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Backup Documents 02/25/2014 Item #16E 3 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIT 6 C 3 TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO J. C 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 Attomey Office. Route to Addressee(s) (List in routing order) Office Initials Date 1. 2. 3. County Attorney Office County Attorney Office 1,201V-4 4. BCC Office Board of County Commissioners v `V/ / 5. Minutes and Records Clerk of Court's Office c—PO 2/24(4 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 Artie Bay - Phone Number 252-3740 Contact/ Department Agenda Date Item was 2/25/13 ` Agenda Item Number 16E3 •J Approved by the BCC Type of Document Grant Application Number of Original 1 ( A)e Attached Documents Attached jc-' .y f a 1 PO number or account Must pick up no later number if document is than noon 2/27 to Fed to be recorded Ex by deadline. INSTRUCTIONS & CHECKLIST Initial the Yes column or mark"N/A"in the Not Applicable column,whichever is Yes N/A(Not appropriate. (Initiap Applicable) 1. Does the document require the chairman's original signature? ab 2. Does the document need to be sent to another agency for additional signatures? If yes, na ✓ 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 signed by the Chairman,with the exception of most letters,must be reviewed and signed ab by the Office of the County Attorney. 4. All handwritten strike-through and revisions have been initialed by the County Attorney's na 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 ab 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 ab signature and initials are required. 7. In most cases(some contracts are an exception),the original document and this routing slip ab 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 2/25/14 (enter date)and all (), changes made during the meeting have been incorporated in the attached document. The County Attorney's Office has reviewed the changes,if applicable. 9. Initials of attorney verifying that the attached document is the version approved by the BCC,all changes directed by the BCC have been made,and the document is ready for the agob.' Chairman's signature. I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revised 2.24.05;Revised 11/30/12 16E3 MEMORANDUM Date: February 25, 2014 To: Artie Bay, Supervisor EMS Operations From: Martha Vergara, Deputy Clerk Minutes & Records Department Re: EMS Matching Grant Application — Florida Department of Health Attached is the original referenced above, (Agenda Item #16E3) approved by the Board of County Commissioners on Tuesday, February 25, 2014. Please forward a fully executed copy when received to the Minutes and Records Department for the Board's Official Record. If you have any questions, please call me at 252-7240. Thank you. Attachment 16E3 EMS MATCHING GRANT APPLICATION FLORIDA DEPARTMENT OF HEALTH on 4 #. Emergency Medical Services Program HEALTH Complete all items un less 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: Tom Henning Position Title: Chairman 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:TomHenning @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: 239-252-3740 Fax Number: 239-252-3298 E-Mail Address:artiebay @colliergov.net DH FORM 1767[2013] 64J-1.015, F.A.C. 1 \�J 16E 3 4. Legal Status of Applicant Organization (Check only one response): (1) ❑ Private Not for Profit[Attach documentation-501 (3)©] (2) ❑ Private For Profit (3) El City/Municipality/TownNillage (4) ® County (5) El State (6) ❑ Other(specify): 5. Federal Tax ID Number(Nine Digit Number). VF 59-0000558 6. EMS License Number: 3670 Type: Transport [Non-transport ❑Both 7. Number of permitted vehicles by type: BLS; 34 ALS Transport; 10 ALS non-transport. 8. Type of Service(check one): ❑ Rescue; ❑ Fire; ® Third Service(County or City Government, nonfire); El Air ambulance; El Fixed wing; ❑ Rotowing; El 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 professional EMS education are not in this project.] Signature: Date: Print/Type: Name of Director FL Med. Lic. No. 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); D) 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). DH FORM 1767[2013] 2 16E 3 7 i 10). Justification Summary Problem Description CCEMS currently has one air ambulance (MedFlightl)that provides trauma transport to patients requiring advanced trauma transport services. MedFlight is located at Naples Municipal Airport, primarily as pre-hospital medevac care provider. MedFlightl covers over 2,000 square miles which makes up Collier County, in addition to mutual aid response to surrounding counties. MedFlightl is currently staffed for 24 hours, 365 days per year with two flight paramedics each day. MedFlightl responded to 300 calls for service in 2013. 90 percent of responses are on-scene calls, assisting ground units in transporting patients from rural areas to local and non-local area hospitals. MedFlightl has been providing services to Collier County for over 30 years. CCEMS enforces the use of aviation life support equipment on every flight that MedFlightl responds. Required aviation life support equipment includes a Nomex flight suit, leather boots, flotation vest and a helmet with a visor. CCEMS requires flight paramedics and pilots to wear helmets and visors during flight periods for hearing safety, protection from head injuries and possibility of a bird strike within the cockpit. Flight helmets have been in use since the early days of aviation. The most common cause of death in aircraft accidents is head injury and several studies show that helmets can provide significant protection. Protective flight helmets have been around for many years and their main purpose is to protect the head from blows and strikes. During early World War I, pilots and crew wore leather, rigid style helmets that did not offer much hearing protection, head movement and minimal crash protection. World War II brought a more robust helmet that had steel plates to provide better crash protection