Agenda 05/09/2017 Item #16E 505/09/2017
EXECUTIVE SUMMARY
Recommendation to approve a Certificate of Public Convenience and Necessity for a Class 1 and
Class 2 Advanced Life Service (ALS) Rescue and intra-facility ambulance transport for the
Seminole Tribe of Florida Fire Rescue within the boundary of the Seminole Tribe in Immokalee.
OBJECTIVE: To proceed in the best interest of the public health, safety and welfare by
granting a Certificate of Public Convenience and Necessity (COPCN), Class 1 Advanced Life Support
(ALS) Transport, and a Class 2 Advanced Life Support (ALS) intra-facility ambulance transport
certificate(s) to the Seminole Tribe of Florida Fire Rescue Department. The Seminole Tribe Fire Rescue
Department operates exclusively for and on the Seminole Reservation in Immokalee. These certificates
are subject to certain conditions noted below.
CONSIDERATIONS: On March 17, 2017, the Collier County's Bureau of Emergency Services
received an application from the Seminole Tribe of Florida for a Certificate of Public Convenience and
Necessity (COPCN) for a Class 1 ALS Transport and Class 2 ALS Transfers. A COPCN may be
approved routinely by the Board as provided by Section 50 of the Collier County Code of Laws and
Ordinances governing medical transportation services.
The Board’s Emergency Medical Authority has reviewed the application and voted on April 12, 2017, in
the affirmative to recommend granting both the Class 1 and Class 2 certificates for a period of one (1)
year following the approval of the Board. The Seminole Tribe of Florida and its Fire Rescue
Department operate numerous fire rescue and ambulance services acrosss the State within the
boundaries of various reservations in a highly cooperative manner with other local county governments
and EMS operations. It is the opinion and findings of the Bureau of Emergency Services that this Class
1 and Class 2 certificate be granted.
The Seminole Fire Rescue Department will be operating and providing services exclusively to the
geographical boundaries of the Reservation. Collier County EMS and the Semiole Fire Rescue
Department may bring forth Memorandums of Understanding to provide for rare situations where
concurrent calls for service at, near, or within the geographical boundaries of both providers occurs and
providing mutual emergency medical services assistance is in the best interest of patient care. Each
agency will work under its respective emergency medical services protocol, dispatch system, billing, and
medical direction. Calls for service on the Seminole Reservation in Immokalee for emergency services
is broadly estimated to be approximately 50 calls for service annually as this first year of service begins
operations.
Seminole Tribe of Florida Fire Rescue Department employees are dually Paramedic, E.M.T., and
certified fire rescue personnel licensed by the State of Florida. The Department’s Medical Director has
adopted the Greater Broward Emergency Medical Directors Association (GBEMDA) Regional Medical
Protocols, which are in compliance with the State of Florida’s standards for medical oversight. The
Department’s Medical Director is Wayne Lee, MD.
Conditions of the Certificates are as follows:
1. For the issuance of a Class 2 ALS intra-facility transport certificate limits transports to tribal
members only as requested by the Seminole Fire Rescue Department application.
2. Staff is recommending the initial COPCN application to expire on May 1st 2018.
3. Seminole Tribe of Florida COPCN shall be required to be renewed annually. Its renewal
application is to be received by the County no later than 90 days prior to its expiration.
4. Seminole Tribe of Florida COPCN will be required to work cooperatively with Collier
16.E.5
Packet Pg. 719
05/09/2017
County EMS, Bureau of Emergency Services, Collier County Sheriff's 911 dispatch
personnel, local licensed facilities and other responders to ensure that their entry into local
and regional ambulance transportation is properly coordinated and services are appropriately
represented. Collier County EMS shall be allowed to conduct any reasonable inspections or site
visits and receive in a timely manner any statistical call volume information needed to evaluate
services, monitor complaints and address any quality of care issues.
FISCAL IMPACT: This redistribution of emergency and non -emergency transports on the
Seminole Reservation in Immokalee by authorizing the Seminole Fire and Rescue Department to receive
a Class 1 and Class 2 certificate is expected to be minimal. There is no increase to the Collier County
EMS budget for granting this Class 1 and Class 2 COPCN if approved. The Board shall also recognize
and accept the $250 application fee within Fund 490.
GROWTH MANAGEMENT IMPACT: There is no Growth Management Impact resulting from
this action.
LEGAL CONSIDERATIONS: This item is approved for form and legality and requires a majority
vote for Board action. - JAB
Additionally, regarding the consideration of this item, Ordinance No. 04-12, Section 7 states:
“The Board of County Commissioners shall not grant a certificate unless it shall find, after public
hearing and based on competent evidence that each of the following standards has been satisfied:
A. That there is a public necessity for the service. In making such determination, the Board of
County Commissions shall consider, as a minimum, the following factors:
(1) The extent to which the proposed service is needed to improve the overall Emergency
Medical Services (EMS) capabilities of the County.
