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Agenda 03/12/2013 Item #16E5 3/12/2013 16.E.5. EXECUTIVE SUMMARY Recommendation to approve the submittal of an EMS Matching Grant Application to the State of Florida Department of Health, Bureau of Emergency Medical Services for bariatric equipment in the amount of$30,000 in grant funds and a required local match of$10,000. OBJECTIVE: To purchase bariatric equipment to provide for safer movement and transport of bariatric patients. CONSIDERATIONS: Emergency Medical Services (EMS) is transporting in excess of 50 patients per year who weigh over 400 lbs. While the department is developing new protocols for handling patients in excess of 300 pounds, we do not currently have the specialized equipment to load and transport these patients with the utmost safety for the patient and the crews who are responsible for moving them. If awarded this grant, EMS proposes to take two older trucks from the reserve fleet and equip them for bariatric transport. These trucks would be outfitted with a bariatric stretcher and a power lift. Since Collier County is geographically the largest county in State and CCEMS is the sole transport agency for some 2025 square miles, we would place one unit in a northern zone and one unit to the south. The crew rotation for these stations would be specially trained in the operation of the loading system and the operation of the stretcher. These ambulances would still be available as a regular transport unit in the event of an emergency activation or if the reserve fleet was exhausted for some reason. FISCAL IMPACT: If awarded this grant, a match of$10,000 (25% of$40,000) will be required and is available within the EMS operating budget —Fund 490. Also if awarded, the grant agreement and any necessary budget amendments would be brought back to the Board for approval. LEGAL CONSIDERATIONS: The Board will have the opportunity to accept or reject the funds if the grant is approved. Accordingly, this Office has no issue with respect to the legal sufficiency of this request, which requires a majority vote for Board action. -JBW GROWTH MANAGEMENT IMPACT: There is no Growth Management Impact resulting from this action. RECOMMENDATION: That the Board of County Commissioners approves the submittal of a matching grant application to the State of Florida Department of Health, Bureau of Emergency Medical Services for bariatric equipment in the amount of$30,000 in grant funds with $10,000 in required local match. Prepared by: Artie Bay, Supervisor, Emergency Medical Services Admin. Attachments: Grant Application Packet Page-1854- 3/12/2013 16.E.5. COLLIER COUNTY Board of County Commissioners Item Number: 16.16.E.16.E.5. Item Summary: Recommendation to approve the submittal of an EMS Matching Grant Application to the State of Florida Department of Health, Bureau of Emergency Medical Services for bariatric equipment in the amount of$30,000 in grant funds and a required local match of$10,000. Meeting Date: 3/12/2013 Prepared By Name: BayArtie Title: Supervisor-Accounting,EMS Operations 2/21/2013 2:19:18 PM Approved By Name: pochopinpat Title: Administrative Assistant,Facilities Management Date: 2/26/2013 3:03:54 PM Name: PriceLen Title:Administrator, Administrative Services Date: 2/27/2013 12:34:53 PM Name: Joshua Thomas Title: Grants Support Specialist, Date: 2/27/2013 12:41:49 PM Name: SummersDan Title: Director-Bureau of Emergency Services, Date: 2/28/2013 8:42:46 AM Name: WhiteJermifer Title: Assistant County Attorney,County Attorney Date: 2/28/2013 2:55:46 PM Name: KlatzkowJeff Title: County Attorney Packet Page-1855- 3/12/2013 16.E.5. Date: 2/28/2013 3:22:44 PM wok Name: PryorCheryl Title: Management/Budget Analyst, Senior,Office of Manag Date: 3/1/2013 11:39:43 AM Name: StanleyTherese Title: Management/Budget Analyst, Senior,Office of Manage Date: 3/1/2013 12:20:31 PM Name: OchsLeo Title: County Manager Date: 3/3/2013 9:34:14 AM Packet Page -1856- 3/12/2013 16.E.5. 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: ❑ Rural ® Matching ID. Code(The State Bureau of EMS will assign the ID Code—leave this blank)_ 1. Organization Name: Collier County EMS 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: Georgia A. Hiller, Esq, Position Title: Chairwoman Address: 3299 Tamiami Trl E Suite 303 City: Naples County: Collier State: Florida Zip Code: 34112 Telephone: 239-252-8097 Fax Number: E-Mail Address:GeorgiaHillert7a colliergov.net 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: Artie R. Bay Position Title: Supervisor- EMS Admin. Address: 8075 Lely Cultural Pkwy Suite 267 • City: Naples County: Collier State: Florida Zip Code: 34113 Telephone: 239252-3740 Fax Number: 239-252-3298 E-Mail Address:ArtieBayAcolliergov.net OH Form 1767,Rev.June 2002 4 Packet Page-1857- 3/12/2013 16.E.5. 4. Legal Status of Applicant Organization(Check only one response): Ask (1) ❑ Private Not for Profit[Attach documentation-501 (3)©) g ,. (2)El Private For Profit (3) []City/Municipality/TownNillage (4) County (5)E] State (6)❑ Other(specify): 5. Federal Tax ID Number(Nine Digit Number). VF 52:60.0Q55 6. EMS License Number: 3393 Type: ®Transport ❑Non-transport ❑Both 7. Number of permitted vehicles by type: BLS 33 ALS Transport 4 ALS non-transport. 