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Item C07BOARD OF COUNTY COMMISSIONERS AGENDA ITEM SUMMARY Meeting Date: hnuary_28, 2009 Division: Emergency Services Bulls Item: Yes X No _ Department: Fire Rescue Staff Contact Person/Phone #: Darice Hayes/6004 AGENDA ITEM WORDING: Approval to submit grant applications to the Florida Department of Health, Bureau of Emergency Medical Services, to fund EMS related equipment and to have the applications signed by the proper County authorities. ITEM BACKGROUND: The State of Florida, Department of Health is accepting applications for emergency medical services (EMS) matching grants (75% State/25% local funds) and rural county matching grants (90% State/10% local funds). EMS matching grants are for projects that demonstrate an improvement and/or expansion of services, while rural county matching grants are additionally for continuation of service projects. Our intent is to apply concurrently through both Grant Programs for the purchase of seven (7) LifePak 12 cardiac monitor defibrillators including all necessary accessories. PREVIOUS RELEVANT BOCC ACTION: None. CONTRACT/AGREEMENT CHANGES: Not applicable. STAFF RECOMMENDATIONS: These new monitor/defibrillator units are needed to enhance the older, and. soon to be obsolete LifePak 10 units that are currently in use on our ALS First Response (non -Transport) engines, and on our back-up Rescue (ALS transport) units, to achieve compliance with Florida Administrative Code 61J-1, Table II, items (p),(q),(r),and (v). Fire Rescue staff recommends approval to apply for this grant funding. TOTAL COST: $154,000.00 INDIRECT COST: BUDGETED:Yes X (see source of funds) No COST TO COUNTY:$15 400 10% - $38 500 25% * *Our portion depends on whether grant is awarded as rural (10%) or not (25%). SOURCE OF FUNDS: Grant and Fire Rescue budgeted dollars **11500-560640 ($20,000); 13001.560640 ($20,000) REVENUE PRODUCING: Yes No X AMOUNT PER MONTH Year APPROVED BY: County At4 OMB/Purchasing Risk Management _ DOCUMENTATION: DISPOSITION: Revised 1/09 Included Not Required AGENDA ITEM # MONROE COUNTY BOARD OF COUNTY COMMISSIONERS CONTRACT SUMMARY Contract with: Florida Dept of Health Contract # Bureau of EMS Effective Date: Grant Application Due 2/6/09 Expiration Date: TBD Contract Purpose/Description. Rural and/or Matching Grant funds are offered by the FL Dept. of Health Bureau of EMS to fond EMS related equipment. Contract Manager: Darice Ha es 6004 Fire Rescue / Stop 14 (Name) (Ext.) (Department/Stop #) for BOCC meeting on Jan. 28, 2009 Agenda Deadline: Jan. 13, 2009 CONTRACT COSTS Total Dollar Value of Contract: $ Current Year Portion: $ Budgeted? Yes® No ❑ Account Codes: 141-11500-560640- Grant: $ $154,000.00 141-13001-560640- - County Match: $ 10% if Rural - $15,400* *Grant funds are intended for purchase of monitor/de- 25% if Matching - $38,500* fibrillators which Fire Rescue has budgeted for with Estimated Ongoing Costs: $ /yr (Not included in dollar value above) OMB Form Revised 2127101 MCP 42 knowledge that grant funds were going to be available ADDITIONAL COSTS For: CONTRACT REVIEW utilities, etc. EMS MATCHING GRANT .APPLICATION FLORIDA DEPARTMENT OF HEALTH Bureau of Emergency Medical Services Complete all items unless instructed differently within the application Type of Grant Requested; M Rural LJ Matching ID. Code (The State Bureau of EMS will assign the ID Code -- leave this blank) 1. Or anization Name: Board of County Commissioners, Monroe County, FL 2. Grant Signer: (The applicant signatory who has authority to sign contracts, grants, and other legal documents. This individual must also sign this application) Name: George Neugent Position Title: Mayor Address: 25 Ships Way City: Big Pine Key County: Monroe State: Florida Zip Code, 33DA3 Telephone: 305-292-4512 Fax Number: 305-872-9195 E-Mail Address: boccdis2@MonroeCount-Fl.Gov 3. Contact Person: (The individual with direct knowledge of the project on a day-to-day basis and responsibility for the implementation of the grant activities. This person may sign project reports and may request project changes. The signer and the contact person may be the same.) Name: James K. Callahan Position Title: Acting Fire Chief:/Division Director Address: 490 63rd ,Street Suite 160 City: Marathon County: Monroe State: Florida Zip Code: Telephone: 305-289-6004 Fax Number: -305-289-61-16 E-mail Address: callah DH Form 1767, Rev. June 2002 MONROE COUNTY ATTORNEY AP ROVE AS TO P M YNTHIA L. HALL ASSISTANT ; COUNTY ATTORNEY Date 3 4 (1) ❑ Private Not for Profit [Attach documentation-501 (3) Oj (2) ❑ Private For Profit (3) ❑ City/Municipality/Town/Village (4) County (5) ❑ State (6) ❑ Other (specify): 5. Federal Tax ID Number (Nine Digit Number), VF5_9 60 00 7 4 9 6. EMS License Number: —295 7 Type: KRTransport ❑Non -transport ❑Both 7. Number of permitted vehicles by type: 0 BLS 9 ALS Transport 5 ALS non -transport. 