Agenda 03/09/2010 Item # 9E
Agenda Item No, 9E
March 9, 2010
Page 1 of 11
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EXECUTIVE SUMMARY
Recommendation to authorize the County Manager or his designee to sign facility use
agreements with the U.S. Census Bureau, enabling them to use County Facilities for
activities to aid in the 2010 Census.
OBJECTIVE: Obtain approval for the County Manager or his designee to sign agreements that
enable the U.S. Census Bureau to use County Facilities in support of the 2010 Census.
CONSIDERATIONS: The U.S. Census Bureau has been using County Facilities to facilitate
the 2010 Census. They require that the County sign U.S. Census Bureau Form D-1281,
'Conditions for Donation of Services and Space Agreement 2010 Census'. The completed forms
for the Library are included as back-up.
GROWTH MANAGEMENT IMPACT: None.
LEGAL IMPACT: The County Attorney's office has approved the documents for legal
sufficiency, enabling signature by the County Manager or his designee.
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RECOMMENDA TlON: Staff recommends that the Board authorize the County Manager or his
designee to sign agreements enabling the U.S. Census Bureau to use County Facilities for the
2010 Census.
Prepared by: Marilyn Matthes, Director
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Agenda Item No. 9E
March 9, 2010
Page 2 of 11
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COLLIER COUNTY
BOARD OF COUNTY COMMISSIONERS
Item Number:
Item Summary:
9E
Meeting Date:
Discussion regarding space needed for upcoming Census count. (Commissioner Coletta
request)
3/9/20109:00:00 AM
Approved By
Ian Mitchell
Supervisor - BCC Office Operations
Date
BCC
BCC
3/11201012:11 PM
Approved By
Michael Sheffield
Assistant to the County Manager
Date
County Managers Office
3/1/201012:45 PM
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Agenda Item No. 9E
March 9, 2010
Page 3 of 11
From: ColettaJim
Sent: Saturday, February 27, 2010 10: 11 AM
To: ochsJ
Subject: Re: The census needs a small space at county libraries and / or Community Centers from 3/1S
to 4/15.
Leo
Thank you.
Jim
From: ochs_'
To: ColettaJim
Cc: marcela.l.rice@census,gov <marcela.l.rice@census.gov>; PrietoEvelyn
Sent: Fri Feb 26 13:59:27 2010
Subject: RE: The census needs a small space at county libraries and / or Community Centers from 3/15
to 4/15.
Commissionerl
I will place this on the next agenda. May I place it under item 9 Bee as a discussion item requested by
you?
From: ColettaJim
Sent: Thursday, February 25, 20105:40 PM
To: ochs_1
Cc: marcela,l.rice@census,gov; PrietoEvelyn
Subject: The census needs a small space at county libraries and / or Community Centers from 3/15 to
4/15.
Leo
In order to assure that the future financial federal draw down
to Collier County is in proportion to our population we need to
assist the upcoming census count. Marcela Rice who works for
the census is in desperate need of small areas in our county
libraries and/ or Community Center from 3/15 to 4/15. Hours of
operation to be determined by county. The Form 1281 needs to
be approved by the county manager or the BCe. Please contact
Marcella 239-357-6111 cell 239-677-7738.
Leo, I am requesting that you place this on the next BCC
agenda if you can't handle this administratively. Thank you for
your consideration and action regarding this request.
Jim Coletta
Commissioner, District 5
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Agenda Item No. 9E
March 9, 2010
Page 4 of 11
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ITEM NO.:
DATE RECEIVED:
FILE NO,:
ROUTED TO:
DO NOT WRITE ABOVE THIS SPACE (Orig. 9/89; Rev. 6/97)
REQUEST FOR LEGAL SERVICES
(Please type or print)
Date: Feb. 26, 2010
To: Office of the County Attorney, Attn: CoUeen Green
From: Marilyn Matthes
(Name)
Director
(Title)
Public Services
(Division)
Library
(Department)
Telephone # (Verv Important): 5933511
Re: space use forms for census
(Subject)
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BACKGROUND OF REQUEST/PROBLEM:
(Describe problem and give background information ~ !!!:'!peeifle. concise. and articulate.)
Census Bureau requires that the attached facilities use agreements be signed so that they may use CountylLibrary
facilities. Need Bee authorization to sign forms. Each Library has agreed to provide space on the days aod times listed
on each form.
