HomeMy WebLinkAboutGrant ApplicationDepartment of Health
EMS GRANT PROGRAM EXPENDITURE REPORT
Organization Name:
Time Period Covered: Beginning Date: Ending Date:
Earned interest: Amount $ as of: Day Month Year
Final Report (Check one): LJYes
-
No
Major Line Items
Approved Budget by Major Line item(s)
TOTAL BUDGETED EXPENDITURES
Grant ID Code
Approved Expendture to Date by Major Line
TOTAL EXPENDITURES
TOTAL
$ 0,00
0.00
BALANCE (Budgeted Less Actual Expenditures) $ 0.00
Include with the progress- hates an explanation or how project personnel, equipment, and any problems or barriers
may impact on the grant progress,
I certify the above reports are true and correct. Expenditures were made only for items allowed by
the above referenced grant.
Signature of Authorized Grantee Official
Printed Name
Date
DH 1684A, December 2008 64J-1.015, F.A.C.
REPORTS
Both the interim reports and final repQrt must begin with a summary page: of the budget and
costs using the state EMS Expenditure Form or its equivalent, Tha form follows this page.
INTERIM REPORTS
Each grantee shall submit two reports to the department. The due dates for the required
reports are specified in the award letter from the department notifying the grantee of the grant
award. These reports shall Include, at a minimum, a narrative of the activities completed ar
the progress of grant activities during the reporting period. A report shall be submitted by the
due date whether ar not any action or expenditures have occurred.
FINAL REPORTS
A final report shall be submitted to the department by its due date. The find report shall at a
minimum contain a narrative describing the activities conducted including any bid or
purchasing process and a copy of all invoices, canceled checks or other payment
documentation relating to the purchase of any equipment, services, expenses, and supplies
if the activity funded was for training a list of all individuals receiving the training shall be
submitted along with the dates, times and location of the training, if the grant was for training
to be obtained by staff then a copy of all invoices and payment documents for the training
shall also be submitted.
if any refund is due to the state, the paper check will need to be sent tows.
Also, please briefly :summarize a description of the impact of the project,
DH 1684A, Deoember2008 64J-1.o15 F,A,C.
EMS MATCHING GRANT APPLICATION
FLORIDA DEPARTMENT OF HEALTH
Bureau of Emergency Medical Services
Complete all items untess instructed differently within the application
Type of Grant Requested: L Rural a, Matching
10..1,..cLxle (The State Bureau of EMS will assign the ID Code — leave this blank)
1. Organization Name: Cityof Miami Department of Fire -Rescue
2, Grant Siciner: (The applic,ant signatory who has authority
to sign contracts, grants, and other legal
documents. This individual must also sign this application)
Name: Lillian Biondet
Position Title: Director of Grants Administration
tr,
Address: 444 S.W. 2na Avenue, 5 Floor
City; Miami
County: Mierni4Oade County
State: Florida
Zip Code: 33130
Telephone: 305-416-1536
Fax Number: 305416-2151
E-Mail Address: iblondetOrniamigov.00rn
3. Contact Person: (The individual with direct knowledge
of the project on a day-to-day basis and
This person may sign project reports and may
person may be the same.)
responsibility for the implementation of the grant activities.
request project changes. The signer and the contact
Name: CaptittLi Adrian Plasencia
Position Title: Fire Captain
Address: 1151 NW 7th Street
City: Miami
County:
Miami -Dade
_
State: Florida
ZipCode:
33136
Telephone: 3 5-416-5450
Fax Number:
305-400-5354
E-Mail Address: a lasencia la i ov.co
DH FORM 1767 (2013)
64J-1,015, F.A.C.
Legal Status of Applicant Organization (Check only one response)
(1) ❑ Private Not for Profit [Attach documentation-501 (3) 0]
(2) ❑ Private For Profit
(3) ►/ .City/Munioipallty/Town/Viflage
(4) ❑ County
(5) ❑ State
(6) 0 Other (specify):
Federal Tax ID Number (Nine Digit Number).. VF 0t4. 378_
6. EMS License Number 2276 Type: ►1Transport :Non -transport DBotl
7. Number of permitted vehicles by type: BLS 24 ALS Transport 3 ALS non -transport;
Type of Service (check one): ORescue OFire ❑Third Service (County or City Government
nonftre) 0Air ambulance: aFixed wing DRotowing ❑Both .[=other (specify).
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
coOuting EMS education in this project. [Na signature is needed if medical equipment and
professional EMS education are not in this project.]
