HomeMy WebLinkAbout20060498.tiff RESOLUTION
RE: APPROVE COLORADO EMS PROVIDER GRANT APPLICATION AND AUTHORIZE
CHAIR TO SIGN
WHEREAS,the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS,the Board has been presented with a Colorado EMS Provider Grant Application
between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County,on behalf of the Weld County Department of Paramedic Services,
and the Colorado Department of Public Health and Environment,with terms and conditions being
as stated in said application, and
WHEREAS,after review,the Board deems it advisable to approve said application, a copy
of which is attached hereto and incorporated herein by reference.
NOW,THEREFORE,BE IT RESOLVED by the Board of County Commissioners of Weld
County,Colorado,that the Colorado EMS Provider Grant Application between the County of Weld,
State of Colorado, by and through the Board of County Commissioners of Weld County,on behalf
of the Weld County Department of Paramedic Services, and the Colorado Department of Public
Health and Environment be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said application.
The above and foregoing Resolution was,on motion duly made and seconded,adopted by
the following vote on the 15th day of February, A.D., 2006.
Eta
BOARD OF COUNTY COMMISSIONERS
WELD COU COLORADO
ATTEST: �, d' o/i�
i
. J. Geile, Chair
Weld County Clerk to the� '.
�1 ; EXCUSED
���� ii � 4 ���ti�,. ,' David E. Long, Pro-Tern
BY:
D uty Cle to the Board k
Wi IV -I. Jerke (���p
iAS TO F "�" V���
Robert D. Masden
to ey \\\1\e1)--
Glenn at /7- �!
Glenn Vaad
Date of signature: 3 l l �b(p
2006-0498
AM0018
CIO ` e
ATTACHMENT A
Fiscal Year 2007
Colorado EMS
0 Provider Grant
Application
Colorado Department of Public Health& Environment
HFEMSD—A2
4300 Cherry Creek Drive South
Denver, CO 80246-1530
CDPHE Use Only
Date Received Stamp
1. Legal Name of Agency 2. Federal Tax ID Number
Weld County Paramedic Services 84-6000813
DBA(Doing Business As—If Applicable)
Wcps
3. Grant Contact Person 4. Phone Numbers
Mr. Dave Bressler Day:97O-353-57OO Pager:97O-346-34O1
(Title) (First) (Last) Fax: 970-304-6408 E-mail:
dbressler@co.weld.co.us
5. Agency Mailing Address 6. Agency Street Address(Required for contract,P.O.Box not
1121 M Street accepted) 1121 M Street
City: Zip Code: City: Zip Code:
Greeley 80631- Greeley 8O631-
7. EMS Agencies are required to submit a 2006 Agency Profile before this application will be considered for funding.
Has this EMS Agency submitted the 2006 Agency Profile to the department?Yes
8. Legal Status of Agency/Organization (Mark all that apply:)
❑ Private Not For Profit 0 Private for Profit ® County/City Government
❑ State Agency 0 Special District ❑ Other:
9.Type of Service ®ALS O BLS ❑ Fire/Rescue ❑Training ❑ Other:
10. Is this a RETAC or statewide grant project? No 10a. List the county your
Note: Grants for RETAC or statewide projects will be reviewed by the SEMTAC only. agency is licensed in: Weld
11. Do you have any current grant requests to other agencies for the current budget year? 11a. List your RETAC
No Describe: Northeast
12.Multi-Agency Application—must read and follow multi-agency instructions New—Your RETAC will score your
❑Yes—This is a multi-agency application. application for 50%of your total
score. See instructions for details.
FUNDING REQUEST
13.The Grant Application assumes a 50/50 split between the state and agency. If a financial waiver application has been filled
out, your request could have an agency share of 10%, 20%,30%or 40%. Please indicate the cash match your agency will
provide for this request: 50 %
The values for the project area summary below will auto-populate from the request Categorys of the application.
