTIVITIES Approved by OMB 

### Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 0348-0046 

### (See reverse for public burden disclosure.) 1. Type of Federal Action: 2. Status of Federal Action: 3. Report Type:

a. contract a. bid/offer/application a. initial filing b. grant b. initial award b. material change c. cooperative agreement c. post-award For Material Change Only:

d. loan year _________ quarter _________ e. loan guarantee date of last report ______________

f. loan insurance 4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is a Subawardee, Enter Name

and Address of Prime:
Tier ______, if known :

Congressional District

, if known : Congressional District

, if known : 6. Federal Department/Agency: 7. Federal Program Na me/Description:

CFDA Number, if applicable : _____________

8. Federal Action Number, if known : 9. Award Amount, if known :
$

10. a. Name and Address of Lobbying Registrant b. Individuals Performing Services ( including address if ( if individual, last name, first name, MI ): different from No. 10a ) ( last name, first name, MI ):

11. Signature:

Print Name:

Title:

Telephone No.: _______________________

Authorized for Local Reproduction

Standard Form LLL (Rev. 7-97) Information requested through this form is authorized by title 31 U.S.C. section

1352. This disclosure of lobbying activities is a material representation of fact

upon which reliance was placed by the tier above when this transaction was made

or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This

informatio n wil l b e availabl e for public inspection. require d disclosur e shal l be subject to a

not mor e tha n $100,00 0 for each such failure. Prime Subawardee



### Federal Use Only: Date: who fails to file the Any person $10,000 and than civil penalty of not less

### INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES

This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of a covered Federal
action, or a material change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or agreement to make
payment to any lobbying entity 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 a covered Federal action. Complete all items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of Management and Budget for additional information.

1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action.

2. Identify the status of the covered Federal action.

3. Identify the appropriate classification of this report. If this is a followup report caused by a material change to the information previously reported, enter

the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting entity for this covered Federal

action.

4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Check the appropriate classification

of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants.

5. If the organization filing the report in item 4 checks "Subawardee," then enter the full name, address, city, State and zip code of the prime Federal
recipient. Include Congressional District, if known.

6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational level below agency name, if known. For

example, Department of Transportation, United States Coast Guard.

7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance
(CFDA) number for grants, cooperative agreements, loans, and loan commitments.

8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number;

Invitation for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number assigned by the Federal agency). Include prefixes, e.g., "RFP-DE-90-001."

9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan

commitment for the prime entity identified in item 4 or 5.

10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting
entity identified in item 4 to influence the covered Federal action.

(b) Enter the full names of the individual(s) performing services, and include full address if different from 10 (a). Enter Last Name, First Name, and
Middle Initial (MI).

11. The certifying official shall sign and date the form, print his/her name, title, and telephone number.

According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB Control

Number. The valid OMB control number for this information collection is OMB No. 0348-0046. Public reporting burden for this collection of information is

estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington,

DC 20503.OMB Number: 4040

- 0004

Expiration Date: 8/31/2016

Application for Federal Assistance SF

- 424

* 1. Type of Submission: * 2. Type of Application: * If Revision, select appropriate letter(s):

Preapplication

Application New

Continuation * Other (Specify):

Changed/Corrected Application Revision

* 3. Date Received: 4. Applicant Identifier:

5a. Federal Entity Identifier: 5b. Federal Award Identifier:

State Use Only:

6. Date Received by State: 7. State Application Identifier:

8. APPLICANT INFORMATION:

* a. Legal Name:

* b. Employer/Taxpayer Identification Number (EIN/TIN): * c. Organizational DUNS:

d. Address:

* Street1:

Street2:

* City:

County/Parish:

* State:

Province:

* Country:

* Zip / Postal Code:

e. Organizational Unit:

Department Name: Division Name:

f. Name and contact information of person to be contacted on matters involving this application:

Prefix: * First Name:

Middle Name:

* Last Name:

Suffix:

Title:

Organizational Affiliation:

* Telephone Number: Fax Number:

* Email:

View Burden Statement

USA: UNITED STATESApplication for Federal Assistance SF

- 424

* 9. Type of Applicant 1: Select Applicant Type:

Type of Applicant 2: Select Applicant Type:

Type of Applicant 3: Select Applicant Type:

* Other (specify):

* 10. Name of Federal Agency:

11. Catalog of Federal Domestic Assistance Number:

CFDA Title:

* 12. Funding Opportunity Number:

* Title:

13. Competition Identification Number:

Title:

14. Areas Affected by Project (Cities, Counties, States, etc.):

* 15. Descriptive Title of Applicant's Project:

Attach supporting documents as specified in agency instructions.