1 Air Ambulance 8. Type of Service (check one): ®Rescue ❑Fire ❑Third Service (County or City Government, nonfire) ❑Air ambulance: ❑Fixed wing ❑Rotowing ❑Both ❑Other (specify) 9. Medical Director of licensed EMS „provider: If this project is approved, I agree by signing below that I will affirm my authority and responsibility for the use of all medical equipment and/or the provision of all continuing EMS education in this roject. [No signature is needed if medical equipment and professional EMS educati e n in this project.] Signature: Date: _ JAN 0 7 2009 Print/Type: Name of Director S,qiti c. rlq SC k we w, Wte-,f` 60, FA,&06tj Fop FL Med. Lic. No. t'!. t� S P 7— Zi Note: All organizations that are not licensed EMS providers must obtain the signature of the medical director of the licensed EMS provider responsible for EMS services in their area of operation for projects that involve medical equipment and/or continuing EMS education. If your activity is a research or evaluation project, omit Items 10, 11, 12, 13, and skip to Item Humber 14. Otherwise, proceed to Item 10 and the fotlowina items. 10. Justification Summary: Provide on no more than three one sided, double spaced pages a summary addressing this project, covering each topic listed below. A) Problem description (Provide a narrative of the problem or need); B) Present situation (Describe how the situation is being handled now); C) The proposed solution (Present your proposed solution); D) Consequences if not funded (Explain what will happen if this project is not funded), E) The geographic area to be addressed (Provide a narrative description of the geographic area); F) The proposed time frames (Provide a list of the time frame(s) for completing this project); G) Data Sources (Provide a complete description of data source(s) you cite); H) Statement attesting that the proposal is not a duplication of a previous effort (State that this project doesn't duplicate what you've done on other grant projects under this grant program). Next, only complete one of the following: Items 11, 12, or 13. Read all three and then select and complete the one that pertains the most to the preceding Justification Summary. Note that on all three, that before -after differences for emergency victim data are the highest scoring items on the Matching Grants Evaluation Worksheet used by reviewers to evaluate your application form. 11. Outcome For Proiects That Provide or Effect Direct Services To Emer enc Victims: This may include vehicles, medical and rescue equipment, communications, navigation, dispatch, and all other things that impact upon on -site treatment, rescue, and benefit of emergency victims at the emergency scene. Use no more than two additional one sided, double-spaced pages for your response. Include the following. A) Quantify what the situation has been in the most recent 12 months for which you have data (include the dates). The strongest data will include numbers of deaths and injuries during this time. B) In the 12 months after this project's resources are on-line, estimate what the numbers you provided under the preceding "(A)" should become. C) Justify and explain how you derived the numbers in (A) and (B), above. D) What other outcome of this project do you expect? Be quantitative and explain the derivation of your figures. E) How does this integrate into your agency's five year plan? 12. Outcome For Training Projects: This includes training of all types for the public, first responders, law enforcement personnel, EMS and other healthcare staff. Use no more than two additional one sided, double-spaced pages for your response. Include the following: A) How many people received the training this project proposes in the most recent 12 month time period for which you have data (include the dates). B) How many people do you estimate will successfully complete this training in the 12 months after training begins? C) If this training is designed to have an impact on injuries, deaths, or other emergency victim data, provide