01/28/2009 DANNYL. KOLHAGE
CLERK OF THE CIRCUIT COURT
DATE: February -1, 2009
TO: Chief James Callahan
Emergency Services
ATTN: Dance Hayes, Executive Assistant
FROM: Pamela G. Hane. .
At the January 28, 2009, Board of County Commissioner's meeting the Board granted
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.
Enclosed are three duplicate originals of each of the above-mentioned for your handling.
Please be sure to return return the fully executed "Monroe County Clerk's Office Original"and
the "Monroe County Finance Department's Original" as soon as possible. Also, pursuant to our
conversation -prior to the return of our originals -please have Dr. Sandra Schwemmer initial in
blue ink next to the photo copy of her signatures. Should you have any questions, please do not
hesitate to contact this office.
cc: County Attorney
Finance
File✓
OKI!v~rY ~o~~~E
(305) 294-4641
(-.' ,......--
BOARD OF COUNTY COMMISSIONERS
Mayor George Neugent, District 2
Mayor Pro Tern Sylvia J. Murphy, District 5
Kim Wigington, District 1
Heather Carruthers, District 3
Mario Di Gennaro, District 4
MEMORANDUM
TO: Pam Hancock
Assistant Deputy Clerk
FROM: Darice Hayes ; AI ~
Fire Rescue ~
SUBJECT: EMS Matching Grant Fund Allocation for #M9088
FY2009-2010
DATE: July 16,2009
As per our conversation earlier this week, please find attached the original DH Form 1767P, Request for
Grant Fund Distribution as per your request. Also attached is State of Florida Warrant No. 04-0006183-0 in
the amount of $82,500.00, and a letter from the State of Florida Department of Health dated 5/27/09. The
request to apply for this grant was approved at the January 28, 2009 MCBOCC meeting as Item C-7. Please
forward whatever is necessary to the Finance Department.
If you require any thing further, please do not hesitate to contact me.
Attachments
FLORIDA DEPARTMENT OF
HEALT
Charlie Crist
Governor
Ana M. Viarnonte Ros, M.D., M.P.H.
State Surgeon General
May 27, 2009
The Honorable George Neugent
Mayor
Monroe County Board
of County Commissioners
25 Ships Way
Big Pine Key, FL 33043
ItIJ!C!IV'~A
.~U
S~: JU^/ 01 2009
~j"::/--~~""'''''''''''.
,RE R~satjs-----'
Dear Mayor Neugent:
It gives me great pleasure to inform you that your organization has l.:>een awarded an
emergency medical services (EMS) matching grant, number M9088, in the amount of
$82,500.00, which is 75 percent of the total project costs. According to section 401.113, Florida
Statutes, the grant is 75 percent state funds and 25 percentm(ltching.funds,\Nhich must be
provided by the applicant. Your required local cash match for this grant is $27,500.00. The
purpose of this grant is to assist your organization in the purchase of five LifePak 12 cardiac
monitors.
You acknowledge acceptance of the grant terms and conditions when you draw or otherwise
obtain funds from the grant payment system. Your signed grant application acknowledges you
have read, understood, and will comply with all terms and conditions of the approved grant and
departmental rules. You may place these funds in any type of bank account you choose;
however, any interest earned on these funds must be returned to the department.
The Bureau of Emergency Medical Services will provide by separate letter a copy of the
approved grant budget, a list of any special grant conditions, and the due dates of the required
grant reports. This matching grant begins on the date of this letter and will end June 30, 2010.
Thank you for your continued support and involvement in improving and expanding the
prehospital EMS system. If you need assistance, please feel free to contact Mr. Alan Van
Lewen, Health Services and Facilities Consultant in the Bureau of EMS, at (850) 245-4440,
extension *2734.
Sincerely,
~ ~ .,- ~ It.. ...:Ii.. p...u
Ana M. Via monte Ros, M.D., M.P.H.