View Attachments Delete Attachments Add Attachments View Attachment Delete Attachment Add AttachmentApplication for Federal Assistance SF

- 424

16. Congressional Districts Of:

* a. Applicant

Attach an additional list of Program/Project Congressional Districts if needed. * b. Program/Project

17. Proposed Project:

* a. Start Date: * b. End Date:

18. Estimated Funding ($):

* a. Federal

* b. Applicant

* c. State

* d. Local

* e. Other

* f. Program Income

* g. TOTAL

* 19. Is Application Subject to Review By State Under Executive Order 12372 Process?

a. This application was made available to the State under the Executive Order 12372 Process for review on

.

b. Program is subject to E.O. 12372 but has not been selected by the State for review.

c. Program is not covered by E.O. 12372.

* 20. Is the Applicant Delinquent On Any Federal Debt? (If "Yes," provide explanation in attachment.)

Yes No

If "Yes", provide explanation and attach

21. *By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements
herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001)

** I AGREE

** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency specific instructions.

Authorized Representative:

Prefix: * First Name:

Middle Name:

* Last Name:

Suffix:

* Title:

* Telephone Number:

* Email: Fax Number:

* Signature of Authorized Representative: * Date Signed: View Attachment Delete Attachment Add Attachment View Attachment Delete Attachment Add Attachment

### INSTRUCTIONS FOR THE SF

- 424

This is a standard form required for use as a cover sheet for submission of pre

- applications and applications and related information under discretionary programs. Some of the items are required and some are optional at the di scretion of the applicant or the federal agency (agency). Required fields on the form are identified with an asterisk (*) and are also specified as “Required” in the instructions belo w. In addition to these instructions, applicants must consult agency ins tructions to determine other specific requirements.

Item Entry: Item: Entry:

1. Type of Submission: (Required) Select one type of submission in accordance with agency instructions.
• Pre

- application • Application • Changed/Corrected Application

– Check i f this submission is to change or correct a previously submitted application. Unless requested by the agency, applicants may not use this form to submit changes after the closing date. 10. Name Of Federal Agency : (Required) Enter the name of the federal ag ency from which assistance is being requested with this application.

11. Catalog Of Federal Domestic Assistance Number/Title: Enter the Catalog of Federal Domestic Assistance number and title of the program under which assistance is requested, as
found in the program announcement, if applicable.

2. Type of Application : (Required) Select one type of application in accordance with agency instructions.

• New

– An application that is being submitted to an agency
for the first time.
• Continuation

- An exte nsion for an additional funding/budget period for a project with a projected completion date. This
can include renewals.
• Revision

- Any change in the federal government’s financial obligation or contingent liability from an existing obligation. If
a revi sion, enter the appropriate letter(s). More than one may be selected. If "Other" is selected, please specify in text box provided.

A. Increase Award D. Decrease Duration B. Decrease Award E. Other (specify)
C. Incr ease Duration 12. Funding Opportunity Number/Title: (Required) Enter the Funding Opportunity Number (FON) and title of the opportunity under which assistance is requested, as found in the program

announcement.

13. Competition Identification Number/Tit le: Enter the competition identification number and title of the competition under which assistance is requested, if applicable.

14. Areas Affected By Project: This data element is intended for use only by programs for which the area(s) affected are lik ely to be different than the place(s) of performance reported on the
SF

- 424 Project/Performance Site Location(s) Form. Add attachment to enter additional areas, if needed.

3. Date Received: Leave this field blank. This date will be assigned by the Federa l agency. 15. Descriptive Title of Applicant’s Project: (Required) Enter a brief descriptive title of the project. If appropriate, attach a map showing project location (e.g., construction or real property projects). For pre

- applications, attach a summary description of the project.

4. Applicant Identifier: Enter the entity identifier assigned buy the Federal agency, if any, or the applicant’s control number if applicable.