(Are there documents or other information needed to review this matter? If yes, attach and reference this information.)
This item haslhas not been previously submitted.
(If previously submitted provide County Attorney's Office File No.) HAS NOT
ACTION REQUESTED:
(Be very specific. Identify exactly what you need in the way of legal services.)
Need approval for legal sufficiency so that BCC can authorize County Manager or his
designee to sign this type of form with Census Bureau.
OTHER COMMENTS:
-
cc:
Marla Ramsy
(All requests must he copied to your appropriate Division Head or Constitutional Officer.)
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FOFW 0.1281
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U.S. DEPARTMENT OF COMMERCE
Eggnomlcsand SlalIIllcs AdmlnlBtrallon
U.S. CENSUS BUREAU
!t:C!\!lllIiT!@NS IFO~ DONATiON Of SEIi'liVICa:S AINIIllI SPACE AGIfIlIEIEINilIEINIT
201 I) CensllBs
The common goal of the U.S. Census Bureau and the Donor is to achieve a complete and accurate
count in the 2010 Census.
A. Donatiion of Space
Under the guidance of the U.S. Census Bureau, the Donor agress to provide space for a Questionnaire
Assistance Center (QAC) within the property of their organization for the purpose of helping those
persons who request assistance in completing their 201Q Census questionnaire.
This donation is subject to the following terms and conditions:
1. The Donor will prOVid, space for the QAC at the following times and on the following
(daysk.ffian - hlA.~'"? to - 12.. tJao,.J . The U.S. Census Bureau expects peak
usage of the Questionnaire Assistance Centers to extend from March 19, 2010 to April 19, 2010. [t
would be most beneficia) to the community if the person working at this QAC spoke the following
language: I:Mjl ',;?VJ .
2. The U.S. Census Bureau will not reimburse the Donor Organization for any expenses related to the
provision of the QAC space.
3. Questionnaire assistance will be provided without any charge whatsoever to the respondent.
4. The U.S. Census Bureau will provide a poster and/or a banner to be placed at the authorized
Questionnaire Assistance Center, designating those piaces as U.S. Census Bureau sanctioned
assistance centers. A Be Counted box will be available on the premises for the respondent to obtain a
Be Counted questionnaire' if they did not receive one at their place of residence or they believe they
were not added to the census questionnaire sent to their place of residence.
5. The Donor Organization agrees to provide or to arrange for the provision of suitable space to be used as
Questionnaire Assistance Centers during the 2010 Census. Questionnaire Assistance Center
Representatives (QAC reps) will occupy the space and provide assistance to those respondents who
visit the Questionnaire Assistance Centers.
This donation is subject to the following terms and conditions:
1. The C,OLLlfALCmc/ll'rY PUblic... LIVIUI'I1"/(otgenization) will donate (oct square feet
of office space in IlA-f\lD8t.I';JIL, lbF.A.CJt li~ (building name), at
16~ \j Orolt>\Li R,ow (address),
-?j I 0 (City, State, and ZIP Co e) for a
period of ~ (number of weeks), commencing on ~ 2q I a (date) through , lC) (date).
2. The space shall accommodate one (1) desk (or table) and two (2) chairs, in which the QAC rap may
interview, privately and undisturbed, the respondent(s) seeking assistance.
3. The space is being donated to the U.S. Census Bureau at no cost to the government.
B. Liability
In the event that Injury or damage is caused a U.S. Census Bureau empioyee while acting within the
scope of his or her authority, the incident will be covered under the Federal Tort Claims Act, Title 28
U.S.C. 92671, at seq. Any claims arising from such incidents may be filed with the U.S. Census Bureau
and will be promptly addressed.
Any injury occurring to a U.S. Census Bureau employee while acting within the scope of his or her
employment will be covered under the Federal Employees Compensation Act, Title 5 U.S.C. ~81 01,
at seq.
Because the Federal Government is self-insured, it IS the U.S. Census Bureau's policy not to purchase
or pay for commercialliabillty insurance. In addition, the Anti-Deficiency Act, Title 31 U.S.C. 91341,
at seq., prohibits any Federal agency from undertaking contingent and undetermined liability without
funds being appropriated by Congress for such purpose. For this reason, the Government cannot agree
to a .hold-harmless" clause nor can it waive the right to sue.
