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See instructional booklet for specific information on how to fill out this application
WELCOME TO THE DEPARTMENT OF LABOR & INDUSTRIES
SAFETY & HEALTH INVESTMENT PROJECTS (SHIP) AWARDS
APPLICATION
We hope the instructions below will help you complete the enclosed application
materials. Important: Please read the SHIP Application Instructions Booklet for
specific details on completing this application. If you have questions, please contact us:
Safety & Health Investment Projects
Department of Labor & Industries
PO Box 44612
Olympia WA 98504-4612
(360) 902-5588
E-mail: invest@Lni.wa.gov
Instructions for applying for a SHIP Award:
Refer to the SHIP Application Instructional Booklet to obtain information on
how to fill out this application:
The SHIP Application consists of five parts:
o “SHIP Application” – information
o Milestones
o Budget
o Project Description and Work Plan
o Certifications and Assurances
Fill out the “Cover Sheet: Safety & Health Investment Projects Application”
after completing the application. The cover sheet is a summary and should not
exceed one page in length.
Include any Supporting materials such as additional text, photos, video, and
audio media that will help explain your proposal (we will not be able to return
these to you).
Please include specific data that supports the problem your project will solve
along with the source(s) of the data.
You may also include Appendices for reference, but extensive materials
included in the appendices may not be reviewed as part of the approval process.
All information relevant to your application should be included in the application
itself.
SHIP Application Page 1 of 14 Revised April 2012
See instructional booklet for specific information on how to fill out this application
Send two signed paper copies of your package to the address above by the
posted deadline. Separately, but at the same time, provide an electronic
version in Word (can be on a CD or by email). Only the signed paper copies will
be used to determine if the submission deadline is met.
NOTE: Your application must be 12 pt Arial type and use one (1) inch margins. The
total package may not exceed 30 pages.
When to apply for a SHIP Award:
You may apply at any time during the open application period so long as it is prior to
the posted deadline. Late applications will not be considered.
Applications must be completed in full by the application deadline in order to be
considered. Incomplete applications will not be considered for funding.
Information Specific to the Current Funding Cycle
Grant Criteria and Limits for Current Funding Cycle:
Applications for SHIP grants must be received or postmarked no later than
[Click to type MMM DD, YYYY]. Late applications will not be considered.
The amount of grant money to be awarded this cycle is approximately [Click
to type $$ amt] and individual grant requests should generally not exceed
[Click to type $$ amt]. Requests larger than [Click to type $$ amt] may be
considered for review by SHIP on a case-by-case basis at its sole discretion.
Funded applicants will be required to attend a grantee orientation.
Please see the SHIP Application Instructional Booklet for more complete information on
how to fill out this application. If you need additional assistance, please call the SHIP
program at 360-902-5588.
SHIP Application Page 2 of 14 Revised April 2012
See instructional booklet for specific information on how to fill out this application
COVER SHEET
SAFETY & HEALTH INVESTMENT PROJECTS APPLICATION
1. Type of Grant Applying for:
Accident Prevention Small Business
2. Applicant (and partners):
3. Type of Organization (Check one)
Trade association Labor union
Business association Employee organization
Employer (check all that apply) Group of employees
Non-profit Joint business/labor group
For-profit Other (explain)
Public agency
Fewer than 25 employees
4. Descriptive Title of Proposed Project:
5. Summary of Proposed Project Purpose: (2-3 sentence maximum)
6. Proposed deliverables:
7. Project Budget:
a. Amount requested from SHIP: $
b. Cash amount requested from other: $
c. In-kind contribution: $
d. Total project Budget: $
8. Have you included a multi-media presentation with this application? Yes or No
SHIP Application Page 3 of 14 Revised April 2012
See instructional booklet for specific information on how to fill out this application
SHIP APPLICATION
(Applications must be completely filled out. Incomplete applications will not be considered for funding.)
PART I
Descriptive Title of Applicant’s Project:
Total SHIP Funding Requested:
APPLICANT QUALIFICATION:
Organization Type
Trade association Labor union
Business association Employee organization
Employer (check all that apply) Group of employees
Non-profit Joint business/labor group
For-profit Other (explain)
Public agency
Fewer than 25 employees
Partnerships
Does your project have more than one entity entering the project as partners?
Yes No
If Yes, please ensure that the applicant qualification refers to the Managing partner.