PROJECT AREA SUMMARY: CDPHE Use
Total Category State Only
No more than 2 categories per application are allowed Cost Agency 50% 50% Amt Funded
Category I -Ambulance, Other Vehicle $147,212.00 73,606.00 73,606.00
Category II -Communications $0.00 0.00 0.00
Category III- Data Collection $0.00 0.00 0.00
Category IV—Defibrillation/Cardiac Monitor
O Medical Director Signature included(Required) $0.00 0.00 0.00
Category V-EMS Equipment $14,710.00 7,355.00 7,355.00
Category VI—EMS Training $0.00 0.00 0.00
Category VII- Extrication Equipment $0.00 0.00 0.00
Category VIII -Injury Prevention $0.00 0.00 0.00
Category IX-Other $0.00 0.00 0.00
1 of 23 pages
State Fiscal Year 2007 Application
2006-0498
ATTACHMENT A
Total Grant Request: $161,922.00 I $80,961.00 I $80,961.00
2 of 23 pages
State Fiscal Year 2007 Application
Agency Information
All applicants must complete this section.
Balance Sheet
for entire Agency listed on page 1, box 1
For 12 months ending: 12/31/2004 +Enter the date of your most current financials here -this date is a
default value, change if it does not match your record year
Note: Use this same accounting period throughout the financial information Category.
Accounting Method: Cash
On this page, you are led through the fields in a certain order when you press "Tab".
You can not use your mouse to navigate on this page.
Assets Liabilities
1. Unreserved Cash Accounts 38,724 12. Accounts Payable 304,362
2. Reserved Cash Accounts 13. Short Term Notes and Loans
3. Unreserved Investments 14. Long Term Notes and Loans 885000
4. Reserved Investments 15. Taxes payable
5. Held in trust for Pension Benefits 16. Payable Payroll Expenses
6. Real Estate and Buildings 104,224 17. Prepaid and Deferred Revenue
7. Equipment
❑ market value ® depreciated 760,201 Total Liabilities $1,189,362.00
value
8. Accounts Receivable 1,005,509 18. Define accounting method for Depreciation and Capital(Hit
Fl for help.): Cash
9. Prepaid Expenses
10. Inventory 19. List new Capital items purchased:
11. Other Assets 28,645
Total Assets $1,937,303.00 Net Worth
$747,941.00
Profit and Loss
for entire Agency listed on page 1, box 1
For 12 months ending: 12/31/2004 +For the financial period listed at the start of this Category
Income/ Revenues Expenses
20. Government 29. Operational Expense 634,885
21. Mil Levy% = enter dollar
revenues 30. Personnel Costs—salaries, benefits, etc. 2,927,436
22. Donations,Contributions,Bequests 31. Depreciation Expense 192,212
23. EMS Fee for Service 9,971,559 32. Debt Service
24. Fund Raising 33. Capital Expenditures
25. Interest& Dividends 34. Other Expenses 5,991,313
26. Grants—list sources: state 50,824 Define: BAD DEBIT, PUR SERV,
ems SUPPLIES, MISC
27. Subscription Program
28. Other Income: 8,955
Total Income $10,031,338.00 Total Expenditures $9,745,846.00
35. List new capital items purchased:
Profit or(Loss) I $285,492.00
3 of 23 pages
State Fiscal Year 2007 Application
Agency Information
All applicants must complete this section.