5a. Federal Entity Identifier : Enter the number assigned to your organization by the federal agency, if any. 16. Congressional Districts Of : 16a. (Required) Enter the applicant’s congressional district. 16b. Enter all district(s) affected by the program or project. Enter in the format: 2
characters state abbreviation

– 3 characters d istrict number, e.g., CA

- 005 for California 5th district, CA

- 012 for California 12 district, NC

- 103 for North Carolina’s 103 district. If all congressional districts in a state are affected, enter “all” for the district number, e.g., MD

- all for all congre ssional districts in Maryland. If nationwide, i.e. all districts within all states are affected, enter US

- all. If the program/project is outside the US,

enter 00

- 000. This optional data element is intended for use only by programs for which the area(s) affected are likely to be different than place(s) of performance reported on the SF

- 424 Project/Performance Site Location(s) Form. Attach an additional list of program/project congressional districts, if
needed. 5b. Federal Award Identifier : For new appl ications, enter NA. For a continuation or revision to an existing award, enter the previously assigned federal award identifier number. If a changed/corrected application, enter the federal identifier in accordance with agency instructions.

6. Date Rec eived by State: Leave this field blank. This date will be assigned by the state, if applicable.

7. State Application Identifier: Leave this field blank. This identifier will be assigned by the state, if applicable.

8. Applicant Information : Enter th e following in accordance with agency instructions:

a. Legal Name : (Required) Enter the legal name of applicant that will undertake the assistance activity. This is the organization that has registered with the Central Contractor Registry (CCR). Infor mation on registering with CCR may be obtained by visiting www.Grants.gov. 17. Proposed Project Start and End Dates : (Required) Enter the proposed start date and end date of the project.

b. Employer/Taxpayer Number (EIN/TIN): (Required) Enter the employ er or taxpayer identification number (EIN or TIN) as assigned by the Internal Revenue Service. If your organization is not in the US, enter 44

- 4444444. 18. Estimated Funding: (Required) Enter the amount requested, or to be contributed during the first fund ing/budget period by each
contributor. Value of in

- kind contributions should be included on appropriate lines, as applicable. If the action will result in a dollar change to an existing award, indicate only the amount of the change. For decreases, enclose the amounts in parentheses.c. Organizational DUNS : (Required) Enter the organization’s
DUNS or DUNS+4 number received from Dun and Bradstreet. Information on obtaining a DUNS number may be obtained by visiting www.Grants.gov. 19. Is Application Subject to Review by State Under Executive
Order 12372 Process? (Required ) Applicants should contact the State Single Point of Contact (SPOC) for Federal Executive Order 12372 to determine whether the application is subject to the State intergovernmental review p rocess. Select the appropriate box. If “a.” is selected, enter the date the application was submitted to the State.

d. Address : Enter address: Street 1 (Required); city (Required); County/Parish , State (Required if country is US), Province, Country (Req uired), 9

- digit zip/postal code (Required if country US). 20. Is the Applicant Delinquent on any Federal Debt? (Required) Select the appropriate box. This question applies to the applicant organization, not the person who signs as the authorized represent ative. Categories of federal debt include; but, may not be limited to: delinquent audit disallowances, loans and taxes. If yes, include an explanation in an
attachment. e. Organizational Unit: Enter the name of the primary organizational unit, departme nt or division that will undertake the assistance activity. 21. Authorized Representative : To be signed and dated by the authorized representative of the applicant organization. Enter the first and last name (Required); prefix, middle name, suffix.
Enter title, telephone number, email (Required); and fax number. A copy of the governing body’s authorization for you to sign this application as the official representative must be on file in the applicant’s office. (Certain federal agencies may require that this authorization be submitted as part of the application.) f. Name and contact information of person to be contacted on matters involving this application: Enter the first and last name (Required); prefix, middle name, suffix, title. Enter organizatio nal affiliation if affiliated with an organization other than that in 7.a. Telephone number and email (Required);
fax number.

9. Type of Applicant: (Required) Select up to three applicant type(s) in accordance with agency instructions.

A. St ate Government
B. County Government
C. City or Township
Government
D. Special District
Government
E. Regional Organization

F. U.S. Territory or
Possession
G. Independent School
District
H. Public/State
Controlled Institution of
H igher Education
I. Indian/Native
American Tribal Government (Federally Recognized)
J. Indian/Native
American Tribal Government (Other than Federally Recognized)
K. Indian/Native American Tribally Designated Organization
L. Public/Indian Ho using Authority M. Nonprofit
N. Private Institution of Higher Education O. Individual
P. For

- Profit Organization (Other than Small Business) Q. Small Business
R. Hispanic

- serving
Institution S. Historically Black Colleges and
Unive rsities (HBCUs)
T. Tribally Controlled Colleges and Universities (TCCUs)
U. Alaska Native and
Native Hawaiian Serving Institutions
V. Non