Signature:
Date:
Print/Type Name of Director Kathleen S. Schrank, MD, FACEP, FACP
FL Med. tic. 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 fot projects
that involve medical equipment and/or continuing EMS}education,
LIf your activity is a research or evaluation project, omit Itemstt1, l 1, �1 3, ; nd skipto Item
umber 14, Otherwise, proceed to Item 10 and the following items.
your activity is a research or evaluation project, omit Items 10, 11, 12, 13, and skip to Item
Number 14. Otherwise, proceed to !tern 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);
S) Present situation (Describe how the situation is being handed 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 1707 [20131
ITEM 10, Justification Summary 3 Pages
A) Problem Description: Miami Fire Rescue (MFR) is currently utilizing cardiac• monitors that do not meet the
increasing needs of the community. They are deteriorated, in need of repair, outdated and lack patient vital
monitoring functions (including heart attack detection) which prohibit MFR from providing the highest level of care
and life saving measures, They lack enhanced lifesaving capabilities such as carbon monoxide (CO) monitoring to
proteot residents and firefighters, real time CPR tracking, current EKG interpretation algorithms to determine the
origin of heart attacks and the outdated screen is difficult to read. In 14 months the vendor will discontinue servicing
these units. We need equipment which will be reliable, can be maintained, and which has the necessary advanced
capabilities to effeetively provide EMS, Due to budget digs, we do not have the funds to jeumhese this equipment.
without state assistance.
In 2012, there were 1,255,000 heart attacks in the U.S., representing 46% of cardiovascular disease
occurrences., Tragically, about 50% of these victims die from heart aftacks.2 In surviving a cardiac emergency,
experts agree time is the single most important critical factor. A plethora of heart attacks were identified in the City
of Miami in 2012. MFR has responded to numerous calls where its monitors could not evaluate CO levels to prevent
death from CO poisoning; annually, more than 400 Americans die from unintentional CO poisoning. Today's
cardiac monitors have sensors which will allow MFR to continuously monitor CO levels to save the lives of residents
and firefighters (as recommended by NFPA 15849.
EMS responders are frequently the first line of defense in treating the aforementioned incidents. The use of
cardiac monitors increases the chances of survival by allowing for more effective treatment of a patient before arrival
at a treatment facility and reducing the time it takes to treat patients on arrival at the facility .3 MFR's cardiac
monitors were used in about 40,000 calls in 2012. MFR is dedicated to continuous quality improvement of its
services for residents, inclusive of rapid on -scene arrival. MFR is charged with responding to all emergency tails
within its jurisdiction and to provide mutual aid in four other municipalities and automatic aid in another. Miami has a
disturbingly high mortality rate, many 'cardiac events and is in need of new cardiac monitors to respond to the over
95,000 calls it receives annually and to increase the probability of patient survival.
4
I3). Present Situation: MFR uses obsolete cardiac monitors which limit and decrease the efficiency in MFR's care
of residents. They are difficult to maintain and require costly repairs which divert funding away from other critical
EMS supplies and equipment. When they are undergoing repairs, MFR's, two spare monitors are utilized. When
these are in use and other monitors malfunction, EMS units lose their EKG capabilities and are at risk of being
placed out of service until a working EKG is available. This impedes MFR's ability to assess patients and respond to
emergencies, it extends the door to math time, increases the risk of cardiac damage and increases chances of death.
MFR provides both fire and EMS services, consisting clf 27 fully staffed ALS rescue units and 28 fire response
BLS non -transport units. Its cardiac monitors are outdated, deteriorated, malfunction frequently and require
extensive servicing In the last two Years, they were placed out of service due to repairs over 60 :Imes and repair
will be unavailable in 14 months, when the vendor discontinues servicing. They also lack the capability to •evaluate
the effectiveness of CPR and to more accurately detect heart attacks. In over 10,000 calls involving smoke, fire or
other respiratory distress, MFR was not able to check the CO levels for the majority of the patients. The same was
true for its personnel involved in over 2000 smoke and/or fire related incidents.
C) Proposed Solution: It is imperative that MFR provide effective treatment and improve its ability to care for the
More than 1 million people transiting through Miami daily. We are requesting financial assistance to purchase 28
cardiac monitors to ensure EMS units do not lose their EKG abilities and are not at risk of being placed out of service
until a working EKG is available. Without all 28 monitors, many of the emergency victims treated during MFR's
95,000 plus calls will not have the lifesaving assistance they require. These cardiac monitors will Include CO
monitoring capabilities, as well as improved EKG algorithms and functionality to assure effective service to our
residents, visitors, and members, In addition, the cardiac monitors will have biphasic defibrillation capabilities,
improved display visibility, end tidal carbon dioxide technology for intubated and non-intubated patients, oxygen
saturation monitoring, non-invasive blood pressure rmnitoring, continuous 12-lead monitoring, 12- lead transmission
capabilities, the ability to store and upload data into patient care reporting systems, and the ability to extract data for
training and qua* improvement. These monitors will allow for increased chances of survival for victims by
providing enhanced lifesaving capabilities and adequate equipment to perform EMS duties. In addition,
maintenance and repair services will be available for this equipment.