Rates and Collection
36. Does your agency charge for service? 37.Who processes this agency's billing and accounting? (Check Only 1)
®Agency 0 Contract Service O No billing/accounting
Service
Base Rate Medicare Allowable
38. BLS (Basic Life Support) non-emergent 1,110.00 217.96
39. BLS—Emergent 1,110.00 312.90
40.ALS1 (Advanced Life Support-Level 1) Non-emergent 1,110.00 249.61
41.ALS1 —Emergent 1,110.00 360.37
42.ALS2- non-emergent 1,380.00 512.77
43. SCT(Specialty Care Transport) non-emergent
44.SCT(Specialty Care Transport)emergent
45. PI (Paramedic ALS Intercept)non-emergent
46. FW(fixed Wing)—non-emergent
47. FW(fixed Wing)—emergent
48. RW(Rotary Wing)—non-emergent
49. RW(Rotary Wing—emergent
50.Treat and Release 1220.00
51. Mileage Rate—Urban 17.00
52. Mileage Rate—Rural 1 to 17 miles 17.00
53. Mileage Rage Rural 18 to 50 miles 17.00
54. Overall collection rate (Percentage): 31 %
EMS Portion of the Agency Budget
for the Agency listed on page 1, box 1, detail the budget allocated to EMS
For 12 months ending: 12/31/2OO44-For the financial period listed at the start of this Category
Income/ Revenues Expenses
55. Government 64. Operational Expense 634,885.00
56. Mil Levy% = enter 65. Personnel Costs—salaries, benefits, etc. 2,927,436.00
dollar revenues—
57. Donations,Contributions,Bequests 66. Debt Service
58. EMS Fee for Service 9,971,559.00 67. Capital Expenditures
59. Fund Raising 68. Depreciation Expense 192,212.00
60. Interest& Dividends 69. Other Expenses 5,991,313.00
61. Grants—List sources: state 50,824.00 Define: Bad debit, supplies, pur sere,
ems fixed charges
62. Subscription Program
63. Other Income: 8,955.00
Total Income $10,031,338.00 Total Expenditures $9,745,846.00
70. List new capital items to be purchased: RE-CHASIS OF TYPE III AMBULANCE
Projected Profit or(Loss) I $285,492.00
4 of 23 pages
State Fiscal Year 2007 Application
Agency Information
All applicants must complete this section.
Financial Narrative - REQUIRED
71. Please summarize below:
o Any information about your agency financials that will help evaluators understand your financial situation, such as
reserves or balances. If your board requires a specific balance or reserve for example, use this space to explain that.
o Explanations of unreserved cash accounts and investments, as well as reserved cash accounts or investments.
o Your cash match source.
o The issues which have dictated your choice for filing a financial waiver. Your comments should include explanations
of extenuating circumstances that have rendered financial hardship or other reasons for requesting a financial waiver.
(The numbers provided throughout section I are based on the fiscal year 2004. These facts
havebeen audited and are accurate. The 2005 financial records have been completed but have
not been audited.)
Weld County Paramedic Services (WCPS) is owned and operated by the Board of County
Commissioners of Weld County. The agency being an enterprise fund is solely responsible for its
budget and financial well being within the county. The agency serves over 4,000 square mile of
North / Northeastern Colorado. Operating as and enterprise of Weld County Government since
1989, WCPS is required to bill and collect all of their operational costs of providing advanced life
support treatment and transportation. The service area and customer base include a population
that is over 50% Medicare, Medicaid and medically indigent.
With the required changes placed on ambulance services in the Medicare / Medicaid fee
schedules and forced acceptance of assignment, coupled with eh changes in the Colorado No
Fault automobile insurance on collections rates, WCPS has experienced a decrease in their
collection rates from 39% to 31% in the last year. This year has been a transition year for WCPS;
the service has had to fill 4 FTE's due to increasing call volume and the need for better system
coverage. WCPS has continued to strictly monitor the budget along with decreasing certain
items, and continuing to electronically bill patients to address the revenue shortfall created by
these changes.
The result being a negative impact on our scheduled replacement of ambulances, along with the
inability to purchase needed EMS equipment. WCPS has had to lengthen the service life of our
ambulances and been unable to provide equipment to the Medical Operations Supervisor
essential equipment when responding alone within the county.
5 of 23 pages
State Fiscal Year 2007 Application
Agency Information
All applicants must complete this section.
Narrative describing your Agency's Structure and Service Area
72. Please use this area to describe your agency to someone from outside your area. Include a description of your district
proper, response area and the number of residents. Assume that the reader does not know the structure and staffing of
your agency,the terrain and roads of your area, and any special circumstances your agency contends with.
Weld County Paramedic Services (WCPS) provides advanced life support response, evaluation,
treatment and transport to the 230,000 citizens and numerous visitors throughout the 4,000
square miles of Weld County Colorado. This service is provided in cooperation with surrounding
ALS providers via mutual aid agreements along with the tiered response of first responders from
the fire departments operating throughout Weld County. Of the near 12,000 calls for service,
over 60% of the calls for service fall into the rural / frontier areas, county roads and highways of
Weld County. The other 40% of calls occur within the city of Greeley.
Advanced Life Support coverage is provided through the fluid deployment of five ambulances
during the day and four ambulances from 2200 to 0600, via fixed stations and system status
placement of resources throughout Weld County. Operating with 38 full time field staff and an
office and administrative staff of 8 Weld County operates as and enterprise of Weld County
Government, billing and collecting all costs of operation.
