Florida Traffic Safety Information Systems

Federal Fiscal Year 2014

Request for Section 405 Funding

Project Title:

Agency Name:

Person Completing Form:

Name:

Title:

Agency:

Address:

City, Zip:

Phone: () - Ext.

E-mail:

Person to Contact Regarding Project:

Name:

Title:

Agency:

Address:

City, Zip:

Phone: () - Ext.

E-mail:

Is this concept: New? Continuation? (Select project year)

Year 2 Year 3 Other

Section 405 Funding Requested for FY2014:$

Project will impact the following Traffic Records Information Systems: (check all that apply)

Crash Roadway Vehicle

Driver Citation/AdjudicationEMS/Injury Surveillance System

Project will impact the following performance area(s): (check all that apply)

Timeliness Completeness Accuracy

Uniformity Accessibility Integration

Specific objective(s) and strategy(ies) from the FloridaTraffic Safety Information System Strategic Plan 2012-2016 the project will address:(include specific objective number, objective description, and strategy description from the Action Step matrix)

Objective / Strategy

Describe the project:

What software and hardware is involved? (If applicable)

List any partner agencies for the project:

List performance measures for the project, including existing benchmarks and future goals:(seeNHTSA’s Model Performance Measures for State Traffic Records Systems)

Performance Measure / Existing Benchmark / Future Goals

How will the project be evaluated?

Authorized Organization Representative – Name and Title (please print)

Authorized Signature (in blue ink)

Date

Proposed Section 405 Budget

First Year Request (October 1, 2013 – September 30, 2014)

Category / Section 405 Funds / Other Federal Funds / State/Local Funds
(including soft match) / Total Funds
Personnel Costs
Contractual Services
Expenses
Operating Capital Outlay
Indirect Cost
Total

Budget Narrative: (Describe the personnel, contractual, and equipment costs included in the budget request. List other funding sources for the project, including soft matches.)

Second Year Request (October 1, 2014 – September 30, 2015)

Category / Section 405 Funds / Other Federal Funds / State/Local Funds
(including soft match) / Total Funds
Personnel Costs
Contractual Services
Expenses
Operating Capital Outlay
Indirect Cost
Total

Budget Narrative: (Describe the personnel, contractual, and equipment costs included in the budget request. List other funding sources for the project, including soft matches.)

Third Year Request (October 1, 2015 – September 30, 2016)

Category / Section 405 Funds / Other Federal Funds / State/Local Funds
(including soft match) / Total Funds
Personnel Costs
Contractual Services
Expenses
Operating Capital Outlay
Indirect Cost
Total

Budget Narrative: (Describe the personnel, contractual, and equipment costs included in the budget request. List other funding sources for the project, including soft matches.)

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