the impact data for the 12 months before the training and project what the data should be in the 12 months after the training. D) Explain the derivation of all figures. E) How does this integrate into your agency's five year plan? 13. Outcome For Other Pro'ects: This includes quality assurance, management, administrative, and other. Provide numeric data in your responses, if possible, that bear directly upon the project and emergency victim deaths, injuries, and/or other data. Use no more than two additional one sided, double- spaced pages for your response. Include the following. A) What has the situation been in the most recent 12 months for which you have data (include the dates)? B) What will the situation be in the 12 months after the project services are on-line? C) If this project is designed to have an impact on injuries, deaths, or other emergency victim data, provide the impact data for the 12 months before the project and what the data should be in the 12 months after the project. D) Explain the derivation of all numbers. E) How does this integrate into your agency's five year plan? DH Form 1767, Rev. 2002 Skip Item 14 and go to Item 15, unless your project is research and evaluation and you have not completed the preceding Justification Summary and one outcome item. 14. Research and Evaluation Justification Summary, and Outcome: You may use no more than three additional one sided, double spaced pages for this item. A) Justify the need for this project as it relates to EMS. B) Identify (1) location and (2) population to which this research pertains. C) Among population identified in 14(B) above, specify a past time frame, and provide the number of deaths, injuries, or other adverse conditions during this time that you estimate the practical application of this research will reduce (or positive effect that it will increase). D) (1) Provide the expected numeric change when the anticipated findings of this project are placed into practical use. (2) Explain the basis for your estimates. E) State your hypothesis. F) Provide the method and design for this project. G) Attach any questionnaires or involved documents that will be used. H) If human or other living subjects are involved in this research, provide documentation that you will comply with all applicable federal and state laws regarding research subjects. 1) Describe how you will collect and analyze the data. 15. Statuto Considerations and Criteria: The following are based on s. 401.113(2)(b) and 401.117, F.S. Use no more than one additional double spaced page to complete this item. Write NIA for those things in this section that do not pertain to this project. Respond to all others. Justify that this project will: A) Serve the requirements of the population upon which it will impact. B) Enable emergency vehicles and their staff to conform to state standards established by law or rule of the department. C) Enable the vehicles of your organization to contain at least the minimum equipment and supplies as required by law, rule or regulation of the department. D) Enable the vehicles of your organization to have, at a minimum, a direct communications linkup with the operating base and hospital designated as the primary receiving facility. E) Enable your organization to improve or expand the provision of: 1) EMS services on a county, multi county, or area wide basis. 2) Single EMS provider or coordinated methods of delivering services. 3) Coordination of all EMS communication links, with police, fire, emergency vehicles, and other related services. OH Form 1767. Rev. 2002 N 16. Work activities and time frames: Indicate the major activities for completing the project (use only the space provided). Be reasonable, most projects cannot be completed in less than six months and if it is a communications project, it will take about a year. Also, if you are purchasing certain makes of ambulances, it takes at least nine months for them to be delivered after the bid is let. Work Activity Number of Months After Grant Starts Begin End Begin RFP/BID Process Ripon Notifiaction of Award _ +60 Da Issue Pur-chaae Order — Order Hni t-4, +60 Days (2 -Months) In Service 4 Months +6 Months As these units will be complement ng/enhancing units of the same make/model already in service on other vehicles further training of personnel 17. County Governments: If this application is being submitted by a county agency, describe in the space below why this request cannot be paid for out of funds awarded under the state EMS county grant program. Include in the explanation why any unspent county grant funds, which are now in your county accounts, cannot be allocated in whole or part for the costs herein. Iry .. .. .. .