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HomeMy WebLinkAboutBack-Up DocumentsFUND TITLE: EMS Matching Grant Award - M7034 RESOURCES: State of Florida Department of Health Florida of EMS Grant Program City Matching Grant from Account No. 00001.184010.899000.0000.00000 APPROPRIATIONS: $112,500.00 $37,496.25 $149,996.25 Mission: To protect, promote & Improve the health of all people In Florida through Integrated state, county & community efforts. Vision: To be the Healthiest State In the Nation Ron DeSantis Governor May 3, 2019 Lillian Blondet, Director City of Miami Grants Administration 444 Southwest 2nd Avenue, 5th Floor Miami, Florida 33130 Dear Ms. Blondet: The Department of Health is pleased to award an Emergency Medical Services (EMS) Matching Grant, ID Code M7034, in the amount of $1'12,500.00, to City of Miami Department of Fire -Rescue. This grant program is funded by the Florida Department of Health, EMS Trust Fund. There are no federal funds involved. The purpose of this grant is to improve and expand EMS by assisting your organization in the purchase of ten automated CPR devices. The grant begins the date of this letter and ends June 30, 2020. Your required local cash match is $37,496.25 with a total budget of $149,996.25. You are required to report grant activities and purchases to the state pursuant to section 401.113(2)(b), Florida Statutes, and in compliance with the Florida Catalog of State Financial Assistance program number 64.003. The reports are due the third week of October 2019, February 2020, and July 2020. Your signed grant application affirms you have read, understand and will comply with the conditions and requirements in the "Florida EMS Matching Grant Program Application Packet, December 2008." You may obtain a copy of the grant application packet from your identified contact person. Thank you for your participation in this state EMS grant. If you need assistance, please contact the Bureau of Emergency Medical Oversight, EMS Section, Health Services and Facilities Consultant, Alan Van Lewen at (850) 558-9550. Sincerely, Jg H. U1�oodlief Division Director Emergency Preparedness and Cornmunity Support DHW/avl cc: Niorge Aragon Florida Department of Dilealtin Division of Emergency Preparedness and Community Support Bureau of Emergency Medical oversight 4052 Bald Cypress Way, Bin A-22 Tallahassee, FL 32399-1722 PHONE: 050/245-4440 . FAX: 050/245-4370 FlorldaPlealthagov Accredited Health Department Public Health Accreditation Board 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 of pre -hospital EMS. DOH Remit Payment To: Name of Agency: City of Miami Department of Fire - Rescue Mailing Address: 1151 NW 7 St. 3rd Floor Miami, FL 33136 Federal Identification Number VF 596000375 Authorized Agency Official: tgnature Lillian Blondet, Director of Grants Administration Type Name and Title Sign and return this page with your application to: DOH Bureau of Emergency Medical Oversight EMS Section, Grants Unit 4052 Bald Cypress Way, Bin 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: $112,500.00 Grant ID Cod-: 7034 Approved By: 4c --.. V Signature of State EMS Grant Officer 2018 - 2019 11 State Fiscal Year: 20'17 20-111— �V I P ° 5(1 Organization Code E.O. OCA1Object Code Category 64-61-70-30-000 03 SF003 -50086'- 059999 751000 Federal Tax ID: VF 5 9 6 0 0 0 3 7 5 131 Da e Grant Beginning Date: May 3, 2019 Grant Ending Date: June 30, 2020 DH FORM 1767P [2013] 9 M7034 Miami Dept. of Fire Rescue, City of 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 Costs: List the price of the item and the source(s) used to identify the price. Justification: State why each of the items and quantities listed is a necessary component of this project. normal expected life of which is 1 year or more. Ten automated Cardio pulmonary Resuscitation (CPR) systems including batteries, accessories, and warranties. $149,996.25 TOTAL: $149,996.25 State Amount (Check applicable program) Matching: 75 Percent ❑ Rural: 90 Percent Local Match Amount (Check applicable program) ® Matching: 25 Percent ❑ Rural: 10 Percent Grand Total $112,500.00 $37,496.25 $149,996.25 DH Form 1767, Rev. 2002 Saturday, May 11, 2019 4:50 PM K:\KMainDrive\FY 2018-2019 Match\Budgets 2019\BudgetMiamiM7034.docx FLORIDA DEPARTMENT OF HEALT FLORIDA DEPARTMENT OF HEALTH BUREAU OF EMERGENCY MEDICAL SERVICES EMS MATCHING GRANT PROGRAM APPLICATION PACKET Revised: December 2008 64J-1.015, F.A.C. TABLE OF CONTENTS Introduction 1 Eligibility 1 Application 3 Request for Grant Fund Distribution 11 EMS Grant Program Change Request 12 EMS Grant Program Expenditure Report 13 Matching Grants Evaluation Worksheet 14 Financial and Compliance Audit Requirements 19 State Funded 19 Conditions Applicable to For -Profit Organizations 19 Section 215.97 F. S. 