6 of 23 pages
State Fiscal Year 2007 Application
Category I — Ambulance, Other Vehicle Request
Complete this category if your grant request includes an ambulance or other vehicle (maximum
of two categories per grant request).
ALL VEHICLE REQUESTS MUST INCLUDE BIDS/QUOTES.
Request for Ambulance
1. 2.Type 3. Description 4.Total $ 5.Agency 6. State Share CDPHE Use
Qty Code Request Share 50% 50% Only
Amount Funded
2 T 111.2 wd RECHASIS OF 2 BRAUN 147212 73,606.00 73,606.00
TYPE III AMBULANCES
7. Is the vehicle requested above: ❑ new addition to inventory? ® Replacement vehicle?—>
7a. If this is a replacement vehicle,which unit number does it replace?21 and 22
1. 2.Type 3. Description 4.Total$ 5.Agency 6. State Share CDPHE Use
Qty Code Request Share 50% 50% Only
Amount Funded
0.00 0.00
7. Is the vehicle requested above: ❑ new addition to inventory? O Replacement vehicle?—>
7a. If this is a replacement vehicle,which unit number does it replace?
1. 2.Type 3. Description 4.Total$ 5.Agency 6. State Share CDPHE Use
Qty Code Request Share 50% 50% Only
Amount Funded
0.00 0.00
7. Is the vehicle requested above: ❑ New addition to inventory? [i Replacement vehicle?
7a. If this is a replacement vehicle,which unit number does it replace?
8. If the requested vehicle(s)is a replacement(s):
• What was the number of calls your agency was unable to respond to due to mechanical unavailability of the emergency
vehicle to be replaced?
• What will be done with the unit that is replaced?
9. Request for Related Equipment for Vehicle—Include the cost of radios, stretchers or equipment specific to stock a
new ambulance separately from the vehicle here. The updated prices for 2007 include lightbar, child safety seat,fire
extinguishers, running boards, mud flaps, paint package, strobe lights,warning triangles,towing devices and an onboard
power center, and those items should not be listed here.
Qty Description Price Total Request Agency State Share CDPHE Use
Each Share 50% 50% only
Amount Funded
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
Total related equipment cost 0.00 0.00 0.00
Total Vehicle Request—vehicle cost plus $147,212.00 73,606.00 $73,606.00
equipment
10. What is the average length of service in miles and or years of vehicles operated by your agency?4 YEARS OR
180,000 MILES
7 of 23 pages
State Fiscal Year 2007 Application
Category I — Ambulance, Other Vehicle Request
Complete this category if your grant request includes an ambulance or other vehicle (maximum
of two categories per grant request).
ALL VEHICLE REQUESTS MUST INCLUDE BIDS/QUOTES.
11. Please describe your agency's vehicle replacement program:
Weld County Paramedic Services (WCPS) has initiated a re-chassis program in which chassis
would be replaced and patient modules would be remounted. The first re-chassis occurred in
2004 and was a great success at an average savings of over $68,000 over the purchase of a new
ambulance. This project will continue until each of the 9 type III ambulances have been
remounted 3 times each. The vehicles with one remount are as follows in 2004 vehicles 16 and
18 were remounted and in 2005 vehicles 17, and 19 were remounted. At the present time we
have one vehicle being remounted for 2006 and it is vehicle 20. We will need to remount vehicles
21, 22, 23, 24 to complete the first cycle of the three remounts.
12. Vehicle request narrative- Please explain if this vehicle will be replacing any previously owned vehicles and
how the cost was determined, as well as any other information that would help an outside person understand
the needs of your vehicle request.
Weld County Paramedic Services (WCPS) is an agency of Weld County government that operates
as and enterprise fund. Funding is provided through fees for service only. The economy,
Medicare, and Medicaid cuts, tort law auto insurance and increasing costs are some of the major
factors that have negatively affected WCPS. Significant mandatory budget cuts have been met.
The management of WCPS continues to search for methods to operate more efficiently and
effectively.
