HomeMy WebLinkAbout2006-088 GRANT NAME: EMS County Awards Grant GRANT # // n
AMOUNT OF GRANT: $ 26 215 .00 0o b O a
DEPARTMENT RECEIVING GRANT: Emergency Medical Services
CONTACT PERSON: Brian Burkeen PHONE NUMBER: 772-562-2028 ext.3015
L How long is the grant for? 1 year Starting Date: FY 2005/06
2. Does the grant require you to fund this function after the grant is over? Yes X No
3. Does the grant require a match? Yes X No
If yes, does the grant allow the match to be In Kind Services? Yes --K—No
4. Percentage of match 0%
5. Grant match amount required $
6. Where are the matching funds coming from (i.e. In Kind Services; Reserve for Contingency)?
7. Does the grant cover capital costs or start-up costs? Yes No
If no, how much do you think will be needed in capital costs or start up costs
(Attach a detail listing of costs) $
8. Are you adding anadditional positions utilizing the grant funds? Yes X No
If yes, please list. ff additional space is needed, please attach a schedule.)
Acct. Description Position Position Position Position Position
011 . 12 Regular Salaries
011 . 13 Other Salaries & Wages (PT)
012. 11 Social Security
012. 12 Retirement-Contributions
012. 13 Insurance-Life & Health
012. 14 Worker's Compensation
012. 17 S/Sec. Medicare Matching
TOTAL
9. What is the total cost of each position including benefits, capital, start-up, auto expense, travel and operating?
Salary and Benefits Operating Costs Capital Total Costs
10. What is the estimated cost of the grant to the county over five years? $
Grant Other Match Costs
Amount Not Covered Match Total
First Year $ $ $ $
Second Year $ $ $ $
Third Year $ $ $ $
Fourth Year $ $ $ $
Fifth Year $ $ $ $
Signature of Preparers Date: March 13 2006
n
GRANT APPLICATION
FLORIDA DEPARTMENT OF HEALTH
Bureau of Emergency Medical Services
Complete all items
ID. Code (The State Bureau of EMS will assign the ID Code — leave this blank) C
I . County Name: Indian River County
Business Address: 1840 2r Street Vero Beach Florida 32960
-Telephone: 772 567-2154
Federal Tax ID Number (Nine Digit Number) . VF 59 - 60006764
2. Certification : (The applicant signatory who has authority to sign contracts, grants,
and other legal documents for the county) I certify that all information and data in this
EMS county grant application and its attachments are true and correct. My signature
acknowledges and assures that the County shall comply fully with the conditions
outlined in the Florida EMS County Grant Application .
- Signature: Date :
Printed Name: Arthur R. Neuberger
Position Title : Chairman , Board of County Commissioners
3. Contact Person : (The individual with direct knowledge of the project on a day-to-
day basis and has responsibility for the implementation of the grant activities. This
person is authorized to sign project reports and may request project changes. The
signer and the contact person may be the same . )
Name : Brian S . Burkeen
Position Title: Assistant Chief
Address: 1840 25n Street Vero Beach Florida 32960
Telephone: 772 562-2028 X 3015 1 Fax Number: 772 770-5147
E-mail Address : bburkeen@ircgov.com
4. Resolution: Attach a current resolution from the Board of County Commissioners
certifying the grant funds will improve and expand the county pre-hospital EMS system
and will not be used to supplant current levels of county expenditures.
5. Budget: Complete a budget page(s) for each organization to which you shall provide
funds.
List the organization (s) below. (Use additional pages if necessary)
Indian River County Department of Emergency Services
DH Form 1684, Rev. June 2002
BUDGET PAGE
A. Salaries and Benefits :
For each position title, provide the amount of salary per hour, FICA per hour, other
fringe benefits, and the total number of hours. Amount
TOTAL Salaries N/A
TOTAL FICA NIA
Grand total Salaries and FICA N/A
B. Expenses: These are travel costs and the usual, ordinary, and incidental expenditures
by an agency, such as , commodities and supplies of a consumable nature excluding
expenditures classified as operating capital outlay see next category) .
List the item and, if applicable, the quantity Amount
NIA
TOTAL N/A
C. Vehicles, equipment, and other operating capital outlay means equipment, fixtures, and
other tangible personal property of a non consumable and non expendable nature with a
normal expected life of one 1 ) year or more.