- US Entity

W. Other (specify)

[ U.S Department of Education note : As of spring, 2010, the FON dis cussed in Block 12 of the instructions c an be found via the following URL: http://www.grants.gov/applicants/find_grant_opportunities.jsp

. ]

# U.S. Department of Education Supplemental Information for the SF

- 424

1. Project Director:

Prefix: * First Name: Middle Name: * Last Name: Suffix:



## Address:

* Street1:

Street2:

* City:

County :



### * State: * Zip Code: Country:

* Phone Number (give area code): Fax Number (give area code):

* Email Address:



## 2. Novice Applicant :

Are you are a novice applicant as defined in the regulations in 34 CFR 75.2 25 (and included in the definitions page in the attached instructions)?

Yes No



## 3. Human Subjects Research:

a. Are any research activities involving human subjects planned at any time during the proposed Pr oject Period?

Yes No

b. Are ALL the research activities proposed designated to be exempt from the regulations?

Yes Provide Exemption(s) # (s ): ⁪ 1 ⁪ 2 ⁪ 3 ⁪ 4 ⁪ 5 ⁪ 6

No Provide Assurance #(s), if available:

c. If applicable, please attach your “Exempt Research” or “Nonexempt Research” narrative to this form as indicated in the definitions page in the attached instructio ns.

OMB Number: 189 4

- 0007 Expiration Date: 8/31/20 17

## Instructions for U.S. Department of Education Supplemental Information for the SF

- 424

1. Project Director. Name, address, telephone and fax numbers, and e

- mail address of the person to be contacted on matters i n volving this application. Items marked w ith an asterisk (*) are mandatory.

2

. Novice Applicant. Check “Yes” if you meet the definition for novice applicants specified in the regulations in 34 CFR 75.225 and included on the attached page entitled “Definitions for U.S. Department of Educat i on S upplemental Information for the SF

- 424”). By checking “Yes” the applicant certifies t h at it meets these novice applicant requirements. Check “No” if you do not meet the definition for novice applicants

.

This novice applicant information will be used by ED to: 1) determine the amount and type of technical assistance that a novice might need , if funded, and 2) determine novice applicant eligibility in discretionary grant competitions that give special consideration to novice applications.

Certain ED disc retionary grant programs give special consideration to novice applications, either by establishing a special competition for novice applicants or by giving competitive preference to novice applicants under the procedures in 34 CFR 75.105(c)(2). If specia l consideration is being given to novice applications under a particular discretionary grant competition, the application notic e for the competition published in the Federal Register will specify this information

3. Human Subjects Research. (See I. A. “ Definitions” in attached page ent i tled “Definitions for U.S. Department of Education Supplemental

Information for the SF

- 424.”)

3a. If Not Human Subjects Research. Check “ No ” if research activities invol v ing human subjects are not planned at any time du ring the proposed project period. The r e maining parts of Item 3 are then not applicable.

3a. If Human Subjects Research. Check “ Yes ” if research activities involving human subjects are planned at any time du r ing the proposed project period, either at t he applicant organization or at any other performance site or collaborating instit u tion. Check “ Yes ” even if the research is exempt from the regul a tions for the protection of human subjects. (See I. B. “Exemptions” in attached page entitled “Definitions f or U.S. Department of Education Supplemental Information for SF

- 424.”)

3b. If Human Subjects Research is Exempt from the Human Subjects Regulations. Check “ Yes ” if all the research activ i ties proposed are designated to be exempt from the regul a tions. Check the exemption number(s) corresponding to one or more of the six exemption categories listed in I. B. “Exemptions.” In addition, follow the instructions in II. A. “Exempt Research Narr a tive” in the attached page entitled “Definitions for U.S. Departm ent of Education Supplemental Information for the SF

- 424.”

3b. If Human Subjects Research is Not Exempt from H u man Subjects Regulations. Check “ No ” if some or all of the planned research activities are covered (not exempt). In addition, follow the ins tructions in II. B. “Nonexempt Research Narr a tive” in the attached page entitled “Definitions for U.S. Department of Education Supplemental Information for the SF

- 424 .”

3b. Human Subjects Assurance Number. If the applicant has an approved Federal Wide A ssurance (FWA) on file with the Office for Human Research Protections (OHRP), U.S. Department of Health and Human Ser v ices, that covers the specific activity, insert the number in the space provided. (A list of current FWAs is available at: http://ohrp.cit.nih.gov/search/search.aspx?styp=bsc ) If the applicant does not have an approved assurance on file with OHRP, enter “None.” In this case, the applicant, by signature on the SF

- 424, is d eclaring that it will comply with 34 CFR 97 and proceed to obtain the human subjects assurance upon request by the designated ED official. If the application is recommended/selected for funding, the de s ignated ED official will request that the applicant o btain the assurance within 30 days after the specific formal request.