In 1998 a decision was made to establish a program that would save and estimated $2.5 million
over the next 12 years. A re-chassis program was undertaken in which ambulances chassis would
be replaced and patient modules would be remounted. The first re-chassis occurred in 2004 at a
savings of approximately $68,000 over the purchase of a new ambulance. This project will
continue until each of the 9 type III ambulances have been remounted 3 times. This project will
require the remounting of 2 units this fiscal year. With considerations for inflation and
variations in the requirements of each specific unit it is estimated that the cost of remounting 2
chassis this year will be $150,000.
WCPS respectfully requests matching funds from the state for our re-chassis project. This
program of remounting ambulances is a responsible and effective utilization of funds that are
increasingly difficult too obtain. It is but one of many methods by which WCPS strive to maintain
the highest quality emergency service with less financial resources.
8 of 23 pages
State Fiscal Year 2007 Application
Category II — Communications Requests
Complete this category if your grant request includes communications equipment(maximum
of two categories per grant request).
1. EXISTING COMMUNICATIONS SYSTEM PROFILE
Agency Primary Operational Frequencies
Purpose
Transmit Receive CTCSS(Hz)or FCC Call Name or Use of Channel (Dispatch,Fire,EMS,
(MHZ) (MHZ) DPL(Code) Sign (i.e.,Smith County Dispatch/Fire/EMS) Mutual Aid, Medical)
VHF (150)
VHF (150)
UHF (450)
UHF (450)
Med Ch
Med Ch
800 MHZ: 0 Trunking -list system: ❑ Other- describe:
Pager and Alerting Information (required for all requests for pagers, paging portables, and alerting monitors)
2. Does your agency use a commercial service to provide paging? If yes, list service:
3a. If your agency does not use a commercial paging service,check the box that describes service provider:
0 Government 0 Agency Owned ❑ Other:
3b. Receiver Frequency Used to Receive Pages: MHZ
Communications Equipment Inventory— list number of units by type
UHF VHF 800 MHZ
0-5 years 6-10 years 11+years 0-5 years 6-10 years 11+years 0-5 years 6-10 years
4. Portables
5. Mobiles
6. Pagers
7. Request for Communications Equipment
For communications systems requests, provide the name and contact information for the individual responsible for
answering questions regarding specifications.
Communications Contact Name Phone Number E-mail
8. Qty 9. Description 10. Price Each 11.Total 12. Agency 13. State CDPHE Use Only
Request Share 50% Share 50% Amount Funded
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
Total Communications Request $0.00 0.00 0.00
9 of 23 pages
State Fiscal Year 2007 Application
Category II — Communications Requests
Complete this category if your grant request includes communications equipment(maximum
of two categories per grant request).
Communications Narrative
Note: For major communications projects, insert separate page or pages that include a functional diagram of the proposed
system and a copy of the communications plan if one exists. If you have vendor quotes that you have used to prepare this
request, please include those following this page.
10 of 23 pages
State Fiscal Year 2007 Application
Category Ill — Data Collection Requests
Complete this category if your grant request includes equipment for participation in the state
EMS Data Collection Project(maximum of two categories per grant request).
Data Collection
4.Total 5.Agency 6. State Share CDPHE Use Only
1. Qty 2. Description 3. Price Each Request Share 50% 50% Amount Funded
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
Total Data Collection Request $0.00 0.00 0.00
7. Data Collection Request Narrative:
11 of 23 pages
State Fiscal Year 2007 Application
Category IV — Defibrillator / Cardiac Monitor Requests
Complete this category if your grant request includes defibrillators or cardiac monitors
(maximum of two categories per grant request).
ALL DEFIBRILLATOR REQUESTS MUST INCLUDE BIDS/QUOTES, LETTER OF SUPPORT
FROM MEDICAL DIRECTOR, AND MEDICAL DIRECTOR SIGNATURE ON LAST PAGE.
Defibrillation History Information
1. Number of EMS runs in the past 2 years that were cardiac arrests:
2. Number of EMS runs in the past 2 years that were witnessed arrests:
3. Number of CPR starts that took place on your EMS runs in the past 2 years:
4. BLS average response time to scene: minutes 5. ALS average response time to scene: minutes
6. Telephone CPR? ❑ Yes ❑ No 7. Citizen CPR Program? ❑ Yes ❑ No
8. Agencies intending to purchase cardiac equipment must have the approval signature of their Medical Director on the
attest form to be mailed in, or attach a letter from their Medical Director approving their request.
