[Each fiscal year, to apply for a grant under 23 U.S.C. 405 or Section 1906, Public Law 109-59, as amended by Section 25024, Public Law 117-58, the State must complete and submit all required information in this appendix, and the Governor's Representative for Highway Safety must sign the Certifications and Assurances.]

State: Fiscal Year:

Instructions: Check the box for each part for which the State is applying for a grant, fill in relevant blanks, and identify the attachment number or page numbers where the requested information appears in the triennial HSP or annual grant application. Attachments may be submitted electronically.

□ Part 1: Occupant Protection Grants (23 CFR 1300.21)

[Check the box above only if applying for this grant.]

All States

[Fill in all blanks below.]

• The State's occupant protection program area plan for the upcoming fiscal year is provided in the annual grant application at ___ (location).

• The State will participate in the Click it or Ticket national mobilization in the fiscal year of the grant. The description of the State's planned participation is provided in the annual grant application at ___ (location).

• Projects demonstrating the State's active network of child restraint inspection stations are provided in the annual grant application at ___ (location). Such description includes estimates for: (1) the total number of planned inspection stations and events during the upcoming fiscal year; and (2) within that total, the number of planned inspection stations and events serving each of the following population categories: urban, rural, and at-risk. The planned inspection stations/events provided in the annual grant application are staffed with at least one current nationally Certified Child Passenger Safety Technician.

• Projects, as provided in the annual grant application at ___ (location), that include estimates of the total number of classes and total number of technicians to be trained in the upcoming fiscal year to ensure coverage of child passenger safety inspection stations and inspection events by nationally Certified Child Passenger Safety Technicians.

Lower Seat Belt Use States Only

[Check at least 3 boxes below and fill in all blanks under those checked boxes.]

□ The State's primary seat belt use law, requiring all occupants riding in a passenger motor vehicle to be restrained in a seat belt or a child restraint, was enacted on ___ (date) and last amended on ___ (date), is in effect, and will be enforced during the fiscal year of the grant.

Legal citation(s): ________.

□ The State's occupant protection law, requiring occupants to be secured in a seat belt or age-appropriate child restraint while in a passenger motor vehicle and a minimum fine of $25, was enacted on ___ (date) and last amended on ___ (date), is in effect, and will be enforced during the fiscal year of the grant.

Legal citations:

• _____ Requirement for all occupants to be secured in seat belt or age appropriate child restraint;

• _____ Coverage of all passenger motor vehicles;

• _____ Minimum fine of at least $25;

• _____ Exemptions from restraint requirements.

□ Projects demonstrating the State's seat belt enforcement plan are provided in the annual grant application at ___ (location).

□ The projects demonstrating the State's high risk population countermeasure program are provided in the annual grant application at ___ (location).

□ The State's comprehensive occupant protection program is provided as follows:

• Date of NHTSA-facilitated program assessment conducted within 5 years prior to the application date: ___ (date);

• Multi-year strategic plan: annual grant application or triennial HSP at ___ (location);

• The name and title of the State's designated occupant protection coordinator is ______.

• List that contains the names, titles and organizations of the statewide occupant protection task force membership: annual grant application at ___ (location).

□ The State's NHTSA-facilitated occupant protection program assessment of all elements of its occupant protection program was conducted on ___ (date) (within 5 years of the application due date);

□ Part 2: State Traffic Safety Information System Improvements Grants (23 CFR 1300.22)

[Check the box above only if applying for this grant.]

All States

• The State has a functioning traffic records coordinating committee that meets at least 3 times each year.

• The State has designated a TRCC coordinator.

• The State has established a State traffic records strategic plan, updated annually, that has been approved by the TRCC and describes specific quantifiable and measurable improvements anticipated in the State's core safety databases, including crash, citation or adjudication, driver, emergency medical services or injury surveillance system, roadway, and vehicle databases.

[Fill in the blank for the bullet below.]

• Written description of the performance measure(s), and all supporting data, that the State is relying on to demonstrate achievement of the quantitative improvement in the preceding 12 months of the application due date in relation to one or more of the significant data program attributes is provided in the annual grant application at ___ (location).

□ Part 3: Impaired Driving Countermeasures (23 CFR 1300.23(D)-(F))

[Check the box above only if applying for this grant.]

All States

• The State will use the funds awarded under 23 U.S.C. 405(d) only for the implementation of programs as provided in 23 CFR 1300.23(j).