3c. If applicable, please attach your “Exempt Research” or “Nonexempt Research” narrative to your submission of the U.S Departmen t of Education Supplemental Information for the SF

- 424 form as instructed in item II

, “ Instructions for Exempt and Nonexempt Human Subjects

R e search Narratives ” in the attached page entitled “Definitions for U.S. Department of Education Supplemental Information for the SF

- 424.”

Note about Institutional Revie w Board Approval. ED does not require certification of Institutional Review Board approval with the application. However, if an application that involves non

- exempt human subjects research is recommended/selected for funding, the designated

ED official w ill request that the applicant obtain and send the certification to ED within 30 days after the formal r e quest



### . No covered human subjects research can be conducted until the study has ED clearance for protection of human subjects in research



### .

Public Burde n Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless su ch collection displays a valid OMB control number. Public reporting burden for this collection of information is esti mated to average 20 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data need ed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain benefit (20 USC 3474 General Education Provisions Act). Send comments regarding the burden estimate or any other aspect of this collection of info rmation, including suggestions for reducing this burden, to the U.S . Department of Education, 400 Maryland Ave., SW, Washington, DC 20210

- 4537 or

email ICDocketMgr@ed.gov and reference the OMB Control Number 1894

- 0007. Note: Please do not return the completed ED SF 424 Supplement al Form to this address.

## Definitions for U.S. Department of Education Supplemental Information for the SF

- 424

Definitions:

Novice Applicant (See 34 CFR 75.225)

For discretionary grant programs, novice applicant means any applicant for a grant fro m ED that

—

• Has never received a grant or subgrant under the

pr o gram from which it seeks funding;

• Has never been a member of a group application,

submi t ted in accordance with 34 CFR 75.127

- 75.129,

that r e ceived a grant under the program from which it

seek s fun d ing; and

• Has not had an active discretionary grant from the

Fe d eral government in the five years before the deadline date for applications under the program. For the purposes of this requirement, a grant is a c tive until the end of the grant’s proje ct or funding period, including any exte n sions of those periods that extend the grantee’s authority to obl i gate funds.

In the case of a group application submitted in accordance with

34 CFR 75.127

- 75.129, a group includes only parties that meet the requir e ments listed above.

PROTECTION OF HUMAN SUBJECTS IN R E SEARCH

I. Definitions and Exemptions

A. Definitions.

A research activity involves human subjects if the activity is research, as defined in the Department’s regulations, and the

r e search activit y will involve use of human subjects, as defined in the regul a tions.

— Research

The ED Regulations for the Protection of Human Su b jects, Title 34, Code of Federal Regulations, Part 97, define research as “a systematic investigation, including research dev elopment,

tes t ing and evaluation, designed to develop or contribute to generali z able knowledge

. Activities which meet this definition constitute research whether or not they are conducted or

su p ported under a program that is considered research for other

p urposes. For example, some demonstration and service

pr o grams may include research activities. — Human Subject

The regulations define human subject as “a living individual about whom an investigator (whether professional or student) conducting research obtains (1) data through intervention or interaction with the individual, or (2) identifiable private

inform a tion.” (1) If an activity involves obtaining information about a living person by manipulating that person or that person’s env i ronment, as might occur when a new instructional technique is tested, or by comm u nicating or interacting with the individual, as occurs with surveys and interviews, the definition of human su b ject is met. (2) If an activity involves obtaining private inform a tion about a liv ing person in such a way that the information can be directly or indirectly linked to that individual), the defin i tion of human subject is met [Private

information includes info r mation about behavior that occurs in a

context in which an individual can re a sonably expect that no observation or recording is taking place, and information which has been provided for sp e cific purposes by an individual and

which the individual can re a sonably expect will not be made public (for example, a school health re c ord).]

B. Exemptions.

Research activities in which the only involvement of human

su b jects will be in one or more of the following six categories of

e x emptions are not covered by the regulations:

(1) Research conducted in established or commonly accepted

ed u cat ional settings, involving normal educational practices, such as (a) research on regular and special education

instru c tional strategies, or (b) research on the effectiveness of or the compar i son among instructional techniques, curricula, or classroom manage ment met h ods. If an educational practice is being introduced to the site and is not widely used for similar populations , it is not covered by this exemption

.