List the item and, if applicable, the quantity Amount
Obese Ambulance Capital Equipment ram s, winches, etc. $49500. 00
ALS En irle Start Up Equipment (quantity 2 $ 12,000.00
Web Quiz Internet Testing Software $700.00
50 Patient MCI Cache for Disaster Pre-Planning $127000.00
TOTAL $29,200.00
GRAND TOTAL $29 ,200.00
DH Form 1684, Rev. June 2002
DEPARTMENT OF HEALTH
EMS GRANT PROGRAM
REQUEST FOR GRANT FUND DISTRIBUTION
In accordance with the provisions of Section 401 . 113(2)(a) , 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: Indian River County Board of County Commissioners
Mailing Address: 1840 25th Street Vero Beach Florida 32960
Federal Identification number VF 59- 00674
Authorized Offici I : - 21 - 06
Signat
-
Signat Date
Arthur R. Neuberger, Chairman B d of County Commissioners
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
64-25-60-00-000 N N2000 7
Federal Tax ID: VF
Grant Beginning Date: October 1 , Grant Ending Date: September 30,
DH Form 1767P, Rev. June 2002
FLORIDA DFPARTNfENT OF
it � 7
FLORIDA DEPARTMENT OF HEALTH
BUREAU OF EMERGENCY MEDICAL SERVICES
EMS COUNTY GRANT PROGRAM
APPLICATION PACKET
Revised: June 2002
TABLE OF CONTENTS
Description of Program 1
County Grant Process 1
Application 3
Request for Grant Fund Distribution 5
EMS Grant Program Change Request 6
EMS Grant Program Expenditure Report 7
General Conditions and Requirements 8
Financial 8
Rollovers 8
Disallowed Expenditures 9
Vehicles and Equipment 9
Transfer of Property 9
Requests for Change 9
Supplanting Funds 9
Deposit of Funds 10
Reports 10
Grant Signature 10
Records 10
Final Reports 10
Communications Equipment 10
Expenditures 11
Credit Statement 11
Financial and Compliance Audit Requirements 11
State Funded 11
Submission of Audit Reports 12
Records Retention 13
DESCRIPTION OF PROGRAM
OVERVIEW:
The Department of Health , Bureau of Emergency Medical Services (EMS) is authorized by
Chapter 401 , Part 11 , F . S. , to dispense grant funds. Forty-five (45) percent of these funds are
made available to the 67 boards of county commissioners (BCCs) to improve and expand
prehospital EMS systems in their county.
On-going costs for EMS and replacement of equipment cannot be funded under this grant
program. These costs remain the responsibility of the counties and EMS agencies and
organizations.
ELIGIBILITY:
EMS County grants are awarded only to BCCs. However, each BCCs is encouraged to
assess its countywide EMS needs and establish priorities before submitting a grant
application . The assessment should be coordinated with area EMS councils, when available.
COUNTY GRANT PROCESS
APPLICATION FORM :
BCCs must copy and complete the form titled "EMS County Grant Application, DH Form 1684 ,
June 2002". The BCCs will return the county grant application and resolution ( item 5 on the
application) to the department.
NOTICE OF GRANT AWARD:
The Department shall send a Notice of Grant Award letter to the BCCs. This is the BCCs
official notice that its grant application has been approved for funding . The letter and its
attachments will include the amount of the award , the beginning and ending dates of the grant,
due dates for required reports, the approved budget, and additional grant conditions, if any.
1
APPLICATION SUBMISSION :
The BCCs must submit:
1 . A completed application (DH Form 1684 , June 2002) with original signatures of the
authorized county official.
2. A county resolution certifying the EMS county grant funds received shall be used to
improve and expand prehospital EMS and that the funds will not be used to supplant
existing county EMS budget allocations (item 4 in the application).
A complete EMS County Grant packet consists of the above two items. No copies are
required .
Mail the application to:
County Grant
Emergency Medical Services
4052 Bald Cypress Way, Bin C18
Tallahassee , Florida 32399-1738
Retain this application packet because it contains the grant conditions and requirements, and
other information and forms needed .
2
EMS COUNTY GRANT APPLICATION
FLORIDA DEPARTMENT OF HEALTH
Bureau of Emergency Medical Services
Complete all items
ID Code (The State Bureau of EMS will assign the ID Code — leave this blank) C
1 . County Name:
Business Address:
Telephone: (000) 123-4967
Federal Tax ID Number Nine Digit Number). VF 123-45-6789
2. Certification : (The applicant signatory who has authority to sign contracts, grants, and other legal
documents for the county) I certify that all information and data in this EMS county grant application and
its attachments are true and correct. My signature acknowledges and assures that the County shall
comply fully with the conditions outlined in the Florida EMS County Grant Application.
