Private Label Agreement Template

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					FORM INFORMATION
Form Name / Title         HHS Checklist
Form Number               HHS-5161-1
Version Number            2.1
Version Date
Description               HHS Checklist form included in the HHS Standard Discretionary Application package HHS-5161-1
OMB Control Number        0990-0317
OMB Expiration Date       8/31/2010
Form Family                 X SF424
(select all that apply)     X SF424 R&R
                                SF424 Individual
                                SF424 Mandatory
                                SF424 Short Organizational
FORM TITLE:                                                                                 HHS Checklist
  [1]                                             [2]                                             [3]                   [4]          [5]           [6]                  [7]                  [8]                          [9]                          [10]                           [11]                        [12]                  [13]                   [14]          [15]            [16]                       [17]

                                                                                                                                                                                                                                                                                                                                                           Min # of       Max # of        Field
                                                 Field                                          Short Field                      Minimum       Maximum              Agency Field                                     Global Library                 Field Type                                                                       List of               Chars or       Chars or   Implementatio
 Field #                                         Label                                            Label            Required?   Occurrences   Occurrences               Name             Field Type                    Field Name                      Source                    Business Rules               Data Type               Values                Min Value     Max Value          n                      Help Tip
0-0        View Burden Statement                                                            View Burden           n/a          n/a           n/a           n/a                         Agency-       n/a                                n/a                              Clicking displays:                n/a           n/a                             n/a           n/a           Button          View Burden Statement
                                                                                            Statement                                                                                  specific                                                                          Public Burden Statement:

                                                                                                                                                                                                                                                                         Public reporting burden of this
                                                                                                                                                                                                                                                                         collection of information is
                                                                                                                                                                                                                                                                         estimated to average 4 - 50
                                                                                                                                                                                                                                                                         hours per response, including
                                                                                                                                                                                                                                                                         the time for reviewing
                                                                                                                                                                                                                                                                         instructions, searching
                                                                                                                                                                                                                                                                         existing data sources,
                                                                                                                                                                                                                                                                         gathering and maintaining the
                                                                                                                                                                                                                                                                         data needed, and completing
                                                                                                                                                                                                                                                                         and reviewing the collection of
                                                                                                                                                                                                                                                                         information. An agency may
                                                                                                                                                                                                                                                                         not conduct or sponsor, and a
                                                                                                                                                                                                                                                                         person is not required to
                                                                                                                                                                                                                                                                         respond to a collection of
                                                                                                                                                                                                                                                                         information unless it displays
                                                                                                                                                                                                                                                                         a currently valid OMB control
                                                                                                                                                                                                                                                                         number. Send comments
                                                                                                                                                                                                                                                                         regarding this burden
                                                                                                                                                                                                                                                                         estimate or any other aspect of
                                                                                                                                                                                                                                                                         this collection of information,
                                                                                                                                                                                                                                                                         including suggestions for
                                                                                                                                                                                                                                                                         reducing this burden to HHS
                                                                                                                                                                                                                                                                         Reports Clearance Officer,
                                                                                                                                                                                                                                                                         200 Independence Ave., SW,
                                                                                                                                                                                                                                                                         Humphrey Bldg., Room 531H,
                                                                                                                                                                                                                                                                         Washington, DC, 20201,
                                                                                                                                                                                                                                                                         ATTN: PRA (0990-0317). Do
                                                                                                                                                                                                                                                                         not send the completed form to
                                                                                                                                                                                                                                                                         this address.

0-1        HHS-5161-1                                                                       n/a                   n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
0-2        OMB Approval No. 0990-0317                                                       n/a                   n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
           Expiration Date: 8/31/2010
0-3        CHECKLIST                                                                        n/a                   n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
0-4        NOTE TO APPLICANT:                                                               n/a                   n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
0-5        This form must be completed and submitted with the original of your              n/a                   n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
           application. Be sure to complete each page of this form. Check the
           appropriate boxes and provide the information requested. This form
           should be attached as the last pages of the signed original of the
           application.
1-0        Type of Application                                                              Type of Application   No           0             1             AppType                     Radio Group   n/a                                AppType                          n/a                               LIST          n/a                             n/a           n/a           Radio Group     n/a
1-1        New                                                                              New                   No           0             1             n/a                         Radio Group   n/a                                AppType                          Only 1 checkbox selection         n/a           New                             n/a           n/a           Radio           Select if this application is a new
                                                                                                                                                                                                                                                                         allowed                                                                                                                     submission which is not related to an
                                                                                                                                                                                                                                                                                                                                                                                                     existing grant.
1-2        Noncompeting Continuation                                                        Noncompeting          No           0             1             n/a                         Radio Group   n/a                                AppType                          Only 1 checkbox selection         n/a           Noncompeting Continuation       n/a           n/a           Radio           Select if this application is a
                                                                                            Continuation                                                                                                                                                                 allowed                                                                                                                     noncompeting continuation submission
                                                                                                                                                                                                                                                                                                                                                                                                     related to an existing grant.

1-3        Competing Continuation                                                           Competing             No           0             1             n/a                         Radio Group   n/a                                AppType                          Only 1 checkbox selection         n/a           Competing Continuation          n/a           n/a           Radio           Select if this application is a competing
                                                                                            Continuation                                                                                                                                                                 allowed                                                                                                                     continuation submission related to an
                                                                                                                                                                                                                                                                                                                                                                                                     existing grant whose project period is
                                                                                                                                                                                                                                                                                                                                                                                                     ending.
1-4        Supplemental                                                                     Supplemental          No           0             1             n/a                         Radio Group   n/a                                AppType                          Only 1 checkbox selection         n/a           Supplemental                    n/a           n/a           Radio           Select if this application is a
                                                                                                                                                                                                                                                                         allowed                                                                                                                     supplemental request related to an
                                                                                                                                                                                                                                                                                                                                                                                                     existing grant.
A0-1       PART A: The following checklist is provided to assure that                       n/a                   n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
           proper signatures, assurances, and certifications have been
           submitted.
A0-2       Included                                                                         n/a                   n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
A0-3       NOT Applicable                                                                   n/a                   n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
A1-0       1. Proper Signature and Date on the SF 424 (FACE PAGE)                           Signature and Date    No           0             1             Check424Sig                 Agency        globLib:YesNoDataType              n/a                              n/a                               n/a           n/a                             n/a           n/a           Check           Applicants must certify that proper
           ...................                                                                                                                                                         Specific                                                                                                                                                                                                      signature and date are entered on the
                                                                                                                                                                                                                                                                                                                                                                                                     SF 424 (Face Page).
A2-0       2. If your organization currently has on file with HHS the following             n/a                   n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           Before a grant or cooperative
           assurances, please identify which have been filed by indicating the                                                                                                                                                                                                                                                                                                                       agreement award can be made, a
           date of such filing on the line provided. (All four have been                                                                                                                                                                                                                                                                                                                             domestic applicant organization must
           consolidated into a single form, HHS 690)                                                                                                                                                                                                                                                                                                                                                 certify that it has filed with the DHHS
                                                                                                                                                                                                                                                                                                                                                                                                     Office for Civil Rights an Assurance of
                                                                                                                                                                                                                                                                                                                                                                                                     Compliance ( HHS 690).

A2-1a      Civil Rights Assurance (45 CFR 80) ...........................................   Civil Rights          No           0             1             CheckCivilRightAssuranc     Agency-       globLib:YesNoDataType              n/a                              n/a                               n/a           n/a                             n/a           n/a           Check           Applicants must certify Assurance of
                                                                                                                                                           e                           specific                                                                                                                                                                                                      Compliance with Title VI of the Civil
                                                                                                                                                                                                                                                                                                                                                                                                     Rights Act of 1964 (P.L. 88-352, as
                                                                                                                                                                                                                                                                                                                                                                                                     amended) which prohibits
                                                                                                                                                                                                                                                                                                                                                                                                     discrimination on the basis of race,
                                                                                                                                                                                                                                                                                                                                                                                                     color, or national origin was filed.
A2-1b      n/a                                                                              Civil Rights Date     No           0             1             CivilRightAssuranceSign     Agency-       n/a                                n/a                              Visible only when previous        DATE          n/a                             n/a           n/a           Field           Enter the date the assurance of
                                                                                                                                                           Date                        specific                                                                          field is checked.                                                                                                           compliance with Title VI of the Civil
                                                                                                                                                                                                                                                                                                                                                                                                     Rights Act of 1964 (P.L. 88-352, as
                                                                                                                                                                                                                                                                                                                                                                                                     amended) was filed.
A2-2a      Assurance Concerning the Handicapped (45 CFR 84) .................               Handicapped           No           0             1             CheckHandicappedAssur       Agency-       globLib:YesNoDataType              n/a                              n/a                               n/a           n/a                             n/a           n/a           Check           Applicants must certify Assurance of
                                                                                                                                                           ance                        specific                                                                                                                                                                                                      Compliance with Section 504 of the
                                                                                                                                                                                                                                                                                                                                                                                                     Rehabilitation Act of 1973 (P.L. 93-112
                                                                                                                                                                                                                                                                                                                                                                                                     as amended), which prohibits
                                                                                                                                                                                                                                                                                                                                                                                                     discrimination on the basis of
                                                                                                                                                                                                                                                                                                                                                                                                     handicaps, was filed. (45 CFR 84)
A2-2b      n/a                                                                              Handicapped Date      No           0             1             HandicappedAssuranceSi      Agency-       n/a                                n/a                              Visible only when previous        DATE          n/a                             n/a           n/a           Field           Enter the date the Assurance of
                                                                                                                                                           gnDate                      specific                                                                          field is checked.                                                                                                           Compliance with Section 504 of the
                                                                                                                                                                                                                                                                                                                                                                                                     Rehabilitation Act of 1973 (P.L. 93-112
                                                                                                                                                                                                                                                                                                                                                                                                     as amended) was filed.
A2-3a      Assurance Concerning Sex Discrimination (45 CFR 86) ..............               Sex Discrimination    No           0             1             CheckSexAssurance           Agency-       globLib:YesNoDataType              n/a                              n/a                               n/a           n/a                             n/a           n/a           Check           Applicants must certify Assurance of
                                                                                                                                                                                       specific                                                                                                                                                                                                      Compliance with Title IX of the
                                                                                                                                                                                                                                                                                                                                                                                                     Education Amendments of 1972 (P.L. 92-
                                                                                                                                                                                                                                                                                                                                                                                                     318, as amended) which prohibits
                                                                                                                                                                                                                                                                                                                                                                                                     discrimination on the basis of sex, was
                                                                                                                                                                                                                                                                                                                                                                                                     filed. (45 CFR 86)
A2-3b      n/a                                                                              Sex Discrimination    No           0             1             SexAssuranceSignDate        Agency-       n/a                                n/a                              Visible only when previous        DATE          n/a                             n/a           n/a           Field           Enter the date the Assurance of
                                                                                            Date                                                                                       specific                                                                          field is checked.                                                                                                           Compliance with Title IX of the
                                                                                                                                                                                                                                                                                                                                                                                                     Education Amendments of 1972 (P.L. 92-
                                                                                                                                                                                                                                                                                                                                                                                                     318, as amended) was filed.
A2-4a      Assurance Concerning Age Discrimination (45 CFR 90 & 45 CFR                      Age Discrimination    No           0             1             CheckAgeAssurance           Agency-       globLib:YesNoDataType              n/a                              n/a                               n/a           n/a                             n/a           n/a           Check           Applicants must certify Assurance of
           91) ...........................................                                                                                                                             specific                                                                                                                                                                                                      Compliance with the Age
                                                                                                                                                                                                                                                                                                                                                                                                     Discrimination Act of 1975 (P.L. 94-
                                                                                                                                                                                                                                                                                                                                                                                                     135), which prohibits discrimination on
                                                                                                                                                                                                                                                                                                                                                                                                     the basis of age, was filed. (45 CFR 90
                                                                                                                                                                                                                                                                                                                                                                                                     and 45 CFR 91)
A2-4b      n/a                                                                              Age Discrimination    No           0             1             AgeAssuranceSignDate        Agency-       n/a                                n/a                              Visible only when previous        DATE          n/a                             n/a           n/a           Field           Enter the date the Assurance of
                                                                                            Date                                                                                       specific                                                                          field is checked.                                                                                                           Compliance with the Age
                                                                                                                                                                                                                                                                                                                                                                                                     Discrimination Act of 1975 (P.L. 94-
                                                                                                                                                                                                                                                                                                                                                                                                     135) was filed.
A3-0       3. Human Subjects Certification, when applicable (45 CFR 46)                     Human Subjects        No           0             1             CheckHumanSubjectCerti      Radio Group   n/a                                CheckHumanSubjectCertification   n/a                               LIST          n/a                             n/a           n/a           Radio Group     Based on the information provided in the
           .....................................                                                                                                           fication                                                                                                                                                                                                                                  RFA, if it has been determined that
                                                                                                                                                                                                                                                                                                                                                                                                     projects funded under the RFA are
                                                                                                                                                                                                                                                                                                                                                                                                     subject to the requirements of 45 CFR
                                                                                                                                                                                                                                                                                                                                                                                                     part 46, Protection of Human Subjects,
                                                                                                                                                                                                                                                                                                                                                                                                     applicants are required to indicate
                                                                                                                                                                                                                                                                                                                                                                                                     whether the Human Subjects
                                                                                                                                                                                                                                                                                                                                                                                                     Certification is included.
A3-a       n/a                                                                              Included              No           0             1             n/a                         Radio Group   n/a                                CheckHumanSubjectCertification   n/a                               n/a           Yes                             n/a           n/a           Radio           Based on the information provided in the
                                                                                                                                                                                                                                                                                                                                                                                                     RFA, if it has been determined that
                                                                                                                                                                                                                                                                                                                                                                                                     projects funded under the RFA are
                                                                                                                                                                                                                                                                                                                                                                                                     subject to the requirements of 45 CFR
                                                                                                                                                                                                                                                                                                                                                                                                     part 46, Protection of Human Subjects,
                                                                                                                                                                                                                                                                                                                                                                                                     applicants are required to indicate
                                                                                                                                                                                                                                                                                                                                                                                                     whether the Human Subjects
                                                                                                                                                                                                                                                                                                                                                                                                     Certification is included.
A3-b       n/a                                                                              N/A                   No           0             1             n/a                         Radio Group   n/a                                CheckHumanSubjectCertification   n/a                               n/a           Not Applicable                  n/a           n/a           Radio           Based on the information provided in the
                                                                                                                                                                                                                                                                                                                                                                                                     RFA, if it has been determined that
                                                                                                                                                                                                                                                                                                                                                                                                     projects funded under the RFA are
                                                                                                                                                                                                                                                                                                                                                                                                     subject to the requirements of 45 CFR
                                                                                                                                                                                                                                                                                                                                                                                                     part 46, Protection of Human Subjects,
                                                                                                                                                                                                                                                                                                                                                                                                     applicants are required to indicate
                                                                                                                                                                                                                                                                                                                                                                                                     whether the Human Subjects
                                                                                                                                                                                                                                                                                                                                                                                                     Certification is included.
B0-1       PART B: This part is provided to assure that pertinent                           n/a                   n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
           information has been addressed and included in the
           application.
B0-2       YES                                                                              n/a                   n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
B0-3       NOT Applicable                                                                   n/a                   n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
B1-0       1. Has a Public Health System Impact Statement for the proposed                  Impact Statement      No           0             1             CheckPHSImpactStateme       Radio Group   n/a                                CheckPHSImpactStatement          n/a                               LIST          n/a                             n/a           n/a           Radio Group     The Public Health System Impact
           program/project been completed and distributed as required?                                                                                     nt                                                                                                                                                                                                                                        Statement (PHSIS) is applicable to
           ...............................................................                                                                                                                                                                                                                                                                                                                           some programs and must be completed
                                                                                                                                                                                                                                                                                                                                                                                                     and distributed. See specific
                                                                                                                                                                                                                                                                                                                                                                                                     instructions in the RFA, if applicable.
                                                                                                                                                                                                                                                                                                                                                                                                     The PHSIS is intended to inform State
                                                                                                                                                                                                                                                                                                                                                                                                     and local health officials of health
                                                                                                                                                                                                                                                                                                                                                                                                     services grant applications submitted by
                                                                                                                                                                                                                                                                                                                                                                                                     organizations within their jurisdictions.