9.Emergency Medical Equipment owned by your agency
1.3 years old 4 + years old
Manual Defibrillators
Semi-automatic defibrillators
Defibrillation Request Information
10. 13. Total 14. Agency 15. State Share CDPHE Use only
Qty 11. Description 12. Price Each Request Share 5O% 5O% Amount Funded
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
Total Defibrillation Request $0.00 0.00 0.00
16. Defibrillation Narrative:
12 of 23 pages
State Fiscal Year 2007 Application
Category V — EMS Equipment Request
Complete this category if your grant request includes EMS equipment(maximum of two
categories per grant request).
EMS Equipment Request Category
1. Qty 2. Description 3. Price Each 4. Total 5.Agency 6. State Share CDPHE Use Only
Request Share 50% 50% Amount Funded
ZOLL AUTO
1 PULSE 14,710.00 14,710.00 7,355.00 7,355.00
SYSTEM
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
Total EMS Equipment Request $14,710.00 7,355.00 7,355.00
13 of 23 pages
State Fiscal Year 2007 Application
Category V — EMS Equipment Request
Complete this category if your grant request includes EMS equipment(maximum of two
categories per grant request).
7. EMS Equipment Request Narrative
Note: It is recommended that narratives include descriptions of plans to train staff on use of equipment, plans to
financially and physically maintain equipment, and an estimation of frequency of use of the equipment.
Weld County Paramedic Services (WCPS) provides advanced life support response, evaluation,
treatment and transport to the 230,000 citizens and numerous visitors throughout the 4,000
square miles of Weld County Colorado. This service is provided in cooperation with surrounding
ALS providers via mutual aid agreements along with the tiered response of first responders from
the fire departments operating throughout Weld County. Of the near 12,000 calls for service,
over 60% of the calls for service fall into the rural / frontier areas, county roads and highways of
Weld County. The other 40% of calls occur within the city of Greeley.
Advanced Life Support coverage is provided through the fluid deployment of five ambulances
during the day and four ambulances from 2200 to 0600, via fixed stations and system status
placement of resources throughout Weld County. Operating with 38 full time field staff and an
office and administrative staff of 8 Weld County operates as and enterprise of Weld County
Government, billing and collecting all costs of operation.
WCPS have encountered a operational issue that in the past was a small problem and that is
being at level zero in our posting plan, which means that all ambulances are out and the on duty
supervisor is the only ambulance available. The supervisor runs by himself and responds to any
call for service within the county or mutual aid district. The problem we have encountered is
that fire departments are reluctant to drive the supervisor back to the hospital for two reasons,
first they have concerns about the insurance coverage issue, and second they do not have the
coverage to send a firefighter out of district. The calls that concern the supervisors are cardiac
arrests in those situations we can normally get a driver but are short handed in the back with
patient care and CPR. The supervisors run approximately 3 to 4 percent of the calls in the
system during the year. The supervisors also respond to all Echo's which statistically are mainly
cardiac arrests. WCPS is requesting funding for the purchase of one Zoll Autopulse for use within
our system and mutual districts. The Autopulse would be located on the supervisor ambulance
and would respond to all cardiac arrest situations to aid in the need for additional personnel
provided by the fire departments. The system would have the Autopulse at its discretion
regardless of which ambualnce responds to the call. WCPS maintains that this is the most fiscally
sound addition to our fleet; at the present time we cannot add any additional ambulances to the
street due to budget constraints. WCPS would maintain the Autopulse and in the states interest
would give feedback to the state on potential outcomes from the use of the Autopulse. WCPS
feels that this is a total win for the system in Weld County by providing needed equipment to run
cardiac arrestes more efficiently and lessen the burden required by the fire departments.
14 of 23 pages
State Fiscal Year 2007 Application
Category VI — EMS Training
Complete this category if your grant request includes EMS Training (maximum of two
categories per grant request).
EMS Training Request Category
Course/Class Name #of Cost per Total Agency State share CDPHE Use Only
students student Cost share 50% 50% Amount Funded
0.00 0.00 0.00
What are the proposed dates of the above course/class?