Mid-Range State Only [Check one box below and fill in all blanks under that checked box.]

□ The State submits its statewide impaired driving plan approved by a statewide impaired driving task force on ___ (date). Specifically—

▪ Annual grant application at ___ (location) describes the authority and basis for operation of the statewide impaired driving task force;

▪ Annual grant application at ___ (location) contains the list of names, titles and organizations of all task force members;

▪ Annual grant application at ___ (location) contains the strategic plan based on Highway Safety Guideline No. 8—Impaired Driving.

□ The State has previously submitted a statewide impaired driving plan approved by a statewide impaired driving task force on ___ (date) and continues to use this plan.

[For fiscal year 2024 grant applications only.]

□ The State will convene a statewide impaired driving task force to develop a statewide impaired driving plan, and will submit that plan by August 1 of the grant year.

High-Range State Only

[Check one box below and fill in all blanks under that checked box.]

□ The State submits its statewide impaired driving plan approved by a statewide impaired driving task force on ___ (date) that includes a review of a NHTSA-facilitated assessment of the State's impaired driving program conducted on ___ (date). Specifically—

▪ Annual grant application at ___ (location) describes the authority and basis for operation of the statewide impaired driving task force;

▪ Annual grant application at ___ (location) contains the list of names, titles and organizations of all task force members;

▪ Annual grant application at ___ (location) contains the strategic plan based on Highway Safety Guideline No. 8—Impaired Driving;

▪ Annual grant application at ___ (location) addresses any related recommendations from the assessment of the State's impaired driving program;

▪ Annual grant application at ___ (location) contains the projects, in detail, for spending grant funds;

▪ Annual grant application at ___ (location) describes how the spending supports the State's impaired driving program and achievement of its performance targets.

□ The State submits an updated statewide impaired driving plan approved by a statewide impaired driving task force on ___ (date) and updates its assessment review and spending plan provided in the annual grant application at ___ (location).

[For fiscal year 2024 grant applications only.]

□ The State's NHTSA-facilitated assessment was conducted on ___ (date) (within 3 years of the application due date); OR

□ The State will conduct a NHTSA-facilitated assessment during the grant year; AND

□ The State will convene a statewide impaired driving task force to develop a statewide impaired driving plan and will submit that plan by August 1 of the grant year.

□ Part 4: Alcohol-Ignition Interlock Laws (23 CFR 1300.23(G))

[Check the box above only if applying for this grant.]

[Check one box below and fill in all blanks under that checked box.]

□ The State's alcohol-ignition interlock law, requiring all individuals convicted of driving under the influence or of driving while intoxicated to drive only motor vehicles with alcohol-ignition interlocks for a period of not less than 180 days, was enacted on ___ (date) and last amended on ___ (date), is in effect, and will be enforced during the fiscal year of the grant.

Legal citations:

• _____ Requirement for alcohol-ignition interlocks for all DUI offenders for not less than 180 days;

• _____ Identify all alcohol-ignition interlock use exceptions.

□ The State's alcohol-ignition interlock law, requiring an individual convicted of driving under the influence of alcohol or of driving while intoxicated, and who has been ordered to use an alcohol-ignition interlock, and does not permit the individual to receive any driving privilege or driver's license unless the individual installs on each motor vehicle registered, owned, or leased by the individual an alcohol-ignition interlock for a period of not less than 180 days, was enacted on ___ (date) and last amended on ___ (date), is in effect, and will be enforced during the fiscal year of the grant.

Legal citations:

• _____ Requirement for installation of alcohol ignition-interlocks for DUI offenders for not less than 180 days;

• _____ Identify all alcohol-ignition interlock use exceptions.

