HomeMy WebLinkAboutGrant ApplicationEMS MATCHING GRANT ApEucgioN
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FLORIDA DEPARTMENT OF HEALTH
Emergency Medical Services Section
MAL
Complete all items unless Instructed differently within the application
Type of Grant Requested: ❑ Rural H Matching
LD. Code (The State Bureau of EMS will assign the ID Code — leave this blank)
1. Organization Na e: City of Miami Department of Fire -Rescue
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: Lillian Blondlet
Position Title; Director of Grants Administration
Address: 444 S.W. 2nd Avenue, 5th Floor
Cit..: Miami I County: Miami Dade County
State: Florida I Zip Code: 33130
Telephone: 305-416-1536 1 Fax Number: 305-416-2151
E -Mail Address: IblondetQmi1amigovxom
3. Contact Person: (The individual with direct knowledge of the project on a day-to-day basis and
responsibility for the implementation of the grant activities. This person may sign project reports and may
request project changes. The signer and the contact person may be the same,)
Name: Adrian Plasencia
Position Title: Assistant Fire Chief
Address, 1151 NW 7TH STREET
City: Miami I county: Miami -Dade County
State: Florida Zip Code; 33136
Telephone: 306-416-5422 Fax Number: 305-4005354
E -Mail Address: _a&sepcia@rnlarni1c1ov.corn
1
Private Not, for Profit [Attach doournentation-501 (3)
Private For Profit,
City/MunlolpalityiTown/Village
County
state
Other (specify):
6, r--edqraljgxjQ Numbgr (Nine Dialt Nuniwb.. Vr 00an
6, WS License Nurnber: MTransport DNon-transport [7jDoth
7, Number of permitted vehicles by type: Jj US; __,27_.A1.$'rranspW!,_6_ALS non transport,
8, Type of $ervice (check one): 9 Rescue; D Flre; (j Third 83ervice (County or GityGovornmont, nonfire); EJ
Air, ornbulanoe; El Fixed wino, I. Rotowhig; E3 Both; [)Other (specify) ___.
9, lc a r f cxvfrl r. If this project Is aPproVed, I agree by signing below that I will affirm
My authority and responsibility for the use of all modlool equipment and/or the provision of all qo_Dt_lr, in EMS
education in this project, [No signature Is noodod If medidall. oquipment and profossionall 60 oducation are
M In this projoot-1 /
ftnature. Date;
PrintlType. Name Df Dimotor Dr. Kathleen KID, FACEP-FAC
FL Med, Llc,. No. ME�0§9e.,
Note: All organizations that are not licensed ISM 8 providers must obtain the signature of the medical director of the
licensed WS provider responsible for EMS servlce8 in their area of operation for proloots,theit Involve medicaf
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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).
ITEM 10. Justification Summar 3y Pages
A) Problem Description: Miami Fire Rescue (MFR) Is currently utilizing a number of stretchers that do not meet the increasing
needs of the community and have a plethora of issues. They are deteriorated, constantly in need of repair,, obsolete, in poor
condition and lack vital functions needed In the care and safe transport of patients. MFR is not able to purchase new stretchers
for all of its fire stations, therefore, stations are equipped with either an obsolete set of stretchers lacking enhanced capabilities
or a set of updated stretchers with enhanced capabilities. Responders are only trained in using the stretchers at their respective
stations and inconsistencies in the stretchers impede front line standardization. When working with stretchers on which they
have not been trained responders are less adroit. These issues compromise MFR's: ability to provide the highest level of care
to the citizens of Miami and cause delays in patient transport and result in an extensive amount of back and shoulder injuries to
MFR's members, The stretchers' lack of enhanced capabilities, such as mechanisms to facilitate a variety of key tasks,
including movement, adequate stretcher height adjustment and effective loading and unloading from the rescue patient
compartment'. Adverse events occur during ambulance stretcher operations and result in significant Injury to patients and
rescue personnel. In 2015, a patient fell off a stretcher, resulting in a 2.5 million dollars settlement against the City of Miami,
MFR responders are critical in the rapid assessment, triage, on scene treatment and transport of voluminous patients in
Miami and in several other Miami -Dade County municipalities where it provides mutual aid and automatic aid. Existing
stretchers are not able to meet the needs of all the patients being served, particularly overweight individuals. Many of the over
100,000 EMS ,calls last year were to assist heavy patients; home to nearly 2.5 million residents, Miami -Dade (the county where
Miami is located) has a 67% rate of obesity7. In 2009, Miami was the most obese city in the U,S,2 In addition, Miami has a
disturbingly high mortality rate, which makes it critical to transport patients expeditiously and without delays. On several
occasions, our current stretchers' have caused transport delays when our rescue units had to call for an additional unit to assist
them in moving heavy patients. Furthermore, excessive malfunctions in stretchers regretfully cause an undue loss of precious
time3.