Signature: Date:
Printed Name:
Position Title:
3. Contact Person : (The individual with direct knowledge of the project on a day-to-day basis and has
responsibility for the implementation of the grant activities. This person is authorized to sign project
reports and may request project changes. The signer and the contact person may be the same.)
Name:
Position Title:
Address:
Tele hone: (000) 000-0000 Fax Number: (000) 000-0000
E-mail Address: abcdefg@zyx.wm
4. Resolution: Attach a current resolution from the Board of County Commissioners certifying the grant
funds will improve and expand the county pre-hospital EMS system and will not be used to supplant
current levels of county expenditures.
5. Budget: Complete a budget page(s) for each organization to which you shall provide funds.
List the organization(s) below. (Use additional pages if necessary)
DH Form 1684, Rev. June 2002
3
BUDGET PAGE
A. Salaries and Benefits:
For each position title, provide the amount of salary per hour, FICA per
hour, other fringe benefits, and the total number of hours. Amount
TOTAL Salaries
TOTAL FICA
Grand total Salaries and FICA
B. Expenses: These are travel costs and the usual, ordinary, and incidental expenditures by an
agency, such as, commodities and supplies of a consumable nature excluding expenditures classified
as oDeratinq capital outlay see next category) .
List the item and, if applicable, the quantity Amount
TOTAL $
C. Vehicles, equipment, and other operating capital outlay means equipment, fixtures, and other
tangible personal property of a non consumable and non expendable nature with a normal expected life
of one 1 year or more.
List the item and, if applicable, the quantity Amount
TOTAL $
Grand Total $
DH Form 1684, Rev. June 2002
4
FLORIDA DEPARTMENT OF HEALTH
EMS GRANT PROGRAM
REQUEST FOR GRANT FUND DISTRIBUTION
In accordance with the provisions of Section 401 . 113(2)(a) , 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:
Mailing Address:
Federal Identification number Fed ID
Authorized 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:
Orqanization Code E.Q. OCA Obiect Code
64-25-60-00-000 N N2000 7
Federal Tax ID: VF_ _ _ _ _ _ _ _ _
Grant Beginning Date: October 1 , Grant Ending Date: September 30,
DH Form 1767P, Rev. June 2002
5
Department of Health
EMS GRANT PROGRAM CHANGE REQUEST
Name of Grantee: Grant ID Code:
BUDGET LINE ITEM CHANGE FROM CHANGE TO
TOTAL $ Is
Justification For Change:
Signature of Authorized Official Date
For department use only.
Approved Yes F1 No Change No :
Departments Authorized Representative Date
DH Form 1684C, Rev. June 2002
6
Department of Health
EMS GRANT PROGRAM EXPENDITURE REPORT
Name of Grantee: Grant ID Code:
Time Period Covered: Beginning Date: 01101/2002 Ending Date: 01101/2002
Earned Interest: Amount $ ; as of _
Day Month Year
Final Report Check one): ❑Yes ❑ No
Major Line Items TOTAL
Approved Budget Expenditure by Major Line Item(s) $
TOTAL BUDGETED EXPENDITURES $
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 Form 1684A, Rev. June 2002
7
GENERAL CONDITIONS AND REQUIREMENTS
The EMS County grant general conditions and requirements are an integral part of the county
grant agreement between the agency/organization (grantee) and the state of Florida,
Department of Health (grantor or department). In the event of a conflict, the following
requirements shall always be controlling:
FINANCIAL
FUND ACCOUNTING :
All state EMS grant funds shall be deposited by the grantee in an account maintained by the
grantee, and assigned an unique accounting code designator for all grant deposits and
disbursements or expenditures thereof. All state EMS grant funds in the account maintained
by the grantee shall be accounted for separately from all other grantee funds.
USE OF COUNTY GRANT FUNDS:
All state EMS grant funds shall be used between the beginning and ending dates of the grant
solely for activities as outlined in the Notice of Grant Award letter, its attachments if any, and
the application including its budget with its revisions, if any, on file in the state EMS office.
The grantee is not restricted to staying within the line item amounts within the approved grant
budget. However, the grantee must adhere to the approved total grant budget. Any
expenditures beyond this budget are the full responsibility of the grantee.
ROLLOVERS
Any unencumbered EMS county grant program funds as of September 30, of each year ,
including interest, remaining in the assigned grantee account at the end of a grant period shall
be reported to the department. The grantee will retain these funds in the EMS County Grant
account and include them in a budget revision request after receipt of approval of their next
county grant application .