(2) The effect of the proposed service on existing services with respect to quality of
service and cost of service.
(3) The effect of the proposed service on the overall cost of EMS service in the
County.
(4) The effect of the proposed service on existing hospitals and other health care
facilities.
(5) The effect of the proposed service on personnel of existing services and the
availability of sufficient qualified personnel in the local area to adequately staff all
existing services.
(6) That the applicant has sufficient knowledge and experience to properly operate the
proposed service.
B. That, if applicable, there is an adequate revenue base for the proposed service.
C. That the proposed service will have sufficient personnel and equipment to adequately cover the
proposed service area.”
Ordinance No. 04-12, Section 8 provides:
“In making the determinations provided for in Section 7 above, the Board may, in its sole discretion,
appoint a Hearing Officer to hold a public hearing and to make factual findings and conclusions as a
result of the hearing. Should a Hearing Officer be appointed, said Hearing Officer shall render a written
report to the Board within 30 days of the hearing, which report shall contain the officer's findings and
conclusions of fact, and a recommended order. The findings and conclusions of fact shall be binding
upon the Board, but the recommended order shall be advisory only.”
16.E.5
Packet Pg. 720
05/09/2017
RECOMMENDATION:
1. To accept the findings of the Board’s Emergency Medical Authority.
2. To accept the findings of the Director of the Bureau of Emergency Services.
3. To approve the Certificate of Public Convenience and Necessity for the Seminole Tribe of
Florida and, up to (2) two ALS ambulances, (1) one ALS Fire Engine GPM Pumper, and (1)
one ALS Fire/EMS Supervisory Vehicle.
4. To authorize the Chairman to execute the Permit and Certificate.
5. To approve a Budget Amendment to recognize and appropriate the $250 application fee.
Prepared by: Dan E. Summers, Director, Bureau of Emergency Services
ATTACHMENT(S)
1. Initial Application for Seminole Tribe CoPCN (PDF)
2. Seminole Tribe 2017 Stamped Permit (PDF)
3. Seminole Tribe 2017 Stamped Certificate (PDF)
4. Seminole VIN List (DOCX)
16.E.5
Packet Pg. 721
05/09/2017
COLLIER COUNTY
Board of County Commissioners
Item Number: 16.E.5
Doc ID: 3086
Item Summary: Recommendation to approve a Certificate of Public Convenience and Necessity
for a Class 1 and Class 2 Advanced Life Service (ALS) Rescue and intra-facility ambulance transport for
the Seminole Tribe of Florida Fire Rescue within the boundary of the Seminole Tribe in Immokalee.
Meeting Date: 05/09/2017
Prepared by:
Title: Executive Secretary – Emergency Management
Name: Kathy Heinrichsberg
04/19/2017 4:57 PM
Submitted by:
Title: Division Director - Bureau of Emer Svc – Emergency Management
Name: Daniel Summers
04/19/2017 4:57 PM
Approved By:
Review:
Administrative Services Department Paula Brethauer Level 1 Division Reviewer Completed 04/24/2017 10:14 AM
Emergency Medical Services Tabatha Butcher Additional Reviewer Completed 04/24/2017 1:18 PM
Emergency Management Daniel Summers Additional Reviewer Completed 04/25/2017 3:44 PM
Administrative Services Department Len Price Level 2 Division Administrator Review Completed 04/25/2017 4:39 PM
County Attorney's Office Jennifer Belpedio Level 2 Attorney of Record Review Completed 04/27/2017 10:33 AM
Office of Management and Budget Valerie Fleming Level 3 OMB Gatekeeper Review Completed 04/27/2017 10:51 AM
Office of Management and Budget Laura Wells Additional Reviewer Completed 04/27/2017 11:03 AM
County Attorney's Office Jeffrey A. Klatzkow Level 3 County Attorney's Office Review Completed 04/27/2017 1:49 PM
County Manager's Office Nick Casalanguida Level 4 County Manager Review Completed 04/30/2017 9:24 AM
Board of County Commissioners MaryJo Brock Meeting Pending 05/09/2017 9:00 AM
16.E.5
Packet Pg. 722
SEMINOLE TRIBE OF FLOR!DA
Fire Rescue DepartmentDonald DiPetrillo
Flre Chiel/Ditcctor
Telephone
Ofi; 954-966-6300
exl. I1611
Fax: 863-983-8045
WEBSITE
www.semtribe.com
March 1", 2017
eresening Life ani lPropoty'
Dan E. Summers, CEM, FPEM, Director
Collier County Bureau of Emergency Services
Emergency Services Center, Suite 445
8075 Lely Cultural Parkway
Naples, Florida 341 l3
Re: Certificate of Public Convenience and Necessity (COPCN) Application - Seminole Tribe of Florida
Class I - ALS Transport & Class 2 - ALS Transfer
Dear Mr. Summers,
In accordance with Collier County Ordinance No. 04-12, Chapter 50, Article III, Sections l-25 please
find attached the Cenirtcarc of Public Convenience and Necessiry (COPCN) Application, for the
Seminole Tribe of Florida Fire Rescue Department, to provide Basic/Advanced Life Suppon Emergency
Medical Services, Class-l Transport and Class-2 Transfer services to the Seminole Indian Immokalee
Reservation, located in Collier County, Florida.