5
0) Consequences if Not Funded: Without this grant, MFR will not be able to fund this project. As previously
stated, its current cardiac monitors are continuously taken out of service for repairs. The current vendor will be
unable to support these monitors in 14 months, hindering ALS capabilities significantly and endangering lives,
Furthermore, current cardiac monitors lack the technology and functionality that can facilitate the effective treatment
and survival of residents, visitors and members. These monitors are the difference between life and death and in our
financial condition; MFR does not have the funds to purchase them without state assistance,
E) The geographic area to be addressed: The City of Miami is comprised of 34 sq. miles with about 408,750
residents. Daily, the population swells to nearly 1 million during working hours. Current vulnerabilities are: 1) High
rate of ill -health due to poverty: Miami has a 27.7% poverty rate and is one of the FIVE MOST IMPOVERISHED
CITIES IN THE U.S. ; 2) High rate of elders: The City has the nation's 7th largest elderly population (over age 65)
comprising 16%• of the total population; 3) High rate of ethnic diversity and rates of cardiac individuals; 4) Mutual
All Obligations. MFR provides automatic aid to the Village of Key Biscayne, and mutual aid to Miami -Dade County,
the cities of Miami Beach, Coral Gables and Hialeah,
F) The proposed time frames:
Months •1 to 5: present award to the city commissioners for approval, research supply and purchase equipment.
MFR anticipates units will arrive two to four weeks from the date ordered;
Months 6 to 8:training of 600 plus firefighters/ paramedics and;
Month 9: implementation of units into service and records and evaluate the positive effects of the newly acquired
monitors.
G) Data Sources: National Heart, Lung & Blood institute, http://www.nhibi,nih.gov I; National Institute of Health,
www,nih.gov2 ; A Guide to Our Emergency Medical Equipment, http://westchesterems,orq/eouloment.htrn13, Miami
Department of Fire Rescue4.; NFPA 15845;
H) Statement of Non -Duplication: This funding will enable MFR to obtain reliable cardiac monitors with necessary
advanced capabilities and establish new respoose capacity in MFR facilities. The City of Miami has not received
funding for cardiac monitors from the Florida EMS matching grant program before and does not duplicate the work of
any other grant funded initiative.
Next, only complete one of .the following. Items 11,12, or 13. Read all three and then select and
complete the one that pertainsthe 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 tNorksheet used by reviewers to evaluate your application form.
11 0utc9me 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 (E), above.
D) What other outcome of this project do you expect? Be quantitative and explain the derivation' of your
figures.
E) Horn dogs this integrate into your agency's five year plan?
ITEM 11, Outcome For Proiects That Provide or Effect Direct Services To Emergency Victims&GES
A) .Quantify Situation in Last 12 Months: From January 1, 2012 through December 31, 2012, MFR responded to
over 95,000 incidents. Of those, 75,935 calls were EMS responses, during which cardiac monitors were employed
in the assessment and treatment of over 40,000 patients, In addition, over 10,000 of those calls involved either
smoke, fire and/ or some type of respiratory distress., where MFR was unable to check the majority of the patients for
elevated CO levels. Miami also has a high level of obesity as well as a high percentage of poverty and elderly. This
exponentially Increases our population's risk of death from heart attacks and other cardiac events,
MFR has had several issues with its current cardiac monitors, where they are constantly removed from
service to undergo repairs and have become unreliable. In many documented instances, our current cardiac
monitors have actually exhibited asystole on viable patients, therefore further increasing our need for functional and
reliable cardiac monitors that have been beyondMFR's reach due to its current fiscal state.
The City of Miami has a large, over 1,000,000 daily population, significant number of high risk patients,
plethora of EMS responses, array of calls necessitating CO monitors, and impending obsoleteness of the monitors in
a few months. These critical issues make it imperative that MFR acquires functional and reliable cardiao monitors
to effectkely serve and decrease the risk of mortality of our residents, visitors and firefighters.