--IM. MINOR= other priority projects throughout the County EMS system, as some programs (such as training) were pulled from our rpgualr budget due to budgetary constraints. The purchase of a new simulation mane uin to enhance our trainigtY of Miami SimLab is of utmost priority, aswell as continued enhancements to our.EMSTARS reporting system. The amount received each year is insufficient to fund these otherprojects and purchase the new LifePacks as well. DH Form 1767, Rev. III 18. Bud et: Salaries and Benefits: For each position title, provide the amount of salary per hour, FICA per hour, fringe benefits, and the total number of hours. Costs Justification: Provide a brief justification why each of the positions and the numbers of hours are necessary for this project. Not Applicable TOTAL: Expenses: These are travel costs and the usual, ordinary, and incidental expenditures by an agency, such as, commodities and supplies of a consumable nature, excluding expenditures classified as operating capital outlay (see next category). Costs: List the price and source(s) of the price identified. Justification: Justify why each of the expense items and quantities are necessary to this project. Not Applicable TOTAL: $ UH Form I t6f, Rev. 2002 Vehicles, equipment, and other- operating capital outlay means equipment, fixtures, and other tangible personal property of a non consumable and non expendable nature, and the normal expected life of which is 1 year or more. Costs: List the price of the item and the source(s) used to identify the price. Justification: State why each of the items and quantities listed is a necessary component of this project. Purchase of seven (7) 22,000 each These.monitors constitute the Medtronics/Physio Control grant request in its entirety. LifePack 12 Cardiac Monitors with irate rated NTBP, ETCO2 Monitoring, Telemetry modem cards, All cabling, cases, . Batteries and accessories TOTAL: $ 15 ,000 State Amount (Check applicable program) ❑ Matching: 75 Percent $ KTRural: 90Percent $ 138,600 Local Match Amount (Check applicable program) ❑ Matching: 25 Percent $ Rural: 10 Percent , • $ 15,400 Grand Total I $ 154,000 bH Fnrrn 1767 Ppv 9n ng 19. Certification: My signature below certifies the following. I I am aware that any omissions, falsifications, misstatements, or misrepresentations in this application may disqualify me for this grant and, if funded, may be grounds for termination at a later date. I understand that any information I give may be investigated as allowed by law. I certify that to the best of my knowledge and belief all of the statements contained herein and on any attachments are true, correct, complete, and made in good faith. I agree that any and all information submitted in this application will become a public document ;pursuant to Section 119.07, F.S. when received by the Florida Bureau of EMS. This includes material which the applicant might consider to be confidential or a trade secret. Any claim of confidentiality is waived by the applicant upon submission of this application pursuant to Section 119.07,F.S., effective after opening by the Florida Bureau of EMS. accept that in the best interests of the State, the Florida Bureau of EMS reserves the right to reject or revise any and all grant proposals or waive any minor irregularity or technicality in proposals received, and can exercise that right. 1, the undersigned, understand and accept that the Notice of Matching Grant Awards will be advertised in the Florida Administrative Weekly, and that 21 days after this advertisement is published I waive any right to challenge or protest the awards pursuant to Chapter 120, F.S. I certify that the cash match will be expended between the beginning and ending dates of the grant and will be used in strict accordance with the content of the application and approved budget for the activities identified. In addition, the budget shall not exceed, the department, approved funds for those activities identified in the notification letter. No funds count towards satisfying this grant if the funds were also used to satisfy a matching requirement of another state grant. All cash, salaries, fringe benefits, expenses, equipment, and other expenses as listed in his application shall be committed and used for the activities approved as a part of this grant. Acceptance of Terms and Conditions: If awarded a grant, I certify that I will comply with all of the above and also accept the attached grant terms and conditions and acknowledge this by signing below. 