Where will the class be offered?
Who will conduct the training?
Name of approved Colorado training center:
How did you determine the number of students per class?
What is the tuition cost per student? O.OO
What costs other than tuition did you include in the class cost. Itemize and explain how you determined these.
Course/Class Name #of Cost per Total Agency State share CDPHE Use Only
students student Cost share 50% 50% Amount Funded
0.00 0.00 0.00
What are the proposed dates of the above course/class?
Where will the class be offered?
Who will conduct the training?
Name of approved Colorado training center:
How did you determine the number of students per class?
What is the tuition cost per student? O.OO
What costs other than tuition did you include in the class cost. Itemize and explain how you determined these.
Course/Class Name #of Cost per Total Agency State share CDPHE Use Only
students student Cost share 50% 50% Amount Funded
0.00 0.00 0.00
What are the proposed dates of the above course/class?
Where will the class be offered?
Who will conduct the training?
Name of approved Colorado training center:
How did you determine the number of students per class?
What is the tuition cost per student? O.OO
What costs other than tuition did you include in the class cost. Itemize and explain how you determined these.
Course/Class Name #of Cost per Total Agency State share CDPHE Use Only
students student Cost share 50% 50% Amount Funded
0.00 0.00 0.00
What are the proposed dates of the above course/class?
Where will the class be offered?
Who will conduct the training?
Name of approved Colorado training center:
How did you determine the number of students per class?
What is the tuition cost per student? 0.00
What costs other than tuition did you include in the class cost. Itemize and explain how you determined these.
Course/Class Name #of Cost per Total Agency State share CDPHE Use Only
students student Cost share 50% 50% Amount Funded
0.00 0.00 0.00
15 of 23 pages
State Fiscal Year 2007 Application
Category VI — EMS Training
Complete this category if your grant request includes EMS Training (maximum of two
categories per grant request).
What are the proposed dates of the above course/class?
Where will the class be offered?
Who will conduct the training?
Name of approved Colorado training center:
How did you determine the number of students per class?
What is the tuition cost per student? O.OO
What costs other than tuition did you include in the class cost. Itemize and explain how you determined these.
Course/Class Name #of Cost per Total Agency State share CDPHE Use Only
students student Cost share 50% 50% Amount Funded
0.00 0.00 0.00 0.00
What are the proposed dates of the above course/class?
Where will the class be offered?
Who will conduct the training?
Name of approved Colorado training center:
How did you determine the number of students per class?
What is the tuition cost per student? 0.00
What costs other than tuition did you include in the class cost. Itemize and explain how you determined these.
Course/Class Name #of Cost per Total Agency State share CDPHE Use Only
students student Cost share 50% 50% Amount Funded
0.00 0.00 0.00
What are the proposed dates of the above course/class?
Where will the class be offered?
Who will conduct the training?
Name of approved Colorado training center:
How did you determine the number of students per class?
What is the tuition cost per student? 0.00
What costs other than tuition did you include in the class cost. Itemize and explain how you determined these.
Course/Class Name #of Cost per Total Agency State share CDPHE Use Only
students student Cost share 50% 50% Amount Funded
0.00 0.00 0.00
What are the proposed dates of the above course/class?
Where will the class be offered?
Who will conduct the training?
Name of approved Colorado training center:
How did you determine the number of students per class?
What is the tuition cost per student? 0.00
What costs other than tuition did you include in the class cost. Itemize and explain how you determined these.
Course/Class Name #of Cost per Total Agency State share CDPHE Use Only
students student Cost share 50% 50% Amount Funded
0.00 0.00 0.00
What are the proposed dates of the above course/class?
Where will the class be offered?
Who will conduct the training?
Name of approved Colorado training center:
How did you determine the number of students per class?
What is the tuition cost per student? 0.00
What costs other than tuition did you include in the class cost. Itemize and explain how you determined these.
16 of 23 pages
State Fiscal Year 2007 Application
Category VI — EMS Training
Complete this category if your grant request includes EMS Training (maximum of two
categories per grant request).
uourse/Loss Name #of Cost per Total Agency State share CDPHE Use Only
students student Cost share 50% 50% Amount Funded
0.00 0.00 0.00
What are the proposed dates of the above course/class?