□ The State's alcohol-ignition interlock law, requiring an individual convicted of, or the driving privilege of whom is revoked or denied, for refusing to submit to a chemical or other appropriate test for the purpose of determining the presence or concentration of any intoxicating substance, and who has been ordered to use an alcohol-ignition interlock, requires the individual to install on each motor vehicle to be operated by the individual an alcohol-ignition interlock for a period of not less than 180 days, was enacted on ___ (date) and last amended on ___ (date), is in effect, and will be enforced during the fiscal year of the grant; and

The State's compliance-based removal program, requiring an individual convicted of driving under the influence of alcohol or of driving while intoxicated, and who has been ordered to use an alcohol-ignition interlock, requires the individual to install on each motor vehicle to be operated by the individual an alcohol-ignition interlock for a period of not less than 180 days, was enacted (if a law) or implemented (if a program) on ___ (date) and last amended on ___ (date), is in effect, and will be enforced during the fiscal year of the grant; and

The State's compliance-based removal program, requiring completion of a minimum consecutive period of not less than 40 percent of the required period of alcohol-ignition interlock installation immediately prior to the end of the individual's installation requirement, without a confirmed violation of the State's alcohol-ignition interlock program use requirements, was enacted (if a law) or implemented (if a program) on ___ (date) and last amended on ___ (date), is in effect, and will be enforced during the fiscal year of the grant.

Legal citations:

• _____ Requirement for installation of alcohol-ignition interlocks for refusal to submit to a test for 180 days;

• _____ Requirement for installation of alcohol ignition-interlocks for DUI offenders for not less than 180 days;

• _____ Requirement for completion of minimum consecutive period of not less than 40 percent of the required period of alcohol-interlock use;

• _____ Identify list of alcohol-ignition interlock program use violations;

• _____ Identify all alcohol-ignition interlock use exceptions.

□ Part 5: 24-7 Sobriety Programs (23 CFR 1300.23(H))

[Check the box above only if applying for this grant.]

[Fill in all blanks.]

The State provides citations to a law that requires all individuals convicted of driving under the influence or of driving while intoxicated to receive a restriction on driving privileges that was enacted on ___ (date) and last amended on ___ (date), is in effect, and will be enforced during the fiscal year of the grant. Legal citation(s): ________.

[Check at least one of the boxes below and fill in all blanks under that checked box.]

□ Law citation. The State provides citations to a law that authorizes a statewide 24-7 sobriety program that was enacted on ___ (date) and last amended on ___ (date), is in effect, and will be enforced during the fiscal year of the grant. Legal citation(s): ________.

□ Program information. The State provides program information that authorizes a statewide 24-7 sobriety program. The program information is provided in the annual grant application at ___ (location).

□ Part 6: Distracted Driving Grants (23 CFR 1300.24)

[Check the box above only if applying for this grant and check the box(es) below for each grant for which you wish to apply.]

□ The State has conformed its distracted driving data to the most recent Model Minimum Uniform Crash Criteria (MMUCC) and will provide supporting data (i.e., the State's most recent crash report with distracted driving data element(s)) within 30 days after notification of award.

□ Distracted Driving Awareness Grant

• The State provides sample distracted driving questions from the State's driver's license examination in the annual grant application at ___ (location).

Distracted Driving Law Grants

[Check at least 1 box below and fill in all blanks under that checked box.]

□ Prohibition on Texting While Driving

The State's texting ban statute, prohibiting texting while driving and requiring a fine, was enacted on ___ (date) and last amended on ___ (date), is in effect, and will be enforced during the fiscal year of the grant.

Legal citations:

▪ _____ Prohibition on texting while driving;

▪ _____ Definition of covered wireless communication devices;

▪ _____ Fine for an offense;

▪ _____ Exemptions from texting ban.

□ Prohibition on Handheld Phone Use While Driving

The State's handheld phone use ban statute, prohibiting a driver from holding a personal wireless communications device while driving and requiring a fine for violation of the law, was enacted on ___ (date) and last amended on ___ (date), is in effect, and will be enforced during the fiscal year of the grant.

Legal citations:

▪ _____ Prohibition on handheld phone use;

▪ _____ Definition of covered wireless communication devices;

▪ _____ Fine for an offense;

▪ _____ Exemptions from handheld phone use ban.

□ Prohibition on Youth Cell Phone Use While Driving

The State's youth cell phone use ban statute, prohibiting youth cell phone use while driving, and requiring a fine, was enacted on ___ (date) and last amended on ___ (date), is in effect, and will be enforced during the fiscal year of the grant.

Legal citations:

▪ _____ Prohibition on youth cell phone use while driving;

▪ _____ Definition of covered wireless communication devices;

▪ _____ Fine for an offense;

▪ _____ Exemptions from youth cell phone use ban.

□ Prohibition on Viewing Devices While Driving

The State's viewing devices ban statute, prohibiting drivers from viewing a device while driving, was enacted on ___ (date) and last amended on ___ (date), is in effect, and will be enforced during the fiscal year of the grant.