B) Data of Change with Project Implementation: Implementation of the cardiac monitors in all City of Miami Fire
Rescue Department ALS vehicles will ensure that MFR can effectively and efficiently perform lifesaving measures,
quickly identify heart attaoks and other lethal arrhythmias and monitor CO levels. The 10,000 calls on which we
could not effectively check for elevated CO levels in the previous 12 months will be eliminated in the 12 months after
implementation of and staff training on using the monitors. Alse, MFR will no longer lack reliability, real time CPR
tracking and the ability to determine the origin of heart attacks which it lacked in 40,000 calls in 2012. Therefore,
MFR expects to see Improvement ire a ) save rates; b) identification of STEMIls; c) door to catherization times in
heart attacks; d) identification of patients with elevated CO levels; e)overall efficiency in EKG interpretation; and f)
improvement in cardiac and other treatments.
MFR has exhibited a significant increase in responses and population served each year. This project is critical
to MFR's efforts and will decrease morbidity and mortality in Miami for years to come, Residents, visitors, and
8
members of the City of Miami will be better protected and receive an extensive increase in quality of care and better
service and the •health of firefighters wili be better protected and monitored at fire incidents.
C) Justification and Explanation of Above Data: Information given in question (A) and (B) was obtained using
data from the Miami FireAescue Department data collection system and other outside resources.
D) Additional Outcomes: The funding of this project will result in the improved well-being of firefighters through
early Monitoring and recognition of the early symptoms of CO poisoning, as well as cardiac monitoring at fire and
other events. MFR will also be able to provide citizens and visitors with consistent state of the art treatment. The
new monitors are extremely durable, have longer battery lives, enhanced screen visibility, improved functionality, will
have a tonger lifespan and require fewer repairs.
E} Integration into Agency's Five Year Plan: Miami Fire -Rescue's five year plan includes a complete review of
our current treatment protocols and equipment needs, and the impact of AHA guidelines. This project integrates
seamlessly into the achievement of MFR's goals. In addition, our plan includes improving the wellness and health of
our members. These monitors will effectuate this by effectively monitoring CO levels in our personnel's blood, as
well as performing cardiac assessments on our members. These assessments clearly save lives as was the case
when one of our member's experienced a heart attack at a recent drill and a cardiac monitor was used to quickly
identify the heart attack and save his life, as well as an array of other instances where cardiac monitors have
identified dangerous antythrnias on our members.
9
kip 14 and -go to
15, unless your project is research and evaluation and you h
completed the preceding us cation
ALt. APPLICANTS MUST COMPLETE ITEM
5.
15. Statutory Considerations and Criteria: The following are based on s. 401.113(2)(b) and 401.117, F.S.
Use ne More than one additional doubie spaced page to complete this item. Write N/A for those things In
this sectiottthat 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 wtCl impact.
S) 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.
C) 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.
10
15, Statutory Considerations and Criteria (1 PAGE):
A) Serving the Requirements of the Population of Miami.: The purchase of cardiac monitors would serve the
needs of the over 1,000,000 people in Miami daily by providing effective treatment for cardiac related events and CO
level monitoring, Miami has a critical need for the monitors due• to its enormous number of middle aged to elderly
oitizens, and others at risk of cardiac emergencies. Also, potential CO poisoning stemming from the increased use of
generators during hurricane and thunderstorm power outages, increase the need forthese cardiac monitors,
B) Enabling of Emergency Vehicles to Conform to Standards This funding will enable MFR to meet state
standards. It will also meet NFPA 1584 startdards which recommend the presence of both pulse oximetry and CO
monitoring on the firegound and in certain training situations. In addition, MFR will be equipped to continue to
conform to Al -IA guidelines and standard of care by offering biphasic defibrillation, infant/pediatric defibrillation, and
3-lead ECG capability in all our advanced life support vehicles.
C) Enable vehicles to contain minimum equipment and supplies: MFR requires that Its vehicles contain cardiac
monitors es a part of its minimum equipment requirement. The requested funding would allow MFR to Purchase 28
cardiac monitors to meet this obligation. D) Enable vehicles communications: This equipment will allow for
increased communication and data transfer of 12 leads during and after events and allow for a Continuous Quality
Improvement (COI) process to be implemented by MFR The improved communications will also allow MFR to
provide the highest standard of care.
E) Enable your organization to improve or expand the provision of services: The acquisition of the cardiac
monitors will exponentially improve MFR's ability to serve populations in the City of Miami and throughout the
county. Increased technology will allow MFR to acquire and analyze data to improve service. The addition of CO
monitoring oapabilities will allow MFR to bettor:protect its residents and firefighters. The ability to upgrade a newer
technology is developed will allow MFR to ensure a long and reliable useful life for the cardiac monitors.
