Loading...
Backup Documents 02/25/2014 Item #16E 6 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIj 6 E 6 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 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. 2. 3. County Attorney Office County Attorney Office (�, ZvyO\\`‘k 4. BCC Office Board of County L Commissioners �LS/ 2\2s‘'k 5. Minutes and Records Clerk of Court's Office -Va\ 2(25(14 C`' 23 PRIMARY CONTACT INFORMATION 1 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 CGSL.9...._- Agenda Date Item was 2/25/13 Agenda Item Number 16E6 Approved by the BCC Type of Document Grant Application Number of Original 1 `I,j ee,c4 Attached Documents Attached 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. (Initial), Applicable) 1. Does the document require the chairman's original signature? ab 1/ 2. Does the document need to be sent to another agency for additional signatures? If yes, na V 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. v 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 t q e 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 16E6 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 #16E6) 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 16E 6 004 EMS MATCHING GRANT APPLICATION FLORIDA DEPARTMENT OF HEALTH on • F•. Emergency Medical Services Program HEALTH 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: 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: 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 16E 6 4. Legal Status of Applicant Organization (Check only one response): (1) ❑ Private Not for Profit[Attach documentation-501 (3)©] (2) ❑ Private For Profit (3) ❑ City/Municipality/TownNillage (4) ® County (5) ❑ State (6) ❑ Other(specify): 5. Federal Tax ID Number(Nine Digit Number). VF 59-6000558 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; El Fire; ® Third Service(County or City Government, nonfire); ❑ Air ambulance; ❑ Fixed wing; ❑ Rotowing; ❑ 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 6 III 10).Justification Summary Problem Description It is an established fact that acts of mass violence can take place just about anywhere and often times with very little warning. Over the last forty-six years the incidence of these types of events has been steadily increasing not only in frequency but in the level of violence as well. The analysis of incidents,' dating back to 1982 to the most recent events, point to the indisputable need for a faster and more aggressive response by the first responders community. The need for an immediate and timely response has held true not only for the law enforcement community, but for pre-hospital medical providers as well. It is safe to argue that although the Columbine High School shooting wasn't the first one of its kind, it can be considered the tipping point for many disciplines, especially law enforcement agencies across the country, forcing them to take a closer look at their response procedures and equipment's capability. Consequently, the pre-hospital medical community has been forced to reconsider its response model as well as the most effective tools to improve the victim's odds of survival. In fact, during a recent active shooter event in a local hospital (leaving one dead and one injured), the lack of a cohesive plan, suitable medical equipment and response procedures were amongst the core issues addressed in the After Action Report(AAR) and Incident Action Plan (IAP). (Physician Regional Pine Ridge, 2011)2 Today, the most significant lingering issue remains the equipment and tools presently available to Collier County EMS (CCEMS) and allied agencies; this equipment was designed with conventional medical emergencies in mind and not that of an Active shooter event. The inefficacy and impracticality of the equipment compound the lack of standard inventory throughout the agencies significantly hinders our ability to adequately respond to such acts of mass violence, further decreasing the odds of survival of the victims and perhaps even augmenting the risk level on the lives of the first responders. Present Situation CCEMS with input from the Collier County Sheriffs Office took the initiative and developed a response plan that received the support of the First Responders community in Collier County. The response plan incorporated several elements from the now popularly known Rescue Task Force program developed in Arlington, VA. The response plan adopted by CCEMS and allied agencies addresses the need for a standard level of training and response plan not previously existing. After the inception of the ASI training, all local agencies share now a standard response plan. The inception of simplified procedures has paved the way and facilitated the smooth integration of law enforcement elements with time sensitive emergency medical resources, promoting the far forward deployment of stabilizing medical forces to assist in the treatment and evacuation of the wounded. S 16E 6 Collier County has taken steps to improve the level of training of the law enforcement community and taught several courses on basic principles of Self Aid/Buddy Aid to the Collier County Sheriffs Office(CCSO). This training has placed on the hands of law enforcement officers the knowledge and skills to save a life should they ever face such situation. Currently, individual agencies are responsible for outfitting their field personnel with the medical equipment inventory carried in to a conventional emergency medical call. These inventories are up to each agency's financial resources; leading at times to a less than desirable situation as not every geographical area receives the same level of response. This issue becomes further acute when analyzing the list of resources allocated by each individual agency for ASI response if any at all; presently, no single agency has been able to put together an adequate Active Shooter Response kit that meet the specifics needs of an Active Shooter Response. 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 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 still a major concern. This has been the experience of not only CCEMS, but the county fire districts and the independent districts as well. This impedes all of our efforts to fund this very worthwhile project. The incidents of active shooters are too frequent and too real. The only unknown is where and when and it is the goal of all county agencies collectively to prepare for responding to such an incident. Although an Active Shooter Response kit inventory has been agreed upon, the lack of financial resources prevents us achieving a uniformed countywide response. The ability to deliver the same level of care countywide remains our priority. Proposed Solution In order to complement the training and response procedures adopted by local law enforcement and pre-hospital agencies in Collier County, CCEMS proposes the procurement of Active Shooter Response kits to be placed strategically in quick response vehicles (QRVs). The deliberate allocation of these kits would ensure an even distribution throughout Collier County and a significant improvement to the readiness level currently in place. The committee tasked with the (53 16E6 development of the response plan worked diligently to devise a response kit that would meet the needs of the community, all while remaining fiscally responsible. The kits as designed to address the