Legal citations:

▪ _____ Prohibition on viewing devices while driving;

▪ _____ Definition of covered wireless communication devices;

□ Part 7: Motorcyclist Safety Grants (23 CFR 1300.25)

[Check the box above only if applying for this grant.]

[Check at least 2 boxes below and fill in all blanks under those checked boxes only.]

□ Motorcycle Rider Training Course

• The name and organization of the head of the designated State authority over motorcyclist safety issues is ______.

• The head of the designated State authority over motorcyclist safety issues has approved and the State has adopted one of the following introductory rider curricula:

[Check at least one of the following boxes below and fill in any blanks.]

□ Motorcycle Safety Foundation Basic Rider Course;

□ TEAM OREGON Basic Rider Training;

□ Idaho STAR Basic I;

□ California Motorcyclist Safety Program Motorcyclist Training Course;

□ Other curriculum that meets NHTSA's Model National Standards for Entry-Level Motorcycle Rider Training and that has been approved by NHTSA.

• In the annual grant application at ___ (location), a list of counties or political subdivisions in the State where motorcycle rider training courses will be conducted during the fiscal year of the grant AND number of registered motorcycles in each such county or political subdivision according to official State motor vehicle records.

□ Motorcyclist Awareness Program

• The name and organization of the head of the designated State authority over motorcyclist safety issues is ______.

• The State's motorcyclist awareness program was developed by or in coordination with the designated State authority having jurisdiction over motorcyclist safety issues.

• In the annual grant application at ___ (location), performance measures and corresponding performance targets developed for motorcycle awareness that identify, using State crash data, the counties or political subdivisions within the State with the highest number of motorcycle crashes involving a motorcycle and another motor vehicle.

• In the annual grant application at ___ (location), the projects demonstrating that the State will implement data-driven programs in a majority of counties or political subdivisions where the incidence of crashes involving a motorcycle and another motor vehicle is highest, and a list that identifies, using State crash data, the counties or political subdivisions within the State ranked in order of the highest to lowest number of crashes involving a motorcycle and another motor vehicle per county or political subdivision.

□ Helmet Law

The State's motorcycle helmet law, requiring the use of a helmet for each motorcycle rider under the age of 18, was enacted on lowbarm;__ (date) and last amended on ___ (date), is in effect, and will be enforced during the fiscal year of the grant.

Legal citation(s): ________. □ Reduction of Fatalities and Crashes Involving Motorcycles

• Data showing the total number of motor vehicle crashes involving motorcycles is provided in the annual grant application at ___ (location).

• Description of the State's methods for collecting and analyzing data is provided in the annual grant application at ___ (location).

□ Impaired Motorcycle Driving Program

• In the annual grant application or triennial HSP at ___ (location), performance measures and corresponding performance targets developed to reduce impaired motorcycle operation.

• In the annual grant application at ___ (location), countermeasure strategies and projects demonstrating that the State will implement data-driven programs designed to reach motorcyclists and motorists in those jurisdictions where the incidence of motorcycle crashes involving an impaired operator is highest (i.e., the majority of counties or political subdivisions in the State with the highest numbers of motorcycle crashes involving an impaired operator) based upon State data.

□ Reduction of Fatalities and Crashes Involving Impaired Motorcyclists

• Data showing the total number of reported crashes involving alcohol-impaired and drug-impaired motorcycle operators are provided in the annual grant application at ___ (location).

• Description of the State's methods for collecting and analyzing data is provided in the annual grant application at ___ (location).

□ Use of Fees Collected From Motorcyclists for Motorcycle Programs

[Check one box only below and fill in all blanks under the checked box only.]

□ Applying as a Law State—

• The State law or regulation requires all fees collected by the State from motorcyclists for the purpose of funding motorcycle training and safety programs are to be used for motorcycle training and safety programs. Legal citation(s): ________.

AND

• The State's law appropriating funds for FY __ demonstrates that all fees collected by the State from motorcyclists for the purpose of funding motorcycle training and safety programs are spent on motorcycle training and safety programs. Legal citation(s): ________.

□ Applying as a Data State—

• Data and/or documentation from official State records from the previous fiscal year showing that all fees collected by the State from motorcyclists for the purpose of funding motorcycle training and safety programs were used for motorcycle training and safety programs is provided in the annual grant application at ___ (location).