State Surgeon General
A VR/avl
cc: Mr. James K. Callahan, Division Director
Office of the State Surgeon General
4052 Bald Cypress Way, Bin AOO. Tallahassee, FL 32399-1701
n'.len~~~ c~~ Oerit'o om~ 01r~
EMS MA TCHING GRANT ApPLICA TION
FLORIDA DEPARTMENT OF HEAL TH
Bureau of Emergency Medical Services
Complete all items unless instructed differently within the application
T e of Grant Re uested: D Rural ~Matchin
10. Code The State Bureau of EMS will assi n the 10 Code - leave this blank
1. Oraanization Name: Board of County Commissioners, Monroe County, FL
2. Grant Sianer: (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: BiQ: Pine Kev County: Monroe
State: Florida Zip Code: ':l ':lOLL ':l
Telephone: 305-292-4512 Fax Number: 305-872-9195
E-Mail Address: boccdis2@MonroeCounty-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: Actin Fire Chief/Division Director
Address:
490 63rd Street Suite 160
Ci : Marathon
State: Florida
Tele hone: 305-289-6004
E-mail Address:
DH Form 1767, Rev. June 2002
3
4. Leaal Status of Aoolicant Oraanization (Check onlv one resoonse):
(1) 0 Private Not for Profit [Attach documentation-501 (3) @]
(2) 0 Private For Profit
(3) 0 City/Municipality/TownNillage
(4) ~ County
(5) 0 State
(6) 0 Other (specify):
5. Federal Tax ID Number (Nine Diait Number). VF 2_~..P_Q...9_Q. 7 4 9
6. EMS License Number: 2957 Type: ~Transport DNon-transport DBoth
7. Number of permitted vehicles by type: ~BLS ~ALS Transport --2.ALS non-transport.
1 Air Ambulance
8. Type of Service (check one): (XlRescue DFire DThird Service (County or City Government,
nonfire) DAir ambulance: DFixed wing DRotowing DBoth DOther (specify)
9. Medical Director of licensed EMS orovider: If this project is approved, I agree by signing below that I
will affirm my authority and res onsibility for the use of all medical equipment and/or the provision of all
continuina EMS educatio i i roject. [No signature is needed if medical equipment and
professional EMS ed a!!2! in this project.]
Date: JAN 0 7 Z009
5cl-1.W-8fM1Jdr 00 .
FL Med. Lie. NOrL O~ c;o 2- 2-
Signature:
PrintlType:
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 e ui ment and/or continuin EMS education.
If your activity Is a research or evaluation project, omit Items 10, 11, 12, 13, and skip to Item
Number 14. Otherwise roceed to Item 10 and the followin Items.
10. Justification Summarv: 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).
DH Form 1767, Rev. 2002
..
4
Next, only complete ~ of the following: Items 11, 12, .2!: 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 Matchin Grants Evaluation Worksheet used b reviewers to evaluate our a lication form.
11. Outcome For Proiects That Provide or Effect Direct Services To Emeraencv 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 Trainina Proiects: 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 Proiects: 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
5
Sldp 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 tha(l 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.
I) Describe h.ow you will collect and analyze the data.
15. Statutorv Considerations and Criteria: The following are based on s. 401.113(2)(b) and 401.117,
F.S. Use no more than ~ additional double spaced page to complete this item. Write N/A 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. 2002
6
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 RFP/BID Process
Be in
Upon Notifiaction of Award -
End
+60 Da
In Service
+6 Months
** As these units will be
same make model alread
units of the
veh~cles further
trainin
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.
Monroe County'~ Award Grant fund~ h.Ave AlreAdy hepn AllorATPd TO
other priority projects throughout the County EMS system, as some
programs (such as training) were pulled fDom our r~gualr budget due
to budgetary constraints. The purchase of a new simulation maneQuin
to enhance our trainig program whic.h i~ run in c.onjunc.tion with the TJniver~ity
of Miami SimLab is of utmost priority, as. well as continued enhancements to
our hEMSTARS reporting system. The amount re.ceived each year is insufficient
to fund these other projects and purchase the new LifePacks as well.