B1-a       n/a                                                                              Yes                   No           0             1             n/a                         Radio Group   n/a                                CheckPHSImpactStatement          n/a                               n/a           Yes                             n/a           n/a           Radio           The Public Health System Impact
                                                                                                                                                                                                                                                                                                                                                                                                     Statement (PHSIS) is applicable to
                                                                                                                                                                                                                                                                                                                                                                                                     some programs and must be completed
                                                                                                                                                                                                                                                                                                                                                                                                     and distributed. See specific
                                                                                                                                                                                                                                                                                                                                                                                                     instructions in the RFA, if applicable.
                                                                                                                                                                                                                                                                                                                                                                                                     The PHSIS is intended to inform State
                                                                                                                                                                                                                                                                                                                                                                                                     and local health officials of health
                                                                                                                                                                                                                                                                                                                                                                                                     services grant applications submitted by
                                                                                                                                                                                                                                                                                                                                                                                                     organizations within their jurisdictions.


B1-b       n/a                                                                              N/A                   No           0             1             n/a                         Radio Group   n/a                                CheckPHSImpactStatement          n/a                               n/a           Not Applicable                  n/a           n/a           Radio           The Public Health System Impact
                                                                                                                                                                                                                                                                                                                                                                                                     Statement (PHSIS) is applicable to
                                                                                                                                                                                                                                                                                                                                                                                                     some programs and must be completed
                                                                                                                                                                                                                                                                                                                                                                                                     and distributed. See specific
                                                                                                                                                                                                                                                                                                                                                                                                     instructions in the RFA, if applicable.
                                                                                                                                                                                                                                                                                                                                                                                                     The PHSIS is intended to inform State
                                                                                                                                                                                                                                                                                                                                                                                                     and local health officials of health
                                                                                                                                                                                                                                                                                                                                                                                                     services grant applications submitted by
                                                                                                                                                                                                                                                                                                                                                                                                     organizations within their jurisdictions.


B2-0       2. Has the appropriate box been checked on the SF-424 (FACE                      Intergovernmental     No           0             1             CheckIntergrovernmental     Agency-       globLib:YesNoDataType              n/a                              n/a                               n/a           n/a                             n/a           n/a           Check           On the face page of the SF-424,
           PAGE) regarding intergovernmental review under E.O. 12372 ? (45                  Review Checked                                                 Review                      specific                                                                                                                                                                                                      applicants must certify whether the
           CFR Part 100) ...............                                                                                                                                                                                                                                                                                                                                                             request is covered under Executive
                                                                                                                                                                                                                                                                                                                                                                                                     Order 12372 and where appropriate, if
                                                                                                                                                                                                                                                                                                                                                                                                     the State has been given an opportunity
                                                                                                                                                                                                                                                                                                                                                                                                     to comment. The date given to State
                                                                                                                                                                                                                                                                                                                                                                                                     must be indicated.
B3-0       3. Has the entire proposed project period been identified on the SF-             Project Period        No           0             1             CheckProjectPeriod424       Agency-       globLib:YesNoDataType              n/a                              n/a                               n/a           n/a                             n/a           n/a           Check           Applicants must assure that the
           424 (FACE PAGE)?..................                                               Identified                                                                                 specific                                                                                                                                                                                                      proposed project period has been
                                                                                                                                                                                                                                                                                                                                                                                                     identified on the SF-424 (FACE PAGE).

B4-0       4. Have biographical sketch(es) with job description(s) been                     Biographical Sketch No             0             1             CheckBiographicalSketch     Radio Group   n/a                                CheckBiographicalSketch          n/a                               LIST          n/a                             n/a           n/a           Radio Group     Applicants must assure that
           provided, when required?..............                                           Attached                                                                                                                                                                                                                                                                                                 biographical sketches with job
                                                                                                                                                                                                                                                                                                                                                                                                     description(s) have been provided. See
                                                                                                                                                                                                                                                                                                                                                                                                     specific instructions in the RFA.
B4-a       n/a                                                                              Yes                   No           0             1             n/a                         Radio Group   n/a                                CheckBiographicalSketch          n/a                               n/a           Yes                             n/a           n/a           Radio           Applicants must assure that
                                                                                                                                                                                                                                                                                                                                                                                                     biographical sketches with job
                                                                                                                                                                                                                                                                                                                                                                                                     description(s) have been provided. See
                                                                                                                                                                                                                                                                                                                                                                                                     specific instructions in the RFA.
B4-b       n/a                                                                              N/A                   No           0             1             n/a                         Radio Group   n/a                                CheckBiographicalSketch          n/a                               n/a           Not Applicable                  n/a           n/a           Radio           Applicants must assure that
                                                                                                                                                                                                                                                                                                                                                                                                     biographical sketches with job
                                                                                                                                                                                                                                                                                                                                                                                                     description(s) have been provided. See
                                                                                                                                                                                                                                                                                                                                                                                                     specific instructions in the RFA.
B5-0       5. Has the "Budget Information" page, SF-424A (Non-Construction                  Budget Information    No           0             1             CheckSF424AC                Agency-       globLib:YesNoDataType              n/a                              n/a                               n/a           n/a                             n/a           n/a           Check           Applicants must assure that the Budget
           Programs) or SF-424C (Construction Programs), been completed                     Completed                                                                                  specific                                                                                                                                                                                                      Information page, SF-424A of SF424C
           and included? ............................                                                                                                                                                                                                                                                                                                                                                has been completed and included.

B6-0       6. Has the 12 month narrative budget justification been provided?                12 Month Detailed     No           0             1             Check12MonthBudgetJus       Radio Group   n/a                                Check12MonthBudgetJustify        n/a                               LIST          n/a                             n/a           n/a           Radio Group     Applicants must assure that the
           ......................................................                           Budget                                                         tify                                                                                                                                                                                                                                      narrative budget justification for the first
                                                                                                                                                                                                                                                                                                                                                                                                     12 months has been provided.
B6-a       n/a                                                                              Yes                   No           0             1             n/a                         Radio Group   n/a                                Check12MonthBudgetJustify        n/a                               n/a           Yes                             n/a           n/a           Radio           Applicants must assure that the
                                                                                                                                                                                                                                                                                                                                                                                                     narrative budget justification for the first
                                                                                                                                                                                                                                                                                                                                                                                                     12 months has been provided.
B6-b       n/a                                                                              N/A                   No           0             1             n/a                         Radio Group   n/a                                Check12MonthBudgetJustify        n/a                               n/a           Not Applicable                  n/a           n/a           Radio           Applicants must assure that the
                                                                                                                                                                                                                                                                                                                                                                                                     narrative budget justification for the first
                                                                                                                                                                                                                                                                                                                                                                                                     12 months has been provided.
B7-0       7. Has the budget for the entire proposed project period with                    Project Period        No           0             1             HasDetailProjectBudget      Radio Group   n/a                                HasDetailProjectBudget           n/a                               LIST          n/a                             n/a           n/a           Radio Group     Applicants must assure that the budget
           sufficient detail been provided? ...................                             Budget                                                                                                                                                                                                                                                                                                   for the entire proposed project period,
                                                                                                                                                                                                                                                                                                                                                                                                     with sufficient detailed justifications, has
                                                                                                                                                                                                                                                                                                                                                                                                     been provided.
B7-a       n/a                                                                              Yes                   No           0             1             n/a                         Radio Group   n/a                                HasDetailProjectBudget           n/a                               n/a           Yes                             n/a           n/a           Radio           Applicants must assure that the budget
                                                                                                                                                                                                                                                                                                                                                                                                     for the entire proposed project period,
                                                                                                                                                                                                                                                                                                                                                                                                     with sufficient detailed justifications, has
                                                                                                                                                                                                                                                                                                                                                                                                     been provided.
B7-b       n/a                                                                              N/A                   No           0             1             n/a                         Radio Group   n/a                                HasDetailProjectBudget           n/a                               n/a           Not Applicable                  n/a           n/a           Radio           Applicants must assure that the budget
                                                                                                                                                                                                                                                                                                                                                                                                     for the entire proposed project period,
                                                                                                                                                                                                                                                                                                                                                                                                     with sufficient detailed justifications, has
                                                                                                                                                                                                                                                                                                                                                                                                     been provided.
B8-0       8. For a Supplemental application, does the narrative budget                     Supplemental          No           0             1             SuppOnlyAdditionalFunds     Radio Group   n/a                                SuppOnlyAdditionalFunds          n/a                               LIST          n/a                             n/a           n/a           Radio Group     If this is an application for supplemental
           justification address only the additional funds requested?                       Application Budget                                                                                                                                                                                                                                                                                       funds, applicants must assure that the
                                                                                                                                                                                                                                                                                                                                                                                                     detailed budget and programmatic
                                                                                                                                                                                                                                                                                                                                                                                                     justifications are provided only for the
                                                                                                                                                                                                                                                                                                                                                                                                     additional funds requested.

B8-a       n/a                                                                              Yes                   No           0             1             n/a                         Radio Group   n/a                                SuppOnlyAdditionalFunds          n/a                               n/a           Yes                             n/a           n/a           Radio           If this is an application for supplemental
                                                                                                                                                                                                                                                                                                                                                                                                     funds, applicants must assure that the
                                                                                                                                                                                                                                                                                                                                                                                                     detailed budget and programmatic
                                                                                                                                                                                                                                                                                                                                                                                                     justifications are provided only for the
                                                                                                                                                                                                                                                                                                                                                                                                     additional funds requested.