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Date
Signature
Data
Name - Please print
Donor
Name - Please print
lRIegslIIID'IIaD Il)Dll'6CtOIi', lI.ll.S. Celi'llslUIS lBlUlll'eSlllll.
Copy distribution: WHDTli! - Assistant Manager for Quality Assurance (AMQA) in the LCO VEILD-OW - Donor of space
USCENSUSBUREAU
FORM 0.1281
(4-2:WlOOi)
u.s. DEPARTMENT OF COMMERCE
Econarnk:aandSIeUIlicIIAdIrlnisItal/on
u.s. CENSUS BUREAU
CONDITIONS IFOR DOINIATIOINI elF SERVICES AINID SPACE AGIREEMIEINlT
2010 CenslLQs
The common goal of the U.S. Census Bureau and the Donor is to achieve a complete and accurate
count in the 2010 Censua
A. Donation of Space
Under the guidance of the U.S. Census Bureau, the Donor agrees to provide space for a Questionnaire
Assistance Center (QAC) within the property of their organization for the purpose of helping those
persons who request assistance in completing their 2010 Census questionnaire.
This donation is subject to the following terms and condftions:
1. The Donor will provide space for the QAC at the following times and on the following
(days): WE.() [TILL''''' ) I - 5 P IY\ . The u.s. Census Bureau expects peak
usage of the Questionnaire Assistance Centers to extend from March 19,2010 to April 19, 2010. It
would be most beneficial to the community if the person working at this QAC spoke the fOllowing
language: .t.NuLI'?1+- "'i 0-pMlI7>lf--
2. The U.S. Census Bureau will not reimburse the Donor Organization for any expenses related to the
provision of the QAC space.
3. Questionnaire assistance will be provided without any charge whatsoever to the respondent.
4. The U.S. Census Bureau will provide a poster and/or a banner to be placed at the authorized
Questionnaire Assistance Center, designating those places as U.S. Census Bureau sanctioned
assistance centers. A Be Counted box will be available on the premises for the respondent to obtain a
Be Counted questionnaire if they did not receive one at their place of residence or they believe they
were not added to the census questionnaire sent to their place of residence.
S. The Donor Organization agrees to provide or to arrange for the provision of suitable space to be used as
Questionnaire Assistance Centers during the 2010 Census. Questionnaire Assistance Center
Representatives (QAC reps) will occupy the space and provide assistance to those respondents who
visit the Questionnaire Assistance Centers.
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This donation is subject to the following terms and conditions:
1. The c'OWE1l l!.ou.rJ't'f PLti;)0lC. Ul;;lM!Af(orgBnizatiOn) will donate 5<:0 square feet
of ollice space in ft.Avrr- I\f MLllN? Dt.M.IOI+- (buiiding name), at
6167 iJl<fv\IMA,1 '-Q.A,L E.. (address),
Fl... ---? Il? (CIty, State, and ZiP, Co eJ for a
period of ~ (number of weeks), commencing on ( C (date) through "2.0 10 (date).
2. The space shall accommodate one (1) desJ( (or table) and two (2) chairs, in which the QAC rep may
interview, privately and undisturbed, the respondent(s) seeking assistance.
3. The space is being donated to the U.S. Census Bureau at no cost to the government.
B. Liability
In the event that injury or damage is caused a U.S. Census Bureau employee while acting within the
scope of his or her authority, the incident will be covered under the Federal Tort Claims Act, Title 28
u.s.e. 92671, at seq. Any claims arising from such Incidents may be flied with the U.S. Census Bureau
and will be promptly addressed.
Any injury occurring to a U.S. Census Bureau employee while acting within the scope of his or her
employment will be covered under the Federal Employees Compensation Act, Title 5 U.S.C. ~8101,
etseq.
Because the Federal Government is self-insured, ft is the U.S. Census Bureau's polley not to purchase
or pay for commercial liability Insurance. In addition, the Anti-Deficiency Act, Title 31 U.S.C. ~1341.
at seq., prohibits any Federal agency from undertaking contingent and undetermined liability without
funds being appropriated by Congress for such purpose. For this reason, the Government cannot agree
to a -hold-harmless. clause nor can It waive the right to sue.