20 Submission of Audit Reports 20 Records Retention 20 Disallowed Expenditures 21 Vehicles and Equipment 21 Transfer of Property 21 Requests for Change 21 Early Ending Date 22 Supplanting Funds 22 Deposit of Funds 22 Reports 22 Grant Signature 22 Records 22 Final Reports 22 Communications Equipment 23 Expenditures 23 Credit Statement 23 THIS DOCUMENT CONTAINS THE EMS GRANT PROGRAM APPLICATION, GUIDELINES AND GRANT EVALUATION WORKSHEET REFERRED TO IN CHAPTER 64J-1.015, FLORIDA ADMINISTRATIVE CODE (F.A.C.). THIS APPLICATION IS TO BE USED FOR BOTH THE RURAL AND MATCHING GRANT PROGRAMS. INTRODUCTION This grant program provides emergency medical services providers, first responder organizations, and other emergency medical service related organizations with funds for projects to acquire, repair, improve, or upgrade emergency medical services systems, or equipment. To apply for an EMS Matching Grant, an applicant must meet specific eligibility requirements. Applicants certify that they meet all requirements in this application and guidelines when they sign and submit the application to the Bureau of Emergency Medical Services. You may submit any number of applications, and there is no limit on the amount of funds you may request for each application. Do not place more than one project in one application. However, do not fragment a request into more than one application if the activities are related. For example, a request for an ambulance, with medical equipment and radios for the ambulance, should all be in one application. However, a communication base station and dispatch equipment or training should not be included with the request for funding to purchase an ambulance. ELIGIBILITY WHO IS ELIGIBLE: To be eligible for funding under the Rural and Matching Grant Programs, an applicant must meet the following criteria: 1. Eligible rural counties are defined in section 401.107(5), Florida Statutes, (F.S.) as "a county with a total population of 100,000 or fewer people and density of less than 100 people per square mile." 2. Only boards of county commissioners and emergency medical services organizations determined by statute to be rural are eligible for rural grants. 3. Rural emergency medical service providers may also apply for funding from the matching grant program (75% state 25% local matching funds). 4. Emergency medical services providers, first responders and other EMS -related organizations are eligible for the matching grant program. 1 WHAT IS ELIGIBLE: 1. The matching grant funds must be used for the improvement and expansion of emergency medical services. Rural matching grant funds may be used to maintain services. 2. The grant funds must be used for one or more of the activities outlined in section 401.113(2)(b), F.S. MANDATORY CRITERIA REVIEW: Applications shall be reviewed to determine that the applicant meets the following criteria applicable to the type of grant submitted: 1. The grant applicant organization shall be based in a rural county if applying for 90% funding. 2. The applicant has received a letter endorsing the grant application from their Board of County Commissioners or the local EMS provider (if not a licensed EMS provider). 3. The application is complete and signed. 4. The applicant demonstrates the grant will be used to reduce morbidity and mortality in the identified service area in an efficient and effective manner. 5. First responder organizations must attach a copy of the memorandum of understanding (MOU) with a licensed emergency medical services provider. If there is no MOU, then documentation must be attached to the application that demonstrates the applicant has made a reasonable effort to obtain one or that the applicant did not receive a response from the providers in the area of operation. 6. If a Private Not -For -Profit organization, a copy of IRS 501 (c)(3) letter or other legal documentation of this status must be attached to the application. 7. The application may not exceed the number of pages listed in the application packet. Letters of support will not be counted as pages, but may be submitted. 8. The following application form, a facsimile of it or an electronic copy shall be used. However, the content of the form shall be identical to the copy received from the Bureau or from its web page. The applicant shall comply with all the instructions provided by the Bureau. 