8
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 county grant expenditure shall be returned to the EMS county grant
account maintained by the grantee within 40 days after the department's notification. The
costs of disallowed items are the responsibility of the county.
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 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, June 2002 . The grantee shall obtain written approval from
the department prior to making the requested changes. The following changes must be
requested :
1 . Changes in the project activities.
2 . Redistribution of the funds between entities or equipment approved .
3. Establishing a new line item in the budget.
4. Changing a salary rate more than 10% .
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.
9
DEPOSIT OF FUNDS
County grant funds provided to an applicant shall be deposited in a separate account. 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.
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
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.
10
EXPENDITURES
No expenditures may be incurred prior to the grant starting date or after the grant ending date .
Rollover funds may be used to meet expenditures prior to receipt of current year funds.
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.
FINANCIAL AND COMPLIANCE AUDIT REQUIREMENTS
This is applicable, if the provider or grantee, hereinafter referred to as provider, is any local
government entity, nonprofit organization , or for-profit organization. An audit, performed in
accordance with section 215.97 , F. S . by the Auditor General shall satisfy the requirement of
this attachment.
STATE FUNDED
This part is applicable if the provider is a nonprofit organization that expends a total of
$ 100,000 or more in funds from the department during its fiscal year, which was not paid from
a rate contract based on a set state or area-wide fixed rate for service, and of which less that
11
$300 ,000 is federally funded . The determination of when a provider has "expended" funds is
based on when the activity related to the award occurs.
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. The financial statements
shall disclose whether or not the matching requirement was met for each applicable 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 . If the grantee receives funds from a
grants and aids appropriation, the provider 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. Department of Health
Office of the Inspector General
4052 Bald Cypress Way, Bin A03
Tallahassee, Florida 32399-1704
B. Department of Health
Bureau of Emergency Medical Services
County Grant Manager
4052 Bald Cypress Way, Bin C18
Tallahassee , Florida 32399-1738
C. Submit to this address only those audits performed or attestation statements
prepared in accordance with Section 215.97, F. S. :
Office of the Auditor General
Post Office Box 1735
Tallahassee , Florida 32302
12
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 five years from the date the audit report is issued ,
unless extended in writing by the department,
13
r ,
RESOLUTION NO. 200& 041
A RESOLUTION OF THE EMERGENCY SERVICES DISTRICT BOARD OF
COMMISSIONERS, INDIAN RIVER GOUTY, FLORIDA, AUTHORIZING THE
APPLICATION FOR FUNDING COUNTY EMERGENCY MEDICAL SERVICES
(EMS) GRANT AWARDS TO BE SUBMITTED TO THE STATE OF FLORIDA
DEPARTMENT OF HEALTH, BUREAU OF EMERGENCY MEDICAL
SERVICES.
WHEREAS, The Florida Department of Health, Bureau of Emergency Medical Services announced that
applications for funding County Emergency Medical Services (EMS) Grant awards are now being accepted and a
grant application has been prepared for Indian River County; and
WHEREAS, an application for grant funds for fiscal year 2005/06 has been prepared by the County; and
NOW, THEREFORE, BE IT RESOLVED BY THE EMERGENCY SERVICES DISTRICT BOARD OF
COMMISSIONERS OF INDIAN RIVER COUNTY, FLORIDA, that the Chairman is authorized to sign and
execute the application for EMS grant funds certifying that monies from the EMS Grant Program For Counties will
improve and expand the County's pre-hospital EMS system and that the funds will not be used to supplant existing
County EMS budget allocations.
The foregoing Resolution was offered by Commissioner Lowther
Who moved its adoption. The motion was seconded by Commissioner Bowden and, upon being put to a
vote, the vote was as follows:
Chairman, Arthur R. Neuberger Aye
Vice Chairman, Gary C. Wheeler _Aye
Commissioner Wesley S. Davis _ A e
Commissioner Thomas S. Lowther Aye
Commissioner Sandra L. Bowden _Aye
The Chairperson thereupon declared the resolution duly passed and adopted this 21 st day of
March 2006.
EMERGENCY SEVICES DISTRICT
BOARD OF COMM SIONERS
Bit �x.Z s��9 Y, FLORIDA
Arthur R. NGeugerger, C
T:
Jeffrey K. Barton, Clerk
Approved as to form and I al
suffi
7
By /(j:
William K. eBraal
Assistant County Attorney