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HomeMy WebLinkAboutEMS Matching Grant ApplicationEMS MATCHING GRANT APPLICATION FLORIDA DEPARTMENT OF HEALTH Bureau of Emergency Medical Services Complete all items unless instructed differently within the application Type of Grant Requested: Rural xx Matching ID. Code (The State Bureau of EMS will assign the ID Code — leave this blank) 1 1. Organization Name: City of Miami Fire -Rescue 2. Grant Signer: (The applicant signatory who has authority to sign contracts, grants, and other this application) legal documents. This individual must also sign Name: Robert Ruano Position Title: Grants Administrator Address: City of Miami 444 SW 2 nd Ave, 5th Floor City: Miami County: Dade State: Florida Zip Code: 33130 Telephone: (305) 416-1532 Fax Number: (305) 416-2151 E-Mail Address: rruano@ci.miami.fl.us 3. Contact Person: (The individual with direct knowledge of the project on a day-to-day basis and of the grant activities. This person may sign project reports and The signer and the contact person may be the same.) Captain Allen Joyce responsibility for the implementation may request project changes. Name: Position Title: Executive Assistant to the Fire Chief Address: 1151 NW 7 St, 3ra Floor City: Miami County Dade State: Florida Zip Code: 33136 Telephone: (305) 416-5430 Fax Number: (305) 400-5029 E-mail Address: ajoyce@ci.miami.fl.us DH Form 1767, Rev. June 2002 1 4. Legal Status of Applicant Organization (Check only one response): (1) ❑ Private Not for Profit [Attach documentation-501 (3) ©] (2) ❑ Private For Profit (3) XX City/Municipality/Town/Village (4) ❑ County (5) ❑ State (6) E Other (specify): 5. Federal Tax ID Number (Nine Digit Number). VF 596000375 6. EMS License Number: 2276 Type: XX Transport ❑Non -transport Both 7. Number of permitted vehicles by type: BLS 34 ALS Transport I ALS non -transport. 8. Type of Service (check one): Rescue XX Fire ❑Third Service (County or City Government, nonfire) ❑,Air ambulance: ❑Fixed wing nRotowing (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: lei '� �-r- c __. Date: . ie/e, Print/Type: Name of Director Kathleen Schrank FL Med. Lic. No. ME 39896 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, Rev. 2002