2 EMS 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: n Rural ❑ Matching ID. Code (The State Bureau of EMS will assign the ID Code — leave this blank) 1. Organization Name: 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: Position Title: Address: City: County: State: Florida Zip Code: Telephone: Fax Number: E-Mail Address: 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 person may be the same.) responsibility for the implementation of the grant activities. may request project changes. The signer and the contact Name: Position Title: Address: City: County: State: Florida Zip Code: Telephone: Fax Number: E-mail Address: DH 1767, December 2008 64J-1.015, F.A.C. 3 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/Town/Village (4) ❑ County (5) ❑ State (6) ❑ Other (specify): 5. Federal Tax ID Number (Nine Digit Number). VF 6. EMS License Number: Type: Transport ❑Non -transport Both 7. Number of permitted vehicles by type: BLS ALS Transport ALS non -transport. 8. Type of Service (check one): ['Rescue 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 1767, December 2008 4 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 1767, December 2008 5 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. 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 1767, December 2008 6 16. Work activities and time frames: Indicate the major activities for completing the project (use only the be completed in less than six months and if it is a if you are purchasing certain makes of be delivered after the bid is let. space provided). Be reasonable, most projects cannot communications project, it will take about a year. Also, ambulances, it takes at least nine months for them to Work Activity Number of Months After Grant Starts Begin 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. DH 1767, December 2008 7 18. Budget: Salaries and Benefits: For each position title, provide the amount of salary per hour, FICA per hour, fringe 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. 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 Costs: List the price and source(s) of the price identified. Justification: Justify why each of the expense items and quantities are necessary to this project. as operating capital outlay (see next category). TOTAL: $ DH 1767, December 2008 8 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 Costs: List the price of the item and the source(s) used to identify the price. Justification: State why each of the items and quantities listed is a necessary component of this project. normal expected life of which is 1 year or more. TOTAL: $ State Amount (Check applicable program) ❑ Matching: 75 Percent ❑ Rural: 90 Percent Local Match Amount (Check applicable program) ❑ Matching: 25 Percent ❑ Rural: 10 Percent Grand Total $ DH 1767, December 2008 9 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. 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 1767, December 2008 10 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: Mailing Address: Federal Identification Number: Authorized Agency Official: Signature Date 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 C18 Tallahassee, Florida 32399-1738 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 EMS Grant Officer Date State Fiscal Year: - Organization Code E.O. OCA Object Code 64-42-10-00-000 750000 Federal Tax ID: VF Grant Beginning Date: Grant Ending Date: DH 1767P, December 2008 64J-1.015, F.A.C. 11 Department of Health EMS GRANT PROGRAM CHANGE REQUEST Name of Grantee: Grant ID Code: BUDGET LINE ITEM CHANGE FROM CHANGE TO TOTAL $ $ Justification For Change: Signature of Authorized Official Date For department use only Approved Yes ❑ No Change No: Department's Authorized Representative DH 1684C, December 2008 64J-1.015, F.A.C. Date 12 Department of Health EMS GRANT PROGRAM EXPENDITURE REPORT Name of Grantee: Grant ID Code: Time Period Covered: Beginning Date: Ending Date: Earned Interest: Amount $ ; as of Day Month Year Final Report (Check one): ❑Yes ❑No Major Line Items Approved Budget Expenditure by Major Line Item(s) TOTAL BUDGETED EXPENDITURES TOTAL Actual Expenditure to Date by Major Line Item(s) TOTAL EXPENDITURES BALANCE Budgeted Less Actual Expenditures Include with the progress notes an explanation of 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 Official Date DH 1684A, December 2008 64J-1.015, F.A.C. 13 MATCHING GRANTS EVALUATION WORKSHEET INSTRUCTIONS FOR 75/25 PERCENT STATE EMS MATCHING GRANTS: The scores will always be 0, 1, or 2. Unless specified otherwise within the form: 2 = the answer of the applicant is complete with no more than one fact omitted; 1 = more than one fact omitted but there is at least one fact present; and 0 = there is no useful information. Fractional scores between 0 and 2 may also be used (e.g. .5, 1.25, 1.5, etc.), but none greater than 2. In order to place the total on a scale of 100, the total for each section is adjusted or multiplied by .69444. Adjusted scores of 55 or above will automatically be eligible for funding. The scores on the following evaluation sections show the maximum scores for each item and section. Note that the maximum score of 100 derives from adding the maximum totals of 11.11 and 88.89 in the two sections shown following. Justification Summary: On no more than three one sided double spaced pages, provide a summary addressing this project for each topic listed below. Item Score Weight Total Team Comments A) Problem description (Provide a narrative of the problem or need and the population impacted). 