B8-b       n/a                                                                              N/A                   No           0             1             n/a                         Radio Group   n/a                                SuppOnlyAdditionalFunds          n/a                               n/a           Not Applicable                  n/a           n/a           Radio           If this is an application for supplemental
                                                                                                                                                                                                                                                                                                                                                                                                     funds, applicants must assure that the
                                                                                                                                                                                                                                                                                                                                                                                                     detailed budget and programmatic
                                                                                                                                                                                                                                                                                                                                                                                                     justifications are provided only for the
                                                                                                                                                                                                                                                                                                                                                                                                     additional funds requested.

B9-0       9. For Competing Continuation and Supplemental applications, has                 Progress Report       No           0             1             CheckProgressReport         Radio Group   n/a                                CheckProgressReport              n/a                               LIST          n/a                             n/a           n/a           Radio Group     If this is a Competing Continuation or
           a progress report been included?                                                                                                                                                                                                                                                                                                                                                          Supplemental application, applicants
                                                                                                                                                                                                                                                                                                                                                                                                     must assure that a progress report has
                                                                                                                                                                                                                                                                                                                                                                                                     been provided.
B9-a       n/a                                                                              Yes                   No           0             1             n/a                         Radio Group   n/a                                CheckProgressReport              n/a                               n/a           Yes                             n/a           n/a           Radio           If this is a Competing Continuation or
                                                                                                                                                                                                                                                                                                                                                                                                     Supplemental application, applicants
                                                                                                                                                                                                                                                                                                                                                                                                     must assure that a progress report has
                                                                                                                                                                                                                                                                                                                                                                                                     been provided.
B9-b       n/a                                                                              N/A                   No           0             1             n/a                         Radio Group   n/a                                CheckProgressReport              n/a                               n/a           Not Applicable                  n/a           n/a           Radio           If this is a Competing Continuation or
                                                                                                                                                                                                                                                                                                                                                                                                     Supplemental application, applicants
                                                                                                                                                                                                                                                                                                                                                                                                     must assure that a progress report has
                                                                                                                                                                                                                                                                                                                                                                                                     been provided.
C0-1       PART C: In the spaces provided below, please provide the                         n/a                   n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
           requested information.
C1-0       Business Official to be notified if an award is to be made                       n/a                   n/a          n/a           n/a           n/a                         Global        globLib:HumanNameDataType          n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           Provide the name of the Business
                                                                                                                                                                                                                                                                                                                                                                                                     Official to be notified if an award is to be
                                                                                                                                                                                                                                                                                                                                                                                                     made. The Official Notice of Grant
                                                                                                                                                                                                                                                                                                                                                                                                     Award will be mailed to the Business
                                                                                                                                                                                                                                                                                                                                                                                                     Official named in Part C.
C1-1       Prefix:                                                                          Business Official     No           0             1             Prefix                      Global        globLib:PrefixName                 n/a                              n/a                               LIST          Mr.&&Mrs.&&Miss&&Ms.&&Dr.       0             10            Combobox        Enter the prefix (e.g., Mr., Mrs., Rev.)
                                                                                            Prefix                                                                                                                                                                                                                       &&Rev.&&Prof.                                                               for the name of the Business Official.
C1-2       First Name:                                                                      Business Official     Yes          1             1             FirstName                   Global        globLib:FirstName                  n/a                              n/a                               AN            n/a                             1             35            Field           Enter Business Official First Name
                                                                                            First Name                                                                                                                                                                                                                                                                                               (Given Name)
C1-3       Middle Name:                                                                     Business Official     No           0             1             MiddleName                  Global        globLib:MiddleName                 n/a                              n/a                               AN            n/a                             0             25            Field           Enter Business Official Middle Name
                                                                                            Middle Name
C1-4       Last Name:                                                                       Business Official     Yes          1             1             LastName                    Global        globLib:LastName                   n/a                              n/a                               AN            n/a                             1             60            Field           Enter Business Official Last Name
                                                                                            Last Name                                                                                                                                                                                                                                                                                                (Surname)
C1-5       Suffix:                                                                          Business Official     No           0             1             Suffix                      Global        globLib:SuffixName                 n/a                              n/a                               LIST          Jr.&&Sr.&&M.D.&&Ph.D            0             10            Combobox        Enter the suffix (e.g., Jr. Sr., PhD), if
                                                                                            Suffix                                                                                                                                                                                                                                                                                                   appropriate for the Business Official.
C1-6       Title:                                                                           Business Official     Yes          1             1             BOTitle                     Global        globLib:HumanTitleDataType         n/a                              n/a                               AN            n/a                             1             45            Field           Enter Business Official Title
                                                                                            Title
C1-7       Organization:                                                                    Business Official     Yes          1             1             BOOrganizationName          Global        globLib:OrganizationNameDataType   n/a                              n/a                               AN            n/a                             1             60            Field           Enter Business Official Organization
                                                                                            Organization                                                                                                                                                                                                                                                                                             Name
C1-8       Street1:                                                                         Business Official     Yes          1             1             BOStreet1                   Global        globLib:Street1                    n/a                              n/a                               AN            n/a                             1             55            Field           Enter the first line of Street Address for
                                                                                            Street1                                                                                                                                                                                                                                                                                                  the Business Official
C1-9       Street2:                                                                         Business Official     No           0             1             BOStreet2                   Global        globLib:Street2                    n/a                              n/a                               AN            n/a                             0             55            Field           Enter the second line of Street Address
                                                                                            Street2                                                                                                                                                                                                                                                                                                  for the Business Official
C1-10      City:                                                                            Business Official     Yes          1             1             BOCity                      Global        globLib:City                       n/a                              n/a                               AN            n/a                             1             35            Field           Enter Business Official City
                                                                                            City
C1-11      State:                                                                           Business Official     Yes          1             1             BOState                     Global        globLib:State                      n/a                              n/a                               LIST          50 US States, US possessions,   1             55            Popup           Enter Business Official State
                                                                                            State                                                                                                                                                                                                                        territories, military codes

C1-12      ZIP / Postal Code:                                                               Business Official     Yes          1             1             BOZipPostalCode             Agency                                           n/a                              Must be 5 numeric digits.         AN            n/a                             5             5             Field           Enter Business Official 5-digit ZIP /
                                                                                            ZIP / Postal Code                                                                          specific                                                                                                                                                                                                      Postal code.
C1-12a     ZIP / Postal Code4:                                                              Business Official     No           0             1             BOZipPostalCodeplus4        Agency                                           n/a                              If entered, must be 4 numeric     AN            n/a                             0             4             Field           Enter Business Official 4-digit ZIP /
                                                                                            ZIP / Postal Code                                                                          specific                                                                          digits.                                                                                                                     Postal code extension.
                                                                                            plus 4
C1-13      E-mail Address:                                                                  Business Official     Yes          1             1             BOEmail                     Global        globLib:EmailDataType              n/a                              E-mail validation                 AN            n/a                             1             60            Field           Enter Business Official's E-mail
                                                                                            Email                                                                                                                                                                                                                                                                                                    Address
C1-14      Telephone Number:                                                                Business Official     Yes          1             1             BOPhone                     Global        globLib:TelephoneNumberDataType    n/a                              n/a                               AN            n/a                             1             25            Field           Enter Business Official Phone Number
                                                                                            Telephone Number                                                                                                                                                                                                                                                                                         with Area Code

C1-15      Fax Number:                                                                      Business Official     No           0             1             BOFax                       Global        globLib:TelephoneNumberDataType    n/a                              n/a                               AN            n/a                             0             25            Field           Enter Business Official Fax Number
                                                                                            Fax Number                                                                                                                                                                                                                                                                                               with Area Code
C2-0       Program Director/Project Director/Principal Investigator                         n/a                   n/a          n/a           n/a           n/a                         Global        globLib:HumanNameDataType          n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           Program Director/Project
           designated to direct the proposed project or program                                                                                                                                                                                                                                                                                                                                      Director/Principal Investigaor
                                                                                                                                                                                                                                                                                                                                                                                                     designated to direct the proposed
                                                                                                                                                                                                                                                                                                                                                                                                     project or program. The individual
                                                                                                                                                                                                                                                                                                                                                                                                     designated to direct the project must be
                                                                                                                                                                                                                                                                                                                                                                                                     the same as the individaul identified in
                                                                                                                                                                                                                                                                                                                                                                                                     Item 5 on the face page of the
                                                                                                                                                                                                                                                                                                                                                                                                     applications.
C2-1       Prefix:                                                                          PDPI Prefix           No           0             1             Prefix                      Global        globLib:PrefixName                 n/a                              n/a                               LIST          Mr.&&Mrs.&&Miss&&Ms.&&Dr.       0             10            Combobox        Enter the prefix (e.g., Mr., Mrs., Rev.)
                                                                                                                                                                                                                                                                                                                         &&Rev.&&Prof.                                                               for the name of the Program Director.
C2-2       First Name:                                                                      PDPI First Name       Yes          1             1             FirstName                   Global        globLib:FirstName                  n/a                              n/a                               AN            n/a                             1             35            Field           Enter Program Director First Name
                                                                                                                                                                                                                                                                                                                                                                                                     (Given Name)
C2-3       Middle Name:                                                                     PDPI Middle Name      No           0             1             MiddleName                  Global        globLib:MiddleName                 n/a                              n/a                               AN            n/a                             0             25            Field           Enter Program Director Middle Name
C2-4       Last Name:                                                                       PDPI Last Name        Yes          1             1             LastName                    Global        globLib:LastName                   n/a                              n/a                               AN            n/a                             1             60            Field           Enter Program Director Last Name
                                                                                                                                                                                                                                                                                                                                                                                                     (Surname)
C2-5       Suffix:                                                                          PDPI Suffix           No           0             1             Suffix                      Global        globLib:SuffixName                 n/a                              n/a                               LIST          Jr.&&Sr.&&M.D.&&Ph.D            0             10            Combobox        Enter the suffix (e.g., Jr. Sr., PhD), if
                                                                                                                                                                                                                                                                                                                                                                                                     appropriate for the Program Director.
C2-6       Title:                                                                           PDPI Title            Yes          1             1             PDTitle                     Global        globLib:HumanTitleDataType         n/a                              n/a                               AN            n/a                             1             45            Field           Enter Program Director Title
C2-7       Organization:                                                                    PDPI Organization     Yes          1             1             PDOrganizationName          Global        globLib:OrganizationNameDataType   n/a                              n/a                               AN            n/a                             1             60            Field           Enter Program Director Organization
                                                                                                                                                                                                                                                                                                                                                                                                     Name
C2-8       Street1:                                                                         PDPI Street1          Yes          1             1             PDStreet1                   Global        globLib:Street1                    n/a                              n/a                               AN            n/a                             1             55            Field           Enter the first line of Street Address for
                                                                                                                                                                                                                                                                                                                                                                                                     the Program Director
C2-9       Street2:                                                                         PDPI Street2          No           0             1             PDStreet2                   Global        globLib:Street2                    n/a                              n/a                               AN            n/a                             0             55            Field           Enter the second line of Street Address
                                                                                                                                                                                                                                                                                                                                                                                                     for the Program Director
C2-10      City:                                                                            PDPI City             Yes          1             1             PDCity                      Global        globLib:City                       n/a                              n/a                               AN            n/a                             1             35            Field           Enter Program Director City
C2-11      State:                                                                           PDPI State            Yes          1             1             PDState                     Global        globLib:State                      n/a                              n/a                               LIST          50 US States, US possessions,   1             55            Popup           Enter Program Director State
                                                                                                                                                                                                                                                                                                                         territories, military codes