DH Form 1767, Rev. 2002
7
18. Budaet:
Salaries and Benefits: For each Costs Justification: Provide a brief justificatipn
position title, provide the amount why each of the positions and the numbers
of salary per hour, FICA per hour, of hours are necessary for this project.
fringe benefits, and the total .
number of hours.
Not Applicabl:.
TOTAL:
Expenses: These are travel costs Costs: List the price Justification: Justify why each of the
and the l}sual, ordinary, and and source( s) of the expense items and quantities are
incidental expenditures by an price identified. necessary to this project.
agency, such as, commodities and
supplies of a consumable nature,
excludina expenditures classified
as operating capital outlay (see
next cateQory).
Not Applicable
TOTAL: $
DH Form 1767, Rev. 2002
8
Vehicles, equipment, and other Costs: List the price Justification: State why each of the items
operating capital outlay means of the item and the and quantities listed is a necessary
equipment, fixtures, and other source( s) used to component of this project.
tangible personal property of a identify the price.
non consumable and non
expendable nature, and the
normal expected life of which is 1
year or more,
Purchase of seven (7) 22,000 each These monitors constitute the
Medtronics/Phy~io Control grant request in its entirety.
LifePack 12 Cardiac
Monitors. with integrated
NIBP, ETC02 Monitoring,
Telemetry modem cards,
All cabling, cases,
Batteries and accessories
TOTAL: $ 154,000
State Amount
(Check applicable program)
fiI Matching: 75 Percent $115.500
D Rural: 90 Percent $
Local Match Amount
(Check applicable program)
fiI Matching: 25 Percent $ 'lR, 1i00
D Rural: 10 Percent $
Grand Total $154 .000
DH Form 1767, Rev. 2002
9
19. Certification:
\ M signature below certifies the followin .
; 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
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 S"ection '
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.
I, 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
rant 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
atisfying this grant if the funds were also used to satisfy a matching requirement of another state
rant. 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.
JAN t 8/2009
MM / DD /VY
j- -'I
MONROE COUNTY ATTORNEY
A~~?~~ Tp
YNTHIA L~AL
ASSISTANT COUNT~RNEY
Date ( - '1- (jI..f)(1~
10
FLORIDA DEPARTMENT OF HEAL TH
EMS GRANT PROGRAM
REQUEST FOR GRANT FUND DISTRIBUTION
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.
DOH Remit Payment To:
Name of Agency: Board of County Commissioners, Monroe County, FL
Mailing Address: 490 63rd Street, Marathon, FL 33050
iA
z:
CC
,......
.2 8 2009
Federal Identification Number
Authorized Agency Official.
N
Date
George Neugent, Mayor
Type Name and Title
Sign and return this page with your application to:
~
...,
D"
c:::t
Ie
...
~~ ~ f.f-;
<( C)
Q :E
Florida Department of Health
BEMS Grant Program
4052 Bald Cypress Way, Bin C18
Tallahassee, Florida 32399-1738
Do not write below this line. For use by Bureau of Emergency MedicalSeivices personnel only
Grant Amount For State To Pay: $ 82 50010()
I
Approved By: A~. v~ ~
Signature of EMS Grant Officer
State Fiscal Year: 200,\ g - 200,8 4
Oraanization Code
64-42-10-00-000
E.O.
03
OCA
SF003
Grant ID Code: M <1 0 88
M 0 2-'1. 2o"~ I
Date ~
,..,
at
I
fr
Obiect Code
750000
""0
IS'
.r:
W ,~--.2 ~;;.
V ' 2010
Federal Tax ID:
VF_~~~~~q_7_49
Grant Beginning Date: M (J 1-7 'Loo1
J
DH Form 1767P, Rev. June 2002
Grant Ending Date:
11
MONROE COUNTY ATTORNEY
AP~lP
NTH A . AL:L
ASSISTANT COUNTY ATT~RNEY
Date f .... q - ,""",00 '