Okaloosa County BOCC — November 18, 2014 — EMS County Grant Application 2014-2015 — reading text

EMS COUNTY GRANT APPLICATION FLORIDA DEPARTMENT OF HEALTH Emergency Medical Services Program Complete all items ID. Code (The State EMS Program will assign the ID Code – leave this blank) C ____ 1. County Name: Okaloosa County Board of County Commissioners Business Address: c/o Office of Contracts & Grants 1804 Lewis Turner Boulevard, Suite 206 Fort Walton Beach, FL 32547 Telephone: (850) 651-7200, Ext. 4381 Federal Tax ID Number (Nine Digit Number). VF 59-6000765 2. Certification: (The applicant signatory who has authority to sign contracts, grants, and other legal documents for the county) I certify that all information and data in this EMS county grant application and its attachments are true and correct. My signature acknowledges and assures that the County shall comply fully with the conditions outlined in the Florida EMS County Grant Application. Signature: Date: Printed Name: Charles K. Windes, Jr. Position Title: Chairman, Okaloosa County Board of County Commissioners 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: Dino J. Villani Position Title: Director, Okaloosa County Department of Public Safety Address: 90 College Boulevard East Niceville, FL 32578 Telephone: (850) 651-7150 Fax Number: (850) 651-7170 E-mail Address: dvillani@co.okaloosa.fl.us 4. Resolution: Attach a current 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. 5. Budget: Complete a budget page(s) for each organization to which you shall provide funds. List the organization(s) below. (Use additional pages if necessary) 1. Okaloosa County EMS - $25,824.00 DH 1684, December 2008 64J-1.015, F.A.C. 1 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 Total Expenses = $ 0.00 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 Venipuncture and Injection Arm (1 @ $520 each) $ 520.00 Training and Simulation Trauma Manikin (1 @ $3,254 each) 3,254.00 Intubation Head (1 @ $1,176.65) 1,176.65 AED Trainer (1 @ $495) / Rhythm Simulator (1 @ $850 each) 1,345.00 Anatomical training models 925.00 LifeSled LS1 (Ski Rescue) (1 @ $1,700 each) 1,700.00 Nissan Outboard Engine (1 @ $1,700 each) 1,700.00 413 Craftsman Tools (1 set @ $550 each) 550.00 Thule Truck Rack (2 @ $500 each) 1,000.00 Soft Rescue Tubes (10 @ $50 each) 500.00 Polaris Ranger 6X6 ATV (1 @ $13,153.35 each) 13,153.35 Total Veh. & Equipment = $25,824.00 Grand Total = $25,824.00 DH 1684, December 2008 2  FLORIDA DEPARTMENT OF HEALTH EMERGENCY MEDICAL SERVICES (EMS) GRANT PROGRAM 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: Name of Agency: Okaloosa County Board of County Commissioners Mailing Address: 302 N. Wilson Street, Suite 203 Crestview, FL 32536 Federal Identification number: 59-6000765 Authorized County Official: Signature Date Charles K. Windes, Jr., Chairman Type or Print Name and Title Sign and return this page with your application to: Florida Department of Health Emergency Medical Services Program, 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 Program Grant Amount For State To Pay: $__________________ Grant ID: Code: C30______ Approved By : Signature of State EMS Grant Officer Date State Fiscal Year: 2014 -__2015 Organization Code E.O. OCA Object Code Category 64-61-70-30-000 05 SF005 750000 059998 Federal Tax ID: VF __ __ __ __ __ __ __ __ __ Grant Beginning Date: ____________________Grant Ending Date: _______________ DH 1767P, December 2008 64J-1.015, F.A.C. 3 OLO/Department: 640000 / Dept. of Health Agency Contact: FLAIR Contract #: Telephone #: Agency Contract #: PO #: Deliverables - None for or to the state. This is a grant for the benefit of the grantee. Deliverables as stated Minimum Performance Deliverable Type of Services Method of in the Contract Grant Levels Price Payment Emergency Advance Medical Services (EMS) Venipuncture and Pre-hospital IV and $520.00 Injection Arm injection training and simulation Training and Simulation Pre-hospital trauma $3,254.00 Trauma Manikin training and simulation Intubation Head Pre-hospital advanced $1,176.65 airway training AED Trainer / Rhythm Pre-hospital cardiac $1,345.00 Simulator rhythm and defib training Anatomical training Continuing skeletal and $925.00 models cardiac education LifeSled LS1 Heavy surf rescue $1,700.00 Nissan Outboard Flood rescue $1,700.00 Engine 413 Craftsman Tools Equipment maintenance $550.00 and repair Thule Truck Rack Rescue equipment $1,000.00 transport Soft Rescue Tubes Water rescue $500.00 Polaris Ranger 6X6 ATV Special event response $13,153.35 and transport DFS-A2-2102