C2-12      ZIP / Postal Code:                                                               PDPI ZIP / Postal     Yes          1             1             PDZipPostalCode             Agency                                           n/a                              Must be 5 numeric digits.         AN            n/a                             5             5             Field           Enter Program Director 5-digit ZIP /
                                                                                            Code                                                                                       specific                                                                                                                                                                                                      Postal code.
C2-12a     ZIP / Postal Code4:                                                              PDPI ZIP / Postal     No           0             1             PDZipPostalCodeplus4        Agency                                           n/a                              If entered, must be 4 numeric     AN            n/a                             0             4             Field           Enter Program Director 4-digit ZIP /
                                                                                            Code plus 4                                                                                specific                                                                          digits.                                                                                                                     Postal code extension.
C2-13      E-mail Address:                                                                  PDPI Email            Yes          1             1             PDEmail                     Global        globLib:EmailDataType              n/a                              E-mail validation                 AN            n/a                             1             60            Field           Enter Program Director's E-mail
                                                                                                                                                                                                                                                                                                                                                                                                     Address
C2-14      Telephone Number:                                                                PDPI Telephone        Yes          1             1             PDPhone                     Global        globLib:TelephoneNumberDataType    n/a                              n/a                               AN            n/a                             1             25            Field           Enter Program Director Phone Number
                                                                                            Number                                                                                                                                                                                                                                                                                                   with Area Code
C2-15      Fax Number:                                                                      PDPI Fax Number       No           0             1             PDFax                       Global        globLib:TelephoneNumberDataType    n/a                              n/a                               AN            n/a                             0             25            Field           Enter Program Director Fax Number
                                                                                                                                                                                                                                                                                                                                                                                                     with Area Code
2-0        HHS Checklist (08-2007)                                                          n/a                   n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
D0-1       HHS-5161-1 (08/2007)                                                             n/a                   n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
D0-2       PART D: A private, nonprofit organization must include                           n/a                   n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           A private, nonprofit organization must
           evidence of its nonprofit status with the application. Any of                                                                                                                                                                                                                                                                                                                             include evidence of its nonprofit status
           the following is acceptable evidence. Check the appropriate                                                                                                                                                                                                                                                                                                                               with the application. Any of the following
           box or complete the "Previously Filed" section, whichever is                                                                                                                                                                                                                                                                                                                              is acceptable evidence. Check the
                                                                                                                                                                                                                                                                                                                                                                                                     appropriate box or complete the
           applicable.
                                                                                                                                                                                                                                                                                                                                                                                                     "Previously Filed" section, whichever is
                                                                                                                                                                                                                                                                                                                                                                                                     applicable.
D1-a       (a) A reference to the organization's listing in the Internal Revenue            Reference to IRS      No           0             1             CheckReferenceIRSList       Agency-       globLib:YesNoDataType              n/a                              If checked, disable D2-0, D2-     n/a           n/a                             n/a           n/a           Check           Check, if applicable; and provide
           Service's (IRS) most recent list of tax-exempt organizations                     501(c)(3)                                                                                  specific                                                                          1, D2-2.                                                                                                                    document
           described in section 501(c)(3) of the IRS Code.
D1-b       (b) A copy of a currently valid Internal Revenue Service Tax                     Tax exempt            No           0             1             CheckIRSCertification     Agency-         globLib:YesNoDataType              n/a                              If checked, disable D2-0, D2-     n/a           n/a                             n/a           n/a           Check           Check, if applicable; and provide
           exemption certificate.                                                           certificate                                                                              specific                                                                            1, D2-2.                                                                                                                    document
D1-c       (c) A statement from a State taxing body, State Attorney General, or             Nonprofit Status      No           0             1             CheckStateTaxCertificatio Agency-         globLib:YesNoDataType              n/a                              If checked, disable D2-0, D2-     n/a           n/a                             n/a           n/a           Check           Check, if applicable; and provide
           other appropriate State official certifying that the applicant                   from State                                                     n                         specific                                                                            1, D2-2.                                                                                                                    document
           organization has a nonprofit status and that none of the net earnings
           accrue to any private shareholders or individuals.

D1-d       (d) A certified copy of the organization's certificate of incorporation   Certificate of               No           0             1             CheckIncorporationCertifi   Agency-       globLib:YesNoDataType              n/a                              If checked, disable D2-0, D2-     n/a           n/a                             n/a           n/a           Check           Check, if applicable; and provide
           or similar document if it clearly establishes the nonprofit status of the Incorporation                                                         cation                      specific                                                                          1, D2-2.                                                                                                                    document
           organization.
D1-e       (e) Any of the above proof for a State or national parent organization, Local Nonprofit                No           0             1             CheckParentOrganzation      Agency-       globLib:YesNoDataType              n/a                              If checked, disable D2-0, D2-     n/a           n/a                             n/a           n/a           Check           Check, if applicable; and provide
           and a statement signed by the parent organization that the applicant Affiliate                                                                  Certification               specific                                                                          1, D2-2.                                                                                                                    document
           organization is a local nonprofit affiliate.

D2-0       If an applicant has evidence of current nonprofit status on file with an         n/a                   n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
           agency of HHS, it will not be necessary to file similar papers again,
           but the place and date of filing must be indicated.

D2-1       Previously Filed with: (Agency)                                                  Previously Filed      No           0             1             AgencyName                  Global        globLib:AgencyNameDataType         n/a                              Disabled if                       AN            n/a                             0             60            Field           If an applicant has evidence of current
                                                                                            With                                                                                                                                                                         CheckReferenceIRSList,                                                                                                      nonprofit status on file with an agency of
                                                                                                                                                                                                                                                                         CheckIRSCertification,                                                                                                      HHS, it will not be necessary to file
                                                                                                                                                                                                                                                                         CheckStateTaxCertification,                                                                                                 similar papers again. Enter the name of
                                                                                                                                                                                                                                                                         CheckIncorporationCertificati                                                                                               previous agency of filing.
                                                                                                                                                                                                                                                                         on, or
                                                                                                                                                                                                                                                                         CheckParentOrganzationCert
                                                                                                                                                                                                                                                                         ification are checked
D2-2       on (Date)                                                                        Date Previously       No           0             1             PreviouslyFiledDate         Agency-       n/a                                n/a                              Disabled if                       DATE          n/a                             n/a           n/a           Field           Enter the previous filing date
                                                                                            Filed                                                                                      specific                                                                          CheckReferenceIRSList,
                                                                                                                                                                                                                                                                         CheckIRSCertification,
                                                                                                                                                                                                                                                                         CheckStateTaxCertification,
                                                                                                                                                                                                                                                                         CheckIncorporationCertificati
                                                                                                                                                                                                                                                                         on, or
                                                                                                                                                                                                                                                                         CheckParentOrganzationCert
                                                                                                                                                                                                                                                                         ification are checked
3-0        INVENTIONS                                                                       n/a                   n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
3-1        If this is an application for continued support, include: (1) the report         n/a                   n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
           of inventions conceived or reduced to practice required by the terms
           and conditions of the grant; or (2) a list of inventions already
           reported, or (3) a negative certification.
4-0        EXECUTIVE ORDER 12372                                                      n/a                         n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
4-1        Effective September 30, 1983, Executive Order 12372                        n/a                         n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
           (Intergovernmental Review of Federal Programs) directed OMB to
           abolish OMB Circular A-95 and establish a new process for
           consulting with State and local elected officials on proposed Federal
           financial assistance. The Department of Health and Human Services
           implemented the Executive Order through regulations at 45 CFR
           Part 100 (Inter-governmental Review of Department of Health and
           Human Services Programs and Activities). The objectives of the
           Executive Order are to (1) increase State flexibility to design a
           consultation process and select the programs it wishes to review,
           (2) increase the ability of State and local elected officials to influence
           Federal decisions and (3) compel Federal officials to be responsive
           to State concerns, or explain the reasons.



4-2        The regulations at 45 CFR Part 100 were published in the Federal                 n/a                   n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
           Register on June 24, 1983, along with a notice identifying the
           Department’s programs that are subject to the provisions of
           Executive Order 12372. Information regarding HHS programs
           subject to Executive Order 12372 is also available from the
           appropriate awarding office.
4-3        States participating in this program establish State Single Points of            n/a                   n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
           Contact (SPOCs) to coordinate and manage the review and
           comment on proposed Federal financial assistance. Applicants
           should contact the Governor’s office for information regarding the
           SPOC, programs selected for review, and the consultation (review)
           process designed by their State.

4-4        Applicants are to certify on the face page of the SF-424 (attached) n/a                                n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
           whether the request is for a program covered under Executive Order
           12372 and, where appropriate, whether the State has been given an
           opportunity to comment.
5-0        BY SIGNING THE FACE PAGE OF THIS APPLICATION, THE                   n/a                                n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
           APPLICANT ORGANIZATION CERTIFIES THAT THE
           STATEMENTS IN THIS APPLICATION ARE TRUE,
           COMPLETE, AND ACCURATE TO THE BEST OF THE
           SIGNER’S KNOW LEDGE, AND THE ORGANIZATION
           ACCEPTS THE OBLIGATION TO COMPLY W ITH U.S.
           DEPARTMENT OF HEALTH AND HUMAN SERVICES’ TERMS
           AND CONDITIONS IF AN AW ARD IS MADE AS A RESULT OF
           THE APPLICATION. THE SIGNER IS ALSO AW ARE THAT ANY
           FALSE, FICTITIOUS, OR FRAUDULENT STATEMENTS OR
           CLAIMS MAY SUBJECT THE SIGNER TO CRIMINAL, CIVIL,
           OR ADMINISTRATIVE PENALTIES.
5-1        THE FOLLOW ING ASSURANCES/CERTIFICATIONS ARE                                     n/a                   n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
           MADE AND VERIFIED BY THE SIGNATURE OF THE
           OFFICIAL SIGNING FOR THE APPLICANT ORGANIZATION
           ON THE FACE PAGE OF THE APPLICATION:


5-2        Civil Rights – Title VI of the Civil Rights Act of 1964 (P.L. 88-                n/a                   n/a          n/a           n/a           n/a                         n/a           n/a                                n/a                              n/a                               n/a           n/a                             n/a           n/a           Label           n/a
           352), as amended, and all the requirements imposed by or pursuant
           to the
           HHS regulation (45 CFR part 80).




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                                               C:\Docstoc\Working\pdf\04858263-e23a-4b33-8950-4b56b23be89d.xls
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5-3    Handicapped Individuals – Section 504 of the Rehabilitation Act      n/a              n/a     n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   Label   n/a
       of 1973 (P.L. 93-112), as amended, and all requirements imposed by
       or
       pursuant to the HHS regulation (45 CFR part 84).


5-4                                                                         n/a              n/a     n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   Label   n/a
       Sex Discrimination – Title IX of the Educational Amendments of
       1972 (P.L. 92-318), as amended, and all requirements imposed by or
       pursuant to the HHS regulation (45 CFR part 86).

5-5    Age Discrimination – The Age Discrimination Act of 1975 (P.L. 94- n/a                 n/a     n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   Label   n/a
       135), as amended, and all requirements imposed by or pursuant to
       the
       HHS regulation (45 CFR part 91).

5-6    Debarment and Suspension – Title 2 CFR part 376.                     n/a              n/a     n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   Label   n/a
5-7    Certification Regarding Drug-Free W orkplace Requirements            n/a              n/a     n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   Label   n/a
       – Title 45 CFR part 82.
5-8    Certification Regarding Lobbying – Title 32, United States           n/a              n/a     n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   Label   n/a
       Code, Section 1352 and all requirements imposed by or pursuant to
       the HHS
       regulation (45 CFR part 93).

5-9    Environmental Tobacco Smoke – Public Law 103-227.                    n/a              n/a     n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   Label   n/a
5-10   Program Fraud Civil Remedies Act (PFCRA)                             n/a              n/a     n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   Label   n/a
6-0    HHS Checklist (08-2007)                                              n/a              n/a     n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   n/a   Label   n/a




                                                                                                                                                                                     3 of 12
                                   C:\Docstoc\Working\pdf\04858263-e23a-4b33-8950-4b56b23be89d.xls
                                   Printed: 7/14/2011
USING THE DATA ANALYSIS TEMPLATE TOOLKIT
      It is recommended that you print this sheet. To do so, click File, Print on the menu at the top the screen.
 1.
      Click on the DAT Instructions tab at the bottom of the screen. It is recommended that you print these instructions to use as a reference during the
 2.   process of creating your Data Analysis Template (DAT). To do so, click File, Print on the menu at the top the screen.

      Click on the Form Info tab at the bottom of the screen. Fill in the requested information about the form. Refer to the instructions printed in 1. for
 3.   guidance.

      Click on the Global Index tab at the bottom of the screen. The Global Index serves two purposes:
 4.
            o It gives you the ability to view the Grants.gov Global Library of standard fields and their attributes
            o It gives you the ability to utilize pre-formatted templates to be used as rows in your form's Data Analysis Template (DAT).

      Now is the time to begin preparing the Data AnalysisTemplate (DAT).


      Determine the first (next) data element on the form. A data element is a data entry field, form title, section header or label.
 5.
                 IS IT A FORM TITLE, SECTION HEADER, OR LABEL?

                       YES. Copy the Label row template into your DAT.
                       Look for Label in the Global Index section III. General Data Element Formats. Click on Label. The template row for a label will be
                       highlighted. Select Edit, Copy from the menu at the top of the screen. Click on the FORM DAT tab at the bottom of the screen. Click
                       on the appropriate row number to paste the template into. From the menu, select Edit, Paste. Use the DAT instructions as guidance
                       for filling in all columns in red.

                       NO. Then it must be a data entry field.

                             Grants.gov has created a required standard for representing names and addresses on forms. Elements related to names and
                             addresses are grouped together in data element groups. If a data element group is selected, all fields within that group must be
                             included.

                             IS THE ELEMENT PART OF A NAME OR ADDRESS?

                             YES. To use the Human Name Group or Address Group, click on the appropriate link in section II of the Global Index. Select
                             Edit, Copy from the menu at the top of the screen. Click on the FORM DAT tab at the bottom of the screen. Click on the row
                             number into which template will be pasted. From the menu, select Edit, Paste. Use the DAT instructions as guidance for filling
                             in all columns in red.