but following World War II helmet use was still not widely available. Accident statistics began to show that fewer head injuries were found when pilots and crew members were wearing helmets. The industry started to recognize that head protection was effective and necessary. Studies have been conducted to show the effectiveness of the helmet during helicopter accidents. Fatal injuries have been found to be 2.4 times more common among the unhelmeted of potentially survivable helicopter accidents than among helmet-wearing occupants. Unhelmeted occupants riding in the rear of the crashed aircraft are at an even higher risk of fatal head injury. Studies of accidents and equipment also show that helmets with visors have played a significant role in protecting helicopter pilots and other crewmembers from serious facial injuries. One study said that visors prevented injury or reduced the severity of injury in 25 percent of 459 Army helicopter accidents in which visor use was documented. Ideal weight of a helmet must be considered for safety and well-being of the flight crew. The ideal flight helmet should be lightweight and the center of gravity of the helmet-head combination should match that of the unhelmeted as closely as possible. A heavy or unbalanced helmet will rapidly cause fatigue or neck pain and could affect performance. r�^� 16E 3 Back and neck injuries from prolonged use of a heavy flight helmet are common in helicopter aircrew so choosing a lightweight helmet benefits the crew in the long term. The helmet should be as streamlined as possible to avoid entanglements within the cockpit. Apart from distributing force from impact a good helmet fulfills a variety of other functions. Helicopters are very noisy and typically have longer flight missions and demand a higher level of noise protection. Helmets with a built in headset can provide clear communication. Clear communication is essential for flight crew members to speak to patients, pilots and air traffic control. Present Situation Currently MedFlightl uses Gentex SPH-5 helmets which have been in service for approximately 15 years. The helmets were issued to the crews that were employed on the aircraft at that time, who have long since retired from the flight program. The helmets have been re-issued to new flight crew members that join the program and have been subjected to abuse with a varying degree of upkeep and maintenance throughout the last 15 years. The newest helmet was purchased 10 years ago. Numerous personnel have been wearing these helmets over the last 15 years. While pooling of helmets does occur in some organizations it is not recommended. Helmet stability may be an issue when helmets are shared and passed down from others. Organizations do not provide footwear to their workers and ask them so share. The same principal should apply with any item worn next to the skin. The current standard within CCEMS MedFlightl is to take available helmets and issue them to new flight paramedics then attempt to make adjustments to get the best fit and repair issues as they arise. CCEMS currently has a wide range of personnel in the program that vary in size and have been utilizing helmets that were not purchased for their fit and have been worn by many people over the last 15 years. Helmets that are not custom sized and adjusted properly can result in neck and back injuries as well as decrease effects of communications with patient and flight crew. The helmets have been repaired and refurbished 3-4 times by the manufacturer and are continually repaired and parts replaced by MedFlightl maintenance staff. The shells have been repainted and decaled multiple times and the integrity of the shell cannot be properly inspected. Additionally one of the safety features of the helmet incorporates Styrofoam which over the years has become compressed, deformed, cracked and has lost much of its integrity. An additional refurbishment of current helmets would most likely result in the same cost as direct replacement. Over the past year CCEMS MedFlightl has seen a marked increase in the number of helmet equipment failures during missions which are a significant safety hazard that can have a negative result in the delivery of quality patient care. Recently we have had two missions where the flight paramedic lost communications with the other crew member and pilot in flight. This could result in a safety hazard for the crew and the patient if pertinent information cannot be transmitted. MedFlightl crews have trouble hearing the ground crews and hospitals and have had to increase the radio volume due to C%) 16E3 malfunctions within the current helmet communication system. The upgraded helmets provide improved communication technology which allows a reduction in volume to 25%, provides better audio clarity and better comprehension of transmissions to ground crews, hospitals and dispatch. These helmet conditions are not optimal for the flight crew or patient communications. Aside from the degradation of the helmets from age and repeated use the weight of the current helmet is one of the heavier helmets offered in the flight industry. Since the time of purchase of the current helmets, many upgraded, lightweight and more streamlined models have become available. Improper fit, exposed pieces, decreased communications and heavy weight can result in a safety hazard and decrease in work of an injured flight paramedic. Proposed Solution CCEMS proposes to purchase 9 flight helmets and equip each of our flight paramedics with an upgraded, new and custom fit helmet. At least three back up helmets should be purchased in case of an emergency. The helmets are lighter than the current model helmets. The current Gentex SPH-5 helmet weighs approximately 1585 grams and the Alpha Eagle weighs 980 grams. The decrease in weight directly reduces neck strain, headaches and fatigue. The result is more crew comfort, increased efficiency on missions and decreased number of injuries. The newer helmets are of modern design with stronger, lighter