Backup Documents 09/24/2019 Item #16E10 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 1 6 E 1 0
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the County Attorney Office
at the time the item is placed on the agenda. All completed routing slips and original documents must be received in the County Attorney Office no later
than Monday preceding the Board meeting.
**NEW** ROUTING SLIP
Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document is already complete with the
exception of the Chairman's signature,draw a line through routing lines#1 through#2,complete the checklist,and forward to the County Attorney Office.
Route to Addressee(s) (List in routing order) Office Initials Date
1. County Attorney Office County Attorney Office to i aa\\
2. BCC Office Board of Countyw\
Commissioners
3. Minutes and Records Clerk of Court's Office
1t:
PRIMARY CONTACT INFORMATION
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,may need to contact staff for additional or missing information.
Name of Primary Staff Erin Page,Accounting Supervisor Contact Information 239-252-3756
Contact/Department Administrative Service Department
Agenda Date Item was September 24,2019 Agenda Item Number 16.E.10
Approved by the BCC
Type of Document EMS County Grant Application,Request Number of Original 3
Attached for Grant Fund Distribution Form and Documents Attached
Resolution. o2Qtq"'
PO number or account "[
number if document is
to be recorded
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark"N/A"in the Not Applicable column,whichever is Yes N/A(Not
appropriate. (Initial) Applicable)
1. Does the document require the chairman's original signa .e STAMP OK EGP
2. Does the document need to be sent to another agency for as 'nal signature . If yes, EGP
provide the Contact Information(Name;Agency;Address;Phone)on an attached sheet.
3. Original document has been signed/initialed for legal sufficiency. (All documents to be EGP
signed by the Chairman,with the exception of most letters,must be reviewed and signed
by the Office of the County Attorney.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's EGP
Office and all other parties except the BCC Chairman and the Clerk to the Board
5. The Chairman's signature line date has been entered as the date of BCC approval of the EGP
document or the fmal negotiated contract date whichever is applicable.
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's EGP
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip EGP
should be provided to the County Attorney Office at the time the item is input into SIRE.
Some documents are time sensitive and require forwarding to Tallahassee within a certain
time frame or the BCC's actions are nullified. Be aware of your deadlines! _
8. The document was approved by the BCC on 09/24/2019 and all changes made during EGP N/A is not
the meeting have been incorporated in the attached document. The County an option for
Attorney's Office has reviewed the changes,if applicable. is line.
9. Initials of attorney verifying that the attached document is the version approved by the /A is not
BCC,all changes directed by the BCC have been made,and the document is ready for th- .n option for
:
Chairman's signature. : this line.
16E10
MEMORANDUM
Date: October 23, 2019
To: Erin Page, Accounting Supervisor
Emergency Services
From: Teresa Cannon, Sr. Deputy Clerk
Minutes & Records Department
Re: Resolution 2019-174: EMS County Grant Application and Request
for Grant Fund Distribution Form
Attached are two (2) original forms and one (1) Certified Resolution as referenced
above, (Item #16E10) as approved by the Board of County Commissioners on
Tuesday, September 24, 2019.
The Board's Minutes & Records Department has kept the original as part of the
Board's Official Records.
If you have any questions, please contact me at 239-252-8411.
Thank you.
Attachment
16E10
RESOLUTION NO. 2019 - 1 7 4
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 equipment and provision of training shall 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 $63,560.00 in the EMS County Grant will be used to provide training and
purchase medical/rescue equipment 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 Q(-1 day of -c 62.., 2019.
ATTEST: BOARD OF COUNTY COMMISSIONERS,
CRYSTAL K KINZEL, CLERK COLLI • COUNTY, FLORIDA
tilt a5 Clerk ,' illiam L. McDaniel, Jr., Chairman
signature only,
Approved as to form and
legality: Item# Li2E19
Agenda q ��lil .n
Date .--�`-r-u
Je er A. Belpedio11-' p Date �O al leiAssistant County Attor' - � Rec,s
4
[19-EMS-00947/1494617/1]
;iGi ity Clerk
16E1 -
FLORIDA DEPARTMENT OF HEALTH
EMERGENCY MEDICAL SERVICES(EMS) GRANT UNIT
REQUEST FOR GRANT FUND DISTRIBUTION
In accordance with the provisions of section 401.113(2) (a), Florida Statutes, the undersigned hereby requests
an EMS grant fund distribution for the improvement and expansion of pre-hospital EMS.