(2) Research involving the use of educational tests (cognitive,

d i agnostic, aptitude, achievemen t), survey procedures, interview procedures or observation of public behavior, unless: (a)

inform a tion obtained is recorded in such a manner that human

su b jects can be identified, directly or through identifiers linked to the subjects; and (b) any disclosu re of the human subjects’ responses outside the r e search could reasonably place the subjects at risk of criminal or civil liability or be damaging to

the su b jects’ financial standing, employability, or reputation. If the subjects are chi l dren, exemption 2 applies only to research involving educ a tional tests and observations of public behavior when the investig a tor(s) do not participate in the activities being observed.

Exemption 2 does not apply if children are su r veyed or interviewed or if the research involves observation of public behavior and the investigator(s) participate in the activ i ties being observed. [C hildren are d e fined as persons who have not attained the legal age for consent to treatments or procedures

### involved in the r e search, under the applicable law or jurisdiction

in which the research will be co n ducted.]

(3) Research involving the use of educational tests (cognitive,

d i agnostic, aptitude, achievement), survey procedures, interview

proc e dures or observation of public behavior that is not exempt under section (2) above, if the human subjects are elected or

a p pointed public officials or candidates for public office; or federal statute(s) require(s) without exception that the confidentiality of the personally identifiable information wil l be maintained throughout the r e search and thereafter.

(4) Research involving the collection or study of existing data, documents, records, pathological specimens, or diagnostic specimens, if these sources are publicly available or if the

information is recorded by the investigator in a manner that

su b jects cannot be identified, directly or through identifiers linked to the subjects

. [This exemption applies only to retrospective studies using data collected before the initiation of the research.]

(5) Research and demonstration projects which are conducted by or subject to the approval of department or agency heads, and which are designed to study, evaluate, or otherwise examine: (a) public benefit or service programs; (b) procedures for

obtai n ing bene fits or services under those programs; (c) possible changes in or altern a tives to those programs or procedures; or (d) possible changes in methods or levels of payment for

ben e fits or services under those programs. [ The standards of this exemption are rare ly met because it was designed to apply only to specific research conducted by the Social Security Administration and some Federal welfare benefits programs

. ]

(6) Taste and food quality evaluation and consumer acceptance studies, (a) if wholesome foods w ithout additives are consumed or (b) if a food is consumed that contains a food ingredient at or

b e low the level and for a use found to be safe, or agricultural

chem i cal or environmental contaminant at or below the level found to be safe, by the Food and D rug Administration or

a p proved by the Environmental Protection Agency or the Food Safety and Inspection Service of the U.S. Department of Agricu l ture.

II. Instructions for Exempt and Nonexempt Human Subjects R e search Narratives

If the applicant marked “ Yes” for Item 3.b. of the U.S. Department of Education Supplemental Information for the SF 424, the a p plicant must attach a human subjects “exempt research” or “nonexempt research” narrative to the U.S. Department of Education Supplemental Information for the SF

424 form. If you have multiple projects and need to provide more than one narrative, be sure to label each set of responses as to the project they address.

A. Exempt Research Narrative. If you marked “Yes” for item 3.b. and designated exemption numbers( s), attach t he “exempt research” narrative to the U.S. Department of Education Supplemental Information for the SF

424. The narr a tive must contain sufficient information about the involvement of human subjects in the proposed research to

allow a de term i nation by ED that the designated exemption(s) are appropriate. The na r rative must be succinct.

B. Nonexempt Research Narrative. If you marked “No” for item 3.b. you must attach the

“none x empt research” narrative to the U.S. Department of

Education Supplemental Information for the SF

- 424 . The

narrative must address the follo w ing seven points. Although no specific page limitation a p plies to this section of the application,

be succinct.

(1) Human Subjects Involvement and Characteristics : Pr o vide a d etailed description of the proposed involvement of

human su b jects. Describe the characteristics of the subject population, including their anticipated nu m ber, age range, and health status. Identify the criteria for inclusion or exclusion of any subpopula tion. Explain the ratio n ale for the involvement of special classes of subjects, such as children, children with

di s abilities, adults with disabilities, persons with mental disabilities, pregnant women, prisoners, institutiona l ized individuals, or others w ho are likely to be vulne r able

(2) Sources of Materials : Identify the sources of research material obtained from individually identifiable living human

su b jects in the form of specimens, records, or data. Indicate

whether the material or data will be obt ained specifically for research pu r poses or whether use will be made of existing specimens, re c ords, or data.