In addition, the department plans to enter into a mutual-aid agreement with the Collier County Emergency
Medical Services (EMS) Division to provide lifesaving assistance where warranted.
Your assistance with this matter is greatly appreciated. Should you have questions please contact me at
your earliest convenience at (954) 966-6300 x1l6l I office.
Respectfully,
//-.4(%
Donald DiPetrillo, Fire Chief/Director
Attachments
cc: file
Original to County Manager's Office
Seminole Tribe Fire Flescue
Administrative Otlices
3105 North State Road 7
HollFvood, FL 33021
fribal Olficets:
Marcellus W. Osceola, Jr.
Chairman
Milchell Ctpress
Vice Chairman
Lavonne M. Roae
Secretary
Peter A, Hahn
frcasurfr
RECEIYED
MAR i 7 2017
EMERGENCY MANAGEMENT
16.E.5.a
Packet Pg. 723 Attachment: Initial Application for Seminole Tribe CoPCN (3086 : Seminole Tribe of Florida Fire Rescue Department)
Seminole Tribe of Florida
Fire Rescue
Ord. No. 04-12, $ 4; Ord. No.05-16, $ 4; Ord. No. 201l-36, $ 2
Sec. 50-55. - Procedure for obtaining ce(ificate
COPCN Application
Collier County
(l) The name, age, and address of the owner of the umbulance or ALS Operutor, or if the
owner is a corporatiotr, then of the directors of the corporution and of all the stockholders
holding more than 259o of the outstanding shares. For governmental units, this information
shall be supplied for ntembers of the governing body.
. SEEATTACHMENT#I
Marcellus W. Osceola, Jr., Chairman Age/DOB: 44 ylo,lJ6ll8l1972
Mitchell Cypress, Vice Chairman Age/DOB: 69 ylo,MlOZl1947
Cicero Osceola, Councilman Age/DOB: 48 ylo, 0913011968
Andrew J. Bowers, Jr. Councilman Age/DOB: 7O ylo, llll0l1946
ChristopherOsceola,Councilman Age/DOB:47ylo,Oll2Oll97O
c/o Seminole Tribe of Florida
6300 Stirling Road
Hollywood, FL 33024
Telephone: (954) 966-6300
(2) The bounduries of the territort desired to be serrcd.
. SEEATTACHMENT#2
The geographical boundaries of the territory served will encompass the entire Seminole
Tribe of Florida Immokalee Reservation as noted in Attachment #2. Occasionally mutual
aid requests by Collier County and/or other Public Safety Agencies may necessitate
responses outside the geographical boundaries of the reservation. In such cases, STFR will
promptly notify the appropriate licensed EMS provider via the Seminole Police/Fire Rescue
Communications Dispatch Center, or authorized interagency mutual aid radio
communications channels of all such incidents.
(-1) The nrunber and brief dest'ription of the antbulances or otlrcr vehicles the applicant n,ill
have available.
. Two (2) Medical Rescue Units (Ambulances)
- Rescue 38 - Class l&2 ALS Transport and Inter-Facility (FL-ALS Permit # 19849)
- Rescue 238 Class l&2 ALS Transpon and Inter-Facility (FL-ALS Permit # 14456)
o One (l) Fire Engine 1250 GPM Pumper
- Engine 38: Class 3 ALS Non-Transport (FL-ALS Permit #15633)
. One (l) Fire/EMS Supervisory Vehicle
- Battalion 38: Supervisor, Exempt [Rescue Services (Non-ALS)w/ Paramedic)]
Note: Only pcrmanently assigned vehiclcs listed ahove. STFR has additional spare Fire/EMS vehicles used
for lemporary maintcnance. back-fill or special events permittcd in accordance with Florida Statutes 401 and
FDOH Rcgulations 6.1-E.