material. The current helicopter helmets used by the flight crew are made of graphite and the upgraded helmets are made of carbon fibers. Graphite is used in pencil lead and breaks apart. Carbon fibers are stronger and do not break apart very easily. This difference explains why graphite works well in pencils and carbon fibers are used to make sports equipment, airplanes and the space shuttle. Our flight crews will be much better protected from a head injury during a crash with helmets made of materials that do not break apart easily. In addition, the design is less complex than the current model which will result in less failure and maintenance costs. The design has a more custom fit to each user which allows for better passive noise reduction than the current helmets. The custom fit and design of the Alpha Eagle helmet does not require the purchase of external active noise reduction equipment due to the design and noise reduction built in to the helmet. This equipment currently accounts for some of the equipment failure in our current helmets. The new helmets will also provide double visors to protect flight crew faces from sun, wind, rotor wash and protection during a possible bird strike. Equipping all flight crew personnel with the upgraded, lightweight helmet will allow better communications and less risk of injury. Over 85% of the Collier County EMS budget is utilized to cover personnel costs. The remaining 15% is utilized to cover operating costs and capital purchases to replace worn equipment. The budget is largely dependent (42%) on ambulance fee revenues. 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. In addition, unemployment and people's loss of health insurance and the economy in general contributes to revenue 16E 3 decline. As the revenues decrease, the offsetting funds must come from ad valorem taxes, which are already strained due to the demands on the infrastructure of the County. While Collier County is beginning to see some recovery in property values, funds are extremely scarce because every agency within the county is vying for funding to put a small dent in the replacements and projects that were not funded in the past due to annual budget cuts. As is the case with CCEMS, replacement of worn out ambulances and medical equipment is a major necessity. Consequently, funds are not available to provide our flight medics with helmets that will improve safety, comfort and communications. Consequences if Not Funded Should this grant not be funded CCEMS would continue to repair flight helmets despite the age of the equipment and the cost and time of maintenance requirements. However, without improved and enhance equipment the safety of the flight crews and the increased injury and malfunction of equipment will continue to rise. This can result in direct result of providing patient care and the safety of the crew. If helmets are not available for the flight crew this can result in MedFlightl not responding to a call for trauma transport services which can be a reduction in appropriate transport to the needed facility. CCEMS has one helicopter for trauma transport. CCEMS MedFlightl is our county's primary means for transporting patients to the Level 2 Trauma Center. 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. Time Frames Receive State Award Size, Purchase and Acquire helmets 30 days Distribution and size adjustment of helmets 14 days Project will be completed within 2 months Data Sources Alpha Eagle, Gentex SPH-5 and Confidential Aviation Hazard Report(CAHR) Attesting Statement- No other applications have been submitted for State grant funding for this project. 16E 3 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 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? DH FORM 1767[2013] 3 16E3 11) Outcome For Projects That Provide or Effect Direct Services to Emergency Victims: A) CCEMS MedFlightl currently has a Confidential Aviation Hazard Report(CAHR) system that allows any flight crew member, pilot or maintenance staff to submit a report on a potential hazard or problem. This report and the reporting procedures have been enhanced greatly in the last 6 months. Previous issues such as helmet malfunction were communicated within the flight hangar and problems were fixed via the maintenance department or flight crew and were not tracked. In the last month MedFlightl crew members have reported helmet malfunctions for various reasons from exposed wires, foam inserts falling out and communication failures with headsets (Dates 12/9, 12/16, 12/23). While CCEMS does not directly track"neck pain"complaints from flight crew members there have been complaints from the flight crews about discomfort. These malfunctions and complaints pose a concern about the flight crew member's level of risk and injury over their career spanning several years. The upgraded helmets provide a nape pad for comfort and stability. Our current helmets do not have this feature. The addition of this improved feature will decrease fatigue and neck pain. In the event of a helicopter crash the design of the upgraded helmets provides better shock absorption and improved fit so the helmet stays in place during the crash. This could prevent the possibility of concussion and severe head injuries. If there should be a crash, conscious flight crew members will be of better use to the patient than would an unconscious crew and by providing a headset to the patient communications between patient and crew will be enhanced. In addition, work related injuries can be reduced from neck and back strains. B) In the 12 months after the deployment of the new flight helmets, we would anticipate at least 95% reduction in helmet malfunctions and neck strain. We would also anticipate at least a 95% reduction in communication issues associated with noise and communication equipment failure. C) These expectations are based on the fact that with new equipment issues will arise and need to be worked through. When purchasing custom fit equipment adjustments to sizing may need to occur for a perfect fit. Communications systems may also need to be adjusted. D) The result of improved, upgraded and enhanced helmets will be tracked through quality review of the new product and the decrease in CAHR reports received for helmet malfunction. 