Backup Documents 12/01/2009 Item #16F1
ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 16- F 1
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach to original document. Original documents should be hand delivered to the Board Office fhe completed routing slip and original
documents are to be forwarded to the Board Office onlv l!.~!: the Board ha'i taken action on the item.)
ROUTING SLIP
Complete routing lines #1 through #4 as appropriate for additional signatures, dates, and/or infonnation needed. If the document is already complete with the
exceDtion ofthc Chairman's siWlature, draw . line throulid routine: lines # 1 throuJdJ #4, comnlete the checklist, and forward to Sue Filson line #5)
Route to Addressee(s) Office Initials Date
(List in routin. order)
I.
2.
3.
4.
:t:"-A0 mere tl € LL.
5. 8lie filsan, Executive Manager Board of County Commissioners i./\..- 17...(bl!O'j
6. Minutes and Records Clerk of Court's Office
PRIMARY CONTACT INFORMATION
(The primary contact is the holder of the original document pending Bee approval. Normally the primary contact is the person who created/prepared the executive
summary. Primary contact information is needed in the event one of the addressees above, including Sue Filson, need to contact staff for additional or missing
infonnation. All original documents needing the BCC Chairman's signature are to be delivered to the sec office only after the BCC has acted to approve the
item.)
Name of Primary Staff Artie Bay Phone Number 252-3740
Contact
Agenda Date Item was December ], 2009 Agenda Item Number 16FI
Aooroved bv the BCC
Type of Document Grant Application, Disbursement Form and Number of Original I-MinUleS&_-P11
Attached Resolution Documents Attached return original- 'IriII plot up
I.
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark "N/ A" in the Not Applicable column, whichever is
a ro riate.
Original document has been signed/initialed for legal sufficiency. (All documents to be
signed by the Chairman, with the exception of most letters, must be reviewed and signed
by the Office of the County Attorney. This includes signature pages from ordinances,
resolutions, etc. signed by the County Attorney's Ollice and signature pages from
contracts, agreements, etc. that have been fully executed by all parties except the BCC
Chairman and Clerk to the Board and ossibl State Ollicials.
All handwritten strike-through and revisions have been initialed by the County Attorney's
Office and all other arties exce the BCe Chairman and the Clerk to the Board
The Chairman's signature line date has been entered as the date ofBCC approval of the
document or the final ne otiated contract date whichever is a licable.
"Sign here" tabs are placed on the appropriate pages indicating where the Chairman's
si lure and initials are uired.
In most cases (some contracts are an exception), the original document and this routing slip
should be provided to Sue Filson in the Bec office within 24 hours ofBCe approval.
Some documents are time sensitive and require forwarding to Tallahassee within a certain
time frame or the BCe's actions are nullified. Be aware of our deadlines!
Tbe document wa' approved by the BCC on _12/1/09 _(enter date) and all
cbang.. made during the meeting have been incorporated in the attached document,
The Coun Attorne', OffICe bas reviewed tbe cban eo, if a licable.
Ce_
.",
'.--{,..--
,_. ,~
I: Forms.! County Fonnsl Bee Forms.! Original Documents Routing Slip WWS Original 9.03,04. Re\'ised 1.26.05, Revised 2.24.05
2.
3.
4.
5.
6.
16F 1
MEMORANDUM
Date:
December 2, 2009
To:
Artie Bay
EMS, Operations Analyst
From:
Martha Vergara, Deputy Clerk
Minutes & Records Department
Re:
Grant Application, Disbursement Form and Resolution
Attached please find one (1) original of each document referenced above, (Agenda
Item #16Fl) approved by the Collier County Board of County Commissioners on
Tuesday, December 1, 2009.
If you have any questions, please call me at 252-7240.
Thank you.
16F 1
. RESOLUTION NO. 2009 - ?82
RESOLUTION OF THE BOARD OF COUNTY
COMMISSIONERS OF COLLIER COUNTY, FLORIDA,
CERTIFYING THAT THE APPLICATION FOR AND USE
OF EMS COUNTY GRANT FUNDS WILL IMPROVE AND
EXPAND PRE-HOSPITAL EMS DEPARTMENT
ACTIVITIES AND WILL NOT SUPPLANT EXISTING
COUNTY EMS BUDGET ALLOCATIONS.
WHEREAS, EMS Department Paramedics and Paramedic/Firefighters provide
basic and advanced life support care and highly technical service to the citizens and
visitors of Collier County; and
WHEREAS, the purchase of medical rescue supplies, medical equipment and
provision of training will greatly enhance the effectiveness of pre-hospital emergency
medical care.
NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF COUNTY
COMMISSIONERS OF COLLIER COUNTY, FLORIDA, that:
The $119,847 in the EMS County Grant will be used to fund the medicallrescue
supplies, medical equipment and training and these funds will not be used to supplant
existing EMS Department budget allocations.
PASSED AND DULY ADOPTED by the Board of County Commissioners of Collier
County, Florida, this 1"51- day of ~C(' n,IJev ,2009.
ATTEST:
DWIGHT E. BROCK, CLERK
_~~.u: RK
.1~ ..- .
