COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF INDUSTRIAL ACCIDENTS OFFICE OF SAFETY WORKPLACE SAFETY TRAINING & EDUCATION GRANT PROGRAM

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1 1. Applicant/Organization Legal Name: COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF INDUSTRIAL ACCIDENTS OFFICE OF SAFETY WORKPLACE SAFETY TRAINING & EDUCATION GRANT PROGRAM COMPANY INFORMATION 2. Grant Administrator /Title: 3. Applicant Address: 4. Phone Number: 5. Address: 6. Federal Employer Identification Number (FEIN) 7. How did you originally hear about this grant program? Type of organization For-Profit Non- Profit Is your company or training provider SOMWBA certified? If yes please specify. 10. Employee Demographics Total Employees Total Employees To Be Trained

2 11 Hazards to be addressed in application (please check all that apply) OSHA Ergonomics CPR/AED Injury Prevention Fire/Electrical Stress Asbestos CTD s Other (explain) Lead Hazards Toxins Right to Know/Hazard Communication 12. Location Demographics: Which counties will training take place (please check all that apply) Barnstable Essex Middlesex Suffolk Berkshire Franklin Nantucket Worcester Bristol Hampden Norfolk Statewide Dukes Hampshire Plymouth 13. Total Amount Requested 14. Signature /Title (electronic signature is acceptable)

3 ORGANIZATION DESCRIPTION Briefly describe the nature of the applicant s business including a description of products or services provided. Be sure to state how long your organization has been established and the number of employees. NEEDS ASSESSMENT Identify and describe the injury history of the targeted occupation(s) or preventative safety issues you intend to address in this proposal TRAINING / CONTINUING EDUCATION PROPOSED TRAINING SUMMARY Provide a brief description of the proposed training plan.

4 BUDGET NARRATIVE Provide a complete and itemized budget plan. This should be a detailed written description of how each line item in the Budget Summary will be utilized. Identify the number of participants to be trained, the number of training sessions, number of participants per session, the names of trainers providing services and number of instructors to be present for each session, training locations, training topic, and length of time per session. In order to evaluate the cost effectiveness of the program approximate projected class sizes are required.

5 COMPANY: GRANT ADMINISTRATOR NAME: ADDRESS: PHONE: ADDRESS: BUDGET SUMMARY DESCRIPTION CONTRACT EXPENDITURE # S COMPLETE ONE OPTION ONLY CONTRACT EXPENDITURE COST COMPLETE ONE OPTION ONLY TOTAL COST NAMES OF TRAINERS OR MATERIAL DESCRIPTION TOTAL # OF PEOPLE TOTAL # OF CLASSES $COST PER PERSON $COST PER CLASS 7% ADMIN COST MAXIMUM OBLIGATION

6 COPY RIGHT Funded programs may be subject to an audit by the State Auditor s Office or authorized officials of the Commonwealth of Massachusetts. All books, records, and other compilations of data pertaining to the performance of the provisions and requirements of the contract to the extent and in such detail as shall properly substantiate claims for payment under the contract, must be maintained for a minimum of 7 years. All published material, including without limitation, report, manuals, pamphlet, articles, etc., prepared by grant recipients with Office of Safety funds shall be created as a work for hire for the purposes of 17 U.S.C., Sections 101 et seq., and the DIA Office of Safety shall be the sole author and owner of the copyright. The selected applicant may distribute the materials subject to a nontransferable, nonexclusive, revocable license. Any reproduction for distribution of these materials must prominently display on the front cover or in the beginning credits: This (fact sheet, manual, video, etc.) was funded by the Massachusetts Department of Industrial Accidents, Office of Safety. Copyright 2014/2015 by the Commonwealth of Massachusetts, Department of Industrial Accidents. The opinions and views expressed herein do not necessarily reflect those of the Massachusetts Department of Industrial Accidents. No reproduction or other use is authorized for this material without the express written approval of the Office of Safety. At the time of training you are required to acknowledge the Department of Industrial Accidents, Office of Safety as the funding source for the training being provided. The Office of Safety may institute additional reporting requirements. All lead applicants will be notified of any changes to the reporting requirements. The Office of Safety reserves the right to suspend or revoke the contract for funding at any time and for any reason. It is the policy of the government that small, minority and women-owned business enterprises shall have the maximum practicable opportunity to participate in the performance of government contracts.