Project Type
Best Practice
Technical Innovation
Training and Education Development
Other (explain):
APPLICANT(S) – If partnership, please enter managing partner information
Name:
Address City State Zip
Phone Fax Email Website (if any)
Federal Tax ID or SSN WA State UBI (if applicable) IRS No-profit (if applicable)
List Supporting Partner(s): (Name, Address, Phone, E-mail)
SHIP Application Page 4 of 14 Revised April 2012
See instructional booklet for specific information on how to fill out this application
Organization(s) Profile for applicants:
- Brief history of organization(s)
- Brief statement of organization’s vision/mission
- Brief description of track record of achievement
- How does this project fit into the work of your organization?
Partners (if applicable):
- How will you assure their participation?
- What significant skills do they contribute to the project?
- How will they help you to meet your performance target?
Project Team
Please provide information (including contact information) on your project team, to include:
Project Sponsor
Project Manager
Other Team Members
SHIP Application Page 5 of 14 Revised April 2012
See instructional booklet for specific information on how to fill out this application
LOCATION TO BE SERVED (check all that apply)
Northwest WA (Everett and north)
Puget Sound area (King and Pierce Counties, Olympic Peninsula)
Southwest WA (Olympia, Grays Harbor and south)
Central WA (Yakima, Tri-Cities, Wenatchee, Moses Lake, etc.)
Eastern WA (Spokane, Colville, Pullman, Walla Walla, etc.)
Statewide WA
Industry Classification (check which industry(s) this project will affect)
11 Agriculture, Forestry, Fishing and Hunting
21 Mining
22 Utilities
23 Construction
31-33 Manufacturing
42 Wholesale Trade
44-45 Retail Trade
48-49 Transportation and Warehousing
51 Information
52 Finance and Insurance
53 Real Estate and Rental and Leasing
54 Professional, Scientific, and Technical Services
55 Management of Companies and Enterprises
56 Administrative and Support and Waste Management and Remediation Services
61 Educational Services
62 Health Care and Social Assistance
71 Arts, Entertainment, and Recreation
72 Accommodation and Food Services
81 Other Services (except Public Administration)
92 Public Administration
State-wide Benefits:
How might your project benefit other Washington businesses and workers?
SHIP Application Page 6 of 14 Revised April 2012
See instructional booklet for specific information on how to fill out this application
PART II
MILESTONES
TARGET DATE MILESTONE COST
Final Date Performance target achieved and report submitted to L&I Total for the Project
SHIP Application Page 7 of 14 Revised April 2012
See instructional booklet for specific information on how to fill out this application
PART III
ITEMIZED BUDGET AND JUSTIFICATION
Note: In general, indirect/administrative costs that exceed 10% of the total project costs will not be
approved. However, costs in excess of 10% will be reviewed on a case-by-case basis.
Indirect/administrative costs determined to be excessive will result in rejection of this application.
Budget Category Amount Requested
Personnel $
Subcontractors $
Travel $
Supplies $
Publications $
Other $
Total Funds Requested $
Investment:
Will your project, or any part of it, be possible without investment from this source?
Explain:
ITEMIZED BUDGET: How will SHIP award funds be used to achieve the purposes listed in your
proposal?
A. PERSONNEL (itemize all Details (indicate percent of time, Proposed Expenses
positions and names, if known) rate of pay/hr or salary) ($ Amount ONLY)
1. $
2. $
3. $
Fringe Benefits (specify rate and
base)
Subtotal $
For each position:
Where will you use these positions?
Why do you need the position to be successful?
Explanation for rate of pay provided for?
I certify that the personnel identified above are aware of their inclusion in this SHIP
application at the salary level provided in the itemized budget.
Signature:
SHIP Application Page 8 of 14 Revised April 2012
See instructional booklet for specific information on how to fill out this application
B. SUBCONTRACTORS (if Activity Proposed Expenses
any) Provide a separate listing for ($ Amount ONLY)
each if more than one.
1. $
2. $
3. $
Subtotal $
For each subcontractor:
How will you assure their participation?
What significant skills do they contribute to the project?
How will they help you meet your performance target?
