OST Self-Certification Eligibility Worksheet

Safe Streets and Roads for All
Self-Certification Eligibility Worksheet
Applicants should follow the instructions in the NOFO to correctly apply for a grant. See the SS4A website
for more information.
Instructions: The purpose of this worksheet is to determine whether an applicant’s existing plan(s) is substantially
similar to an Action Plan for purposes of applying for an Implementation Grant or to conduct Supplemental
Planning/Demonstration Activities only. Use of this worksheet is required. Applicants should not adjust the formatting
or headings of the worksheet.
For each question below, answer “yes” or “no.” If “yes,” cite the specifc page in your existing Action Plan or other
plan(s) that corroborate your response, or cite and provide other supporting documentation separately.
An applicant is eligible to apply for an Action Plan Grant that funds supplemental action plan activities, or an
Implementation Grant, only if the following two conditions are met:
• Answer “yes” to Questions 3

7

9

• Answer “yes” to at least four of the six remaining Questions 1

2

4

5

6

8

If both conditions are not met, an applicant is still eligible to apply for an Action Plan Grant that funds creation of a
new Action Plan.
Lead Applicant:

1

UEI:

Are both of the following true?

YES

• Did a high-ranking offcial and/or governing body in the jurisdiction
publicly commit to an eventual goal of zero roadway fatalities and
serious injuries?

NO

If yes, provide documentation:

• Did the commitment include either setting a target date to reach zero,
OR setting one or more targets to achieve signifcant declines in
roadway fatalities and serious injuries by a specifc date?

2 To develop the Action Plan, was a committee, task force, implementation
group, or similar body established and charged with the plan’s
development, implementation, and monitoring?

3 Does the Action Plan include all of the following?

YES
If yes, provide documentation:

YES

• Analysis of existing conditions and historical trends to baseline the level
of crashes involving fatalities and serious injuries across a jurisdiction,
locality, Tribe, or region;

NO

NO

If yes, provide documentation:

• Analysis of the location where there are crashes, the severity, as well as
contributing factors and crash types;
• Analysis of systemic and specifc safety needs is also performed, as
needed (e.g., high risk road features, specifc safety needs of relevant
road users; and,
• A geospatial identifcation (geographic or locational data using maps)
of higher risk locations.
Still have questions? Visit the SS4A website
SS4A Self-Certifcation Eligibility Worksheet | Page 1 of 2

Safe Streets and Roads for All
Self-Certification Eligibility Worksheet
4 Did the Action Plan development 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.
5 Did the Action Plan development include all of the following?
• Considerations of equity using inclusive and representative processes;
• The identifcation of underserved communities through data; and
• Equity analysis, in collaboration with appropriate partners, focused on
initial equity impact assessments of the proposed projects and strategies,
and population characteristics.
6 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, and/or standards.

7 Does the plan identify a comprehensive set of projects and strategies to
address the safety problems in the Action Plan, time ranges when
projects and strategies will be deployed, and explain project
prioritization criteria?

8 Does the plan include all 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.
9 Was the plan fnalized and/or last updated between 2018 and June
2023?

YES

NO

If yes, provide documentation:

YES

NO

If yes, provide documentation:

YES

NO

If yes, provide documentation:

YES

NO

If yes, provide documentation:

YES

NO

If yes, provide documentation:

YES

NO

If yes, provide documentation:

Still have questions? Visit the SS4A website
SS4A Self-Certifcation Eligibility Worksheet | Page 2 of 2