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Home My WebLink AboutSS4A_FY25-Self-Certification-Worksheet SS4A Self-Certification Eligibility Worksheet | Page 1 of 5 Safe Streets and Roads for All Self -Certification Eligibility Worksheet All applicants should follow the instructions in the NOFO to correctly apply for a grant. See the SS4A website for more information. Table 1 of the SS4A NOFO describes seven components of an Action Plan, which correspond to the questions in this worksheet. Applicants should use this worksheet to determine whether their existing plan(s) contains the required components to be considered an eligible Action Plan for SS4A. This worksheet is required for all SS4A Implementation Grant applications and any Planning and Demonstration Grant applications to conduct Supplemental Planning/Demonstration Activities only. Please complete the form in its entirety, do not adjust the formatting or headings of the worksheet, and upload the completed PDF with your application. Eligibility An Action Plan is considered eligible for an SS4A application for an Implementation Grant or a Planning and Demonstration Grant to conduct Supplemental Planning/Demonstration Activities if the following two conditions are met: • You can answer “YES” to Questions 3, 6, and 8 in this worksheet; and • You can answer “YES” to at least three of the five remaining Questions, 1, 2, 4, 5, and 7. If both conditions are not met, an applicant is still eligible to apply for a Planning and Demonstration Grant to fund the creation of a new Action Plan or updates to an existing Action Plan to meet SS4A requirements. Applicant Information Lead Applicant: ______________________________________________ UEI: ____________________________________ Action Plan Documents In the table below, list the relevant Action Plan and any additional plans or documents that you reference in this form. Up to three plans or documents may be included. Please provide a hyperlink to any documents available online or indicate that the Action Plan or other documents will be uploaded in Valid Eval as part of your application. Note that, to be considered an eligible Action Plan for SS4A, the plan(s) coverage must be broader than just a corridor, neighborhood, or specific location. Document Title Link Date of Most Recent Update SS4A Self-Certification Eligibility Worksheet | Page 2 of 5 Action Plan Components For each question below, answer “YES” or “NO.” If “YES,” list the relevant plan(s) or supporting documentation that address the condition and the specific page number(s) in each document that corroborates your response. This form provides space to reference multiple plans, but please list only the most relevant document(s). 1. Leadership Commitment and Goal Setting Are BOTH of the following true? •A high-ranking official and/or governing body in the jurisdiction publicly committed to aneventual goal of zero roadway fatalities and serious injuries; and •The commitment includes either setting a target date to reach zero OR setting one or moretargets to achieve a reduction in roadway fatalities and serious injuries by a specific date. YES NO Note: This may include a resolution, policy, ordinance, executive order, or other official announcement from a high-ranking official and the official adoption of a plan that includes the commitment by a legislative body. If “YES,” please list the relevant document(s) and page number(s) that corroborate your response. Document Title Page Number(s) 2.Planning Structure To develop the Action Plan, was a committee, task force, implementation group, or similar bodyestablished and charged with the plan’s development, implementation, and monitoring? YES NO Note: This should include a description of the membership of the group and what role they play in thedevelopment, implementation, and monitoring of the Action Plan. If “YES,” please list the relevant document(s) and page number(s) that corroborate your response. Document Title Page Number(s) SS4A Self-Certification Eligibility Worksheet | Page 3 of 5 3. Safety Analysis Does the Action Plan include ALL of the following? • Analysis of existing conditions and historical trends to provide a baseline level of crashes involving fatalities and serious injuries across a jurisdiction, locality, Tribe, or region; • Analysis of the location(s) of crashes, the severity, contributing factors, and crash types; • Analysis of systemic and specific safety needs, as needed (e.g., high-risk road features or specific safety needs of relevant road users); and, • A geospatial identification (geographic or locational data using maps) of higher risk locations. YES NO Note: Availability and level of detail of safety data may vary greatly by location. The Fatality and Injury Reporting System Tool (FIRST) provides county- and city-level data. When available, local data should be used to supplement nationally available data sets. If “YES,” please list the relevant document(s) and page number(s) that corroborate your response. Document Title Page Number(s) 4. Engagement and Collaboration Did development of the Action Plan include ALL of the following activities? • Engagement with the public and relevant stakeholders, including the private sector and community groups; • Incorporation of information received from the engagement and collaboration into the plan; and • Coordination that included inter- and intra-governmental cooperation and collaboration, as appropriate. YES NO Note: This should include a description of public meetings, participation in public and private events, and proactive meetings with stakeholders. If “YES,” please list the relevant document(s) and page number(s) that corroborate your response. Document Title Page Number(s) SS4A Self-Certification Eligibility Worksheet | Page 4 of 5 5. Policy and Process Changes Are BOTH of the following true? • The plan development included an assessment of current policies, plans, guidelines, and/or standards to identify opportunities to improve how processes prioritize safety; and • The plan discusses implementation through the adoption of revised or new policies, guidelines, YES NO Note: This may include existing and/or recommended Complete Streets policy, guidelines for community engagement and collaboration, policy for prioritizing areas of greatest need, local laws (e.g., speed limit), design guidelines, and other policies and processes that prioritize safety. If “YES,” please list the relevant document(s) and page number(s) that corroborate your response. Document Title Page Number(s) 6. Strategy and Project Selections Does the plan identify a comprehensive set of projects and strategies to address the safety problems in with information about time ranges when projects and strategies will be deployed, and explanation of project prioritization criteria? YES NO Note: This should include one or more lists of community-wide multi-modal and multi-disciplinary projects that respond to safety problems and reflect community input and a description of how your community will prioritize projects in the future. If “YES,” please list the relevant document(s) and page number(s) that corroborate your response. Document Title Page Number(s) SS4A Self-Certification Eligibility Worksheet | Page 5 of 5 7. Progress and Transparency Does the plan include BOTH of the following? • A description of how progress will be measured over time that includes, at a minimum, outcome data. • The plan is posted publicly online. YES NO Note: This should include a progress reporting structure and list of proposed metrics. If “YES,” please list the relevant document(s) and page number(s) that corroborate your response. Document Title Page Number(s) 8. Action Plan Date Was at least one of your plans finalized and/or last updated between 2020 and June 26, 2025? YES NO Note: Updates may include major revisions, updates to the data used for analysis, status updates, or the addition of supplemental planning documents, including but not limited to an ADA Transition Plan, one or more Road Safety Audits conducted in high-crash locations, or a Vulnerable Road User Plan. If “YES,” please list your most recent document, date of finalization, and page number(s) that corroborate your response. Document Title Date of Most Recent Update Page Number(s)