leading causes of preventable death in the aftermath of an active shooter event such as external hemorrhage from a Tourniquet amenable site, Sucking Chest Wounds and Airway complications. Furthermore each kit would facilitate the expeditious deployment of life saving equipment for 11 to 15 seriously injured patients each. Consequences if Not Funded Should this grant not be funded CCEMS and its allied agencies will continue to prepare to the best of their capabilities to respond to acts of mass violence in spite of the inadequacy and limitations of their resources. However, without a standard inventory our ability to respond in a safe and efficient fashion significantly diminishes, and so too, the odds of survival of the victims. Geographic Area CCEMS is the sole provider of emergency medical transport services in Collier County, Florida and is supported by 9 independent fire districts which provide a combination of Basic Life Support(BLS) and Advance Life Support(ALS). Collier County 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 and miles of beaches attract a multitude of visitors each day, swelling the population to nearly 400,000 during peak season.' Time Frames Receive State Award Purchase and acquire ASI Kit 30 days Distribution of equipment 7 days Refresher Training 15 days Data Sources ' More Guns, More Mass Shootings-Coincidence? By Mark Fullman, Published on Mother Jones, Dec.15, 2012 2 After Action Report(AAR) and Incident Action Plan (IAP). (Physician Regional Pine Ridge, 2011) 'Collier County Comprehensive Planning (population and demographics) Attesting Statement - No other applications have been submitted for State grant funding for this project. I 16E6 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 16E6 11). Outcome for Projects That Provide or Effect Direct Services to Emergency Victims A. Thankfully Active shooter events are not an everyday occurrence and one that as a first responder's community we hope we never get to experience; however despite our best hopes their likelihood and incidence is one we cannot ignore. As this document is being prepared, yet another school shooting has occurred. Active shooter events are"just one call away" and because of their intrinsic characteristics very little data is available in how to prevent them; the only option left for us is to prepare our agencies to mitigate to the best of our abilities these types of events. Taking in consideration the ever increasing incidence of Active shooter events it is safe to assume that it is a matter of"when" one would occur and not"if". B. In the 12 months after the deployment of the Active Shooter Medical kits and the tactical/medical training already completed by our first responders community Collier County will have a countywide uniformed response process in place that will allow us to respond effectively to an Active shooter event. C. As it has already been established, forecasting the number of mass violence incidents that could possibly take place in our area is unrealistic. However, our anticipation for a potential event is founded in the ever increasing number of these events and the unpredictability of the venue. D. Another outcome for this project would be the ability to equip our first responders with the most appropriate tools available to implement and execute the training they have already received. Collier County has taken a countywide approach to the training and preparation of all essential personnel potentially responding to an Active shooter event. The weak link at this time remains the lack of uniformed equipment inventory, hence the disparity in response capabilities as a countywide system. All 9 independent fire districts in coordination with CCEMS have adopted and completed the Rescue Task Force curriculum developed by Arlington Fire Department in Virginia. 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. W.) 16E 6 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 6 15. Statutory Considerations and Criteria A. Serves the requirements of the population upon which it will impact. The acquisition of Active Shooter Medical kits will complement the training already completed by our first responder community to deliver in a timely manner, life saving interventions to casualties of an active shooter event. An adequate training curriculum combined with the right tools has been proven to increase the victim's odds of survival. 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 meets the local requirements adopted by the county agencies for the timely delivery of critical life saving interventions in the aftermath of an active shooter event. 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 department and countywide regulations the Active Shooter Medical kits meet all the requirements for equipment and treatment of patients. D. Enables the vehicles in your organization to have, at a minimum, a direct communications linkup with the operating base and hospitals 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 directly the population and visitors of Collier County at a countywide level and mutual aid surrounding counties. 2. Single EMS provider or coordinated methods of delivering services. Collier County EMS is the only licensed 911 Transport provider in Collier County; however the equipment allocation will ensure an equal distribution of resources thus enhancing the level service delivered. 3. Coordination of all EMS communication links,with police,fire, emergency vehicles, and other related services. N/A 16E 6 1 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 U Purchase and Acquire AKI Kits 1 Distribute Kits 1 1 Provide Refresher Training 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 under the state county grant program have been committed entirely for other necessary projects. DH FORM 176712013] 5 CA( 16E 6 4 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 16 6 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. 84 ASI Kits @ 506.81 ea $42,572.04 To provide ASI Kits countywide TOTAL: $42,572.04 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 p date Field"to calculate Total $31,929.03 ❑ Rural: 90 Percent Right click on 0.00 then left click on $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 "Update Field"to calculate Total $10,643.01 ❑ Rural: 10 Percent Right click on 0.00 then left click on $ 0.00 "Update Field"to calculate Total Grand Total Right click on 0.00 then left click on $42,572.04 DH FORM 1767[2013] 7 16E 6 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. A cceptance of Terms and Conditions: If awarded a grant, I certify that I will comply with all of the above and also accept the a tached grant terms and conditions and acknowledge this by signing below. a� ►.,� F -5 Signature of Authorized ia:nt Signer MM / DD/YY (Individual Identified in em 2) DH FORM 1767[2013] 8 THE TOP PART OF THE FOLLOWING PAGE MUST ALSO BE COMPLETED AND SIGNED. • A`T'rEs1 .. Approved as to form and legality DWIGHT E. - : •Cc Clerk • jaa AsInt County Att A n19 ttest as toChatrm. signature nnly 16E6 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 59-600%58 / Authorized Agency Official: 4, 0`..„ j`_ c /c.5 /Li Signature / 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 1T671).[201,4, ` : 9 ATTE� a .HT E.,i3:iv fork +pproved as to form and legality By�- L -� =4 ' ,l//.'7 -- Attest as to airman's �• • ssistant Co / Attorney '` ) signature only