8. Type of Service(check one): []Rescue []Fire Third Service(County or City Government, nonfire) DAir ambulance: ❑Fixed wing DRotowing ❑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 project. No signature Is needed if medical equipment and professiona ►. -d 'o is project.] Signature: • #44P Date: 1 /ca, /1 -5 Print/Type: Name of Director Robert Boyd Tober, MD, FACEP FL Med. Lic. No. ME30891 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 10 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); 0) 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). OH Form 1767,Rev.2002 2 Packet Page-1858- 3/12/2013 16.E.5. • 10)Justification Summary Problem Description Collier County Emergency Medical Services (CCEMS) responded to 36,359 calls for emergency medical services in FY 2012 and provided 24,058 transports.' Emergency medical services are provided to the County via 166 full-time Paramedics and EMTs, along with 11 field supervisors. This agency is transporting in excess of 50 patients per year who weigh over 400 lbs., approximately 10% weighing in excess of 700 lbs. and 60%of . those patients weigh in excess of 1,000 lbs.' All are aware that the obesity rate in the United States is on the rise. The rate of obesity in the State of Florida in 1986 was 9.8%. By 2002, that rate rose to 19.4% -- an astonishing 98% increase. in 2011 the obesity rate in Florida was 24.2% and in 2012 it had risen to 26.6% --a 10% increase in just one year and exceeding the national average of 25%. 2 CCEMS is currently unequipped to efficiently and safely load and transport obese patients. While the department is developing new protocols for handling patients in excess of 300 pounds, we do not have the specialized equipment to load and transport these patients with the utmost safety for the patient and the crews who are responsible for moving them. All over the State of Florida, the referendum to reduce property taxes, along with the decrease in property values has crippled county agencies from obtaining necessary funding through ad valorem taxes. Nearly 80%of the Collier County EMS budget is to cover personnel costs. The remaining 20% is utilized to cover operating costs and capital purchases to replace worn equipment. CCEMS' capital budget has been cut radically. Our FY13 capital budget for equipment has shrunk to 17% of the FY08 level, preventing the replacement of worn out equipment and certainly preventing the purchase of additional equipment. Also, the budget is largely dependent on revenue. With the majority of the county being agricultural, there is a large influx of both a migrant population and indigent patients. As such, Collier County experiences a high volume of write- offs for ambulance services. As you have most likely seen, ambulance fee collections have taken a negative turn due to the trend by insurance companies to short-pay claims (payments substantially less than that billed), unemployment and people's toss.of group insurance, and the economy in general. Most individuals will choose to keep their lights on and feed their families before paying for an ambulance ride. Present Situation Currently, if a patient is mobile, the ambulance will be backed up as near to the pick-up location as possible and the crews will assist the patient in walking to the truck. However, many of these patients are not mobile. Packet Page-1859- 3/12/2013 16.E.5. CCEMS is developing new protocols to move these patients in a more dignified and efficient method. We have recently purchased Mega Mover Portable Transport Units, which are essentially a tarp with handles. Moving patients in excess of 300 lbs. is much safer utilizing these units in that the crew members can lift the tarp with less physical contact with the patient. This helps in preventing injury to the patient by handling them less directly. This method still requires 8 to 12 crew members and it is our hope that utilizing the Mega Movers will abate crew injuries as well. Our existing stretchers are only rated for patients up to 650 lbs. and because of our side mounts, it is physically impossible to fit an obese patient on the stretcher in the ambulance. Consequently, the stretcher cannot be utilized and the patient will be situated on the floor of the ambulance and secured with straps as well as possible. This is not an optimal situation for the patient. Aside from the comfort and dignity factors, the inability to secure the patient in the normal fashion can place the patient in great danger in the event of an accident. In fact, in just such a transport several years ago, the ambulance was involved in an MVA, overturned and the patient died of complications from her injuries. Had the patient been secured on a stretcher that would accommodate her size, her outcome may have been different. Proposed Solution Asok CCEMS proposes to take two ambulances from our reserve fleet and equip them for bariatric transports. These ambulances would be outfitted with a bariatric stretcher which can accommodate up to 1600 lbs. and a power lift system which has a 1300 lb. capacity. Since the stretcher itself weighs only 111 lbs., the capacity of the power lift system would easily accommodate our heaviest patients to date. We considered a less expensive ramp and winch system, but deemed the requirements for storage, the lifting and placement of the ramps and the overall safety for the patient and crews justified the cost of the power system. Since Collier County is geographically the largest county in the State and CCEMS is the sole transport