2 1 2 B) Present situation (Describe how the situation is being handled now). 2 1 2 C) The proposed solution (Present your proposed solution). 2 1 2 D) Consequences if not funded (Explain what will happen if this project is not funded). 2 1 2 E) The geographic area to be addressed (Provide a narrative description of the geographic area). 2 1 2 F) The proposed time frames, (Provide a list of the time frame(s) for completing this project). 2 1 2 G) Data Sources (Provide a complete description of data source(s) you cite). 2 1 2 H) Statement attesting that the proposal is not a duplication of a previous effort. (State this project doesn't duplicate what has been done on other grant projects under this grant program). 2 1 2 TOTAL XXX XXX 16 ADJ. TIMES .69444 XXX XXX 11.11 14 DH 1767G. December 2008 64J-1.015. F.A.C. 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: Item Score Weight Total Team Comments 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. 2 3 6 B) In the 12 months after this 2 3 6 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. 2 5 10 Before and After Difference 2 50 100 D) What other outcome of this project do you expect? Be quantitative and explain the derivation of your figures. 2 3 6 SUBTOTAL XXX XXX 128 Multiply subtotal if the data and information documentation and credibility by 1; .5 credibility; and .1 for low credibility. Any between .1 and 1 may also be used for fall between the decimals cited. The subtotal. Write the multiplication figure have high for doubtful decimals judgments that result is the new used 128 ADJ. TIMES .69444 XXX XXX 133.3 3 Outcome For Training Proiects: This includes all training of all other healthcare staff. Use Include the following: types for the public, first responders, law no more than two additional one sided enforcement personnel, EMS and double spaced pages for your response. Item Score Weight Total Team Comments 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). 2 3 6 B) How many people do you estimate will successfully complete this training in the 12 months after training begins? 2 3 6 Before and After Difference 2 13 26 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 2 40 80 15 the project and what the data should be in the 12 months after the training. D) Explain the derivation of all figures. 2 5 10 SUBTOTAL XXX XXX 128 Multiply subtotal if the data and information have high documentation and credibility by 1; .5 for doubtful credibility; and .1 for low credibility. Any decimals between .1 and 1 may also be used for judgments that fall between the decimals cited. The result is the new subtotal. Write the multiplication figure used 128 ADJ. TIMES .69444 XXX XXX 133.3 3 GRAND TOTAL ALL ITEMS XXX XXX 100.0 XXXXXXXXXXXXXXXXXXXX Outcome For Other Protects: This includes quality assurance, if possible, that data. Use no more the following: management, administrative, and others. bear directly upon the project and emergency than two additional one sided double spaced Provide numeric data in your responses, victim deaths, injuries, and/or other pages for your response. Include Item Score Weight Total Team Comments A) What has the situation been in the most recent 12 months for which you have data (include the dates)? 2 3 6 B) What will the situation be in the 12 months after the project 2 3 6 services are on-line? Before and After Difference 2 13 26 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 2 40 80 the project and what the data should be in the 12 months after the project. D) Explain the derivation of all figures. 2 5 10 SUBTOTAL XXX XXX 128 Multiply subtotal if the data and information documentation and credibility by 1; .5 credibility; and .1 for low credibility. Any between .1 and 1 may also be used for fall between the decimals cited. The subtotal. Write the multiplication figure have high for doubtful decimals judgments that result is the new used•128 ADJ. TIMES .69444 XXX XXX 133.3 3 GRAND TOTAL ALL ITEMS XXX XXX 100.0 XXXXXXXXXXXXXXXXXXXXXX Research and Evaluation Justification Summary, and Outcome Item Score Weight Total Team Comments A) Justify the need for this 2 4 8 16 project as it relates to EMS. B) Identify (1) location and (2) population to which this research pertains. 2 2 4 C) Among population identified in 14(B) of the application, 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). 