B) Present Situation: MFR provides both fire and EMS services, consisting of 27 fully staffed ALS rescue transport units and
over 24 other ALS and BLS non -transport units, Some of our stretchers are outdated, deteriorated, malfunction frequently and
require extensive servicing. They do not facilitate field portability and are not strong enough to handle large patient loads. They
lack enhanced capabilities such as mechanisms to facilitate a variety of key tasks including movement, adequate height
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adjustment and effective loading at rescues'. The stretchers limit and decrease the efficiency in MFR'S care of residents and
visitors.
In 2015 MFR transported 41,114 patients to hospital emergency departments and responded to over 100,000 EMS calls.
There were 32 injuries attributed to ineffective stretchers. These injuries equated to 4.5% of MFR total injuries and $66,970 in
workers' compensation claims, which equates to an over 63% increase in claims in the last two years. MFR'S obsolete
stretchers are an average of nine years old, .difficult to maintain and result in tens of thousands of stretcher maintenance/repair
costs, These costs divert funding away from other critical EMS supplies and equipment. In 2015, stretcher malfunctions
resulted in excessive costs related to patient injuries. Litigation costs due to people falling from the stretchers also severely
burden MFR. In 2015, the City paid a 25 million dollars lawsuit settlement for a claim a patient's injuries resulted from a fall off
an MFR stretcher. Further, levers malfunction at times, rendering stretchers dysfunctional and requiring several lifts and non -
ergonomic movements to' lift patients into rescue vehicles, thus resulting in unnecessary injuries to MFR personnel, These
stretchers lack sturdiness and the ability to transport obese patients forcing MFR to constantly call and wait upon other units to
arrive and assist with transport, This results in critical delays in hospital arrival and treatment and increases the chance of
permanent injury and death3.
Cj Proposed Solution; It is imperative that MFR provides 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 20 battery powered hydraulic
stretchers to ensure EMS units do not lose their ability to safely transport patients and are not at risk of endangering patients'
lives and safety by having to wait on assistance in patient transport, Without these stretchers, many of the emergency victims
treated during MFR's over 100,000 EMS calls will not have the rapid lifesaving transport they require. These stretchers will
include a hydraulic lift system with manual backup, oversized expandable surface to support a variety of patient sizes, steering
locks and several other features to ensure effective service to all of our residents, visitors and members, These stretchers will
allow for increased .chances of survival for patients by providing enhanced transporting capabilities and afford MFR members
the ability to safely transport patients without the risk of injury.
D) Consequences If Not Funded; Without this grant, MFR will not be able to fund this project, patient lives may be
endangered and patients and members .will be at risk of injury, Workers' compensation claims for stretcher related injuries "and
legal costs from patient injuries will continue to rise and further deplete MFR's budget and funds available for EMS services and
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patients. These stretchers are continuously out of service for repairs, are deteriorated, obsolete, in poor condition and lack vital
functions. If this continues, MFR's ability to provide the highest level of care to Miami's citizens and visitors will be compromised
and there may be delays in patient transport as well as extensive injuries to members, Furthermore, the stretchers do not
facilitate field portability and are not strong enough to handle large patient loads. They lack enhanced capabilities such as
mechanisms to facilitate a variety of key tasks. These new stretchers are the difference between life and death, Unfortunately,
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 square miles with about 430,332 residents,
Daily, the population swells to over 1 million during working hours. Current vulnerabilities are: 1) High rate of 111 -health due to
poverty: Miami has a 29.9% poverty rate4 and the nation's second -lowest median incomes ; 2) High rate of elders: The City
ranks third in the nation in seniorsfi.(over age 65) who comprise 16% of the total population; 3) High rate of obesity: Miami -
Dade County has a 67% rate of obesity; 4) Mutual Aid 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 of equipment. MFR anticipates units will arrive in four to five weeks from the date ordered; Month 6 to 7: training of
700 plus firetighterslparamedics and; Month 8 implementation of units into service and record and evaluate the positive effects
of the newly acquired stretchers,
C) Data Sources: (1) Ambulance Stretcher Adverse Events, htip://www.heaithoarosystemsengineering.com
Idown load s/Wang-AmbuIan ce%o20Stretch ers.,pdf; (2) Most Obese Cities in the U.S., http:llwww.lowdensity lifestyle.com/the-
most- obese -cities- 1 n-th e -u -s/ ; (3) Miami Department of Fire Rescue; (4) U.S. Census; (5) http://www.npr.Qrg/
2014/11/29L367,26897 /forel-dIlars•-fuel-aµnew-condo-now-ir7-m arni; (6)www.fgrbes.com Aging America: The U.S. Cities
Going Gray the Fastest; (7) Communities putting Prevention to Work, www,cdc.org.