Page I of 4
16.E.5.a
Packet Pg. 724 Attachment: Initial Application for Seminole Tribe CoPCN (3086 : Seminole Tribe of Florida Fire Rescue Department)
Seminole Tribe of Florida
Fire Rescue
(4) The uddress of the intended heodquarters und any substdtions.
COPCN Application
Collier County
Fire Rescue Headquarters:
- Seminole Tribe of Florida
Fire Rescue Department
30280 Josie Billie Highway
Clewiston. FL 33440
Fire Rescue Substations:
- Fire Station #38
I I l0 South I st Street
Immokalee. FL 34142
- Fire Station #2
30280 Josie Billie Highway
Clewiston, FL 33440
Fire Station #7
660 East Hamey Pond Road
Okeechobee. FL 34974
Fire Station # 108
3l 05 State Road 7
Hollywood. FL 33021
(Executive Admin. Offices)
(s)The training and experience of the applicant.
Experience - The Seminole Tribe of Florida Fire Rescue (STFR) Department was established in
2003 and has provided single-tier, Advanced Life Support Emergency Medical Services
(ALS/EMS) since 2005 at all eight Tribal reservations and non-trust lands state wide directly or
indirectly via contractual relationships. STFR employs over 130 dual certified fire and rescue
personnel licensed through the State of Florida. The department directly serves 4,000 tribal
members and over 22 million visitors annually at its public venues and attractions. Annually STFR
and its contractual partners respond to over 12,000 requests for 9-l-l emergency and non-
emergency fire rescue services.
The Seminole Tribes Fire Rescue Depanment manages or provides Fire/EMS services in multiple
statewide locations including Broward, Dade, Hendry, Okeechobee, Saint Lucie, Polk and
Hillsborough Counties. The department is highly recognized by the State of Florida DOH/EMS
Bureau and receives outstanding ratings on all annual EMS in-service inspections. It is 1007o
complaint on annual data reports to DOH/EMS, NFIRS and FFIRS incident data collection systems
sent directly to federal, state and local agencies. As the primary base of operations for the Tribe is
in Hollywood, Florida; the Broward County Office of Medical Examiner/Trauma Services
continually reviews the department's operations and receives excellent ratings among all local EMS
providers. STFR routinely participates in county, state and regional associations or activities for
fire rescue and emergency medical services in each community served.
STFR's Executive/Management team averages 34+ years' experience in fire and emergency
medical services: and field operations personnel average 9+ years of experience. Several staff
members have been recognized by the state or other EMS organizations and awarded such
distinctions as; "Firefighter/Paramedic of the Year", and "Paramedic Instructor of the Year".
Page 2 of 4
16.E.5.a
Packet Pg. 725 Attachment: Initial Application for Seminole Tribe CoPCN (3086 : Seminole Tribe of Florida Fire Rescue Department)
Seminole Tribe of Florida
Fire Rescue
(5) Continued
COPCN Application
Collier County
A'I'TACHMEN'I'#3
Training- All Seminole Tribe of Florida Fire Rescue (STFR) employees are dual-certified fire and
rescue personnel licensed by the State of Florida. The depanment provides vigorous six (6) week
multi-disciplinary Fire/EMS orientation training program for all new employees. An additional ( l2)
month probationary "in-service" skills sign-off program is mandated for successful completion by
all new employees. Every two years all personnel must successfully complete a continuing
education medical training matrix including but not limited to the State of Florida EMS mandatory
thirty (32) contact hours to include ACLS, Protocols and "hands on" lab skills testing, etc.
The department's Medical Director has adopted the Greater Broward Emergency Medical Directors
Association (GBEMDA) Regional Medical Protocols, which are in compliance with the State of
Florida's standards for medical oversight. The Tribes Medical Director Wayne Lee, MD is a
certified Ernergency Medical physician with more than 40 years' experience as a local and
statewide leader in the field of medicine.
In addition during 2016, the department delivered 187 life safety classes (CPR/AED/Fire
Extinguisher training) to 3,157 Tribal Gaming employees; and Crowd Manager Classes to 480
employees. In addition STFR provided 269 Youth Safety, Senior Safety and Fire Drill presentations
to 7,039 Tribal children, seniors and employees and also 3l CPR /AED classes to 370 Tribal members
and employees. This pro-active life safety training reached over I1,000 people in 480 presentations
totalingT ,771 staff hours.
The rumres and addresses of three Collier Countl' residents who u'ill uct as rekretrces for
the applirunt.
Tina Marie Osceola,5920 Westport Lane, Maples, FL 341 16, Ph. (239) 298-3279
O.B. Osceola, Sr., 5870 Westpon Lane, Naples, FL 341 16, Ph. (239) 455-2171
Michael D. Murphy, 1280 San Marco Rd., Marco Island, FL 34145, Ph. (239) 393-0099
(7)A schedule of rates w'hich the sert'ice intends to charge.
