PRS Specific Checklist

Appendix B

Pandemic Response and Safety Grant Program

Round One: Activity Checklist

Business/Organization Name: [data field]

Duns Number: [DUNS]

Applicant Name: [First] [Last]

Eligible Industry: [Appendix A NAICS drop down + farmers market]

By submitting this application, I attest that:

• My organization meets the SBA small business standard for the industry code selected above.

• Between January 27, 2020 and December 31, 2021, my organization has implemented and/or plans to implement the activity or activities selected below, and the funding amount requested in my application reflects the fair market value of the goods and services associated with the selected activity or activities and the corresponding outcome(s).

• No other Federal funds were used to cover the cost of the activity or activities selected below.

Instructions: Column A provides the outcomes and activities funded by PRS. The funding request to offset costs associated with the outcomes and activities is entered in column B.

A: Eligible Outcomes and Activities	B: Funding Request
Implement workplace safety measures to protect workers against COVID-19 Provide personal protective equipment, thermometers, cleaning supplies, sanitizer, or hand washing stations Installation and purchase of air filters or new signage	[Enter $ Amount]
Implement market pivots to protect workers against COVID–19 Develop and implement online platforms Utilize online or print materials to communicate market pivots	[Enter $ Amount]
Retrofit Facilities for Worker and Consumer Safety to protect against COVID–19 Installation and purchase of protective barriers made of plexiglass or plastic sheeting, walk up windows, heat lamps/heaters, fans, tents, propane, weights, tables, chairs and lighting	[Enter $ Amount]
Provide additional transportation options to maintain social distancing and worker and consumer safety to protect against COVID-19 Secure additional transportation services for workers Offer new delivery routes or distribution services	[Enter $ Amount]
Provide worker housing that protects workers against COVID-19 Secure additional housing resources/services to maintain social distancing or to allow for quarantining of new or exposed employees	[Enter $ Amount]
Provide health services to protect workers against COVID-19 Offer or enable vaccinations, testing, or healthcare treatment of infected employees, including any paid leave due to COVID-19 infection.	[Enter $ Amount]
Total Funding Request (This amount must be between $1,500 and $20,000)	[Auto Sum]

Pandemic Response and Safety Grant Program

Assistance Listing Number: 10.181