H) Statement of Non -Duplication, With this funding, MFR will obtain reliable stretchers with necessary advanced capabilities
and establish new response capacity in MFR facilities. We received funding from the Florida EMS matching grant program in
2014 for 12 new stretchers. This "request is for 20 more stretchers, 1.2 not funded in 2014, five for additional ALS transport units
placed into service and three backups. This does not duplicate the work of any other grant funded initiative.
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DH FORM 1767 [2013]
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.
8) 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?
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ITEM 11. Outcome for Projects That Provide or Effect Direct Services to Emergency Victims; (2 PAGES)
A) Quantify Situation in Last 12 Months: From January 1, 2015 through December 31, 2015, MFR responded to over
100,000 incidents. Of those, 85,071 calls were EMS responses, during which stretchers were employed in the assessment and
treatment of 41,114 patients, During the lost 2 years, we had an over 63% increase in costs associated with lifting and.patient
movement injuries, which could have been prevented with battery powered hydraulic stretchers. In the last 12 months, this
equated to $66,970 in workers compensation claims and a total of 148 days that injured personnel were unable to work in
emergency response positions. In 2015, the City paid 2.5 million dollars for a lawsuit which claimed a patient's injuries resulted
from a fall off an MFR stretcher, 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, cardiac and other events and Intensifies our need for
stretchers which allow the safe and rapid transport of patients.
MFR had several issues with its obsolete stretchers. 'They are constantly removed from service to undergo repairs,
have become unreliable, are in poor condition and lack vital functions needed in the care of patients. These issues impede
MFR's ability to provide the highest. level of care to citizens, cause injuries and delays patient transport, The stretchers do not
facilitate field portability and are not strong enough to handle'large patient loads, increasing the need for functional and reliable
stretchers for MFR's daily use. MFR'S use of obsolete stretchers in some stations and the latest type stretchers in others,
impedes frontline standardization and causes inefficiencies. Miamihas a significant number of high risk patients, a plethora of
EMS responses and an array of calls necessitating effective stretchers, These critical issues make it imperative that all of
MFR'S stretchers are, functional and reliable to effectively serve and decrease the risk of Injury and death of our residents,
visitors and firefighters,
C3) Data of Change with Project Implementation; Equipping all ALS vehicles with battery powered hydraulic stretchers will
result in front line standardization and ensure that MFR can safely, effectively and efficiently perform lifesaving transport and
assessments on over 100,000 EMS calls MFR responds fo annually; We expect to,decrease stretcher and patient lifting
related injuries by -over 90%, as this has been exhibited in studies where agencies acquired these stretchers. This would result
in an over 90% ($60,273) decrease in costs associated with these injuries, a 90% (133 days) decrease in staffing shortages
due to lifting and patient moving injuries, an over 4,5% decrease in MFR total injuries, an almost 100% decrease in litigation
costs associated with patient injuries due to stretcher malfunctions, decreased transport times overall, a four minute average
3
decrease in transports that would have required additional assistance (significantly improving patient survival), a 100%
decrease in stretcher maintenance costs and assure MFR is afforded the ability to transport patients of all sizes easily and
effectively with personnel already on scene. More funding would be available for EMS equipment and training to save lives. We
expect to have zero patient stretcher related injuries, Statistics exhibit an over 90% improvement in injuries and having all new
functional stretchers under warranty will eliminate maintenance costs. Recent litigation costs due to stretcher malfunctions could
have been avoided with new stretchers, thus assuring .available monies for integral EMS services. Yearly, MFR's calls and
population served increase significantly. This project is critical to MFR's efforts in effectively serving our community and in
decreasing mortality in Miami. Residents, visitors and members will be better protected; there will be an extensive increase in
quality of care and better service; and members' health will be better protected. There will be more expeditious lifesaving
treatment as stretcher malfunction delays will be eliminated; intubations, CPR and other lifesaving procedures will be more
effectively performed with these stronger, sturdier stretchers which can easily carry the weight of life saving equipment
C) Justification and Explanation of Above Data: information,given in question (A) and (B) was obtained using data from the
Miami Fire -Rescue Department data collection system and the article, "The Impact of Gurney Design on EMS Pergonnel".