Class I - ALSiIf LS Emergency Transports Only
** The Seminole Tribe of Florida contracts with ADPl-Intermedix, 500 NW 165 St., Ste. 102.
Miami, FL 33169, (30-5) 945-2280 for all EMS patient transportation billing/collections services.
All non-emergency Class 2 - EMS lnterfacility Transports are strictly for the private use of
Seminole Tribal mernbers and billed directly to Medicare eligible patients only.
(6)
**Mileage Rate = $15.O0/mile
Page 3 of 4
Call Level Rate
BLS s660.00
ALSI $800.00
ALS2 $ 1,000.00
16.E.5.a
Packet Pg. 726 Attachment: Initial Application for Seminole Tribe CoPCN (3086 : Seminole Tribe of Florida Fire Rescue Department)
Seminole Tribe of Florida
Fire Rescue
(8) Such other perlinent information as the administrator may require.
COPCN Application
Collier County
o ATTACHMENT#4
Florida Depanment of Health
Bureau of Emergency Medical Oversight
Advanced Life Support License #2603
o ATTACHMENT#5
Cenificate of General Liability Insurance (STOF)
o ATTACHMENT#6
Hany W. Lee, M.D. - Medical Director License
o ATTACHMENT#7
Florida State Fire Marshal - Ce(ificate of Appreciation 2015
o ATTACHMENT#E
Certificate of General Liability Insurance (Medical Director)
(9) An uppliuttion or renewol fee of $250.00. (Exceptiur Collier County EMS).
o ATTACHMENT#9
Payment to Collier County enclosed with application - Check # 7MEl5
(10) Financial data includirtg assets and liabilities of the operator. A sr:hedule of all debts
encunrbering an! equipment shall be irrcluded.
o ATTACHMENT#10
Seminole Tribe of Florida Fire Rescue Department FY' l7 Annual Budget
Mission Statement:
"To protect and enhance the quality of life of the Seminole Tribe of Florida communities, through a
comprehensive program of services committed toward education, prevention and control of fire, rescue,
medical emergencies, life safety, forestry and all hazard responses."
Motto:.LOVE ALL, SERVE ALL"
Laa pkon Aa nookaa- c he k, laapkon Em pac lrc k
Values:
We e.ypect to make a clifference in the quali* of hfe to the Seminole Tribe and guests- To this end, we
focus our resources for the most enduring benefit.. Improve the quality of life safety through education and code enforcement to
prevent fires, reduce injuries and other harmful events.o Deliver responsive and caring emergency services.. Protect life and property from fire, hazards, injuries and illness.o Mitigate emergencies and disasters, both man-made and natural.o Enhance customer and communitv relations.
Page 4 of 4
16.E.5.a
Packet Pg. 727 Attachment: Initial Application for Seminole Tribe CoPCN (3086 : Seminole Tribe of Florida Fire Rescue Department)
Collier County
COPCN Application
2017
ATTACHMENTS:
16.E.5.a
Packet Pg. 728 Attachment: Initial Application for Seminole Tribe CoPCN (3086 : Seminole Tribe of Florida Fire Rescue Department)
Seminole Tribe of Florida
Fire Rescue ATTACHMENT #1
COPCN Application
Collier County
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Packet Pg. 737 Attachment: Initial Application for Seminole Tribe CoPCN (3086 : Seminole Tribe of Florida Fire Rescue Department)
Seminole Tribe of Florida
Fhe Rescue
COPCN Application
Collier CountyATTACHMENT #3
SEMINOLE TRIBE
FIRE RESCUE DEPARTMENT
TRAINING DIVISION
BIANNUAT SKI
1. Patient History from an Alert and Oriented
Patient
2. Comprehensive Normal Adult Physical
Assessment Techniques
3. Comprehensive Normal Pediatric Physical
Assessment Techniques
4. Airway, Oxygenation, and Ventilation
5. DirectOrotracheal lntubationAdult
5. Direct Orotracheal lntubation Pediatric
7. Nasotracheal lntubation Adult
8. Supraglottic Airway Device Adult (LMA)
9. Needle cricothyrotomy
10. Surgical Cricothyrotomy
11. CPAP
12. Trauma Adult Physical Assessment
13. Pleural Decompression
14. spinal lmmobilization Adult (Supine Patient)
15. Spinal lmmobilization Adult (Seated Patient)