□ Part 8: Nonmotorized Safety Grants (23 CFR 1300.26)

[Check the box above only if applying for this grant and only if NHTSA has identified the State as eligible because the State annual combined nonmotorized road user fatalities exceed 15 percent of the State's total annual crash fatalities based on the most recent calendar year final FARS data, then fill in the blank below.]

• The list of project(s) and subrecipient(s) information that the State plans to conduct under this program is provided in the annual grant application at ___(location(s)).

□ Part 9: Preventing Roadside Deaths Grants (23 CFR 1300.27)

[Check the box above only if applying for this grant, then fill in the blank below.]

□ The State's plan describing the method by which the State will use grant funds is provided in the annual grant application at ___(location(s)).

□ Part 10: Driver and Officer Safety Education Grants (23 CFR 1300.28)

[Check the box above only if applying for this grant.]

[Check one box only below and fill in required blanks under the checked box only.]

□ Driver Education and Driving Safety Courses

[Check one box only below and fill in all blanks under the checked box only.]

□ Applying as a law State—

The State law requiring that driver education and driver safety courses include instruction and testing related to law enforcement practices during traffic stops was enacted on ___(date) and last amended on ___(date), is in effect, and will be enforced during the fiscal year of the grant.

Legal citation(s): ________.

□ Applying as a documentation State—

• The State has developed and is implementing a driver education and driving safety course throughout the State that require driver education and driver safety courses to include instruction and testing related to law enforcement practices during traffic stops.

• Curriculum or course materials, and citations to grant required topics within, are provided in the annual grant application at ___(location).

□ Peace Officer Training Programs

[Check one box only below and fill in all blanks under the checked box only.]

□ Applying as a law State—

The State law requiring that the State has developed and implemented a training program for peace officers and reserve law enforcement officers with respect to proper interaction with civilians during traffic stops was enacted on ___(date) and last amended on ___(date), is in effect, and will be enforced during the fiscal year of the grant.

Legal citation(s): ________.

□ Applying as a documentation State—

• The State has developed and is implementing a training program for peace officers and reserve law enforcement officers with respect to proper interaction with civilians during traffic stops.

• Curriculum or course materials, and citations to grant required topics within, are provided in the annual grant application at ___(location).

□ Applying as a qualifying State—

• A proposed bill or planning or strategy documents that identify meaningful actions that the State has taken and plans to take to develop and implement a qualifying law or program is provided in the annual grant application at ___(location).

• A timetable for implementation of a qualifying law or program within 5 years of initial application for a grant under this section is provided in the annual grant application at ___(location).

□ Part 11: Racial Profiling Data Collection Grants (23 CFR 1300.29)

[Check the box above only if applying for this grant.]

[Check one box only below and fill in all blanks under the checked box only.]

□ The official document(s) (i.e., a law, regulation, binding policy directive, letter from the Governor or court order) demonstrates that the State maintains and allows public inspection of statistical information on the race and ethnicity of the driver for each motor vehicle stop made by a law enforcement officer on all public roads except those classified as local or minor rural roads are provided in the annual grant application at ___(location).

□ The projects that the State will undertake during the fiscal year of the grant to maintain and allow public inspection of statistical information on the race and ethnicity of the driver for each motor vehicle stop made by a law enforcement officer on all public roads except those classified as local or minor rural roads are provided in the annual grant application at ___(location).

In my capacity as the Governor's Representative for Highway Safety, I hereby provide the following certifications and assurances—

• I have reviewed the above information in support of the State's application for 23 U.S.C. 405 and Section 1906 grants, and based on my review, the information is accurate and complete to the best of my personal knowledge.

• As condition of each grant awarded, the State will use these grant funds in accordance with the specific statutory and regulatory requirements of that grant, and will comply with all applicable laws, regulations, and financial and programmatic requirements for Federal grants.

• I understand and accept that incorrect, incomplete, or untimely information submitted in support of the State's application may result in the denial of a grant award.

I understand that my statements in support of the State's application for Federal grant funds are statements upon which the Federal Government will rely in determining qualification for grant funds, and that knowing misstatements may be subject to civil or criminal penalties under 18 U.S.C. 1001. I sign these Certifications and Assurances based on personal knowledge, and after appropriate inquiry.

Signature Governor's Representative for Highway Safety Date Printed name of Governor's Representative for Highway Safety