D) Additional outcomes: The funding of this project will result in the improved transportation and wellbeing of obese patients
by providing stretchers with enhanced abilities.to support and transport them in a timely and efficient manner. It will alleviate the
burden of increasing call volumes and serious logistical issues posed by the growing number of people, particularly obese
people in Miami, It will improve MFR's ability to provide mutual aid. MFR morale and confidence will also be improved as the
new stretchers will reduce chronic back problems when our members respond to over 100,000 calls, MFR will also be able to
provide citizens and visitors with consistent state of the art treatment. The new stretchers are extremely durable, safer and
have been baffle tested by several other agencies in South Florida.
E) Integration into Agency's Five Year Pian: MFR'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 MFR's goals. In
addition, our plan includes improving the wellness and health of our members, These stretchers will effectuate this by lessening
the likelihood and frequency of injury and by achieving front line standardization. This is critical when statistics show that one in
four RMS providers suffer a career -ending injury in their first four years on the job (htfp://www.ems1.com/ems-productslpatient-
1 handling/articles11371825-A=virtual-plague-could-becoming-to-EMS/).
F'
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DH FORM 1767 [2013]
Skip Item 14 and go to [tern 15, unless your project is research and evaluation and you have not
completed the preceding Justification
ALL APPLICANTS MUST COMPLETE ITEM 15,
15. Statutn
Y-h-e-Collowng are based on e.401. 1 401117'F,8. Use
nomore than one .additional double spaced page tncomplete this item. Write N/A for those things |nth|osection
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 bylaw orrule ofthe
department.
CA Enable the vehicles ofyour organization bocontain atleast the minimum equipment and supplies aerequired
bvlaw, rule urregulation ofthe department.
D\ Enable the vehicles nfyour organization tuhave, atm m(n|[oum, a direct communications |(nkupwith the
operating base and hospital designated osthe primary receiving facility.
E) Enable your organization bzimprove orexpand the provision of:
1 EMS services unacounty, multi county, orarea wide basis.
Single EMS provider orcoordinated methods ofdelivering services.
3> Coordination of all EMS communication links, with police, fire, emergency vehicles, and other related
ann/ioey.
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15. Statutory Considerations and Criteria (1 PAGE):
A) Serving, the Requirements of the Population of Miami: The purchase of these stretchers would serve the needs of the
over 1,000,000 people who live and visit Miami daily by providing effective, safe transport to hospitals, Also, it will provide the
effective transportation and life-saving acute medical care necessary when treating critically injured people
(http://www,nobi,.nim,nih.gov/pubmedl22792181). Miami has a critical need for these stretchers due to its voluminous number of
transports and the large number of obese residents that live here. These stretchers will also reduce transport times through
effective loading and unloading of patients of all sizes..
8) Enabling of Emergency Vehicles to Conform to Standards: This funding will assist MFR in meeting Goal 9 of the Florida
EMS Strategic Pian 2012 -- 2014 to, "increase access to care by improving patient safety, responder safety, and the safety of
the general public". The battery powered hydraulic stretchers will reduce the number of patient and personnel injuries by over
90%, therefore, extensively reducing workers compensation costs, litigation costs and transport times. Obtaining these new
stretchers will also allow MFR to conform to two new standards, NFPA 1917 and the CHAS GVS v1.0 standard, which will place
a new set of requirements on ambulance cots and equipment once they are accepted (anticipated in 2016)
(http://www.fern oems, com/—/media/site-us/P DFs/Ferno_SAE%20Executive%20Summary_v2.ashx),
C) Enable vehicles to contain minimum equipment and supplies: The new stretchers comply with the requirements of the
Florida Administrative Code 64J and well exceed our current system regarding patient safety. In addition, MFR requires that its
vehicles contain stretchers as a part of its minimum equipment requirement.