17. Traction Splinting
18. Hemorrhage Control
19. Medical and Cardiac Physical Assessment
20. lntravenous Therapy
21. lntraosseous Therapy
22. lntravenous / lntraosseous Bolus Medication
Administration
23. lntramuscular Administration
24. lntranasal Medication Administration
25. lnhaled Medication Administration
26. Glucometer
27. l2-lead ECG
28. Synchronized Cardioversion
29. Defibrillation
30. Transcutaneous Pacing
31. Normal oelivery with Newborn Care
32. Abnormal Delivery with Newborn Care
NT SKIttS tAB - STA
8. lntraosseousTherapy
9. lntravenous / lntraosseous Bolus Medication
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10. 12-lead ECG
11. Synchronized Cardioversion
12. Defibrillation
13. Transcutaneous Pacing
1. Direct Orotracheal lntubation Adult
2. Direct Orotracheal lntubation Pediatric
3. Supraglottic Airway Device Adult (tMA)
4. NeedleCricothyrotomy
5. SurgicalCricothyrotomy
6. CPAP
7. PleuralDecompression
16.E.5.a
Packet Pg. 738 Attachment: Initial Application for Seminole Tribe CoPCN (3086 : Seminole Tribe of Florida Fire Rescue Department)
Seminole Tribe of Florida
Fire Rescue
STATION SKILLS tAB
COPCN Applicaiion
Collier County
License f:
ATTACHMENT #3
SEMINOLE TRIBE
FIRE RESCUE DEPARTMENT
TRAINING DIVISION
NAME:YEAR:EMT OR PARAMEDIC ID tr:
skiI Date lnitials tD t Date lnitials tDf Date lnitials ID fl
1. Direct Orotracheal lntubation Adult
2. Direct Orotracheal lntubation
Pediatric
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(LMA)
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5. Surgicalcricothyrotomy
6. CPAP
7. PleuralDecompression
8. lntraosseousTherapy
9. lntravenous / lntraosseous Bolus
Medication Administration
10. 12-lead EcG
11. Synchronized Cardioversion
12. Defibrillation
13. Transcutaneous Pacing
District Chief Name:
District Chief Signature:
16.E.5.a
Packet Pg. 739 Attachment: Initial Application for Seminole Tribe CoPCN (3086 : Seminole Tribe of Florida Fire Rescue Department)
Seminole Tribe of Florida
Fire Rescue
COPCN Applicaiaon
Collier CountyATTACHMENT #3
SEMINOLE TRIBE
FIRE RESCUE DEPARTMENT
TRAINING DIVISION
NAME:
DEPARTMENT SKILLS LAB
EMT OR PARAMEDIC ID #:YEAR;License f:
skill Date lnitials tDr
1. Direct Orotracheal lntubation Adult
2. Direct Orotracheal lntubation Pediatric
3. Supraglottic Airway Device Adult (LMA)
4. Needle Cricothyrotomy
5. Surgical Cricothyrotomy
6. CPAP
7. PleuralDecompression
8. lntraosseousTherapy
9. lntravenous / lntraosseous Bolus Medication Administration
10. 12-lead ECG
11. Synchronized Cardioversion
12. Defibrillation
13. Transcutaneous Pacing
14. Patient History from an Alert and Oriented Patient
15. Comprehensive Normal Adult Physical Assessment Techniques
16. Comprehensive Normal Pediatric Physical Assessment Techniques
17. Airway, Oxygenation, and Ventilation
18. Nasotracheal lntubation Adult
19. Supraglottic Airway Device Adult (LMA)
20. Trauma Adult Physica I Assessment
21. Spinal lmmobilization Adult (Supine Patient)
22. Spinal lmmobilization Adult (Seated Patient)
23. Joint Splinting
24. Traction Splinting
25. Hemorrhage Control
25. Medical and Cardiac Physical Assessment
27. lntravenous Therapy
28. lntramuscular Administration
29. lntranasal Medication Administration
30. lnhaled Medication Administration
31. Glucometer
32. Normal Delivery with Newborn Care
33. Abnormal Delivery with Newborn Care
Proctor Name:Signature:
16.E.5.a
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Packet Pg. 741 Attachment: Initial Application for Seminole Tribe CoPCN (3086 : Seminole Tribe of Florida Fire Rescue Department)
CERTIFICATE OF LIABILITY INSURANCE of 21 09 /29 /20L6
rHE CERTIFICATE IS ISSUEOAS A MATTER OF INFORUATION ONLYANO CONFERS NO RIGHIS UPOt{ IHE CERTIFICATE HOLOER. THIS
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REPRESENTATME OR PRODUCER, ANDTHE CERTIFICATE HOLOER.