(3) Recruitment and Informed Consent : Describe plans for the recruitment of subjects and the consent procedures to be

followed. I n clude the cir cumstances under which consent will be sought and obtained, who will seek it, the nature of the information to be pr o vided to prospective subjects, and the method of documenting consent. State if the Institutional Review Board (IRB) has autho r ized a modif ication or waiver of the elements of consent or the requirement for document a tion of

consent.

(4) Potential Risks : Describe potential risks (physical, psych o logical, social, legal, or other) and assess their likelihood

and seriou s ness. Where appropriate, describe alternative treatments and procedures that might be advant a geous to the subjects.

(5) Protection Against Risk : Describe the procedures for
protec t ing against or minimizing potential risks, including risks

to conf i dentiality, and assess their lik ely effectiveness. Where

appropr i ate, discuss provisions for ensuring necessary medical or profe s sional intervention in the event of adverse effects to the subjects. Also, where appropriate, d e scribe the provisions for monitoring the data collected to en sure the safety of the

su b jects.

(6) Importance of the Knowledge to be Gained : Discuss the

i m portance of the knowledge gained or to be gained as a result

### of the proposed research. Discuss why the risks to subjects are

re a sonable in relation to the antici pated benefits to subjects and in relation to the importance of the knowledge that may

re a sonably be expected to result.

(7) Collaborating Site(s) : If research involving human su b jects will take place at collaborating site(s) or other perfo r mance site(s), name the sites and briefly describe their involv e ment or
role in the research.

Copies of the Department of Education’s Regulations for the Protection of Human Subjects, 34 CFR Part 97 and other pertinent materials on the protection of human subjects in

r e search are available from the Office of the Chief Financial Officer, U.S. Department of Education, Washington, D.C.

20202

- 4331, tel e phone: (202) 245

- 8090 , and on the U.S. Department of Education’s Protection of Human Su b jects in
Research Web Site: http:/ /www.ed.gov/about/offices/list/ocfo/humansub.html

NOTE: The State Applicant Identifier on the SF

- 424 is for State Use only. Please complete it on the SF

- 424 in the upper right corner of the form (if applicable).OMB Control No. 1894

- 0005 (Exp. 03/31/201 7 )



## NOTICE TO ALL APPLICANTS

The purpose of this enclosure is to inform you about a new provision in the Department of Education's General Education Provisions Act (GEPA) that applies to applicants for new grant awards under Department programs. This provision is Section 427 of GEPA, enacted as part of the Improving America's Schools Act of 1994 (Public Law (P.L.) 103

- 382).

To Whom Does This Provision Apply?

Section 427 of GEPA affects applicants for new grant awards under this program. ALL APPLICANTS

FOR NEW AWARDS MUST INCLUDE
INFORMATION IN THEIR APPLICATIONS
TO ADDRESS THIS NEW PROVISION IN
ORDER TO RECEIVE FUNDING UNDER THIS
PROGRAM.

(If this program is a State

- formula grant program, a

State needs to provide this description only for projects or activities that it carries out with funds

reserved for State

- level uses. In addition, local school districts or other eligible applicants that apply to the State for funding need to provide this description in their applications to the State for funding. The State would be responsible for ensuring that the school district or other local entity has

submitted a sufficient section 427 statement as described below.)

What Does This Provision Require?

Section 4 27 requires each applicant for funds (other than an individual person) to include in its application a description of the steps the applicant proposes to take to ensure equitable access to, and participation in, its Federally

- assisted program for students, teachers, and other program beneficiaries with special needs. This provision allows applicants discretion in developing the required description. The statute highlights six types of barriers that can impede equitable access or participation: gender,

rac e, national origin, color, disability, or age. Based on local circumstances, you should determine whether these or other barriers may prevent your students, teachers, etc. from such access or participation in, the Federally

- funded project or activity. Th e description in your application of steps

to be taken to overcome these barriers need not be lengthy; you may provide a clear and succinct description of how you plan to address those barriers that are applicable to your circumstances. In addition, the i nformation may be provided in a single narrative, or, if appropriate, may be discussed in connection with related topics in the application.

Section 427 is not intended to duplicate the requirements of civil rights statutes, but rather to ensure that, in designing their projects, applicants for Federal funds address equity concerns that may affect the ability of certain potential beneficiaries to fully participate in the project and to achieve to high standards. Consistent with program requirements and

it s approved application, an applicant may use the

Federal funds awarded to it to eliminate barriers it

identifies.