                             NO. IS THE ELEMENT A GLOBAL DATA ELEMENT?

                             A global data element is a data element that is commonly used on forms across agencies. Grants.gov has standardized the
                             attributes for global data elements. Some global data elements may be pre-populated from the application cover sheets, some
                             may be post-populated after submission to Grants.gov, and some may be forward-populated from the application cover sheets.
                             The Global Index in section I provides a list of global data elements.

                                   YES. Copy the element's template into your DAT.
                                   Click on the name of the element. The template row for a label will be highlighted. Select Edit, Copy from the menu at the
                                   top of the screen. Click on the FORM DAT tab at the bottom of the screen. Click on the row number into which the
                                   template will be pasted. From the menu, select Edit, Paste. Use the DAT instructions as guidance for filling in all columns
                                   in red.
                                   NO. THEN THE ELEMENT MUST BE AGENCY-SPECIFIC.
                                   Determine the General Field Format in section III of the Global Index that best reflects the data element. Click on the
                                   name of the format or one of the options beneath it. The template row(s) will be highlighted. Select Edit, Copy from the
                                   menu at the top of the screen. Click on the FORM DAT tab at the bottom of the screen. Click on the row number into
                                   which the template will be pasted. From the menu, select Edit, Paste. Use the DAT instructions as guidance for filling in
                                   all columns in red. For information about pre-populating, post-populating, and forward-populating, refer to the DAT
                                   instructions.

      Repeat all of the steps in 5. until all elements on the form are represented on the DAT. The data elements on the DAT should be in the same order
      they appear on the form. For answers to questions about the process of preparing a Data Analysis Template, contact the PMO Program Advisor.
FORM INFORMATION
 ROW                ROW NAME                                                                                          ROW DEFINITION
  [A]    Form Name / Title           The name of the form to be displayed on the Grants.gov system
  [B]    Form Number                 The number associated with the form within the agency.
  [C]    Version Number              The version number of the form within the agency.
  [D]    Version Date                The version date of the form.
  [E]    Description                 A short description of the form.
  [F]    OMB Control Number          The control number issued by the Office of Management and Budget (OMB) when a form is cleared.
  [G]    OMB Expiration Date         The expiration date issued by the Office of Management and Budget (OMB.)
  [H]    Form Family                 The families this form should be include with.




FORM ELEMENTS
COLUMN            COLUMN NAME                                                                                               COLUMN DEFINITION
  [1]  Field #                       A unique, sequential number for (a) each field on the form for which data will be entered or selected and (b) form title, section headers or labels. Use the block number on the form mock up, if
                                     any, otherwise start the count with 1. Format is <block#>-<field#> (e.g. Block 15, field 1 would be represented as 15-1.)
  [2]    Field Label                 The name of the field as presented on the form. This label will be used at the beginning of the Help Tip and Accessibility Text. If the label has more than 25 characters, then provide an
                                     abbreviated version in the Short Field Label [3] column. This column is also used when Field Implementation [16] is label and you are specifying the form title, section headers, or labels. You
                                     may change any Global Library template label in red to the label as specified on the form.
  [3]    Short Field Label           Enter condensed version for use at the beginning of Help Tip and Accessibility Text. Please limit to 40 characters or less and do not abbreviate words.

  [4]    Required?                   - Enter "Yes" if the field must be completed before the application can be submitted.
                                     - If the field is optional, conditional, or "Required if" then enter "No" in this column.
                                     - If the field is calculated (see BUSINESS RULES [11]) and all fields involved in the calculation are optional, enter “No” in this column.
                                     - If the field is calculated (see BUSINESS RULES [11]) and one or more of the fields involved in the calculation are mandatory, enter “Yes” in this column.
                                     - If the field is to be forward-populated (see FIELD TYPE [8]), then the value for this column should be the same as the value of the source field (e.g. if the source field is optional, the destination
                                     field is optional, if the source field is mandatory, the destination field is mandatory).
  [5]    Minimum Occurrences         - The minimum number of entries that can be made for the same field.
                                     - Enter 0 if the field is optional.
                                     - Enter 1 or more if the field must be completed before the application can be submitted.
  [6]    Maximum Occurrences         - The maximum number of entries that can be made for the same field.
                                     - Must be 1 or more.
  [7]    Agency Field Name           Short name that describes the field. This name will be used as an input to the XML schema. For Global Data Elements, a suggested name is pre-filled in red, though it may be changed.
                                     Grants.gov may modify names as needed to meet guidelines and standards. Note: Each Agency Field Name must be unique on a DAT.
  [8]    Field Type                  Select one from the following 5 options:
                                        Pre-populated                - Field will be populated with data from the application package. See Global Index Section II for a list of qualifying fields.
                                        Post-populated               - Field will be populated in a form after submission to Grants.gov. See the Global Index Section III for a list of qualifying fields.
                                        Forward-populated            - Field will be populated with data from the application cover page (e.g., SF424, SF424 (R&R)) or
                                                                     - Field will be populated with data entered earlier in the form.
                                        Global                       - Field is a global data element that is not forward-populated or a global data element group.
                                        Agency Specific              - Field is unique to your agency. Enter values in ALL columns in this DAT as indicated by the instructions.
                                        Radio Group                  - Agency-specific field that displays a limited set of alternatives. Applicant has the option of selecting one value.
   [9]   Global Library Field Name   - Pre-formatted for your convenience. No action required.
  [10]   Field Type Source              If Pre-populated             - Pre-formatted for your convenience. No action required.
                                        If Post-Populated            - Pre-formatted for your convenience. No action required.
                                        If Foward-Populated          - If "Foward-populated" was selected in the Field Type [8] column, enter the source's form name (as found on the PureEdge version of the form) and field #. Should
                                                                     be in the format <form name>-<block #>-<field #> (e.g. SF424-6-1.)
                                        If Global                    - If "Global" was selected in Field Type [8] column, enter n/a.
                                        If Agency Specific           - Pre-formatted for your convenience. No action required.
                                        If Radio Group               - If "Radio Group" was selected in the Field Type [8] column, then enter the name radio group. The radio group name may be the same as the Field Label.
  [11]   Business Rules              Simple rules about the field, such as:
                                           - Is a specific format required (e.g., 4 digit year and 5 digit code like "2004-abcdf")? Remember to indicate this format in the element's help tip.
                                           - Is a calculation required for this field (e.g., Total = 15-1 + 15-2 + 15-3 + 15-4)
                                           - Is this field conditionally required (e.g., Required if 3-1 is Yes)
                                           - NOTE: Grants.gov does not enforce business rules across forms.
                                           - Enter n/a if there are no business rules for the field.
  [12]   Data Type                   - Pre-formatted for your convenience. No action required.
FORM ELEMENTS
COLUMN           COLUMN NAME                                                                                                   COLUMN DEFINITION
  [13] List of Values                 - If theData Type [12] is LIST, provide a list of values that you want to be given to the user.
                                      - The format of each list item should be <id>: <description>. Use && to separate each value (e.g. MD: Maryland&& VA: Virginia)
                                      - For Minimum # of Characters [14] and Maximum # of Characters [15], enter the character count for the shortest and longest values in the list
                                      - If the field is required, it must have a default value. Mark the default value with an asterisk before the value, if any (e.g. *MD: Maryland.) If the user does not change
                                        the selection, the field will automatically be filled with the default value.
                                      - Enter n/a if a list of values does not apply.
                                      - NOTE: No list of values is needed for Radio Groups. This list of values is the Field Labels for the Radio Group's radio options.
  [14]   Minimum # of Characters or   - If the Data Type [12] is AN, enter the minimum number of characters that may be entered into a field (minimum field length.) If the field is optional, enter 0.
         Minimum Value                - If the Data Type [12] is INTEGER, $, or DECIMAL(2), enter the minimum value for the field including decimals where applicable
                                        (e.g. enter "5000" if the value cannot be less than 5000.)
                                      - If the Data Type [12] is LIST, FILE, MULTIFILE or DATE, enter "n/a" in this column.
                                      - A hyphen is not counted as a character if it is included on the form for presentation purposes. It is counted if it is to be stored with the data.
  [15]   Maximum # of Characters or   - If the Data Type [12] is AN, enter the maximum number of characters that may be entered into a field (maximum field length.)
         Maximum Value                - If the Data Type [12] is INTEGER, $, or DECIMAL(2), enter the maximum value for the field including decimals where applicable
                                        (e.g. enter "10,000" if the value cannot be more than 10,000.)
                                      - If the Data Type [12] is LIST, FILE, MULTIFILE, or DATE, enter "n/a" in this column.
                                      - A hyphen is not counted as a character if it is included on the form for presentation purposes. It is counted if it is to be stored with the data.
  [16]   Field Implementation         - Pre-formatted for your convenience.
  [17]   Help Tip                     Text that will be displayed when the applicant clicks on the help icon. Please compose the wording carefully, as this text will be used for the Accessibility text as well as the Help Tip. Use the
                                      following guidelines for creating help tips:

                                           - If the field is required, then the help tip should end with the statement "This field is required." Add "This field is required" to the end of global help tips if they are required.
                                           - If the field has a certain format, then the tip should contain text describing the required format.
                                           - If a Radio Group is required, then the help tip on the Radio Group Header should state "One selection is required."
                                                            Grants.gov Global Index
                         Click on an element name, data element group name, or general element format to view its DAT row template.
                                         Follow the instructions to copy and paste template rows into the Form DAT.

                                    I. GLOBAL DATA ELEMENTS                                                                  III. GENERAL DATA ELEMENT FORMATS
Agency Name                                 Employer/Taxpayer Identification Number (EIN/TIN)                    Alphanumeric
Applicant ID                                Fax                                                                  Button
CFDA Number                                 Federal Award Identifier                                             Date
CFDA Title                                  Federal Entity Identifier                                            Degree Earned
Congressional District: Applicant           Organization Name (Legal Name)                                       Dollar Amount
Congressional District: Program/Project     Phone Number                                                         Dollar Amount Total
Country                                     Project Name                                                         File Attachment - Single
Department Name                             Project Title                                                             Optional              Required
Division Name                               Social Security Number                                               File Attachment - Multiple
DUNS Number                                 Title                                                                     Optional              Required
Email                                       Type of Applicant                                                    Numeric
        DATA ELEMENTS THAT CAN BE PRE-POPULATED FROM THE APPLICATION PACKAGE                                          with 2 decimals       without decimals
Agency Name                                 Competition Identification Number                                    Label
CFDA Number                                 Competition Identification Title                                     List - Drop Down (one selection from a drop-down list of values)
CFDA Title                                  Funding Opportunity Number                                           List - Checkbox (Check for yes. May select multiple options)
                                            Funding Opportunity Title                                            List - Radio Group (one selection from a group of options)
        DATA ELEMENTS THAT ARE POST-POPULATED AFTER SUBMISSION TO GRANTS.GOV                                          Optional              Required
AOR Signature                                                                                                    Percent
Date Received                                                                                                         with 2 decimals       without decimals
Date Signed                                                                                                      Year
                                II. GLOBAL DATA ELEMENT GROUPS                                                   Yes/No Radio Group
Address Group                               Street1, Street2, City, County, Province, State, Zip Code, Country        Optional              Required
Human Name Group                            Prefix, First Name, Middle Name, Last Name, Suffix                   Yes/No/Other Radio Group
                                                                                                                      Optional              Required
                                                                                                                 Yes/No/Not Applicable
                                                                                                                      Optional              Required
DATA ANALYSIS ROW TEMPLATES
INSTRUCTIONS: Listed below are Data Analysis row templates for data elements and formats defined in the Global Library. To
copy into your DAT, select Edit, Copy from the menu at the top of the screen. Click on the FORM DAT tab at the bottom of the
screen. Click on the row number you want to paste the template into. From the menu, select Edit, Paste. Use the instructions on
the DAT INSTRUCTIONS tab as guidance for filling in all columns in red.