2 5 10 D) (1) Provide the expected numeric change when the anticipated findings of this project are placed into practical use. 2 43 86 (2) Explain the basis for your estimates. 2 8 16 E) State your hypothesis. 2 2 4 F) Provide the method and design for this project. 2 2 4 G) Attach any questionnaires or involved documents that will be used. 2 2 4 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. 2 2 4 I) Describe how you will collect and analyze the data. 2 2 4 SUBTOTAL XXX XXX 144 Multiply subtotal if the data and information documentation and credibility by 1; .5 credibility; and .1 for low credibility. Any between .1 and 1 may also be used for fall between the decimals cited. The subtotal. Write the multiplication figure have high for doubtful decimals judgments that result is the new used 144 ADJ. TIMES .69444 XXX XXX 100 Bonus Points for Statutory Considerations and Criteria: The following are based on s. 401.113(2)(b) and 401.117, F.S. Item Score Weight Total Team Comments A) Serve the requirements of the population upon which project will impact. 2 1 2 B) Enable emergency vehicles and their staff to conform to state standards established by law or rule of the department. 2 1 2 C) Enable the vehicles of your 2 1 2 17 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 2 1 2 E) Enable your organization to improve or expand the provision of: 1) EMS services on a county, multi county, or area wide basis. Single EMS provider or coordinated methods of delivering services. 2) Coordination of all EMS communication links, with police, fire, emergency vehicles, and other related services. 2 1 2 SUBTOTAL XXX XXX 10 INSTRUCTIONS FOR 90/10 PERCENT STATE EMS RURAL MATCHING GRANTS: Applicant Information 1. Explain the problem. 2. Explain why the resources you are requesting will resolve the problem. Evaluation of the Application The likelihood, based upon the information provided by the applicant, in the next 12 months the lives and health of the population being served will be adversely affected without the requested resources. Scores between 0 and 5 may also be used (e.g. .5, 1.25, 2.0, 2.5, 3.5, 4, 4.5, etc.), but none greater than 5. 5 High 3 Medium 1 Low 0 Not sufficiently established in the information provided Explanation for assigned score. Note: If there are tie scores among applications and it affects whether or not which ones will be offered funding, the following priorities will prevail among the affected tie scores: 1. Medical equipment used at emergency scenes. 2. Rescue equipment used at emergency scenes. 18 3. Injury prevention. 4. Communications equipment. 5. EMS staff training. FINANCIAL AND COMPLIANCE AUDIT REQUIREMENTS This section is applicable to all grantees. An audit, performed in accordance with Section 215.97, F.S., performed by the Auditor General shall satisfy the requirement of this attachment. STATE FUNDED The grantee agrees to have an annual financial audit performed by independent auditors in accordance with the current Government Auditing Standards issued by the Comptroller General of the United States. Such audits shall cover the entire organization for the organization's fiscal year. The scope of the audit performed shall cover the financial statements and include reports on internal control and compliance. The reporting package shall include a schedule that discloses the amount of expenditures and/or receipts by grant number for each grant with the Department in effect during the audit period. Compliance findings related to grants with the Department shall be based on the grant requirements, including any rules, regulations, or statutes referenced in the grant. All questioned costs and liabilities due to the Department shall be fully disclosed in the audit report with reference to the Department grant involved. CONDITIONS APPLICABLE TO FOR -PROFIT ORGANIZATIONS The method of payment to for -profit organizations is cost reimbursement. For -profit organizations shall request reimbursement as follows: 1. Submit reimbursement requests to the Department accompanied by signed invoices and copies of both sides of the payment checks. If the grantee doesn't regularly receive copies of checks from its financial institution, the Department may accept other documentation evidencing payment. The invoices must clearly indicate the service or product delivered, date delivered, date paid, item cost, total cost, and the person receiving the service or product. 2. A copy of the approved budget must be in the reimbursement material. The grantee must show which item in the budget corresponds to each item in the reimbursement form. Every item on the reimbursement form must be identical to or clearly included under the approved budget items. 