D) Enable vehicles communications: N/A
E) Enable your organization to improve or expand the provision of services: The acquisition of these stretchers will
exponentially improve MFR's ability to serve populations in the City of Miami and throughout the county. The improved capacity
to safely and expeditiously transport the numerous patients MFR transports each year, as well as the many obese patients MFR
transports will allow MFR to better protect its residents. The reduction in injuries will also facilitate increased longevity in the
careers of.MFR members and assure that healthy personnel are always available to assist residents and visitors,
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DH FORM 1767 r20131
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 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 Aftor Grant Starts
Be In end
Grant Acceptance (commission approval)
1 2
Bid Issuance and vendor selection
3 5
Purchase unit
5 6
Training
7 7
Unit Deployment
8 8
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
Not Ap licable
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DH FORM 1767 [2013]
18. Bud et:
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.
Casts
Justification: Provide a brief justification why each
of the positions and the numbers of hours are
necessary for this project.
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
category).
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,
TOTAL:
0.00
Right click on 0.00 then left click on "Update Field"
to calculate Total
13
DH FORM 1767 r26131
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.
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.
20 - Stretchers
$315,820
The units are sold at $15,791 each and are all
necessary to facilitate the goals of this grant.
Matching.; 75 Percent
$236,866.00
to calculate Total
Right click on 0.00 then left click on, "Update Field"
❑ Rural: 90 Percent
to calculate Total
0 00
Local Match Amount
(Check applicable program)
Right click on 0,00 then left click on "Update Field"
9 Matching: 25 Percent
78 955.00
to calculate Total
Right click on 0.00 then left click on "Update Field"
El Rural: 10 Percent
TOTAL:
$375.,_820.00
Right click on 0,00 then left click on "Update Field"
to calculate Total
State amount
(Check applicable program)
Rightclick on 0.00 then left click on "Update Field"
Matching.; 75 Percent
$236,866.00
to calculate Total
Right click on 0.00 then left click on, "Update Field"
❑ Rural: 90 Percent
to calculate Total
0 00
Local Match Amount
(Check applicable program)
Right click on 0,00 then left click on "Update Field"
9 Matching: 25 Percent
78 955.00
to calculate Total
Right click on 0.00 then left click on "Update Field"
El Rural: 10 Percent
0.00
to calculate Total
Grand Total
Right click on 0.00 then left click on "Update Field"
$.315 82,0 00
to calculate Total
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DH FORM 1767 [20131
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, Florida Statutes (F.S.), when received by the Florida Bureau of Emergency Medical
Oversignt. This includes material that 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 Emergency Medical Oversignt,
I accept that in the best interests of the state, the Florida Bureau of Emergency Medical Oversignt
reserves the right to reject or revise any and ail grant proposals or waive any minor irregularity or
technicality in proposals received, and can exercise that right.
1, the undersigned, understand and accept that the Notice of Matching Grant Awards will be advertised in
the Florida Administrative Register, 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. Nofunds 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
pl the attached grant terms and conditions and acknowledge this by pigning below.
Signet re of Authorized Grant Signer MM/DDi YY
(Individual Identified in Item 2)
DH FORM 1767 [20131
15
THE TOP PART OF THE THIS PAGE MUST ALSO BE COMPLETED AND,SIGNED--
FLORIDA DEPARTMENT OF HEALTH
EMS GRANT PROGRAM
In accordance with the provisions of Section 401.113(2)(b), F. S., the undersigned hereby request's 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: 1151 NW 7 St. 31 Floor
Miami, FL 33136
Federal Identification Number VF596000375
Authorized Agency Official:
pignature Date
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 notwrite below this line. For use by the Florida Emergency Medical Services Section
Grant Amount For State To Pay: $ Grant ID Code:
Approved By;
Signature of State EMS Grant Officer Date
State Fiscal Year: 2014 - 2015
Organization Code E.O. OCA obiect cod
64-61-70-30-000 03 SF003 750000
Federal Tax ID: VF
Grant Beginning Date:
DH FORM 1767P [2013]
Grant Ending Date:
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ATTEST:
Todd B. Hannon
City Clerk
APPROVED AS TO FORM AND
CORRECTNESS:
Victoria Mendez
City Attorney
THE CITY OF MIAMI, a municipal
Corporation of the State of Florida
Daniel J. Alfonso
City Manager
APPROVED AS TO INSURANCE
REQUIREMENTS:
Ann -Marie Sharpe, Director
Department of Risk Management