   [1]                      [2]                   [3]                  [4]             [5]             [6]                  [7]                 [8]                             [9]                                   [10]                                [11]                    [12]                    [13]              [14]              [15]              [16]                            [17]
                                                                                                                                                                                                                                                                                                                          Min # of           Max # of
                        Field                 Short Field                       Minimum         Maximum             Agency Field                                          Global Library                          Field Type                                                                             List of          Chars or          Chars or           Field
 Field #                Label                   Label          Required?       Occurrences     Occurrences             Name                 Field Type                     Field Name                               Source                         Business Rules            Data Type                   Values           Min Value         Max Value     Implementation                     Help Tip



GLOBAL DATA ELEMENTS
Fill In    Agency Name:                 Agency Name          Fill In         Fill In         Fill In         AgencyName                Global or            globLib:AgencyNameDataType              If Field Type [8] = Forward-populated   n/a                            AN            n/a                          Fill In         60                Field              Enter the name of the Federal Agency.
Unique #                                                                                                                               Forward-populated                                            then Fill In source, else n/a
Fill In    Applicant ID:                Applicant ID         Fill In         Fill In         Fill In         ApplicantID               Global or            globLib:ApplicantIDDataType             If Field Type [8] = Forward-populated   n/a                            AN            n/a                          Fill In         30                Field              Enter the applicant's control number (if
Unique #                                                                                                                               Forward-populated                                            then Fill In source, else n/a                                                                                                                                          applicable)
Fill In    CFDA Number:                 CFDA Number          Fill In         Fill In         Fill In         CFDANumber                Global               globLib:CFDANumberDataType              If Field Type [8] = Forward-populated   n/a                            AN            n/a                          Fill In         15                Field              Enter the Catalog of Federal Domestic
Unique #                                                                                                                                                                                            then Fill In source, else n/a                                                                                                                                          Assistance number. The first two digits
                                                                                                                                                                                                                                                                                                                                                                           identify the Federal department or
                                                                                                                                                                                                                                                                                                                                                                           agency that administers the program,
                                                                                                                                                                                                                                                                                                                                                                           and the last three numbers are assigned
                                                                                                                                                                                                                                                                                                                                                                           in numerical sequence.

Fill In    CFDA/Program Title:          CFDA/Program Title Fill In           Fill In         Fill In         CFDAProgramTitle          Global               globLib:CFDATitleDataType               If Field Type [8] = Forward-populated   n/a                            AN            n/a                          Fill In         120               Field              Enter the Catalog of Federal Domestic
Unique #                                                                                                                                                                                            then Fill In source, else n/a                                                                                                                                          Assistance program title.
Fill In    Congressional District:      Applicant District   Fill In         Fill In         Fill In         CongressionalDistrictAppli Global or           globLib:CongressionalDistrictDataType   If Field Type [8] = Forward-populated   n/a                            AN            n/a                          Fill In         6                 Field              Enter the Congressional District in the
Unique #   Applicant:                                                                                        cant                       Forward-populated                                           then Fill In source, else n/a                                                                                                                                          format: 2 character State Abbreviation -
                                                                                                                                                                                                                                                                                                                                                                           3 character District Number. Examples:
                                                                                                                                                                                                                                                                                                                                                                           CA-005 for California's 5th district, CA-
                                                                                                                                                                                                                                                                                                                                                                           012 for California's 12th district.

                                                                                                                                                                                                                                                                                                                                                                           If outside the US, enter 00-000.

Fill In    Congressional District:      Program District     Fill In         Fill In         Fill In         CongressionalDistrictProgr Global or           globLib:CongressionalDistrictDataType   If Field Type [8] = Forward-populated   n/a                            AN            n/a                          Fill In         6                 Field              Enter the Congressional District in the
Unique #   Program/Project:                                                                                  amProject                  Forward-populated                                           then Fill In source, else n/a                                                                                                                                          format: 2 character State Abbreviation -
                                                                                                                                                                                                                                                                                                                                                                           3 character District Number. Examples:
                                                                                                                                                                                                                                                                                                                                                                           CA-005 for California's 5th district, CA-
                                                                                                                                                                                                                                                                                                                                                                           012 for California's 12th district.

                                                                                                                                                                                                                                                                                                                                                                           If all districts in a state are affected,
                                                                                                                                                                                                                                                                                                                                                                           enter "all" for the district number.
                                                                                                                                                                                                                                                                                                                                                                           Example: MD-all for all congressional
                                                                                                                                                                                                                                                                                                                                                                           districts in Maryland.

                                                                                                                                                                                                                                                                                                                                                                           If nationwide (all districts in all states),
                                                                                                                                                                                                                                                                                                                                                                           enter US-all.

                                                                                                                                                                                                                                                                                                                                                                           If the program/project is outside the US,
                                                                                                                                                                                                                                                                                                                                                                           enter 00-000.


Fill In    Country:                     Country              Fill In         Fill In         Fill In         Country                   Global or            globLib:CountryDataType                 If Field Type [8] = Forward-populated   n/a                            LIST          ISO 3166 Country Code List   Fill In         49                Popup              Select the Country from the provided list.
Unique #                                                                                                                               Forward-populated                                            then Fill In source, else n/a                                                                                                                                          This field is required.
Fill In    Department Name:             Department Name      Fill In         Fill In         Fill In         DepartmentName            Global or            globLib:DepartmentNameDataType          If Field Type [8] = Forward-populated   n/a                            AN            n/a                          Fill In         30                Field              Enter the name of primary
Unique #                                                                                                                               Forward-populated                                            then Fill In source, else n/a                                                                                                                                          organizational department, service,
Fill In    Division Name:               Division Name        Fill In         Fill In         Fill In         DivisionName              Global or            globLib:DivisionNameDataType            If Field Type [8] = Forward-populated   n/a                            AN            n/a                          Fill In         30                Field              laboratory, or equivalent level within the
                                                                                                                                                                                                                                                                                                                                                                           Enter the name of primary
Unique #                                                                                                                               Forward-populated                                            then Fill In source, else n/a                                                                                                                                          organizational division, office, or major
Fill In    DUNS Number:                 DUNS Number          Fill In         Fill In         Fill In         DUNSNumber                Global or            globLib:DUNSIDDataType                  If Field Type [8] = Forward-populated   If entered length is 9, then   AN            n/a                          9               13                Field              subdivision which will undertake the of
                                                                                                                                                                                                                                                                                                                                                                           Enter the DUNS or DUNS+4 number
Unique #                                                                                                                               Forward-populated                                            then Fill In source, else n/a           append '0000'                                                                                                                  the applicant organization.
Fill In    Email:                       Email                Fill In         Fill In         Fill In         Email                     Global or            globLib:EmailDataType                   If Field Type [8] = Forward-populated   E-mail validation              AN            n/a                          Fill In         60                Field              Enter a valid Email Address.
Unique #                                                                                                                               Forward-populated                                            then Fill In source, else n/a
Fill In    Employer/Taxpayer            EIN/TIN              Fill In         Fill In         Fill In         EmployerTaxpayerIdentific Global or            globLib:EmployerIDDataType              If Field Type [8] = Forward-populated   n/a                            AN            n/a                          9               30                Field              Enter either TIN or EIN as assigned by
Unique #   Identification Number                                                                             ationNumber               Forward-populated                                            then Fill In source, else n/a                                                                                                                                          the Internal Revenue Service. If your
           (EIN/TIN):                                                                                                                                                                                                                                                                                                                                                      organization is not in the US, enter 44-
                                                                                                                                                                                                                                                                                                                                                                           4444444
Fill In    Fax:                         Fax                  Fill In         Fill In         Fill In         Fax                       Global or            globLib:TelephoneNumberDataType         If Field Type [8] = Forward-populated   n/a                            AN            n/a                          Fill In         25                Field              Enter the Fax Number.
Unique #                                                                                                                               Forward-populated                                            then Fill In source, else n/a
Fill In    Federal Award Identifier:    Federal Award        Fill In         Fill In         Fill In         FederalAwardIdentifier    Global or            globLib:ProjectAwardNumberDataType      If Field Type [8] = Forward-populated   n/a                            AN            n/a                          Fill In         25                Field              Enter the award number previously
Unique #                                Identifier                                                                                     Forward-populated                                            then Fill In source, else n/a                                                                                                                                          assigned by the Federal agency, if any.

Fill In    Federal Entity Identifier:   Federal Entity       Fill In         Fill In         Fill In         FederalEntityIdentifier   Global or            globLib:FederalIDDataType               If Field Type [8] = Forward-populated   n/a                            AN            n/a                          Fill In         30                Field              Enter the number assigned to your
Unique #                                Identifier                                                                                     Forward-populated                                            then Fill In source, else n/a                                                                                                                                          organization by the Federal agency.
Fill In    Organization Name (Legal     Organization Name    Fill In         Fill In         Fill In         OrganizationName          Global or            globLib:OrganizationNameDataType        If Field Type [8] = Forward-populated   n/a                            AN            n/a                          Fill In         60                Field              Enter the legal name of the applicant
Unique #   Name):                                                                                                                      Forward-populated                                            then Fill In source, else n/a                                                                                                                                          that will undertake the assistance
                                                                                                                                                                                                                                                                                                                                                                           activity.



Fill In    Telephone Number:            Telephone Number     Fill In         Fill In         Fill In         PhoneNumber               Global or            globLib:TelephoneNumberDataType         If Field Type [8] = Forward-populated   n/a                            AN            n/a                          Fill In         25                Field              Enter the daytime Telephone Number.
Unique #                                                                                                                               Forward-populated                                            then Fill In source, else n/a                                                                                                                                          This field is required.
Fill In    Project Name:                Project Name         Fill In         Fill In         Fill In         ProjectName               Global or            globLib:ProjectNameDataType             If Field Type [8] = Forward-populated   n/a                            AN            n/a                          Fill In         60                Field              Enter the name of the project.
Unique #                                                                                                                               Forward-populated                                            then Fill In source, else n/a
Fill In    Project Title:               Project Title        Fill In         Fill In         Fill In         ProjectTitle              Global or            globLib:ProjectTitleDataType            If Field Type [8] = Forward-populated   n/a                            AN            n/a                          Fill In         200               Field              Enter a brief, descriptive title of the
Unique #                                                                                                                               Forward-populated                                            then Fill In source, else n/a                                                                                                                                          project.


                                                                                                                                                                                                                                                                                                                                                                                                                     22
    [1]                     [2]                     [3]                 [4]             [5]             [6]                [7]                       [8]                            [9]                                  [10]                             [11]                [12]                      [13]                            [14]              [15]              [16]                            [17]
                                                                                                                                                                                                                                                                                                                                      Min # of           Max # of
                         Field                Short Field                          Minimum         Maximum          Agency Field                                              Global Library                           Field Type                                                                      List of                        Chars or          Chars or            Field
   Field #              Label                     Label         Required?       Occurrences     Occurrences            Name                     Field Type                      Field Name                               Source                      Business Rules      Data Type                     Values                         Min Value         Max Value      Implementation                    Help Tip
Fill In      Social Security Number :     Social Security     Fill In         Fill In         Fill In         SocialSecurityNumber          Global or           globLib:SocialSecurityNumberDataType   If Field Type [8] = Forward-populated   SSN format validation   AN            n/a                                         11               11                Field               Enter a 9-digit Social Security Number.
Unique #                                  Number                                                                                            Forward-populated                                          then Fill In source, else n/a                                                                                                                                                    Disclosure of SSN is voluntary. Please
                                                                                                                                                                                                                                                                                                                                                                                        see the application package instructions
                                                                                                                                                                                                                                                                                                                                                                                        for the agency’s authority and routine
                                                                                                                                                                                                                                                                                                                                                                                        uses of the data.

Fill In      Title:                       Title               Fill In         Fill In         Fill In         Title                         Global or           globLib:HumanTitleDataType             If Field Type [8] = Forward-populated   n/a                     AN            n/a                                         Fill In          45                Field               Enter the position title.
Unique #                                                                                                                                    Forward-populated                                          then Fill In source, else n/a
Fill In      Type of Applicant:           Type of Applicant   Fill In         Fill In         Fill In         TypeofApplicant               Global or           globLib:ApplicantTypeCodeDataType      If Field Type [8] = Forward-populated   n/a                     LIST          A. State Government&&                       Fill In          82                Popup               Select the appropriate applicant type
Unique #                                                                                                                                    Forward-populated                                          then Fill In source, else n/a                                                 B. County Government&&                                                                             code.
                                                                                                                                                                                                                                                                                     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
                                                                                                                                                                                                                                                                                         Higher 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 Housing Authority&&
                                                                                                                                                                                                                                                                                     M. Nonprofit with 501C3 IRS Status
                                                                                                                                                                                                                                                                                     (Other
                                                                                                                                                                                                                                                                                         than Institution of Higher
                                                                                                                                                                                                                                                                                     Education)&&
                                                                                                                                                                                                                                                                                     N. Nonprofit without 501C3 IRS Status
                                                                                                                                                                                                                                                                                         (Other than Institution of Higher
                                                                                                                                                                                                                                                                                         Education)&&
                                                                                                                                                                                                                                                                                     O. Private Institution of Higher
                                                                                                                                                                                                                                                                                     Education&&
                                                                                                                                                                                                                                                                                     P. Individual&&
                                                                                                                                                                                                                                                                                     Q. For-Profit Organization (Other than
                                                                                                                                                                                                                                                                                         Small Business)&&
                                                                                                                                                                                                                                                                                     R. Small Business&&
                                                                                                                                                                                                                                                                                     S. Hispanic-serving Institution&&
                                                                                                                                                                                                                                                                                     T. Historically Black Colleges and
                                                                                                                                                                                                                                                                                         Universities (HBCUs)&&
                                                                                                                                                                                                                                                                                     U. Tribally Controlled Colleges and
                                                                                                                                                                                                                                                                                         Universities (TCCUs)&&