3. The grantee shall submit invoices for personnel services and fees on a time/rate basis. The invoices must identify each individual by name, state the services provided, the time period covered by the invoice, and the hourly rate and number of hours worked for each individual. Appropriate time sheets or time logs must accompany the invoice. 19 4. The grantee must submit a final invoice for payment to the Department within 40 days after the grant ends or is terminated. If the grantee fails to comply and does not obtain a written waiver from the Department, all rights to payment are forfeited. SECTION 215.97 F. S. (GRANTS AND AIDS APPROPRIATION) If the grantee receives funds from a grants and aids appropriation, the grantee shall have an audit, or submit an attestation statement, in accordance with Section 215.97, F. S. The audit report shall include a schedule of financial assistance, which discloses each state grant by number and indicates which grants are funded from state grants and aids appropriations. The grantee has "received" funds when it has obtained cash from the Department or when it has incurred reimbursable expenses. The grantee agrees to submit the required reports. SUBMISSION OF AUDIT REPORTS Copies of the audit report and any management letter by the independent auditors, or attestation statement, required by this attachment shall be submitted within 180 days after the end of the grantee's fiscal year to the following, unless otherwise required by F. S.: A. Send one copy to: Florida Department of Health Contract Administrative Monitoring Unit 4052 Bald Cypress Way, BIN B01 Tallahassee, Florida 32399-1729 B. Submit to this address only those audits performed or attestation statements prepared in accordance with Section 215.97, F. S.: Send two copies to: Auditor General's Office Local Government Audits/342 Claude Pepper Building, Room 401 111 West Madison Street Tallahassee, Florida 32399-1450 C. Do not send this report to the state Bureau of EMS. RECORDS RETENTION The grantee shall ensure that audit working papers are made available to the Department, or its designee, upon request for a period of six years from the date the audit report is issued, unless extended in writing by the Department. 20 DISALLOWED EXPENDITURES No expenditures are allowable as grant costs unless they are clearly specified as a line item in the approved grant budget, including approved change requests, or are clearly included under an existing line item. Any disallowed EMS grant expenditure shall be returned to the Department by the grantee within 40 days after the Department's notification. The costs of disallowed items are the responsibility of the grantee. VEHICLES AND EQUIPMENT The grantee shall own all items, including vehicles and equipment purchased with the state EMS grant funds, unless otherwise described in the approved grant application. The grantee shall clearly document the assignment of equipment ownership and usage; and maintain these documents so they are available to the Department. The owner of the vehicle shall be responsible for the proper insurance, licensing and, permitting and maintenance. All equipment purchased with grant funds shall continue to be used for pre -hospital EMS or the purpose for which it was purchased throughout its useful life. When any grant -funded equipment is no longer usable, it may be sold for scrap or disposed of in the customary procedure of the receiving agency. TRANSFER OF PROPERTY A private organization owning any equipment funded through the grant program in whole or in part, and purchased that equipment to provide services for a municipality, county or other public agency ceasing operation within five years of the ending date of a grant awarded to the organization, shall transfer the equipment or other items to the local agency. There shall be no cost to the recipient organization. This provision is applicable when services cease operating due to a contract ending as well as any other reason. REQUESTS FOR CHANGE After a grant has been awarded, all requests for change shall be on DH Form 1684C EMS Grant Program Change Request, December 2008. The grantee shall obtain written approval from the Department prior to making the requested changes. The following changes must be requested: 1. Extension of the grant's ending date. If an extension is being requested, the proposed new ending date shall be identified in the request. The grant extension request shall be received by the Department prior to the ending date indicated in the award letter. 2. Changes in the project activities. 3. Redistribution of the funds between entities or equipment approved. 4. Establishing a new line item in the budget. 5. Changing a salary rate more than 10%. 