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tha tarma and cordruorlt ol thc pollcy, ccrtaln pollcl6 may rrqulrr an andortrmont A 3tatanant on thla cortlflcalr do6 not co.rfaa rlghta to tho
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COPCN Application
Collier CountyATTACHMENT #5
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16.E.5.a
Packet Pg. 742 Attachment: Initial Application for Seminole Tribe CoPCN (3086 : Seminole Tribe of Florida Fire Rescue Department)
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Packet Pg. 744 Attachment: Initial Application for Seminole Tribe CoPCN (3086 : Seminole Tribe of Florida Fire Rescue Department)
Seminole Tribe of Florida
Fire Rescue ATTACHMENT #8
COPCN Application
Collier Countyd
cE?iTIiiHrE oF LrABrLrrY rNSURf;fi&
CERNFIC TE I{OLDER CAI{CELLATIOX
MRH
THIS CERNFICATE IS ISSU€O AS A iIATTER OF II{FOR ATIO
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REPRESEiIIANVE OR PROOUCE& AXD THE CERNFICATE HOLOER.
the tenns and condldona ot tha pollcy, cortaln pollcloa may Bqulro an ondoEemonl A rtatoment on tht! co.tmcato dos!not conL. rlghl! to tha
confbats holder ln lleu ot ruch
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3250 N. 29th Avc
Hollytvood, FL 33020
Hsry Wayno Loa, MD
cro S.mlnolo Trlbs of Florlda
6300 Surllng Ro.d
Hollywood, FL 3302,1
CERTIFICATE NUMBER:
THIS IS IO CERTIFY THAT T}€ POLICIES OF INSI'RANCE LISTEO SELOW HAVE BEEN ISSLED TO THE INSUREO NAMEO AAOVE FOR THE POIICY PERI@
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16.E.5.a
Packet Pg. 745 Attachment: Initial Application for Seminole Tribe CoPCN (3086 : Seminole Tribe of Florida Fire Rescue Department)
ATTACHMENT #10
COPCN Application
Collier CountySeminole Tribe of Florida
FY17 Budget
Fire Rescue Department
Revenue 7,465,700
Salary & Benefits L3,322,700
70000-Contract Services 351,100
70045-Hardware/Software Maintenance Contracts 50,000
04-Contract Services 411,100
71000-Telephone & Communications 6,300
71010-Wireless Communications 31,900
71315-Cable/Satellite 3,100
05-utilities 41,300
71500-Building & Grounds Maintenance 57,700
71740-Gas, Oil, & Diesel Fuel 151,400
71750-Equip Maintenance & Repair 76,100
71755-Vehicle Repair And Maintenance 268,400
05-Maintenance 553,600
71800-Equipment 240,700
71815-Medical Equipment 10,200
71835-Audio/video 6,800
07-Equipment 257,100
72000-Equipment Rental & Lease 3,000
72040-Vehicle Leases 5,000
08-Rental & Lease 8,000
73000-Office Supplies 6,900
73060-Office Furniture 3,000
73070-Printing 5,300
73200-Postage & Mailing 300
73300-Dues, subs & Books 15,400
73400-Department Food Supplies 1,500
73500-Department Supplies 205,000
7351o-Copy Machine Expense 18,600
73530-Uniforms 82,800
7375o'Construction Materials & Suppl 7,400
09-Supplies & Material 342,200
74020-Mileage Reimbursement 2,000
74090-Parking And Tolls 200
74460-Airfare 2,704
74470-Hotel 72,204
74480-Rental Car 100
74490-Meals 5,700
10-Travel 22,300
75210-Motor Vehicles lnsurance 115,100
12-lnsurance 116,100
75890-lmmokalee Fire Rescue 75,000
75855-St. Lucie Co. Fire Rescue 25,000
75850-City Of Hollwood Fire Rescue 300,000
14-Security & Protection 400,000
76030-workshop/training 26,700
76200-Meeting Fees & Expense 200
15-Trainin&/Meetings 26,900
16.E.5.a
Packet Pg. 746 Attachment: Initial Application for Seminole Tribe CoPCN (3086 : Seminole Tribe of Florida Fire Rescue Department)
seminore Tribe of Frorida ATTA.HMENT#1. ""t"Affillff"'il
FYU Budget
Fire Rescue Department
75550-Community Activities 2,500
17-Event Activities 2,500
79020-Food & Beverage 3,900
79095-Auction Fees 100
79100-Bad Debt Expense 258,000
20-Other 262,O00
94000-lnterest 27,904
94030-Capital Lease Payments 375,500
31-Finan€ing 397,400
71825-Computers & Printers 43,000
79135-Software License Expense 81,500
37-lnformation Technoloty 124,500
Total Expenses 2,95s,000
Total 8,822,000
16.E.5.a
Packet Pg. 747 Attachment: Initial Application for Seminole Tribe CoPCN (3086 : Seminole Tribe of Florida Fire Rescue Department)
COLLIER COUNTY FLORIDA
Cle*r (1, end Clesr .2' COPCN
Name of Service: Seminole Tribe of Florida
Namc of Owner: Seminole Tribc of Florida
Principlc Address of Service: 6300 Stirline Road
Hollywood. FL 33024
Busincss Telephone: (954) 966-6300
Description of Service: Class "1" Emergency Medical Transoort: Class ..2', Intra-faciliw
and out-of-county transport for tribal membcrs.