11
16. Work activities and time frames: Indicate the major activities for completing the project (use only the
space Provided). Be reasonable, mostprojects 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
Grant Acceptance (commission approval)
Number of Months after Grant Starts
BeIrt End
(MM/DONYYNO. (IVIM/DDNYYY)
Bid Issuance and vendor selection
Purchase unit
Training
6
Unit Deployment
9
6
9
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
aocounts, cannot be allocated in whole or part for the costs herein.
&A.
DH FORM 1767 [2013
12
1 : Bud et
Salaries and Benefits: For each
position title, provide the amount of
salary per hour, FICA per hour,
(tinge benefits, and the total
number of hours.
Costs
Justification. Provide a brief justification
why each of the positions and the numbers
of hours are necessary for this project.
t'
TOTAL.:
$ 0.00
Right click on 0.00 then left click on
"Update Field" to. calculate Total
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 Cate e o
DM FORM 1767 [2O13]
Costs: List tine price
and source(s) of the
price identified.
,Justification: Justify why each of the
expense Items and quantities are
necessary to this project.
Right click on 0.00 then left click on
°Update Meld" to calculate Total
Vehicles, equipment, and other
operating capital outlay means
equipment, fixtures, and other
tangible personal property of a non
consumable and non expendable
nature, and the normal expected
life of which is 1 year or more.
28 — Cardiac monitors
Costs: List the price
of the itern and the
source(s) used to
identify the price.
$72 000
$728,OOii,O0
Justification: State why each of the items
and quantities listed is a necessary
component of this project.
The units are sold at $26,000 each and are
all necessary to facilitate The goals of this grant
and reduce mortality in the City of Miami.
Cardiac monitor
SA02 Capability
CO Capability
3 & 12 lead capability
ETCO2 capability
Bp capability
Cables
Batteries'
Wifi "f Bluetooth capabilities
Clinical training included
Data Management "package
Biphasic defribillation capabilities
Right click on 000 then eft
"(iodate Field" to calculate Total
Mate Amount
(Check applicable program)
Matching: 75 Percent
Rural: 90 Percent
Local Match Amount
(Check applicable program)
Matching: 25 Percent
0 Rural: 10 Percent
Grand Total
OH FORM 1707 [2913]
$546,O00 OO.
$182,Ot)t1.0
14
0.0
Right click on 0.00 then left click on.
"Llpdate Field" to calculate Total
Right click on 0,00 then left click on
"Update Field" to calculate Total
Right click on 000 then left click on
"Update Field".to calculate Total
Right click on 0.00 then left click on
Update Field" to calculate Total
'Right click on 0.00 then Ieft click on
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. 1 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 aectio.
119.07,F.S, effective after opening by the Florida bureau of EMS.
accept that in the best interests of the Stage, heFloridaBureau of EMS reserves the right to
ject or revise any and all grant proposals or waive any minor irregularity or technicality in
proposals received, and can exercise that right.
, the undersigned, understand and accept that the Notice of Matching Grant. Awards will be
dvertised in the Florida Administrative Weekly, and that 21 days after this advertisement is
ublished 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 thatching requirement of another
state grant All cash, salaries, fringe benefits, expenses, equipment, and other expenses as
listedin 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 c
above and also accept the attached grant terms and conditions and acknowledge this by sig
below.
`Signature of Authorized Grant Signer
Individual Identified in Item 2
DH FORM 1767 [201
MM`i DD !'YY
THE TOP PART OF THE FOLLOW ING..PAc3F IViUST:ALSO ICE TED AND SIGNED.
15
FLORIDA DEPARTMENT OF DEALT,
EMS GRANT PROGRAM
REQUEST FOR GRANT FUND DISTRIBUTION
In accordance with the previsions of Section 401 11 S(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 Miami Department of Fire - Rescue
Mailing Address:
Federal ldentificatian Number
Authorized Agency Official.
1151 NW 7 St, 3rd Floor
mm Miami, FL 33136
VF 596000375
Signature
il.lien Blondet, Director of Grants , dministratlon
Type Name and Title
Sign and return this page with your application to:
Florida Department of ,Health
BEMS Grant Prograrn
4052 Bald Cyprasa Way, Bin C18
Tallahassee, Florida 32399-1738
Date
3
Do not write below this line, For use by Bureau of Emer eracy'Medical Senile personnel y
Grant Amount For State To Pay: $
Approved By:
Signature of State E(S Grant Officer
State Fiscal Year:
Organization Code E.O.
4-42-10-00-000 03
Federal Tax ID VF_
Grant. Beginning Date:
Grant ID Code:
*biect Code
SF003 750000
Ending Date:
DH FORM 1767p [20131