DATA ELEMENTS THAT MAY BE PRE-POPULATED FROM THE APPLICATION PACKAGE
Fill In      Agency Name:                 Agency Name         Yes             1               1               AgencyName                    Pre-populated       globLib:AgencyNameDataType             SubmissionDef.AgencyName                n/a                     AN            n/a                                         1                60                Field               Pre-populated from    the Application
Unique #                                                                                                                                                                                                                                                                                                                                                                                cover sheet.
Fill In      CFDA Number:                 CFDA Number         No              0               1               CFDANumber                    Pre-populated       globLib:CFDANumberDataType             SubmissionDef.CFDANumber                n/a                     AN            n/a                                         0                15                Field               Pre-populated from    the Application
Unique #                                                                                                                                                                                                                                                                                                                                                                                cover sheet.
Fill In      CFDA/Program Title:          CFDA/Program Title No               0               1               CFDAProgramTitle              Pre-populated       globLib:CFDATitleDataType              SubmissionDef.CFDATitle                 n/a                     AN            n/a                                         0                120               Field               Pre-populated from    the Application
Unique #                                                                                                                                                                                                                                                                                                                                                                                cover sheet.
Fill In      Competition Identification  Competition Number Yes               1               1               CompetitionIdentificationN    Pre-populated       globLib:CompetitionIDDataType          SubmissionDef.field_CompetitionID       n/a                     AN            n/a                                         1                40                Field               Pre-populated from    the Application
Unique #     Number:                                                                                          umber                                                                                                                                                                                                                                                                     cover sheet.
Fill In      Competition Identification  Competition Title   Yes              1               1               CompetitionIdentificationTi   Pre-populated       globLib:CompetitionIDTitleDataType     SubmissionDef.field_CompetitionIDTitle n/a                      AN            n/a                                         1                255               Field               Pre-populated from    the Application
Unique #     Title:                                                                                           tle                                                                                                                                                                                                                                                                       cover sheet.
Fill In      Funding Opportunity Number: Opportuntity Number Yes              1               1               FundingOpportunityNumbe       Pre-populated       globLib:OpportunityIDDataType          SubmissionDef.OpportunityID             n/a                     AN            n/a                                         1                40                Field               Pre-populated from    the Application
Unique #                                                                                                      r                                                                                                                                                                                                                                                                         cover sheet.
Fill In      Funding Opportunity Title:   Opportunity Title   Yes             1               1               FundingOpportunityTitle       Pre-populated       globLib:OpportunityTitleDataType       SubmissionDef.OpportunityIDTitle        n/a                     AN            n/a                                         1                255               Field               Pre-populated from    the Application
Unique #                                                                                                                                                                                                                                                                                                                                                                                cover sheet.



DATA ELEMENTS THAT ARE POPULATED AFTER SUBMISSION TO GRANTS.GOV (POST-POPULATED)
Fill In      AOR Signature:               AOR Signature       Yes             1               1               AORSignature                  Post-Populated      globLib:SignatureDataType              n/a                                     n/a                     AN            n/a                                         1                144               Label               Completed by Grants.gov upon
Unique #                                                                                                                                                                                                                                                                                                                                                                                submission.
Fill In      Date Received:               Date Received       Yes             1               1               DateReceived                  Post-Populated      globLib:DateReceivedDataType           n/a                                     n/a                     DATE          n/a                                         n/a              n/a               Label               Completed by Grants.gov upon
Unique #                                                                                                                                                                                                                                                                                                                                                                                submission.
Fill In      Date Signed:                 Date Signed         Yes             1               1               DateSigned                    Post-Populated      globLib:DateSignedDataType             n/a                                     n/a                     DATE          n/a                                         n/a              n/a               Label               Completed by Grants.gov upon
Unique #                                                                                                                                                                                                                                                                                                                                                                                submission.



DATA ELEMENT GROUPS
Address Group
Fill In      Address Group Label          n/a                 Fill In         Fill In         Fill In         Fill In                       Global              globLib:AddressDataType                n/a                                     n/a                     n/a           n/a                                         n/a              n/a               Label               Fill In or n/a
Unique #
Fill In      Street1:                     Street1             Yes             1               1               Street1                       Global or           globLib:Street1                        If Field Type [8] = Forward-populated   n/a                     AN            n/a                                         1                55                Field               Enter the first line of the Street Address.
Unique #                                                                                                                                    Forward-populated                                          then Fill In source, else n/a                                                                                                                                                    This field is required.
Fill In      Street2:                     Street2             No              0               1               Street2                       Global or           globLib:Street2                        If Field Type [8] = Forward-populated   n/a                     AN            n/a                                         0                55                Field               Enter the second line of the Street
Unique #                                                                                                                                    Forward-populated                                          then Fill In source, else n/a                                                                                                                                                    Address.




                                                                                                                                                                                                                                                                                                                                                                                                                                23
    [1]                     [2]                        [3]                 [4]             [5]               [6]                   [7]                 [8]                             [9]                               [10]                                 [11]                      [12]                     [13]                           [14]              [15]                [16]                           [17]
                                                                                                                                                                                                                                                                                                                                              Min # of           Max # of
                           Field                   Short Field                        Minimum           Maximum                Agency Field                                       Global Library                       Field Type                                                                               List of                       Chars or          Chars or             Field
   Field #                 Label                     Label         Required?         Occurrences       Occurrences                Name            Field Type                       Field Name                            Source                          Business Rules            Data Type                    Values                        Min Value         Max Value       Implementation                    Help Tip
Fill In      City:                          City                 Yes             1                 1                 City                     Global or           globLib:City                         If Field Type [8] = Forward-populated   n/a                               AN            n/a                                       1                35                 Field               Enter the City. This field is required.
Unique #                                                                                                                                      Forward-populated                                        then Fill In source, else n/a
Fill In      County:                        County               No              0                 1                 County                   Global or           globLib:County                       If Field Type [8] = Forward-populated   n/a                               AN            n/a                                       0                30                 Field               Enter the County.
Unique #                                                                                                                                      Forward-populated                                        then Fill In source, else n/a
Fill In      State:                         State                No              0                 1                 State                    Global or           globLib:State                        If Field Type [8] = Forward-populated   Conditionally required if         LIST          50 US States, US possessions, territories, 0               55                 Popup               Select the state, US possession or
Unique #                                                                                                                                      Forward-populated                                        then Fill In source, else n/a           Country is US then active. If                   military codes                                                                                    military code from the provided list. This
                                                                                                                                                                                                                                               Country is not US, then                                                                                                                           field is required if Country is the United
                                                                                                                                                                                                                                               inactive                                                                                                                                          States.
Fill In      Province:                      Province             No              0                 1                 Province                 Global or           globLib:Province                     If Field Type [8] = Forward-populated   If Country is US then inactive.   AN            n/a                                       0                30                 Field               Enter the Province.
Unique #                                                                                                                                      Forward-populated                                        then Fill In source, else n/a           If Country is not US, then
                                                                                                                                                                                                                                               active
Fill In      Country:                       Country              Yes             1                 1                 Country                  Global or           globLib:Country                      If Field Type [8] = Forward-populated   n/a                               LIST          ISO 3166 Country Code List                1                49                 Popup               Select the Country from the provided list.
Unique #                                                                                                                                      Forward-populated                                        then Fill In source, else n/a                                                                                                                                                             This field is required.
Fill In      Zip / Postal Code:             Zip / Postal Code    No              0                 1                 ZipCode                  Global or           globLib:ZipPostalCode                If Field Type [8] = Forward-populated   Conditionally required if       AN              n/a                                       0                30                 Field               Enter the Postal Code (e.g., ZIP code).
Unique #                                                                                                                                      Forward-populated                                        then Fill In source, else n/a           Country is US then required. If                                                                                                                   This field is required if Country is the
                                                                                                                                                                                                                                               Country is not US, then                                                                                                                           United States.
                                                                                                                                                                                                                                               optional.



Human Name Group
Fill In      Human Name Group Label         n/a                  Fill In         Fill In           Fill In           Fill In                  Global              globLib:HumanNameDataType            n/a                                     n/a                               n/a           n/a                                       n/a              n/a                Label               Fill In or n/a
Unique #
Fill In      Prefix:                        Prefix               No              0                 1                 Prefix                   Global or           globLib:PrefixName                   If Field Type [8] = Forward-populated   n/a                               LIST          Mr.&&Mrs.&&Miss&&Ms.&&Dr.&&Rev.&&         0                10                 Combobox            Select the Prefix from the provided list or
Unique #                                                                                                                                      Forward-populated                                        then Fill In source, else n/a                                                           Prof.                                                                                             enter a new Prefix not provided on the
                                                                                                                                                                                                                                                                                                                                                                                                 list.
Fill In      First Name:                    First Name           Yes             1                 1                 FirstName                Global or           globLib:FirstName                    If Field Type [8] = Forward-populated   n/a                               AN            n/a                                       1                35                 Field               Enter the First Name. This field is
Unique #                                                                                                                                      Forward-populated                                        then Fill In source, else n/a                                                                                                                                                             required.
Fill In      Middle Name:                   Middle Name          No              0                 1                 MiddleName               Global or           globLib:MiddleName                   If Field Type [8] = Forward-populated   n/a                               AN            n/a                                       0                25                 Field               Enter the Middle Name.
Unique #                                                                                                                                      Forward-populated                                        then Fill In source, else n/a
Fill In      Last Name:                     Last Name            Yes             1                 1                 LastName                 Global or           globLib:LastName                     If Field Type [8] = Forward-populated   n/a                               AN            n/a                                       1                60                 Field               Enter the Last Name. This field is
Unique #                                                                                                                                      Forward-populated                                        then Fill In source, else n/a                                                                                                                                                             required.
Fill In      Suffix:                        Suffix               No              0                 1                 Suffix                   Global or           globLib:SuffixName                   If Field Type [8] = Forward-populated   n/a                               LIST          Jr.&&Sr.&&M.D.&&Ph.D                      0                10                 Combobox            Select the Suffix from the provided list or
Unique #                                                                                                                                      Forward-populated                                        then Fill In source, else n/a                                                                                                                                                             enter a new Suffix not provided on the
                                                                                                                                                                                                                                                                                                                                                                                                 list.



GENERAL DATA ELEMENT FORMATS
Fill In      ALPHANUMERIC field             Fill In              Fill In         Fill In           Fill In           Fill In                  Agency-specific     n/a                                  n/a                                     Fill In                           AN            n/a                                       Fill In          Fill In            Field               Fill In
Unique #     template
             Fill In Field Label
Fill In      BUTTON template                Fill In              n/a             n/a               n/a               n/a                      Agency-specific     n/a                                  n/a                                     Fill In                           n/a           n/a                                       n/a              n/a                Button              Fill In
Unique #     Fill In Button Label
Fill In      DATE field template            Fill In              Fill In         Fill In           Fill In           Fill In                  Agency-specific     n/a                                  n/a                                     Fill In                           DATE          n/a                                       n/a              n/a                Field               Enter the date in the format
Unique #     Fill In Field Label                                                                                                                                                                                                                                                                                                                                                                 MM/DD/YYYY.
Fill In      DEGREE EARNED template         Fill In              Fill In         Fill In           Fill In           Fill In                  Global              globLib:EducationDegreeDataType      n/a                                     Fill In                           AN            n/a                                       Fill In          50                 Field               Enter the highest degree earned.
Unique #     Fill In Field Label

Fill In      DOLLAR AMOUNT template         Fill In              Fill In         Fill In           Fill In           Fill In                  Agency-specific     globLib:BudgetAmountDataType         n/a                                                                       $             n/a                                       0.00             999999999999.99    Field               Enter the dollar amount.
Unique #     Fill In Field Label                                                                                                                                                                                                               Fill In

Fill In      DOLLAR AMOUNT TOTAL      Fill In                    Fill In         Fill In           Fill In           Fill In                  Agency-specific     globLib:BudgetTotalAmountDataType    n/a                                                                       $             n/a                                       0.00             9999999999999.99   Field               Enter the total dollar amount.
Unique #     template                                                                                                                                                                                                                          Fill In
             Fill In Field Label
Fill In      FILE ATTACHMENT template Fill In                    No              0                 1                 Fill In                  Global              globLib:SingleAttachmentDataType     n/a                                     Fill In                           FILE          n/a                                       n/a              n/a                Single_File         Attach a file using the appropriate
Unique #     Fill In Field Label                                                                                                                                                                                                                                                                                                                                                                 buttons.

Fill In      FILE ATTACHMENT template Fill In                    Yes             1                 1                 Fill In                  Global              globLib:SingleAttachmentDataType     n/a                                     Fill In                           FILE          n/a                                       n/a              n/a                Single_File         Attach a file using the appropriate
Unique #     Fill In Field Label                                                                                                                                                                                                                                                                                                                                                                 buttons. This attachment is required.