Date
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Name - Please prInt
lIJJoD'Dor
Name - Please print
Regioll'Ds! IDffll'ecil:oll'r lIJl.S. Cell'Dsus BWlIl'eSllI
Copy distributiom WHITE - Assistant Manager for Quality Assurance (AMQA) in the LCO YEl!.lLOW _ Donor of space
USCENSUSBUREAU
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FORM D.1281
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u.s. DEPARThlENT OF COMMERCE
E<:oncm/csand StallsllcsAdrm115l1B(1cn
U.S. CENSUS BUREAU
C@li\!Il!lli'll'DCiIIIS IFOil'! Dll@I!IiA'fiOIi\!! OIF SERViCES AINIIllI 51JOACIE AiGlRlElEMl!:lNI1'
2010 CensMs
The common goal of the U.S. Census Bureau and the Donor is to achieve a complete and accurate
count in the 2010 Census.
A.. Donatuoll1 of Space
Under the guidance of the U,S. Census Bureau, the Donor agrees to provide space for a Questionnaire
Assistance Center (QAC) within the property of their organization for the purpose of helping those
persons who request assistance in completing their 2010 Census questionnaire.
This donation is subject to the following terms and conditions:
1. The Donor will provide space for the QAC at the following times and on the following
(days): [Y\OI\ -11i"~,,,,) IOI'M - 2r<V\ . The U.S. Census Bureau expects peak
usage of the Questionnaire Assistance Centers to extend from March 19, 2010 to April 19, 2010. It
would be most beneficial to the community If the person working at this QAC spoke the following
language, W4L1";/\\- '\' 'Sp,l.,1,J (<::>!-j-
2. The U.S. Census Bureau will not reimburse the Donor Organization for any expenses related to the
provision of the QAC space.
3. Questionnaire assistance will be provided without any charge whatsoever to the respondent.
4. The U.S. Census Bureau will provide a poster and/or a banner to be placed at the authorized
Questionnaire Asslstance Center, designatIng those places as U.S. Census Bureau sanctioned
assistance centers. A Be Counted box will be available on the premises for the respondent to obtain a
Be Counted questionnaire if they did not receive one at their place of residence or they believe they
were not added to the census questionnaire sent to their place of residence.
5. The Donor Organization agrees to provide or to arrange for the provision of suitable space to be used as
Questionnaire Assistance Centers during the 2010 Census. Questionnaire Assistance Center
Representatives (QAC reps) will occupy the space and provide assistance to those respondents who
visit the Questionnaire Assistance Centers.
This donation is sue:t to the ~!lowing terms and conditions:
1. The Co'-uE>IL /J.~'r\f yu.!bUC L It>~ (organization) will donate 12-0 square feet
of office space in ~ tJ~Jf (I:J~ (building name), at
IUol" &::wEN <SkIT. LVb k) (address),
Fl... I (Cily, State, and ZIP Co e) for a
period of..2L (number of weeks), commencing on 7..,0 t a (date) through 4- l Lo \ <:::l(date).
2. The space shall accommodate one (1) desk (or table) and two (2) chairs, in which the QAC rep may
interview, privately and undisturbed, the respondent(s) seeking assistance.
3. The space is being donated to the U.S. Census Bureau at no cost to the government.
B. Liability
In the event that injury or damage is caused a U.S. Census Bureau employee while acting within the
scope of his or her authority; the incident will be covered under the Federal Tort Claims Act, TItle 28
U.S.C. 92671, at seq. Any claims arising from such incidents may be filed with the U.S. Census Bureau
and will be promptly addressed.
Any injury occurring to a U.S. Census Bureau employee while acting within the scope of his or her
employment wlll be covered under the Federal Employees Compensation Act, TItle 5 U.S.C. ~8101,
etseq.
Because the Federal Government is self-insured, it is the U.S. Census Bureau's policy not to purchase
or pay for commercial liability insurance. In addition, the Anti-Deficiency Act, Title 31 U.S.C. 91341,
et seq., prohibits any Federal agency from undertaking contIngent and undetermined liability without
funds being appropriated by Congress for such purpose. For this reason, the Govemment cannot agree
to a "hold-hannless. clause nor can it waive the right to sue.