1 1 Signature of Authorized Grant Signer MM 1 DID 1 YY Individual Identified in Item 2 urn corm 1it) r, Kev. June Zuuz MONROE COUNTY ATTORNEY AP OVED S. TO F M: C NTH1A L. ALL ASSISTANT COUNTY ATTOR EY Date 10 FLORIDA DEPARTMENT OF HEALTH EMS GRANT PROGRAM In accordance with the provisions of Section 401.113(2)(b), F. S., the undersigned hereby requests an EMS grant fund distribution for the improvement and expansion or continuation of pre -hospital EMS. Name of Agency: Board of County Commissioners, Monroe County, FL Mailing Address.. 490 63rd Street, Marathon, FL 33050 Federal Identification Number 5 9 6 0 0 0 7 4 9 Authorized Agency Official: Signature Date George Neugent, Mayor Type Name and Title Sign and return this page with your application to: Florida Department of Health BEMS Grant Program 4052 Bald Cypress Way, Bin C18 Tallahassee, Florida 32399-1 738 Do not write below this line. For use by Bureau of E Grant Amount For State To Pay: $ Approved By: Signature of EMS Grant Officer State Fiscal Year: 2007 - 2008 Organization Code E.O. OCA 64-42-10-00-000 03 SF003 Federal Tax ID: VF Grant Beginning Date: UH F-orm I Aj[F, Rev. ,rune 2002 Medical Services personnel Grant ID Code: Date Obiect Code 750000 Grant Ending Date: MONROE COUNTY ATTORNEY AP OVE AS F R YNTHIA L, HALL ASSISTANT COUNTY ATTORNEY 11 Date FLORIDA DEPARTMENT OF HEALTH Bureau of Emergency Medical Services Complete all items unless instructed differently within the application Type of Grant Requested. ❑ Rural ElMatchin ID. Code The State Bureau of EMS will assign the ID Code — leave this blank? I. Or anization Name: Board of County Commissioners, Monroe County, FL 2. Grant Signer: (The applicant signatory who has authority to sign contracts, grants, and other legal documents. This individual must also sign this application) Name: George Neugent Position Title: Mayor Address: 25 Ships Way City: Bia Pine Key County: Monroe State: Florida Zip Code: 33043 Telephone: 305-19-2-4512 Fax Number: 305-872-9195 E-Mail Address: boccdis2@MonroeCount—Fl.Gov 3. Contact Person: (The individual with direct knowledge of the project on a day-to-day basis and responsibility for the implementation of the grant activities. This person may sign project reports and may request project changes. The signer and the contact person may be the same.) Name., James K. Callahan Position Title: Acting Fire Chief/Division Director Address: 490 63rd Street Suite 160 City: Marathon county: Monroe State: Florida Zip Code: Telephone: 305-289_6004 Fax Number: E-mail Address: ally urE Form _i t6t, Rev. June 2002 3 4. (1) L Private Not for Profit (Attach documentation-501 (2) ❑ Private For Profit (3) ❑ City/Municipality/Town/Village (4) 0 County (5) ❑ State (6) ❑ Other (specify): (3) Oj 5. Federal Tax lD Number Nine Digit Number). VF5 9 6 0 0 0 7 4 9 6. EMS License Number: 2957 Type: ®Transport ❑Non -transport ❑Both 7. Number of permitted vehicles by type: 0 BLS —9 ALS Transport 5 ALS non -transport. 1 Air Ambulance 8. Type of Service (check one): PRescue ❑Fire ❑Third Service (County or City Government, nonfire) ❑Air ambulance: ❑Fixed wing ❑Rotowing ❑Both ❑Other (specify) Medical9. or Direct of licensed EMS provider: If this project is approved, I agree by signing below that I will affirm y y and responsibility for the use of all medical equipment and/or the provision of all continuing EMS educatio i this roject. [No signature is needed if medical equipment and professional EMS ed}fon a not in this project.] Signature: dU VDate: JAN 0 7 2009 Print/Type: Name of Director 506&K # At`.06P, FAGU4) FL Med. Lic. No. —FL 1 �2 `1© 2,2, Note: All organizations that are not licensed EMS providers must obtain the signature of the medical director of the licensed EMS provider responsible for EMS services in their area of operation for projects that involve medical equipment and/or continuing EMS education. If your activity is a research or evaluation project, omit Items 10, 11, 12, 13, and skip to Item !Number 14. Otherwise, proceed to Item 14 and the following items. 