Healthy School Facility Fund (HSFF) Application

Healthy School Facility Fund (HSFF) Application

Please enter all information below. You may submit only one application at a time but you may submit multiple applications, if necessary.

Funding Year*

Select

Date Request Submitted*

Priority*

If you have multiple applications to submit enter priority number of each (1, 2, 3, etc.)

Select

PSC Number*

Enter in 00.000 format

School Name*

Enter the name of the School

Project Type*

Select the type of project from the dropdown list

Select

Project*

Describe type of project

County*

Select

Detailed Project Description*

Facility Closure(s)*

Confirm whether the school facility closed during the school year due to issue(s) identified in the scope of work.

Select

How many times has the school been closed?*

Select

Date of Prior State Funding of Building System

Provide the date the building system was last replaced with State funds.

Alternative Solution*

What else can be done to correct this problem?

What caused this problem?*

Normal wear and tear, poor contractor performance, poor materials, improper maintenance, etc.

Consequences if this project is not approved*

Check all that apply

1 - Failure of system is likely to cause shutdown of facility for purposes of delivering educational programs and services.

2 - System is currently adversely affecting the delivery of educational programs & services.

3 - System is currently causing serious threats to life, safety, or health of facility occupants.

4 - System is currently causing violations of building or other official codes.

5 - System is currently causing or will imminently cause damage to other building systems.

6 - Replacement/installation will increase the remaining useful lifespan (RUL) of other building systems in the facility, thereby extending the RUL of the facility.

Has Design Been Completed?*

Select

Anticipated Completion Date for Design*

Document Submission*

Provide the date when document(s) will or have been submitted.

Is Design Funding Being Requested?*

Select

LEA Total Construction Cost Estimate*

LEA Design Cost Requested*

Total State HSFF $ Req for Design and Construction*

Enter total amount requested

Local HSFF $ Approved*

Anticipated Date Work Begins*

Anticipated Date Work Completed*

Name of person completing form*

Email address of person completing form*

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