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, safe, research based, cost effective, compassionate and professional, placing the best interest of patient care first-always. 116E 3 vi4 Skip Item 14 and go to Item 15, unless your project is research and evaluation and you have not 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. ALL APPLICANTS MUST COMPLETE ITEM 15. 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. 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[2013) 4 16E 3 4 15.) Statutory Considerations and Criteria A. Serves the requirements of the population upon which it will impact. The acquisition of the upgraded flight helmets will aid in a safety and well-being of the flight crew and enhanced communications with pilot, ground crews, and patient. This enhanced communication and noise reduction will allow the flight paramedic to provide quality patient care without distractions of hearing loss, cockpit noise and malfunctioning equipment. It will also provide direct communication with flight crew and ground crews for safety during landing procedures. 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 industry and local requirements for the safe transport of flight crew and patients. 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. The equipment requested meets local department requirements adopted by the county for safety of flight crew and adequate communications with crew, ground crews and patients. 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. The equipment requested will aid in communications between the flight paramedics providing care and the receiving hospital. The communication system will allow the flight crew member to transmit patient care reports to the receiving hospital to aid in timely care on arrival. E. Enable your organization to improve or expand the provision of: 1. EMS services on a county, multi county, or area wide basis. This equipment will allow communications of flight and ground crews within Collier County as well as the multiple other counties in which we provide mutual aid., while maintaining the safety of the flight crew. 2. Single EMS provider or coordinated methods of delivering services. Collier County EMS is the only licensed 911 transport provider in Collier County. MedFlightl is the only air ambulance transport provider within Collier County; however, the equipment will benefit all communications and patient care in the county. 3. Coordination of all EMS communication links,with police,fire,emergency vehicles,other related services. This equipment will aid in communication with flight crew members to air traffic control, dispatch center, ground EMS and fire crews, sheriffs office and out of county ground agencies. The upgraded helmets will provide better audio clarity and improved comprehension between crews. 16E3 3 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 Receive State Award 0 • Size Purchase and Acquire Helmets 0 1 Size and sitribute helmets 1 2 • • 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. Funds received for the county grant have been entirely committed to other necessary projects. DH FORM 1767[2013] 5 ( ) 16E 3 ` 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: $ 0.00 Right click on 0.00 then left click on "Update Field" to calculate 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: $ 0.00 Right click on 0.00 then left click on "Update Field"to calculate Total DH FORM 1767[2013] 6 16E3 Vehicles, equipment, and other Costs: List the price Justification: State why each of the items 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. 12 helmets @ $2015.20 each $24,182.40 Upgrade flight helmets for safety/communications TOTAL: $24,182.40 Right click on 0.00 then left click on "Update Field" to calculate Total State Amount (Check applicable program) Right click on 0.00 then left click on • Matching: 75 Percent U date Field"to calculate Total $18,136.80 p Right click on 0.00 then left click on ❑ Rural: 90 Percent $0.00 "Update Field" to calculate Total Local Match Amount (Check applicable program) Right click on 0.00 then left click on • Matching: 25 Percent U date Field"to calculate Total $6,045.60 p Right click on 0.00 then left click on ❑ Rural: 10 Percent $ 0.00 "Update Field" to calculate Total Grand Total $24,182.40 Right click on 0.00 then left click on DH FORM 1767[2013] 7 7.J 16E 3 19. Certification: My 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. I, 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. cceptance 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. a '5 Signature of Authoriz- - ant Signer MM / DD /YY (Individual Identifi-An Item 2) DH FORM 1767[2013] 8 THE TOP PART OF THE FOLLOWING PAGE MUST ALSO BE COMPLETED AND SIGNED. AT TEgr: Approved as to form and legality D GHt . 9i:#. .I I - AL " ►,.... Assistant County Attd&ne freSt as t0 Ufa nan lj slgn e� ;' - '7" 16E 3 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 Commissioners - EMS Mailing Address: Finance Department • P. O. Box 413016 Naples, FL 34101-3016 Federal Identification Number 59-6000/.58 Authorized Agency Official: , _ c l 5 )14 Signature 40 Date Tom Henning, Chairman Type Name and Title Sign and return this page with your application to: Florida Department of Health EMS Program Grants 4052 Bald Cypress Way, A-22 Tallahassee, Florida 32399-1722 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 State EMS Grant Officer Date State Fiscal Year: 2013 - 2014 Organization Code E.O.. OCA Object Code 64-61-70-30-000 03 SF003 750000 Federal Tax ID: VF Grant Beginning Date: Grant Ending Date: DH FORM.17C{rp jzQy h,7,4.,.' 7,� ATTEST: fir Approved as to form and legality DIN T E. BROCK:6t■rk VI 8y:: = -. '+��` . ' Assistant County omey Attests to Chairs an's 'j . cinnatura nntu \`