Number of Ambulances: (2) Two. (1) One Fire Engine 1250 GMp pumper. and fl) One
Fire/EMS S uoervisorv Vehicl e.
See attachment "A" for description ofvchicles.
This pennit, as provided by Ordiunce No. 2004-12, as amendeq shall allow the above
naned Ambulance Service to operate intra-facility and out ofcounty transports for a fce
or charge for the following area(s): Seminole Tribe ofFlorida Fire Rcscue Department
borurdaries for one year fiom the date executed herco& except thal this p€f,rnit may be
rcvokcd by thc Board of County Commissioners of Collier Courty at any timc the service
namcd herein shall fail to comply with any local, state or fcderal laws or rcgulation
application to the provisions of Emergency Mcdical Serviccs.
Issued and approved this day of 2017
ATTEST:
DWIGHTE. BROCK CLERK
,Depny Clerk
Approved as to form and legality:
Jennifer A. Belpedio
Assislart County AttorDey
BOARD OF COUNTY COMMISSIONERS
COLLIER COUNTY, FLORIDA
Penny Taylor, Chairman
^F ^t's" o\-
[ 17.EMG.00390/ l3]3747l I l
/.\{>-1\..Q,/
16.E.5.b
Packet Pg. 748 Attachment: Seminole Tribe 2017 Stamped Permit (3086 : Seminole Tribe of Florida Fire Rescue Department)
WHEREAS,
WHEREAST
ATTEST:
DWIGHT E. BROCK, CLERK
, Dcputy CIGrk
Approved I ao form and lcgality:
SEMINOLE TRIBE OF FLORIDA FIRE RESCUE
CERTIFICATE OT PUBLIC CONVENID,NCE AND NECESSITY
WHEREAS, thc SEMINOLE TRTBE OF FLORIDA FIRE RESCUE (hcreinaftcr .,seminolc Tribe")
wishcs to proido intra-facility transports and out ofcourty transpons for a fee or charge; and,
it has bccn dcrnonstratod that thcre is a ne€d for this ombulancs s€rvicc to opcratc wifiin the boundary of
thc Scminolc Tribe in Immokalee
thc above mentioned service has indicatcd that it will comply with all requircmcnts of Chspter 4Ol,
Florida Siatutcs, goveming €mergency m€dical tclecommunications and transportation, the Board of
counry commissioners of coLLlER couNTy hcr€by issues a ccrtificarc of public convcnicncc and
Neccssity to this ambulance service for onc ycar from effcctive dste. ln issuing this ccrtificatc, it is
unddsaood that thc above named Embulancc scrvicc will m€cl the rcquircmcnts ofOrdinance 2O(N-12, as
amendcd, applicablc laws and rcgulations and provide service on a 24 hour basis.
BOARD OF COUNTY COMMISSIONERS
COLLIER COTJNTY, FLORIDA
Penny Taylor, Cheirman
Jennifer A- Bclpedio
Asistrmt Couty Attomcy s's\'*\J
Ilate Signed
Efrcctivc DEl.: Msy 9, 20 I 7
Expiradon Darc: May I , 20 I 8
16.E.5.c
Packet Pg. 749 Attachment: Seminole Tribe 2017 Stamped Certificate (3086 : Seminole Tribe of Florida Fire Rescue
Attachment “A”
Seminole Tribe of Florida Fire Rescue Department
Immokalee Reservation Station
VIN List - 2017
. Two (2) Medical Rescue Units (Ambulances)
- Rescue 38 - Class l&2 ALS Transport and Intra-Facility (FL-ALS Permit # 19849)
- Rescue 238 Class l&2 ALS Transport and Intra-Facility (FL-ALS Permit # 14456)
. One (l) Fire Engine 1250 GPM Pumper
- Engine 38: Class 3 ALS Non-Transport (FL-ALS Permit #15633)
. One (l) Fire/EMS Supervisory Vehicle
- Battalion 38: Supervisor, Exempt [Rescue Services (Non-ALS)w/ Paramedic)]
16.E.5.d
Packet Pg. 750 Attachment: Seminole VIN List (3086 : Seminole Tribe of Florida Fire Rescue Department)