21 EARLY ENDING DATE If the project accomplishes the listed objectives and all funds have been expended, the grantee may request that the grant be closed prior to the ending date indicated in the award letter. The grantee shall submit a final expenditure report and a written narrative description of the grant activities and the impact the purchase or training had on the delivery of EMS. SUPPLANTING FUNDS The applicant cannot propose to use grant funds to supplant or replace any county or other funding source. Funds received under the county award grant program cannot be used to fulfill the matching requirement for the matching grant program. DEPOSIT OF FUNDS Matching grant funds provided to an applicant shall be deposited in a separate account and any interest earned shall be returned to the Department with the final report. All interest earned shall be documented on the required reports. REPORTS Each grantee shall submit two reports to the Department. The due dates for the required reports shall be specified in the letter from the Department notifying the grantee of the grant award. These reports shall include, at a minimum, a narrative of the activities completed or the progress of grant activities during the reporting period. A report shall be submitted by the due date whether or not any action or expenditures have occurred. GRANT SIGNATURE The authorized individual listed on page one of the application shall sign each original application. Should this not be possible before the due date, a letter shall be submitted to the Department explaining why and when the signed application shall be received. The Department shall receive the signed application no less than 5 working days prior to the grant review team meeting, published in the FAW. RECORDS The grantee shall maintain financial and other documents related to the grant to support all revenue and expenditures. A file shall be maintained by the grantee, which includes a copy of the "Notice of Grant Award" letter, a copy of the application and department approved budget and a copy of all approved changes. FINAL REPORTS Within 120 days of the grant ending date a final report shall be submitted to the Department. The final 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 relating to the purchase of any equipment 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 22 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. COMMUNICATIONS EQUIPMENT The grantee shall have all communications activities, services, and equipment approved in writing by the Department of Management Services, Information Technology Program (ITP). The approval shall be dated after the beginning date of the grant. Any commitment to purchase the requested equipment and service shall also be dated after the beginning date of the grant. EXPENDITURES No expenditures may be incurred prior to the grant starting date or after the grant ending date. CREDIT STATEMENT The grantee ensures that where activities supported by this grant produce original writing, sound recording, pictorial reproductions, drawings or other graphic representations and works of any other nature, notices, informational pamphlets, press releases, advertisements, descriptions of the sponsorship of the program, research reports, and similar public notices prepared and released by the provider shall include the statement: "Sponsored by [Your Organization's Name] and the State of Florida, Department of Health, Bureau of Emergency Medical Services." If the sponsorship reference is in written or other visual material, the words, "State of Florida, Department of Health, Bureau of Emergency Medical Services" shall appear in the same size letter or type as the name of the grantee's organization. One complimentary copy of all such materials shall be sent to the Department within three weeks of their reproduction and delivery to the grantee. If the proper credit statement is not included, or if a copy of each item produced is not provided to the Department within three weeks, the cost for any such materials produced shall be disallowed. Where activities supported by this grant produce writing, sound recordings, pictorial reproductions, drawings, or other graphic representations and works of any similar nature, the Department has the right to use, duplicate and disclose such materials in whole or in part, in any manner or purpose whatsoever and others acting on behalf of the Department. If the materials so developed are subject to copyright, trademark, or patent, legal title and every right, interest, claim, or demand of any kind in and to any patent, trademark or copyright, or application for the same, will vest in the State of Florida, Department of State, for the exclusive use and benefits of the state. Pursuant to section 286.02 (1), F.S., no person, firm or corporation, including parties to this grant, shall be entitled to use the copyright, patent or trademark without the prior written consent of the Department of State. 23