What are Examples of How an Applicant Might Satisfy the Requirement of This Provision?

The following examples may help illustrate how an

app licant may comply with Section 427.

(1) An applicant that proposes to carry out an adult literacy project serving, among others, adults with limited English proficiency, might describe in its application how it intends to distribute a brochure about the p roposed project to such potential participants in their native language.

(2) An applicant that proposes to develop instructional materials for classroom use might

describe how it will make the materials available on audio tape or in braille for students w ho are

blind.

(3) An applicant that proposes to carry out a model science program for secondary students and is concerned that girls may be less likely than boys to enroll in the course, might indicate

how it intends to conduct "outreach" efforts to girls , to encourage their enrollment.

(4) An applicant that proposes a project to increase school safety might describe the special efforts it will take to address concern of lesbian, gay, bisexual, and transgender students, and

efforts to reach out to and inv olve the families of

LGBT students

We recognize that many applicants may already be implementing effective steps to ensure equity of access and participation in their grant programs, and we appreciate your cooperation in responding to the requirements of this provision.

Estimated Burden Statement for GEPA Requirements

**According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public re**  **porting burden for this collection of information is estimated to average 1.5 hours per response, including time for reviewing**  **instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collec**  **tion of information. The obligation to respond to this collection is required to obtain or**
**retain benefit (Public Law 103**

**- 382. Send comments regarding the burden estimate or any other aspect of this**  **collection of information, including suggestions for red ucing this burden, to the U.S. Department of Education,**  **400 Maryland Ave., SW, Washington, DC 20210**

**- 4537 or**  **email ICDocketMgr@ed.gov**  **and reference the OMB Control Number**

**1894**

**- 0005.** Certification for Contracts, Grants, Loans, and Cooperative Agreements

(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 of Lobbying Activities,'' 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 $10,00 0 and not more than $100,000 for each such failure.

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 of Lobbying Activities,'' 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 subjec t to a civil penalty of not less than $10,000 and not more than $100,000

for each such failure.

* APPLICANT'S ORGANIZATION

* SIGNATURE: * DATE: * PRINTED NAME AND TITLE OF AUTHORIZED REPRESENTATIVE

Suffix: Middle Name:

* Title: * First Name:

* Last Name: Prefix: 

### CERTIFICATION REGARDING LOBBYING

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

Statement for Loan Guarantees and Loan Insurance

The undersigned states, to the best of his or her knowledge and belief, that:OMB Approval No. 0348-0040


### ASSURANCES - NON-CONSTRUCTION PROGRAMS

NOTE:

As the duly authorized representative of the applicant, I certify that the applicant:

Previous Edition Usable Standard Form 424B (Rev. 7-97) 

### Authorized for Local Reproduction Prescribed by OMB Circular A-102 

### Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0040), Washington, DC 20503.



### PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET.

SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.

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.

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 cost) to ensure proper planning, management and completion of the project described in this application.

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.

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.

Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding

agency.

Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C. §§4728-4763) relating to prescribed standards for merit systems for programs funded under one of the 19 statutes or regulations specified in Appendix A of OPM's Standards for a Merit System of Personnel Administration (5 C.F.R. 900, Subpart F).

Will comply with all Federal statutes relating to

nondiscrimination. 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 basis 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 nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and
Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as amended, relating to

nondiscrimination on the basis 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 alcohol and drug abuse patient records; (h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; (i) any other nondiscrimination provisions in the specific statute(s) under which application for Federal assistance is being made; and, (j) the requirements of any other nondiscrimination statute(s) which may apply to the application.

Will comply, or has already complied, 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.

Will comply, as applicable, with 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. 1.

2.

3.

4.

5.

6. 7.

8.

### SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL TITLE

APPLICANT ORGANIZATION DATE SUBMITTED

Standard Form 424B (Rev. 7-97) Back

### Will comply, as applicable, with the provisions of the DavisBacon 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.

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.

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 EO 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.); (f) conformity of Federal actions to State (Clean Air) Implementation Plans under Section 176(c) of the Clean 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). 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.

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.).

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.

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.

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 construction or

rehabilitation of residence structures.

Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act Amendments of 1996 and OMB Circular No. A-133, "Audits of States, Local Governments, and Non-Profit Organizations."

Will comply with all applicable requirements of all other Federal laws, executive orders, regulations, and policies governing this program. 9.

10.

11. 12.

13.

14.

15.

16.

17.

18.