10. Justification Summary: Provide on no more than three one sided, double spaced pages a summary addressing this project, covering each topic listed below. A) Problem description (Provide a narrative of the problem or need); B) Present situation (Describe how the situation is being handled now); C) The proposed solution (Present your proposed solution); D) Consequences if not funded (Explain what will happen if this project is not funded); E) The geographic area to be addressed (Provide a narrative description of the geographic area); F) The proposed time frames (Provide a list of the time frame(s) for completing this project); G) Data Sources (Provide a complete description of data source(s) you cite); H) Statement attesting that the proposal is not a duplication of a previous effort (State that this project doesn't duplicate what you've done on other grant projects under this grant program). W1I vul 111 fruf, rxt,v, 4UU1_ 4 Next, only complete one of the following: Items 11, 12, or 13. Read all three and then select and complete the one that pertains the most to the preceding Justification Surnmary. Note that on all three, that before -after differences for emergency victim data are the highest scoring items on the Matching Grants Evaluation Worksheet used by reviewers to evaluate your application form. 11. Outcome For Proeects That Provide or Effect Direct Services To Emergency Victims: This may include vehicles, medical and rescue equipment, communications, navigation, dispatch, and all other things that impact upon on -site treatment, rescue, and benefit of emergency victims at the emergency scene. Use no more than two additional one sided, double-spaced pages for your response. Include the following. A) Quantify what the situation has been in the most recent 12 months for which you have data (include the dates). The strongest data will include numbers of deaths and injuries during this time. B) In the 12 months after this project's resources are on-line, estimate what the numbers you provided under the preceding "(A)" should become. C) Justify and explain how you derived the numbers in (A) and (B), above. D) What other outcome of this project do you expect? Be quantitative and explain the derivation of your figures. E) How does this integrate into your agency's five year plan? 12. Outcome For Training Projects: This includes training of all types for the public, first responders, law enforcement personnel, EMS and other healthcare staff. Use no more than two additional one sided, double-spaced pages for your response. Include the following: A) How many people received the training this project proposes in the most recent 12 month time period for. which you have data (include the dates). B) How many people do you estimate will successfully complete this training in the 12 months after training begins? C) If this training is designed to have an impact on injuries, deaths, or other emergency victim data, provide the impact data for the 12 months before the training and project what the data should be in the 12 months after the training. D) Explain the derivation of all figures. E) How does this integrate into your agency's five year plan? 13. Outcome For Other Promects: This includes quality assurance, management, administrative, and other. Provide numeric data in your responses, if possible, that bear directly upon the project and emergency victim deaths, injuries, and/or other data. Use no more than two additional one sided, double- spaced pages for your response. Include the following. A) What has the situation been in the most recent 12 months for which you have data (include the dates)? B) What will the situation be in the 12 months after the project services are on-line? C) If this project is designed to have an impact on injuries, deaths, or other emergency victim data, provide the impact data for the 12 months before the project and what the data should be in the 12 months after the project. D) Explain the derivation of all numbers. E) How does this integrate into your agency's five year plan? UH corm 'I /b(, Kev. 2002 5 Skip item 14 and go to It:en, 15, unless your project is research and evaluation and you have not completed the preceding Justification Summary and one outcome item. 14. Research and Evaluation Justification Summa and Outcome: You may use no more than three additional one sided, double spaced pages for this item. A) Justify the need for this project as it relates to EMS. B) Identify (1) location and (2) population to which this research pertains. C) Among population