Fill In      MULTIPLE FILE                  Fill In              No              0                 1                 Fill In                  Global              globLib:MultipleAttachmentDataType   n/a                                     Fill In                           MULTIFILE     n/a                                       n/a              n/a                Multi_file          Attach file(s) using the appropriate
Unique #     ATTACHMENT                                                                                                                                                                                                                                                                                                                                                                          buttons.
             Fill In Field Label
Fill In      MULTIPLE FILE                  Fill In              Yes             1                 1                 Fill In                  Global              globLib:MultipleAttachmentDataType   n/a                                     Fill In                           MULTIFILE     n/a                                       n/a              n/a                Multi_file          Attach file(s) using the appropriate
Unique #     ATTACHMENT                                                                                                                                                                                                                                                                                                                                                                          buttons. Attachments are required.
             Fill In Field Label
Fill In      NUMERIC WITHOUT                Fill In              Fill In         Fill In           Fill In           Fill In                  Agency-specific     n/a                                  n/a                                     Fill In                           INTEGER       n/a                                       Fill In          Fill In            Field               Fill In
Unique #     DECIMALS
             field template
             Fill In Field Label
Fill In      NUMERIC WITH DECIMALS          Fill In              Fill In         Fill In           Fill In           Fill In                  Agency-specific     n/a                                  n/a                                     Fill In                           DECIMAL(2)    n/a                                       Fill In          Fill In            Field               Fill In
Unique #      field template
             Fill In Field Label
Fill In      LABEL template                 n/a                  n/a             n/a               n/a               n/a                      n/a                 n/a                                  n/a                                     n/a                               n/a           n/a                                       n/a              n/a                Label               Fill In or n/a
Unique #     Fill In Label from form
Fill In      LIST field template            Fill In              Fill In         Fill In           Fill In           Fill In                  Agency Specific     n/a                                  n/a                                     Fill In                           LIST          Fill In                                   Fill In          Fill In            Popup               Fill In
Unique #     Fill In Field Label
Fill In      CHECKBOX template              Fill In              Fill In         Fill In           Fill In           Fill In                  Agency-specific     globLib:YesNoDataType                n/a                                     Fill In                           n/a           n/a                                       n/a              n/a                Check               Check to select.
Unique #     Fill In Option 1 Field Label
Fill In      CHECKBOX template              Fill In              Fill In         Fill In           Fill In           Fill In                  Agency-specific     globLib:YesNoDataType                n/a                                     Fill In                           n/a           n/a                                       n/a              n/a                Check               Check to select.
Unique #     Fill In Option 2 Field Label

RADIO GROUP OPTIONAL



                                                                                                                                                                                                                                                                                                                                                                                                                                           24
    [1]                   [2]                      [3]                 [4]             [5]               [6]                   [7]                 [8]                         [9]                                [10]                         [11]               [12]                     [13]           [14]             [15]              [16]                          [17]
                                                                                                                                                                                                                                                                                                        Min # of          Max # of
                           Field               Short Field                        Minimum           Maximum                Agency Field                                  Global Library                          Field Type                                                               List of       Chars or         Chars or           Field
   Field #                Label                  Label        Required?          Occurrences       Occurrences                Name             Field Type                 Field Name                               Source                 Business Rules     Data Type                    Values       Min Value         Max Value     Implementation                    Help Tip
Fill In      RADIO GROUP HEADER          n/a                 No              0                 1                 Fill In                  Radio Group       n/a                                  Fill in Radio Group Name       Fill In                    LIST          n/a                        n/a            n/a               Radio Group        Fill in or n/a
Unique #     Fill In Radio Group Label                                                                                                                                                           (may be same as Field Label)
Fill In      Fill in Radio Group         Fill In             No              0                 1                 n/a                      Radio Group       n/a                                  Fill in Radio Group Name       Fill In                    n/a           n/a                        n/a            n/a               Radio              Click to select option.
Unique #     Option 1 Label
Fill In      Fill in Radio Group         Fill In             No              0                 1                 n/a                      Radio Group       n/a                                  Fill in Radio Group Name       Fill In                    n/a           n/a                        n/a            n/a               Radio              Click to select option.
Unique #     Option 2 Label

RADIO GROUP REQUIRED
Fill In  RADIO GROUP HEADER              n/a                 Yes             1                 1                 Fill In                  Radio Group       n/a                                  Fill in Radio Group Name       Fill In                    LIST          n/a                        n/a            n/a               Radio Group        One selection is required.
Unique # Fill In Radio Group Label                                                                                                                                                               (may be same as Field Label)
Fill In  Fill in Radio Group             Fill In             No              0                 1                 n/a                      Radio Group       n/a                                  Fill in Radio Group Name       Fill In                    n/a           n/a                        n/a            n/a               Radio              Click to select option.
Unique # Option 1 Label
Fill In  Fill in Radio Group             Fill In             No              0                 1                 n/a                      Radio Group       n/a                                  Fill in Radio Group Name       Fill In                    n/a           n/a                        n/a            n/a               Radio              Click to select option.
Unique # Option 2 Label



Fill In      PERCENT WITH DECIMALS Fill In                   Fill In         Fill In           Fill In           Fill In                  Agency-specific   globLib:PercentDecimalDataType       n/a                                                       DECIMAL(2)    n/a                        0.00           100.00            Field              Enter in the percentage with decimals.
Unique #     Fill In Field Label                                                                                                                                                                                                Fill In

Fill In      PERCENT WITHOUT             Fill In             Fill In         Fill In           Fill In           Fill In                  Agency-specific   globLib:PercentIntegerDataType       n/a                                                       INTEGER       n/a                        0              100               Field              Enter in the percentage as a whole
Unique #     DECIMALS                                                                                                                                                                                                           Fill In                                                                                                                 number.
             Fill In Field Label
Fill In      YEAR field template         Fill In             Fill In         Fill In           Fill In           Fill In                  Agency-specific   n/a                                  n/a                            Fill In                    YEAR          n/a                        4              4                 Field              Fill In
Unique #     Fill In Field Label

YES/NO OPTIONAL
Fill In  YES/NO RADIO GROUP              n/a                 No              0                 1                 Fill In                  Radio Group       globLib:YesNoDataType                Fill in Radio Group Name       n/a                        LIST          n/a                        n/a            n/a               Radio Group        Fill in or n/a
Unique # HEADER                                                                                                                                                                                  (may be same as Field Label)
         Fill In Field Label
Fill In  Yes                             Fill In             No              0                 1                 n/a                      Radio Group       n/a                                  Fill in Radio Group Name       Fill In                    n/a           Yes                        n/a            n/a               Radio              Click to select option.
Unique #
Fill In  No                              Fill In             No              0                 1                 n/a                      Radio Group       n/a                                  Fill in Radio Group Name       Fill In                    n/a           No                         n/a            n/a               Radio              Click to select option.
Unique #

YES/NO REQUIRED
Fill In  YES/NO RADIO GROUP              n/a                 Yes             1                 1                 Fill In                  Radio Group       globLib:YesNoDataType                Fill in Radio Group Name       n/a                        LIST          n/a                        n/a            n/a               Radio Group        A selection is required.
Unique # HEADER                                                                                                                                                                                  (may be same as Field Label)
         Fill In Field Label
Fill In  Yes                             Fill In             No              0                 1                 n/a                      Radio Group       n/a                                  Fill in Radio Group Name       Fill In                    n/a           Yes                        n/a            n/a               Radio              Click to select option.
Unique #
Fill In  No                              Fill In             No              0                 1                 n/a                      Radio Group       n/a                                  Fill in Radio Group Name       Fill In                    n/a           No                         n/a            n/a               Radio              Click to select option.
Unique #

YES/NO/OTHER OPTIONAL
Fill In  YES/NO/OTHER RADIO              n/a                 No              0                 1                 Fill In                  Radio Group       globLib:YesNoOtherDataType           Fill in Radio Group Name       n/a                        LIST          n/a                        n/a            n/a               Radio Group        Fill in or n/a
Unique # GROUPHEADER                                                                                                                                                                             (may be same as Field Label)
         Fill In Field Label
Fill In  Yes                             Fill In             No              0                 1                 n/a                      Radio Group       n/a                                  Fill in Radio Group Name       Fill In                    n/a           Yes                        n/a            n/a               Radio              Click to select option.
Unique #
Fill In  No                              Fill In             No              0                 1                 n/a                      Radio Group       n/a                                  Fill in Radio Group Name       Fill In                    n/a           No                         n/a            n/a               Radio              Click to select option.
Unique #
Fill In  Other                           Fill In             No              0                 1                 n/a                      Radio Group       n/a                                  Fill in Radio Group Name       Fill In                    n/a           Other                      n/a            n/a               Radio              Click to select option.
Unique #

YES/NO/OTHER REQUIRED
Fill In  YES/NO/OTHER RADIO              n/a                 Yes             1                 1                 Fill In                  Radio Group       globLib:YesNoOtherDataType           Fill in Radio Group Name       n/a                        LIST          n/a                        n/a            n/a               Radio Group        A selection is required.
Unique # GROUP HEADER                                                                                                                                                                            (may be same as Field Label)
         Fill In Field Label
Fill In  Yes                             Fill In             No              0                 1                 n/a                      Radio Group       n/a                                  Fill in Radio Group Name       Fill In                    n/a           Yes                        n/a            n/a               Radio              Click to select option.
Unique #
Fill In  No                              Fill In             No              0                 1                 n/a                      Radio Group       n/a                                  Fill in Radio Group Name       Fill In                    n/a           No                         n/a            n/a               Radio              Click to select option.
Unique #
Fill In  Other                           Fill In             No              0                 1                 n/a                      Radio Group       n/a                                  Fill in Radio Group Name       Fill In                    n/a           Other                      n/a            n/a               Radio              Click to select option.
Unique #

YES/NO/NOT APPLICABLE OPTIONAL
Fill In  YES/NO/NA RADIO GROUP           n/a                 No              0                 1                 Fill In                  Radio Group       globLib:YesNoNotApplicableDataType   Fill in Radio Group Name       n/a                        LIST          n/a                        n/a            n/a               Radio Group        Fill in or n/a
Unique # HEADER                                                                                                                                                                                  (may be same as Field Label)
         Fill In Field Label
Fill In  Yes                             Fill In             No              0                 1                 n/a                      Radio Group       n/a                                  Fill in Radio Group Name       Fill In                    n/a           Yes                        n/a            n/a               Radio              Click to select option.
Unique #
Fill In  No                              Fill In             No              0                 1                 n/a                      Radio Group       n/a                                  Fill in Radio Group Name       Fill In                    n/a           No                         n/a            n/a               Radio              Click to select option.
Unique #
Fill In  Not Applicable                  Fill In             No              0                 1                 n/a                      Radio Group       n/a                                  Fill in Radio Group Name       Fill In                    n/a           Not Applicable             n/a            n/a               Radio              Click to select option.
Unique #

YES/NO/NOT APPLICABLE REQUIRED
Fill In  YES/NO/NA RADIO GROUP n/a                           Yes             1                 1                 Fill In                  Radio Group       globLib:YesNoNotApplicableDataType   Fill in Radio Group Name       n/a                        LIST          n/a                        n/a            n/a               Radio Group        A selection is required.
Unique # HEADER                                                                                                                                                                                  (may be same as Field Label)
         Fill In Field Label
Fill In  Yes                   Fill In                       No              0                 1                 n/a                      Radio Group       n/a                                  Fill in Radio Group Name       Fill In                    n/a           Yes                        n/a            n/a               Radio              Click to select option.
Unique #
Fill In  No                    Fill In                       No              0                 1                 n/a                      Radio Group       n/a                                  Fill in Radio Group Name       Fill In                    n/a           No                         n/a            n/a               Radio              Click to select option.
Unique #



                                                                                                                                                                                                                                                                                                                                                                                             25
    [1]                  [2]              [3]            [4]              [5]               [6]                 [7]                [8]                  [9]                           [10]                      [11]            [12]                        [13]           [14]             [15]             [16]                          [17]
                                                                                                                                                                                                                                                                         Min # of          Max # of
                         Field         Short Field                     Minimum           Maximum            Agency Field                           Global Library                   Field Type                                                             List of       Chars or         Chars or           Field
   Field #              Label            Label        Required?       Occurrences       Occurrences            Name             Field Type          Field Name                        Source               Business Rules     Data Type                    Values       Min Value         Max Value     Implementation                    Help Tip
Fill In      Not Applicable      Fill In             No           0                 1                 n/a                  Radio Group       n/a                    Fill in Radio Group Name     Fill In                    n/a           Not Applicable             n/a            n/a               Radio              Click to select option.
Unique #




                                                                                                                                                                                                                                                                                                                                                     26

				
DOCUMENT INFO
Description: Private Label Agreement Template document sample