Signature
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Name - Please print
lRegionaU llJlull'ec'S:orr, IlD.S. Ce61lslUIs BQ.IlU'eSllUl
COPIr distnbution: WNBT!. - Assistant Manager for Quality Assurance (AMaA) in the LCD VIEIl.LOW - Donor of space
USCENSUSBUREAU
FOAM D.1281 '
(4~-2009)
u.s. DEPARTMENT OF COMMERCE
EconDITIlc:8andSlallsllcsAdtnWslrllllllll
u.s. CENSUS BUREAU
CiOlIIIlIlllTiOIi\llS IFOR DONA'Il'iON iCliF SlElRViCES AIIIIIIll SPACE AGREEMEN'Il'
2010 CensWls
-
The common goal of the U.S. Census Bureau and the Donor is to achieve a complete and accurate
count in the 2010 Census.
A. Donation of Space
Under the guidance of the U.S. Census Bureau, the Donor agrees to provide space for a Questionnaire
Assistance Center (QAC) within the property of their organization for the purpose of helping those
persons who request assistance In completing their 2010 Census questionnaire.
This donation is subject to the following terms and conditions:
1. The Donor will provide space for the QAC at the following times and on the following
(days),\'i\OI\ 'TILe"", 1\-'1 ~..iJ.d..hi "1-0 . The U.S. Census Bureau expects peak
usage of the Questionnaire Assistance Centers to extend from March 19, 2010 to April 19, 2010. It
would be most beneficial to the community if the person working at this QAC spoke the following
language: E.lc.q,:>l\-, ~PMl I'\Jfi-, "i.c./..€.ou::..
2. The U.S. Census Bureau will not reimburse the Donor Organization for any expenses related to the
provision of the QAC space.
3. Questionnaire assistance will be provided without any charge whatsoever to the respondent.
4. The U.S. Census Bureau will provide a poster and/or a banner to be placed at the authorized
Questionnaire Assistance Center, designating those places as U.S. Census Bureau sanctioned
assistance centers. A Be Counted box will be available on the premises for the respondent to obtaln a
Be Counted questionnaire if they did not receive one at their place of residence or they believe they
were not added to the census questionnaire sent to their place of residence.
S. The Donor Organization agrees to provide or to arrange for the provision of suitable space to be used as
Questionnaire Assistance Centers during the 2010 Census. Questionnaire Assistance Center
Representatives (OAC reps) will occupy the space and provide assistance to those respondents who
visit the Questionnaire Assistance Centers.
This donation is subject to the following terms and conditions:
1. The C,OLl,.\Ul., CoIA/J"fJIAl?Wt. LIP:J~ (organization) will donate ~ square feet
of office space In ~Mo~ tJeAN<!.ll \.:1 ~u,'I!.Af (building name), at
--Y:1.J ~. \ '7r :'.JTu:er (address),
-:::t:M Mo FL.. 1-+'2- (City, Slate, and ZIP Code) for a
period of -==9- (number of weeks), commencing on G> '"2..! L.c 10 (date) through l '"2.C lc:::, (date).
2. The space shall accommodate one (1) desk (or table) and two (2) chairs, in which the QAC rap may
interview, privately and undisturbed, the respondent(s} seeking assistance.
3. The space is being donated to the U.S. Census Bureau at no cost to the govemment.
II. I.iability
In the event that injury or damage is caused a U.S. Census Bureau employee while acting within the
scope of his or her authority, the inddent wlll be covered under the Federai Tort Claims Act, TItle 28
U.S.C. ~2671, et ssq. Any claims arising from such incidents may be filed with the U.S. Census Bureau
and will be promptly addressed.
Any injury occurring to a U.S. Census Bureau employee while acting within the scope of his or her
employment will be covered under the Federal Employees Compensation Act, lltle 5 U.S.C. ~81 01,
etseq.
Because the Federal Govemment is self~insured, it is the U.S. Census Bureau's polley not to purchase
or pay for commercial liability insurance. In addition, the Anti-Deficiency Act, TItle 31 U.S.C. ~1341,
at seq., prohibits any Federal agency from undertaking contingent and undetermined Iiabllfty without
funds being appropriated by Congress for such purpose. For this reason, the Government cannot agree
to a .hold-harmless" clause nor can it waive the right to sue.