identified in 14(B) above, specify a past time frame, and provide the number of deaths, injuries, or other adverse conditions during this time that you estimate the practical application of this research will reduce (or positive effect that it will increase). D) (1) Provide the expected numeric change when the anticipated findings of this project are placed into practical use. (2) Explain the basis for your estimates. E) State your hypothesis. F) Provide the method and design for this project. G) Attach any questionnaires or involved documents that will be used. H) If human or other living subjects are involved in this research, provide documentation that you will comply with all applicable federal and state laws regarding research subjects. 1) Describe how you will collect and analyze the data. 15. Statutory Considerations and Criteria: The following are based on s. 401.113(2)(b) and 401.117, F.S. Use no more than one additional double spaced page to complete this item. Write NIA for those things in this section that do not pertain to this project. Respond to all others. Justify that this project will: A) Serve the requirements of the population upon which it will impact. B) Enable emergency vehicles and their staff to conform to state standards established by law or rule of the department. C) Enable the vehicles of your organization to contain at least the minimum equipment and supplies as required by law, rule or regulation of the department. D) Enable the vehicles of your organization to have, at a minimum, a direct communications linkup with the operating base and hospital designated as the primary receiving facility. E) Enable your organization to improve or expand the provision of: 1) EMS services on a county, multi county, or area wide basis. 2) Single EMS provider or coordinated methods of delivering services. 3) Coordination of all EMS communication links, with police, fire, emergency vehicles, and other related services. DH Form 1767. Rev. 2€ 02 16. Work activities and time frames: Indicate the major activities for completing the project (use only the space provided). Be reasonable, most projects cannot be completed in less than six months and if it is a communications project, it will take about a year. Also, if you are purchasing certain makes of ambulances, it tastes at least nine months for them to be delivered after the bid is let. Worts Activity Number of Months After Grant Sta is Begin End Begin RFP/BID Process Upon Notifiaction of Award - +60 Da Issue Fur Rpopi-w-P Units — Program And Place — In Service 4 Months +6 Months * As these units will be complementing/enhancing units of the same matte/model already in service on other vehicles further trains 17. County Governments: If this application is being submitted by a county agency, describe in the space below why this request cannot be paid for out of funds awarded under the state EMS county grant program. Include in the explanation why any unspent county grant funds, which are now in your county accounts, cannot be allocated in whole or part for the costs herein. other priority projects throughout the County EMS system, as some programs (such as training) were pulled from our rpgualr budget due to budgetary constraints. The purchase ofanew simulation maneauin enhan ty Of Miami SimLab is of utmost priority, as.well as continued enhancements to our.EMSTARS reporting system. The amount received each year is insufficient to fund these other projectsand purchase the new LifePacks as well. orm 1767, Rev. 2002 7 9 S. Budget:_ Salaries and Benefits: For each Position title, provide the amount of salary per hour, FICA per hour, fringe benefits, and the total number of hours. Costs Justification: Provide a brief justification why each of the positions and the numbers of hours are necessary for this project. Not Applicabl TOTAL: Expenses: These are travel costs and the usual, ordinary, and incidental expenditures by an agency, such as, commodities and supplies of a consumable nature, excluding expenditures classified as operating capital outlay (see next category). Costs: List the price and source(s) of the price identified. Justification: Justify why each of the expense items and quantities are necessary to this project. Not Applicable TOTAL: $ vn rulm 1lot, rCCV. LVVL Vehicles, equipment, and other operating capital outlay means equipment, fixtures, and other tangible personal property of a non consumable and non expendable nature, and the