C. TRAVEL (itemized – not to Details Proposed Expenses
exceed State of Washington rates) ($ Amount ONLY)
1. $
2. $
3. $
Subtotal $
Justification for Travel Budget:
D. SUPPLIES (itemized by Details Proposed Expenses
category) ($ Amount ONLY)
1. $
2. $
3. $
Subtotal $
Justification for Supplies Budget:
E. PUBLICATIONS (production Details Proposed Expenses
and distribution) ($ Amount ONLY)
1. $
2. $
3. $
Subtotal $
Justification for Publications Budget:
SHIP Application Page 9 of 14 Revised April 2012
See instructional booklet for specific information on how to fill out this application
F. OTHER Details Proposed Expenses
($ Amount ONLY)
1. $
Subtotal $
Justification for Other Budget request:
Total Budget Request $
G. IN-KIND CONTRIBUTIONS Details Monetary Value
($ Amount ONLY)
1. $
Subtotal $
SHIP Application Page 10 of 14 Revised April 2012
See instructional booklet for specific information on how to fill out this application
PART IV
PROJECT DESCRIPTION AND WORK PLAN
FRAME
Problem Statement:
Goals:
Objectives:
PROJECT PLAN
What is the plan for implementation? What resources will be used?
Timeline Responsible Party Activities Outputs
How and why was the project approach developed?
-
What factors, outside your control, could potentially negatively impact your project’s success?
-
Factors your projects counting on that will contribute to the project’s success.
-
How do you expect people to know about and use the results of your project?
-
OUTCOMES
What measurable outcomes will be achieved during the grant period (i.e. short-term
outcomes)?
-
What are the measurable longer-term outcomes of this project? (Intermediate and long-term
outcomes)
-
SHIP Application Page 11 of 14 Revised April 2012
See instructional booklet for specific information on how to fill out this application
EVALUATION OF OUTCOMES
What methods or strategies will be used to gather data on the project? Do you plan to conduct
a project evaluation?
-
OTHER CONSIDERATIONS
Information Sharing:
How do you expect people to know about and use the results of your project?
-
SHIP Application Page 12 of 14 Revised April 2012
See instructional booklet for specific information on how to fill out this application
PART V
CERTIFICATIONS AND ASSURANCES
We, the applicant, make the following certifications and assurances as a required element of the
application to which this is a part, understanding that the truthfulness of the facts affirmed here
and the continuing compliance with these requirements are conditions precedent to the award or
continuation of related activity/ies.
We authorize all references, employers (past and present), business and professional associates
(past and present), and all governmental agencies and institutions (local, state, or federal) to
release to L&I any information, files, or records required for the evaluation of this application.
We certify that all joint applicants and sub-contractors have signed this application.
We understand that L&I will not reimburse us for any costs incurred in the preparation of th is
application. All applications become the property of L&I, and we claim no proprietary right to the
ideas, writings, items or samples unless so stated in the application.
We understand and acknowledge that all products developed as a result of an approved SHIP
award belong in the public domain and their dissemination and use shall not be restricted in any way.
Such products may not be copyrighted, patented, claimed as trade secrets, or otherwise restricted in
any other way. The department retains the right to publish or otherwise disseminate these products
as the department in its sole discretion deems appropriate. Such products will be available free of
charge through L&I.
In preparing this application, we have not been assisted by any current or form er employee of the
state of Washington whose duties relate or did relate to this application or prospective SHIP
award, and who was assisting in other than his or her official, public capacity. Neither does such
person nor any member of his/her immediate family have any financial interest in the outcome of
this application.
We agree that submission of the attached application constitutes acceptance of all of the
application contents, including but not limited to, procedures, evaluation criteria, requiremen ts,
administrative instructions, and other terms and conditions. If there are any exceptions to these
assurances that we would like L&I to consider, we have described those exceptions in
detail on a separate page titled Exceptions to Assurances. L&I is not required to make the
requested changes. If selected as an apparent successful applicant, and if after negotiation we
cannot agree to award terms with L&I, we agree that L&I can reject this offer.
SHIP Application Page 13 of 14 Revised April 2012
See instructional booklet for specific information on how to fill out this application
Signature of Applicant
I certify that I am the (title) of the
(organization name) and am
authorized to sign and submit this application, along with the agreement that will follow, if funded, on
behalf of my organization. The information submitted with this application is accurate and true to the
best of my knowledge.
Signature: Date:
Print Name:
Signature of Joint Applicant or Subcontractor (Collaborator)
I certify that I am the (title) of the
(organization name) and am
authorized to sign this application on behalf of my organization. The information submitted with this
application is accurate and true tot eh best of my knowledge.
Signature: Date:
Print Name:
Signature of Joint Applicant or Subcontractor (Collaborator)
I certify that I am the (title) of the
(organization name) and am
authorized to sign this application on behalf of my organization. The information submitted with this
application is accurate and true tot eh best of my knowledge.
Signature: Date:
Print Name:
Note: Copy and use additional pages if further signatures are required.
SHIP Application Page 14 of 14 Revised April 2012