Date
Signature
Date
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Name - Please print
RegftoD'llzU IClfi!recltoD', 1UI.S. Ce!l1Sl!lls Iilllll'eanur
Copy distributiom WHITE - Assistant Manager for Quality Assurance (AMQA) In the LCD V!9:LLOW _ Donor of space
US CENSUS BUREAU
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FOAM 1).1281
1-
U.S. DEPARTMENT OF COMMERCE
EconomIcGaodSlBlIsllc:sAdmlnllllrBllon
U.S. CENSUS BUREAU
Ci!lIlNIlIlliTiOI\llS FOIR I!llOINlA'Il'iOi\!l Of SlElIIlll'iCIES AINID SPACE AillIIi'ilIEEMIEINI'Il'
2<<lUIiC..""..s
The common goal of the U.S. Census Bureau and the Donor is to achieve a complete and accurate
count in the 2010 Census.
A. Donation of Space
Under the guidance of the U.S. Census Bureau, the Donor agrees to provide space for a Questionnaire
Assistance Center (QAe) within the property of their organization for the purpose of helping those
persons who request assistance in completing their 2010 Census questionnaire.
This donation is subject to the following terms and conditions:
1. The Donor will provide space for the QAC at the following times and on the following
. \\_~ (days):f'/\"" /TJJ""", \ ~ Q ~M j lii"",/W.J. 10 - "> . The U.S. Census Bureau expects peak
~\ usage of the Questionnaire ASSIstance Centers to extend from March 19, 2010 to April 19, 2010. It
would be most bene~cial to the commur;1ity If the person working at this QAe spol<e the following
language: ~\l':>h of ~,2b..
2. The U.S. Census Bureau will not reimburse the Donor Organization for any expenses related to the
provision of the QAC spaca
3. Questionnaire assistance will be provided without any charge whatsoever to the respondent.
4. The U.S. Census Bureau will provide a poster and/or a banner to be placed at the authorized
Questionnaire Assistance Center, designating those places as U.S. Census Bureau sanctioned
assistance centers. A Be Counted box will be available on the premIses for the respondent to obtain a
Be Counted questionnaire if they did not receive one at their place of residence or they believe they
were not added to the census questionnaire sent to their place of residence.
5. The Donor Organization agrees to provide or to arrange for the provision of suitable space to be used as
Questionnaire Assistance Centers during the 2010 Census. Questionnaire Assistance Center
Representatives (QAC reps) will occupy the space and provIde assistance to those respondents who
visit the Questionnaire Assistance Centers.
This donation is subject to the following terms and conditions:
1. The CbLI..l!W- 0su."''Y PIA.f.JLIC,. L, ~rganization) will donate I ~ square feel
of office space in MI\12i. "J:<,i..ANll tJUNct-f-- (building name), at
1.-10 "j, ~DC>O DlllVE. (address),
CD \'1lA'N FL '<:i I (City. State, and ZIP Co 0) for a
period of -22 (number af weeks), commencing on -ZC! ?-OlD (date) through \ "U::lLa (date).
2. The space shall accommodate one (1) desk (or table) and two (2) chairs, in which the QAC rep may
interview, privately and undisturbed, the respondent(s) seeking assistance.
3. The space is being donated to the U.S. Census Bureau at no cost to the government.
B. Liability
In the event that injury or damage is caused a U.S. Census Bureau employee while acting within the
scope of his or her authority, the incident will be covered under the Federal Tort Claims Act. Title 28
U.S.C. 92671, st ssq. Any claims arising from such incidents may be filed with the u.s. Census Bureau
and will be promptly addressed.
Any injury occurring to a U.S. Census Bureau employee while acting within the scope of his or her
employment will be covered under the Federal Employees Compensation Act, TItle 5 U.S.C. ~81 01,
etseq.
Because the Federal Government is self~insurBd, it is the U.S. Census Bureau's polley not to purchase
or pay for commercia/liability insurance. In addition, the AntiMDeficiency Act, Title 31 U.S.C. ~1341,
et seq., prohibits any Federal agency from undertaking contingent and undetermined liability without
funds being appropriated by Congress for such purpose. For this reason, the Govemment cannot agree
to a .hold-harmless~ clause nor can It waive the right to sue.