normal expected life of which is 1 year or more. Costs: List the price of the item and the source(s) used to identify the price. Justification: State why each of the items and quantities listed is a necessary component of this project. Purchase of seven (7) 22,000 each These monitors constitute the Medtroni.cs/Physio Control grant request in its entirety. LifePack 12 Cardiac Monitors with integrated NIBP, ETCO2 Monitoring, Telemetry modem cards, All cabling, cases, . Batteries and accessories TOTAL: $ 154,000 State Amount (Check applicable program) J2 Matching: 75 Percent $ 115 , 500 ❑ Rural: 90 Percent $ Local Match Amount (Check applicable program) U Matching: 25 Percent $ 3$., 500 ❑ Rural: 10 Percent $ Grand Total bH Form 1767. Rev 0 19. Certification-. My signature below certifies the following. I am aware that any omissions, falsifications, misstatements, or misrepresentations in this application may disqualify me for this grant and, if funded, may be grounds for termination Jar later date. I understand that any information I give may be investigated as allowed by law. certify that to the best of my knowledge and belief all of the statements contained herein and on any attachments are true, correct, complete, and made in good faith. I agree that any and all information submitted in this application will become a public document `pursuant to Section 119.07, F.S. when received by the Florida Bureau of EMS. This includes material which the applicant might consider to be confidential or a trade secret. Any claim of. confidentiality is waived by the applicant upon submission of this application pursuant to Section 119.07,F.S., effective after opening by the Florida Bureau of EMS. I accept that in the best interests of the State, the Florida Bureau of EMS reserves the right to reject or revise any and all grant proposals or waive any minor irregularity or technicality in proposals received, and can exercise that right. 1, the undersigned, understand and accept that the Notice of Matching Grant Awards will be advertised in the Florida Administrative Weekly, and that 21 days after this advertisement is f published I waive any right to challenge or protest the awards pursuant to Chapter 120, F.S. I certify that the cash match will be expended between the beginning and ending dates of the grant and will be used in strict accordance with the content of the application and approved budget for the activities identified. In addition, the budget shall not exceed, the department, approved funds for those activities identified in the notification letter. No funds count towards satisfying this grant if the funds were also used to satisfy a matching requirement of another state grant. All cash, salaries, fringe benefits, expenses, equipment, and other expenses as listed in this application shall be committed and used for the activities approved as a part of this grant. i Acceptance of Terms and Conditions: If awarded a grant, I certify that I will comply with all of the above and also accept the attached grant terms and conditions and acknowledge this by signing below. l l Signature of Authorized Grant Signer MM I DD 1 YY Individual Identified in Item 2 . . QH Farm 7767, Rey. June 2002 MONROE COUNTY ATTORNEY A - ROV D CIS TO R CYNTHIA L. 'A L --- ASSISTANT COUNTY DateRNEY 10 FLORIDA DEPARTMENT OF HEALTH EWS GRANT PROGRAM DISTRIBUTIONREQUEST FOR GRANT FUND In accordance with the provisions of Section 401.113(2)(b), F. S., the undersigned hereby requests an EMS grant fund distribution for the improvement and expansion or continuation of pre -hospital EMS. emit Name of Agvayment i o: Board of County Commissioners, Monroe County, FL ency: Mailing Address: 490 63rd Street, Marathon, FL 33050 Federal Identification Number Authorized Agency Official: 5 9 6 0 0 0 7 4 9 Signature George Neugent, Mayor Type Name and Title Sign and return this page with your application to: Florida Department of Health BEMS Grant Program 4052 Bald Cypress Way, Bin C98 Tallahassee, Florida 32399-9738 Do not write below this line. For use by Bureau of Grant Amount For State To Pay: $ Approved By: Medical Services Grant ID Code: Signature of EMS Grant Officer Date State Fiscal Year: 2007 - 2008 Organization Code EEO. OGA Object Code 64-42-10-00-000 03 SF003 750000 Federal Tax ID: Grant Beginning Date: VF fn rorm i row, Kev. June zuu1 Grant Ending Date: Date Ion MONROE COUNTY ATTORNEY AP OVE AS TC�MFI� 91 C THIA L. HALL NEY ASSISTANT O NTY� Date