agency for some 2025 square miles, we would place one ambulance in a northern zone and one ambulance to the south. The crew rotation for these stations would be specially trained in the operation of the loading system and the operation of the stretcher. These ambulances would still be available as a regular transport unit in the event of an emergency activation or if the reserve fleet was exhausted for some reason. Consequences if Not Funded Should this grant not be funded, CCEMS would continue to seek methods to move and transport bariatric patients in the safest possible way. However, without this equipment, patients will still be in danger of physical injury, discomfort and much worse in the event of a vehicle accident. Our crews and assisting firefighters are Packet Page-1860- 3/12/2013 16.E.5. subject to injuries related to moving and/or lifting these patients.. Also, due to the manpower currently required for this nature of patient care, both CCEMS crews and assisting firefighters are unavailable for other emergencies. Geographic Area CCEMS is the sole provider of emergency medical transport services for all of Collier County, Florida. Collier is the largest county geographically in the state, encompassing 2025 square miles,with a combination of urban, suburban and rural areas. Collier County is located on the southwest coast of Florida with a permanent population of 321,520 (based on the 2010 census). Approximately 20,000 workers increase the population each day. In addition, the moderate climate, miles of beaches, three airports and numerous marinas attract a multitude of visitors each day, swelling the population level to nearly 400,000 during peak season. 3 Time Frames Receive State Award Purchase and acquire bariatric equipment 60 days Installation of loading system 30 days Train personnel and deploy trucks 90 days Project will be completed within one year. Data Sources 'Call data—CCEMS patient care reporting system—EMSTARS compliant 2Obesity data-National Conference of State Legislatures and Countyhealth.findthedata.org 3Population data—US Census Bureau and Collier County Comprehensive Planning Department Attesting Statement No other applications have been submitted for State grant funding for this project. Packet Page-1861- 3/12/2013 16.E.5. 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 ;n< 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 Projects 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 Projects: 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? OH Form 1767, Rev.2002 • Packet Page-1862- 3/12/2013 16.E.5. 11) Outcome For Projects That Provide or Effect Direct Services To Emergency Victims: A) Our patient care reporting system does not provide a means for us to report on specific injuries to bariatric patients without actually looking at the narratives. However it is very common, especially in the morbidly obese patients, to suffer bruises, skin tears, respiratory complications and hemodynamic compromise in moving, loading, and transporting these patients. Positioning of these patients can severely exacerbate their medical complaint and lead to life threatening complications which could be avoided with a system designed to support and secure them based on their physical dimensions. As our population rises and the obesity rates continue to increase, we do expect that the 50 plus transports we are currently doing each year will increase proportionately. Also, while we have been very fortunate over the past 12 months in not experiencing a repeated incident where not having the proper equipment to move and transport bariatric patients contributed to their death, that possibility is ever present utilizing the methods we must employ at this time. In addition, while our Risk Management Department does not keep records for injuries to our personnel related strictly to moving or lifting bariatric patients, that type of injury is most prevalent in dealing with bariatric patients. B) In the 12 months after the deployment of our bariatric units, we would anticipate at least a 90% reduction in patient injuries and the absence of risk of a bariatric patient dying because of our inability to properly secure them in the ambulance. We would also expect at least a 90% reduction in crew injuries while working with • bariatric patients. C) These expectations are based on the fact that some patients, being forced into a sedentary lifestyle, will still experience some bruising and respiratory issues while being moved and loaded into an ambulance. All patients will be properly secured so we would anticipate no risk of death to the patient because they were not. Finally, while the dedicated bariatric units, with crews trained especially in bariatric care, will greatly aid in loading a bariatric patient, a risk remains in the transfer stage once the patient reaches the hospital. D) Another outcome for this project would be more efficient use of resources. In the loading process for a bariatric patient, as many as 12 personnel may be called upon to assist. This effort ties up resources for both our agency and that of the assisting fire departments. E) This project is consistent with our five year plan to: 1. Continue to deliver world class best value pre-hospital care to citizens and guests in Collier County; and 2. Continue to find ways to be innovative, clinically based, cost effective, compassionate and professional placing the best interest of patient care first-always. Packet Page-1863- 3/12/2013 16.E.5. Skip item 14 and go to Item 15, unless your project is research and evaluation and you have not Ask 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. i) 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 N/A for those things in this section that do not pertain to this project. Respond to all others. Amok 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 d Packet Page-1864- 3/12/2013 16.E.5. 