-Signature
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Donor
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Regiona6 lOlull'ecitilJllI', 1UI.S. Censllls lB\llIll'eau
COPV distribution: WHITIE - AssIstant Manager for Quallty Assurance (AMOA) In the LCO yre;!.LOW - Donor of space
USCENSUSBUREAU
FORM D-1281
,........,
u.s. DEPARTMENT OF COMMERCE
EllOI'lClmIca andSIlII"Uca Aclmlnl$lmIlon
U.S. CENSUS BUREAU
CONDiTiONS FOR 1Ill0NATION OIF SERVICIES ANIIll SPACE A<lliREIE!\IIIEINl'1l'
2010 Cens<l/Is
--
The common goal of the U.S. Census Bureau and the Donor is to achieve a complete and accurate
count In the 2010 Census.
A. Donation of Space
Under the guidance of the U.S. Census Bureau, the Donor agrees to provide space for a Questionnaire
Assistance Center (QAC) within the property of their organization for the purpose of helping those
persons who request assistance in completing their 2010 Census questionnaire.
This donation is subject to the following terms and conditions:
1. The Donor will provide space for t e QAC at the following times and on the following
(days): l'I\oV\clo.. '1 - II I\'lV\ --ri\ .... C/-II . The U.S. Census Bureau expects peak
usage of the Questionnaire Assistance Centers to extend from March 19,2010 to April 19, 2010. It
would be most beneficial to the comlTtunity If the person working at this QAC spoke the following
language: 6;)\c:>h I ';j?QV\,l"b~ .
2.. The U.S. Census Bureau will not reimburse the Donor Organization for any expenses related to the
provision of the QAC space.
3. Questionnaire assistance will be provided without any charge whatsoever to the respondent
4. The U.S. Census Bureau will provide a poster and/or a banner to be placed at the authorized
Questionnaire Assistance Center, designating those places as U.S. Census Bureau sanctioned
assistance centers. A Be Counted box will be available on the premises for the respondent to obtain a
Be Counted questionnaire if they did not receive one at their place of residence or they believe they
were not added to the census questionnaire sent to their place of residence.
S. The Donor Organization agrees to provide or to arrange for the provision of suitable space to be used as
Questionnaire Assistance Centers during the 2010 Census. Questionnaire Assistance Center
Representatives (QAC reps) wlll occupy the space and provide assistance to those respondents who
visit the Questionnaire Assistance Centers.
--
This donation is subject to the following terms and conditions:
1. The tOLClEAL (~.CiUrJTy 91.Af?LA0 LII?W!Af (organization) will donate ?aD
01 office space In J\f/l(/l~ lL€.G.10tJA-L lttJ~ (buildingname),at
?-p ~ IW
~ [02-
period of .:!2.. (number of weeks), commencing on
square feet
(address),
(City, State, and ZIP Co e) lor a
7-.OLO (date)tI1rough I ;0.0 II:> (date).
2. The space shall accommodate one (1) desk (or table) and two (2) chairs, in which the QAC rap may
interview, privately and undisturbed, the respondent(s) seeking assistance.
3. The space is being donated to the U.S. Census Bureau at no cost to the government.
II. LDability
In the event that injury or damage is caused a U.S. Census Bureau employee while acting within the
scope of his or her authority, the incident will be covered under the Federal Tort Claims Act, TItle 28
U.S.C. ~2671, at seq. Any claims arising from such Incidents may be flied wIth the U.S. Census Bureau
and will be promptly addressed.
Any injury occurrIng to a U.S. Census Bureau employee while acting within the scope of his or her
employment will be covered under the Federal Employees Compensation Act, Title 5 U.S.C. ~8101,
etseq.
Because the Federal Government Is self-insured, It Is the U.S. Census Bureau's policy not to purchase
or pay.for commercial liability insurance. In addition, the Antl~Deficlency Act, TItle 31 U.S.C. ~1341.
st seq., prohibits any Federal agency from undertaking contingent and undetermined liability without
funds being appropriated by Congress for such purpose. For thIs reason, the Government cannot agree
to a .hold-harmless~ clause nor can It waive the right to sue.
Date
)>
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(1)
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~om
'Signature
Date
Signature
-
Name - Please print
lDlonoB'
Name - Please print
RegicDilaU li:Ilihl'ectlIDD', ILII.S. Call1lSIllIS BUJI'eau
Co~ distribution: WHBTE - Assistant Manager for Quality Assurance (AMOA) in the LCO VIaLLOW _ Donor of space
USCENSUSBUREAU
,_ _.,_ ._..._<,_.__,_."... ____.m'___'.~___
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,
FORM 1).1281
f.......
