Fort Walton Beach Council agenda — 06-09-09 regular — reading text

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 1757, Rev. 2002 49- 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 1 month 12 months Purchase and receipt of: One ( 1) Advanced Life Support Adult Sin ulaid One ( 1) Advanced Life Support Pediatric Simulaid One ( 1) Basic Life Support CPR Package which includes 4 Adult and 4 Pediatric manikins Integrate into monthly training 2 months ( No foreseeable end) 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. NIA DH Form 1767, Rev. 2002 50- 18. Bud et: Salaries and Benefits: For each Costs Justification: Provide a brief justification . position title, provide the amount why each of the positions and. the numbers_ of salary per hour, FICA per hour, of hours are necessary for this project. fringe benefits, and the total number of hours. N/ A 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). N/ A TOTAL: DH Form 1767, Rev. 2002 51- 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 identify the price. non consumable and non expendable nature, and the normal expected life of which is 1 year or more. A) 1 Adult Advanced Life 5, 100. 00 The Simulaids listed here were Support Simulaid with Deluxe chosen for ease of use, reliability, Head* fair price, service warranty included B) 1 Pediatric Advanced Life 3, 500. 00 and familiarity to personnel involved Suppo i Simulaid in training. C) Basic Life Support CPR 695.95 Package ** D) 3 Year Service Warranty Included E) Shipping 90.70 I!;- ALL psi L' a-s pe -r— TOTAL: 9, 386. 65 State Amount Check applicable program) E,, Matching: 75 Percent $ 7, 039. 99 Rural: 90 Percent $ Local Match Amount Check applicable program) 2, 346. 66 dMatching: 25 Percent $ Rural: 10 Percent $ 9, 386. 65 Grand Total 1$ DH Form 1767, Rev. 2002 A) with deluxe airway management capability. B) with deluxe airway management capability. C) including 4 adult and 4 pediatric manikins 52-  19. Certification: My signature.:below certifies the following....._ .., ...._.._.:_. l 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 l 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, com plete, and made in good faith. M............................_..................._..._... ..........._................... _......................._...:......._......_................_................_........._..........._............................_.............. ..............................; 1 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. w..................................................... ...... ..........:.......................................................................................... ........ ...................... :....._ ............. _.............................. ...................... ... .... 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 w give any minor irregularity or technicality in proposals received, and can exercise that right. 1, the undersigned,. understand and accept that the Noti ce 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 Ii sted in jthis application shall be committed and used for the activities approved as a part of this grant. a .... ..... .............. ...::....,.....:.... ...... ....,..................... ,..:...:.....__.....,.:. Acceptance 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. Signature of Authorized Grant Signer MM ! DD / YY individual Identified in item 2) DH Form 1767, Rev. June 2002 53-  FLORIDA DEPART1UfENT OF HEALTH EMS GRANT PROGRAM liq 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: City of Fort Walton Beach Fire Department 5 NE Hollywood Boulevard Mailing Address: Fort Walton Beach, FL 32548 Federal Identification Number 59- 6000 -323 Authorized Agency Official: , 2. 3 -o 9 Signature Date Michael Dutton, Fire Chief Type Name and Title Sign and return this page with your application to: Florida Department of Health BEMS Grant Program 4052 Bald Cypress Way, Bin C IS dhahassee, Florida 32399 -1738 Pao 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 FMR rrant nfficPr Date State Fiscal Year: Oto 9 Zo ©g Organization Code E. O. OCA Obiect Code 64- 42 -10 -00 -000 03 SF003 750000 Federal Tax ID: VF Grant Beginning Date: Grant Ending Date: DH Form 1767P, Rev. June