DOH Remit Payment To:
The agency name, address, and federal ID number must be in the state MyFloridaMarketPlace (MFMP)
system. Ask a finance person in your organization who does business with the state to provide these.
Name of Agency: Collier County Board of County Commissioners
Mailing Address: 3299 Tamiami Trail East,Suite 700
Naples, FL 34112-5747
Federal 9-digit Identification -u •b-r R 158 3-digit seq. code
Authorized County Official: '.
Si:. ature Date
William L. McDaniel,Jr., Chairman
Type or Print Name and Title
Sign and return this page with your application to:
Florida Department of Health
Emergency Medical Services Unit, Grants
4052 Bald Cypress Way, Bin A-22
Tallahassee, Florida 32399-1722
• Do not write below this line. For use by State Emergency Medical Services Section
Grant Amount for State to Pay: $ Grant ID: Code: C80 _
Approved By:
Signature of State EMS Unit Supervisor Date
Approved By: _
Signature of Contract Manager Date
State Fiscal Year: 2019 - 2020
Organization Code E.O. OCA Object Code Category
64-61-70-30-000 05 SF005 751000 059998
Federal Tax ID:VF Seq. Code:
Grant Beginning Date: Grant Ending Date:
DH 1767P, December 2008(rev. June 8,2018), incorporated by reference in F.A.C.64J-1.015
ATTEST: 3 Approved as to form and legality
CRY L. K. KI ' -L, CLERK
� G4.
Deputy ClerkA J1ant County Attpn
Attest as to Chairman's —_
Sinnattira emit/
1 6 E 1 0
EMS COUNTY GRANT APPLICATION
rn ,_ 4..� FLORIDA DEPARTMENT OF HEALTH
hat 1 a ci Emergency Medical Services Program
HEALTH Complete all items
ID. Code(The State EMS Program will assign the ID Code—leave this blank) C80
1. County Name: Collier
Business Address: 3299 Tamiami Trail East, Suite 700
Naples, FL 34112-5747
Telephone: 239-252-3740
Federal Tax ID Number(Nine Digit Number): VF 59-6000558
2. Certification: (The applicant : • who has authority to sign contracts, grants, and other legal
documents for the county) I _ert' it all infoo mat on and data in this EMS county grant application and
its attachments are tr - -•d . signature'acknowledgesd assures that the county shall
comply fully with the • '. s ou/lb. th Florida EMS 'ty grant Application.
Signature: �i�Jp Date: c\`"Ly�\ck,
Printed Name: illiam L.Mc aniel,Jr.
Position Title: hairman
3. Contact Person: (The individual with direct knowledge of the project on a day-to-day basis 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: Erin Page
Position Title: Accounting Supervisor
Address: 8075 Lely Cultural Pkwy,Naples, FL 34113
Telephone: 239-252-3756 Fax Number: 239-252-3298
E-mail Address: Erin.page@colliercountyfl.gov
4. Resolution: Attach a 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. We cannot process for funds without this resolution.
5. Organization List: Complete a budget page(s)for each organization, which at your option you will .
provide funds. List the organization(s) below. (Use additional pages if necessary)
Collier County Emergency Medical Services
DH 1684, December 2008(Rev.July 2018) 64J-1.015, F.A.C.
1
ATTEST:
Al K. KI Li., CLEH Approved as to form and legality
\�
�..a't,as tQ"t"half/get Clerk
s '
k L`
nature only. Assistant County Ata nc c6--N.
16E10
BUDGET PAGE
A. Salaries 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 = $ 0.00
TOTAL FICA& Other Benefits=
Total Salaries & Benefits= $ 0.00
B. Expenses: These are travel costs and the usual, ordinary, and incidental expenditures by an
agency, such as, commodities and supplies of a consumable nature excluding expenditures classified as
operating capital outlay (see next category).
List the item and, if applicable,the quantity Amount
Training 5,000
Tuition for Paramedic School 50,000
1
Total Expenses = $ 55,000.00
}
C. Vehicles,equipment, and other operating capital outlay means equipment, fixtures, and other
tangible personal property of a non-consumable and non-expendable nature with a normal expected life
of one(1)year or more,
List the item and, if applicable,the quantity Amount
{
Medical/Rescue Equipment 8,560.00
Total Vehicles & Equipment= $ 8,560.00
Grand Total= $ 63,560.00
DH 1684, December 2008
2