U.S. DEPARTMENT OF COMMERCE
EalnllmlcsandSlallsticsAdm!nll;I~
U.S. CENSUS BUREAU
iC@lNIlllii'l'llliINlS i'@IIIlItllOINlA'I'iCINI lOll' Sl!!lIIlViCIES AINlIlJi SIJ>ACIE AGlIIllElEii\lillEllIi'l'
2010 C.."SIlIlS
The common goal of the U.S. Census Bureau and the Donor is to achieve a complete and accurate
count in the 2010 Census.
A. DonaiiiOn of Space
Under the guidance of the U.S. Census Bureau, the Donor agrees to provide space for a Questionnaire
Assistance Center (QAC) within the property of their organization for the purpose of helping those
persons who request assistance in completing their 2010 Csnsus questionnaire.
This donation is subject to the following terms and conditions:
1. The Donor will provide.3P~ce for the QAC at the following times and on the following
(days):.:fUe.0. "f \-V'"l ) 1- '3 f:nq . The U.S. Census Bureau expects peak
usage of the Questionnaire Assistance Centers to extend from March 19, 2010 to April 19. 201 o. It
would be mos!)leneficial to the community if the person working at this QAC spoke the following
language: ~lf't)Y1 .
2. The U.S. Census Bureau will not reimburse the Donor Organization for any expenses related to the
provision of the QAC space.
3. Questionnaire assistance will be provided without any charge whatsoever to the respondent.
4. The U.S. Census Bureau will provide a poster and/or a banner to be placed at the authorized
QuestionnaIre Assistance Center, designating those places as U.S. Census Bureau sanctioned
assistance centers. A Be Counted box will be available on the premises for the respondent to obtain a
Be Counted questionnaire if they did not receive one at their place of residence or they believe they
were not added to the census questionnaire sent to their place of residence.
5. The Donor Organization agrees to provide or to arrange for the provision of suitable space to be used as
Questionnaire Assistance Centers during the 2010 Census. Questionnaire Assistance Center
Representatives (OAC reps) will occupy the space and provide assistance to those respondents who
visit the Questionnaire Assistance Centers.
(address),
(City. State, and ZIP Co e) for a
period of ~ (number of weeks), commencing on O\() (date) through 4-- t 20ID (date).
2. The space shall accommodate one (1) desk (or table) and two (2) chairs, in which the QAC rap may
interview, privately and undisturbed, the respondent(s) seeking assistance.
This donation is subject to the forrowing terms and conditions:
1. The tolLlEiL c.c,UN'1_~t;;1UG LI~ (organization) will donate ?<.D
of office space in gcru:n. l2€.QICl/J'M.. L, (building name), at
50100 Le:u <'-ut:lu11.AL Mx..vJ
NMl h... II
square feet
3. The space is being donated to the U.S. Census Bureau at no cost to the government.
B. Liability
In the event that injury or damage is caused a U.S. Census Bureau employee while acting within the
scope of his or her authority, the Incident will be covered under the Federal Tort Claims Act, TItle 28
U.S.C. ~2671, at seq. Any claims arising from such incidents may be filed with the U.S. Census Bureau
and will be promptly addressed.
Any injury occurring to a U.S. Census Bureau employee while acting within the scope of his or her
employment wlll be covered under the Federal Employees Compensation Act, Title 5 U.S.C. ~8101,
etseq.
Because the Federal Government is self~jnsured, it is the U.S. Census Bureau's policy not to purchase
or pay for commercial liability insurance. In addition, the Anti-Deficiency Act, Title 31 U.S.C. ~1341.
at seq., prohibits any Federal agency from undertaking contingent and undetermined liability without
funds being appropriated by Congress for such purpose. For this reason, the Government cannot agree
to a "hold-harmless. clause nor can it waive the right to sue.
Date
Signature
Date
)>
CD
m
:J
c-
"(J s: OJ
C' -.
(
-
D
3
~~..uZ
o NO
-0'
~~<D
~om
Signature
Name - Please print
Donor
Name - Please print
lRegnolrnCllG iCl5Il'SC'ltCD', IlII.Si. CSlI"IISWlS !ilUlD'ealUl
Copy distribution: WHITE: - Assistant Manager for Quality Assurance (AMOA) in the LCD VEILLOW - Donor of space
USCENSUSBUREAU