Approval. ! fqr' form and legal
Sufficiency:
By:
BOARD OF COUNTY COMMISSIONERS
OF COLLlEffOUNTY, FLO~IDA
If/. ,;- "
^f~.- ~/ <t~
,
DONNA FIALA, CHAIRMAN
~e)~~
Jennife . White
Assistant County Attorney
Item# lto F I
Agenda 'I")' I L 0'<\'\
Date ~
Date 12-/1.-{ O~
Rec'd
16F 1
EMS COUNTY GRANT ApPLlCA TION
RomDADEPARTMENTOFHEALTH
Bureau of Emergency Medical Services
Complete aI/items
10. Code IThe State Bureau of EMS will assign thelD Code - leave this blank) C
1. Countv Name: c..., Cou,ty
Business Address:3301 Tamlami Trail East
Naplea,Fl34112
Teleohone: ""252.37<0
Federal Tax 10 Number (Nine Digit Number). VF 59-6000558
2. Certification: (The applicant SlgiWho has authority to sign contracts, grants, and other legal
documents for the county) I certify that formation and data in this EMS county grant application and
its attachments are true and correct.' ignature acknowledOes and assures that the County shall
comply fully with the conditions outl~ . the Florida EM~ 'fl!unty ~ant Application. ) I, )/
Sionature: "rft~'~r'..., '>' / d .~. Date: I:) I re;
Printed Name: 000'. F~~ . I
Position Title: Chairmen
3. Contact Person: (The individual with direct knowledge of the project on a day-to-day besis and has
responsibility for the implementation of the grant activities. This person is authorized to sign project
reports and may request project changes. The signer and the contact person may be the same.)
Name: J.nPllll
Position Title: CO.f
Address: 6075llllyClIInPkwv
Su~. 2e7
Naplft,FL 34113
T elenhnnA: 239-262-3740 I Fax Number: 239.252.32911
E-mail Address: jB"_~""",,,
4. Resolution: Attach a current resolution from the Board of County Commissioners certifying the grant
funds will improve and expand the county pre-hospital EMS system and will not be used to supplant
current levels of county expenditures.
5. Budget: Complete a budget page(s) for each organization to which you shall provide funds.
List the organization(s) below. (Use additional pages if necessary)
Medical Equipment/Supplies $30,000
Training 5,000
Medical/Rescue Equipment 84,847
DH Form 1684 Rey. J"ne 2002
3
2\pp(ova~;,':.~ ., ~ t~{rn '"~ j.;q~'.ti 6pmcl~"
OllputyCferk
AttetC ... te .
"~t... .,,
" ~~~~
n.~W_,"_.nn " n .....
Sf..NNI Ft:c. 6. W.J.J/Tc...
.
1.6F 1
BUDGET PAGE
A Salarle. and Benefits.
For each position title, provide the amount of salary per hour, FICA per
hour, other fringe benefits, and the total number of hours, Amount
TOTAL Salaries
TOTAL FICA .
Grand total Salaries and FICA
B. Expenses: These are travel costs and the usual, ordinary, and incidental expenditures by an
agency, such as, commod~ies and supplies of a consumable nature excludina expenditures classified
as oMratina caDital ouUav (see next catecorvl,
List the Item and, If applicable, the quantity Amount
Medical EquipmenVSupplles 30,000
Training 5,000
TOTAL $ 35,000
C. Vehicles, equipment, and other operating capital outlay means equipment, fixtures, and other
tangible personal property of a nan consumable and non expendable nature w~h a normal expected life
of one (1) vear or more,
List the Item and, If applicable, the quantity Amount
Medical/Rescue Equipment 84,847
TOTAL $ 84.847
Grand Totel $ 119,847
DH Fonn 1684, Rev, June 2002
4
16F 1
FLORIDA DEPARTMENT OF HEALTH
EMS GRANT PROGRAM
BEQUEST FOR GRANT FUND DISTRIBUTION
In accordance with the provisions of Section 401.113(2)(a), F. S., the undersigned hereby
requests an EMS grant fund distribution for the improvement and expansion of pre-hosp~al
EMS.
DOH Remit Pavment To: Collier County Board of County Commissioners
Name of Agency:
Mailing Address: 3301 Tamiami Trail East
Naples, FL 34112
Federal Identification number Fep/? 59-6000558 I
, , n /t )r'<)
1 f.l '>./f ,,, .'
Authorized Official: . J. " , t':", '"Z>-"}- '~, o~' ~dt
Sign'sture Date
Donna Fiala, Chairman
Type Name and TRia
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 Emergencv Medical Service. personnel only
Grant Amount For State To Pay: $ Grant 10: Code:
Approved By
Signature of EMS Grant Officer Date
State Fiscal Year: -
Oraanlzation Code E&. Ql;A Obiect Code
64-25-60-00-000 N - N2000 7
Federal Tax 10: VF ---------
Grant Beginning Date: October 1, Grant Ending Date: September 30,
A,It:3f': .
o T E. B~QCK. CLERK
~~. . . OeputyClerk' /~
.'ut. tAt Olt
.tFIh... M.,
DH Form 1767P, Rev. June 2002
.,.ppr~"R'l ,,, '. '~ .
-, ,< ':<', ." lu(r:.l'{ 11.'{' -ti '~li'~f:"'l" l' .
. '.. ."1 '.. ". r . " , . ," ~;.,
5
\\ -12.. ".) ~ ~
.~.... \ L~.J ~,,",-, ..<<-
\:_~':,::":~" _..,~t"t:' ,- ;'!'
I