Backup Documents 09/28/2021 Item #16E 5 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 1 6 E
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO
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 Attorn ffice no later
than Monday preceding the Board meeting. ^ter
**NEW** ROUTING SLIP (.1
r-t
Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document is already complet8 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 Attomeyt Office.
Route to Addressee(s) (List in routing order) Office Initials Date
1. County Attorney Office County Attorney Office
2ou8 9i21
2. BCC Office Board of County c b - tz
Commissioners J 1 Q. a1
3. Minutes and Records Clerk of Court's Office
1 -1 l0:0+c
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 Cook,Accounting Supervisor Contact Information 239-252-3756
Contact/Department EMS
Agenda Date Item was September 28,2021 Agenda Item Number
Approved by the BCC
Type of Document Grant Application,Grant Fund Distribution, Number of Original 3
Attached Resolution Documents Attached
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 STAMP OK li_
2. Does the document need to be sent to another agency for additiona u - . If yes, EC
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 EC
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 EC
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 EC
document or the final negotiated contract date whichever is applicable.
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's EC
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip EC
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 09/28/2021 and all changes made during EC 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. this line.
9. Initials of attorney verifying that the attached document is the version approved by the N/A is not
BCC,all changes directed by the BCC have been made,and the document is ready for the 5coaan option for
Chairman's signature. this line.
16E 5
RESOLUTION NO. 2021 - 199
A 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, IT RESOLVED BY THE BOARD OF COUNTY
COMMISSIONERS OF COLLIER COUNTY, FLORIDA, that:
The $66,374.00 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.
THIS RESOLUTION PASSED AND DULY ADOPTED by the Board of County
Commissioners of Collier County, Florida, this 28`h day of September, 2021.
ATTEST: BOARD OF COUNTY COMMISSIONERS,
CRYSTAL K KINZEL, CLERK COLLIE COUNTY, FLORIDA
•
BY: BY: L.34
Atteit to Chairtic iA pu PENN" AYLc1A1RAN
signature only.
Approved as to form and
legality:
Jennifer . Belpedio
Assistant County Attorney
16E 5
EMS COUNTY GRANT APPLICATION
FLORIDA DEPARTMENT OF HEALTH
Emergency Medical Services Program
HEALTH Complete all items
li ID. Code (The State EMS Program will assign the ID Code—leave this blank)
1. County Name: Collier
Business Address: 3299 Tamiami Trail East Suite, 700
Naples, FL 34112-5747
Telephone: 239-252-3 740
Federal Tax ID Number(Nine Digit Number): VF 59-6000558
2. Certification: (The a plic ignatory who has authority to sign contracts, grants, and other legal
documents for the coun ify that all inforwrTfibn and data in this EMS county grant application and
its attachments are tru d correct. y sigp ature acknowledges and assures that the county shall
comply fully with the ed in the Florida EMS County Grant Application.
Signature: • Date:
Printed Name: Penny ylor
Position Title: Chairman
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 Cook
Position Title: Accounting Supervisor
Address: 8075 Lely Cultural Parkway Suite 267
Naples, FL 34113
Telephone: 239-252-3756 Fax Number: 239-252-3298
Email Address: Erin.Cook@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
Ap roved as to form and legality ATTEST�` C ,STAL K. ZEL,CLERK
'-
As stunt County Attorn BY: "C:4
Attest as to airman..
signature only.
16E 5
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 $5,000.00
Tuition for Paramedic School $50,000.00
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 $11,374.00
Total Vehicles & Equipment= $ 11,374.00
Grand Total = $ 66,374.00
DH 1684, December 2008
2
CAO
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 county name, address, and corresponding federal ID number must be in the state MyFloridaMarketPlace
(MFMP) system. A finance person in your organization who does business with the state must provide these.
Name of County: Collier County Board Of County Commissioners
Mailing Address: 3299 Tamiami Trail East, Suite 700
Naples, FL 3 11 47
Federal 9-digit Identification nu 5 -6 005 3-digit seq. code
Authorized County Official: • (1)4 .1
Signature Date
Penny Taylor, 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:
Approved By:
Signature of State EMS Unit Supervisor Date
Approved By:
Signature of Contract Manager Date
State Fiscal Year: 2021 - 2022
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
C AL K.K1 ,C1_,E.R1( CAO
BY: As County Att a,0��"
. CS\
to t►ire only.