ࡱ> #` zbjbj <RRRR4444t4LE57777K9:|:@EEEEEEE$FhTI=Eu:)9"K9::=ERR77E-<-<-<:R877E-<:E-<-<-<75 |4:p-<@E0E-<JY;J-<-<JJw<::-<:::::=E=E<:::E::::RRRRRR Nebraska Department of Roads (NDOR) Highway Safety Improvement Program (HSIP) Public Information and Education Funding Request Please TypeDATE: FORMTEXT      APPLICANT:  FORMTEXT      CONTACT NAME: FORMTEXT      ADDRESS:  FORMTEXT      CITY, STATE, ZIP: FORMTEXT      TELEPHONE NO.:( FORMTEXT    )  FORMTEXT      FAX NO.: FORMTEXT      FEDERAL I.D. NO.: FORMTEXT      EMAIL: FORMTEXT      STARTING DATE: FORMTEXT      COMPLETION DATE: FORMTEXT      PROJECT DESCRIPTION: The purpose of this funding request is to provide funding assistance to the applicant for a specific public information and/or education campaign/activity in the emphasis area of: (Check One)  FORMCHECKBOX  Impaired Driving,  FORMCHECKBOX  Young Drivers, or  FORMCHECKBOX  Occupant Restraint. All activities funded by this request must be above and beyond the current level of activity. Please complete items 1-5 below using the definitions on the reverse side, and submit a copy of your organizations current seat belt policy and drug-free workplace policy.1. Baseline Information: FORMTEXT       FORMTEXT      2. Objective: FORMTEXT       FORMTEXT      3. Activity: FORMTEXT       FORMTEXT      4. Budget: FORMTEXT       FORMTEXT      5. Impact Evaluation: FORMTEXT       FORMTEXT      NDOR will fund approved projects at 90% of the project cost. The applicant/organization must provide the balance of funding. NDOR will finance this funding request on a reimbursement basis. The NDOR reserves the right to determine appropriate hard match contributions. The applicant/organization must receive written approval for the project from NDOR before applicant incurs any expenses in order to receive the federal share of the funding request. The applicant must request reimbursement from the NDOR within sixty (60) days of the conclusion of the activity. After sixty (60) days, NDOR will not honor reimbursements. Applicant will provide the following supporting documentation: 1) An invoice from the applicant to the NDOR requesting reimbursement. The invoice must itemize each expenditure. 2) Copy of the check(s) paid by the applicant for each line item expenditure on the invoice. 3) Copy of the invoice(s) from vendors for each expenditure. 4) An activity report and project summary. The applicant agrees to comply with all rules and regulations as set forth by the U.S. Department of Transportation, the Federal Highway Administration, the State of Nebraska, and the Nebraska Department of Roads.Authorized Signature of Applicant DatePrint or Type NameNebraska Department of Roads Representative DatePrint or Type NameReturn completed form to: Nebraska Department of Roads, Attn: Traffic Engineering, P.O. Box 94759, Lincoln, NE 68509-4759 Phone: (402) 479-4594  FAX: (402) 479-4325 TO BE COMPLETED BY NDORFUNDING ASSISTANCE: The NDOR will provide reimbursement for the expenditures outlined in the Budget not to exceed $_______________FOR NDOR USE ONLY:Project No.:          C.N.     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Non-fatal serious injury crash data may provide a more complete picture. OBJECTIVE Every public information and education campaign/activity must have an objective to reduce fatal and serious injury crashes as outlined by the baseline information. The objective states exactly how much injury reduction will be achieved in a specific period of time. The contributing factors must also be addressed (i.e., alcohol, speed, etc.). Every objective must be SMART: Specific, Measurable, Action oriented, Realistic, and have a Time frame. ACTIVITY The activity must coincide with the problems outlined in the baseline data and respond to the stated objective. The specific activities to be completed must be included. BUDGET The budget must include specific line item expenditures for the proposed campaign/activity. The total amount of funding assistance being requested must be supported in the budget. IMPACT EVALUATION answers the question  Did we reduce injuries? In the application, explain what you will evaluate. In the project summary (submitted after the completion of the activity), answer the following: Question #1: Did the activity reduce the types of injuries that were targeted? 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