15) Statutory Consideration and Criteria A. Serve the requirements of the population upon which it will impact. The acquisition of bariatric equipment will aid in the timely, safe and efficient movement of bariatric patients as well as the safety and health of medics and firefighters who assist these patients. B. Enable emergency vehicles and their staff to conform to state standards established by law or rule of the department. The equipment requested for this grant will meet all state and local requirements for the safe transport of patients to and from vehicle and during transport. 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. As per state requirements and department regulations, the bariatric equipment meets all requirements for equipment and safe transport of a patient. 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. N/A E. Enable your organization to improve or expand the provision of: 1. EMS services on a county,multi county,or area wide basis. This project will serve the population and visitors of Collier County, mutual aid with surrounding counties and the statewide disaster response plan. 2. Single EMS provider or coordinated methods of delivering services. Collier County EMS is the only licensed 911 Transport provider in Collier County. The equipment will benefit each and every bariatric patient in the county. This equipment will enhance unit availability because there will be dedicated units for transport of bariatric patients. 3. Coordination of all EMS communication links, with police, fire, emergency vehicles, and other related services. N/A Packet Page-1865- 3/12/2013 16.E.5. 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 Purchase and acquire equipment 0 2 Installation of loading system 2 3 Train personnel and deploy trucks 3 6 jl 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. Amok Funds received through the State EMS county grant have been dedicated to another project to inprove emergency services in Collier County and unavailable for this purpose. OH Form 1767, Rev. 2002 eft • Packet Page-1866- 3/12/2013 16.E.5. 18. Budget: Salaries and Benefits: For each Costs Justification: Provide a brief justification position title, provide the amount of why each of the positions and the numbers salary per hour, FICA per hour, of hours are necessary for this project. fringe benefits, and the total number of hours. • TOTAL: Expenses: These are travel costs Costs: List the price Justification: Justify why each of the and the usual, 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, excluding expenditures classified as operating capital outlay(see next category). TOTAL: DH Form 1767,Rev. 2002 • Packet Page-1867- 3/12/2013 16.E.5. • Vehicles, equipment,and other Costs: List the price Justification: State why each of the items Itlok 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 non identify the price. consumable and non expendable nature, and the normal expected life of which is 1 year or more. Bariatric Strechers 2 @ 7500.00 $15,000.00 Stretcher capacity of up to 1600 lbs. Power Lift Systems 2 @ 12,500.00 $25,000.00 Power lift capacity of 1300 lbs., includes installation • TOTAL: $40,000.00 Asok State Amount (Check applicable program) ®Matching: 75 Percent $30,000.00 ❑Rural: 90 Percent Local Match Amount (Check applicable program) Matching: 25 Percent $10,000.00 El Rural: 10 Percent Grand Total $40,000.00. DH Form 1767,Rev.2002 • 7 Packet Page -1868- 3/12/2013 16.E.5. 19. Certification: M 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 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. 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 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. 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. / / Signature of Authorized Grant Signer MM/DD/YY (Individual Identified in Item 2) DH Form 1767,Rev.June 2002 A7'rEsT; DW►Cew.E. BROOK, Clerk Approved as to form & legal Su9 Oirmey AssiSt t cocrnty Attorney 8 Packet Page-1869- 3/12/2013 16.E.5. FLORIDA DEPARTMENT OF HEALTH 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:Collier County Board of Comissioners-EMS Mailing Address: Finance Department 3299 Tamiami Trl E, Suite 700 Naples, Fl 34112-5746 Federal Identification Number 58-6000558 Authorized Agency Official: Signature Date Georgia A. Hiller, Esq., Chairwoman 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 32399-1738 Do not write below this line. For use by Bureau of Emergency Medical Services personnel only Grant Amount For State To Pay: $ Grant ID Code: Approved By: Signature of EMS Grant Officer Date State Fiscal Year: 2007- 2008 Oroanization Code E.O.. OCA Object Code 64-42-10-00-000 03 SF003 750000 Federal Tax ID: VF Grant Beginning Date: Grant Ending Date: DH Form 1767P,Rev.June 2002 ATTEST: Appmv+sd as to form & legal Suf olsiey DWIGHT E. BROCK, Clerk 4,m%, By: 9 AssAttorney t County Packet Page-1870-