Where will the class be offered?
Who will conduct the training?
Name of approved Colorado training center:
How did you determine the number of students per class?
What is the tuition cost per student? 0.00
What costs other than tuition did you include in the class cost. Itemize and explain how you determined these.
Combined cost of all requested classes Total Agency State Share CDPHE Use Only
Share 50% 50% Amount Funded
Total Training Request $0.00 0.00 0.00
Training Request Narrative-
Please use the narrative section to describe your agency's method of determining who is eligible for training tuition
assistance. Describe any agreement you have with students in order to be eligible for tuition assistance, including
commitment to the agency. Please also describe how the agency's match will be obtained. Explain how your
agency will sustain a training program in future years. Include any other specifics that would help an outside person
understand the needs of your agency's training request.
17 of 23 pages
State Fiscal Year 2007 Application
Category VII — Extrication Equipment
Complete this category if your grant request includes extrication equipment (maximum of two
categories per grant request).
Extrication Equipment Information
1. List the location, distance,travel time and type(RS-10, Hurst, etc.)of nearest extrication equipment:
2. Do you have a written or verbal agreement to share extrication equipment?
3. List any other agencies that plan to share in the use of equipment bought with funding from this grant:
4. How many of your agency's EMS runs required extrication equipment in the past year?
5.Average time of extrication: minutes
6.Extrication Equipment
#Spreaders #Cutters # Rams #Air Bags
1 to 5 yrs
6+yrs
Extrication Equipment Request Information
CDPHE Use
10.Total 11. Agency 12. State Share Only
7. Qty 8. Description 9. Price Each Request Share 50% 50% Amount Funded
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
Total Extrication Request • $0.00 0.00 0.00
13. Extrication Narrative
18 of 23 pages
State Fiscal Year 2007 Application
Category VIII — Injury Prevention Request
Complete this category if your grant request includes injury prevention (maximum of two
categories per grant request).
Injury Prevention
4.Total 5. Agency 6. State Share CDPHE Use Only
1. Qty 2. Description 3. Price Each Request Share 50% 50% Amount Funded
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
Total Injury Prevention Request $0.00 $ 0.00 $ 0.00
7. Injury Prevention Request Narrative:
Injury Prevention (background information on planning, implementing and evaluating injury
prevention programs is available at http://www.cdphe.state.co.us/em/SEMTAC/ipac/IP 03-
08finalstrategicplan.pdf and www.cdphe.state.co.us/ps/bestpractices/bestpracticeshom.asp )
19 of 23 pages
State Fiscal Year 2007 Application
Category IX — Other
Complete this category if your grant involves any other project (maximum of two categories
per grant request).
Other Request Category
1. Qty 2. Description 3. Price Each 4. Total 5.Agency 6. State Share CDPHE Use Only
Request Share 50% Amount Funded
50%
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
Total Other Request $0.00 $ 0.00 $ 0.00
7. Other Request Narrative:
20 of 23 pages
State Fiscal Year 2007 Application
Colorado EMS IMPORTANT-One copy of this entire signed
application,the W-9,and any attachments,
bid quotes and letters of support must be
Provider Grant mailed to:
CDPHE
Attest Form Attention EMS Grants
HFEMSD-A2
4300 Cherry Creek Drive South
Colorado Department of Public Health& Environment Denver,CO 80246-1530
HFEMSD—A2
4300 Cherry Creek Drive South
Denver, CO 80246-1530
1. Legal Name of Agency 2. Federal Tax ID Number ❑ Yes, I have attached my W-9 Form
Weld County Paramedic Services 84-6000813
DBA(Doing Business As—If Applicable)
We in;
3. Grant Contact Person 4. Phone Numbers
Mr. Dave Bressler Day: 970-353-5700 Pager:970-346-3401
(Title) (First) (Last) Fax: 970-304-6408 E-mail: dbressler@co.neld.co.us
.
5. Agency Mailing Address 6. Agency Street Address(Required for contract, P.O.Box not
1121 M Street accepted) 1121 M Street
City: Zip Code: City: Zip Code:
Greeley - 80631- Greeley 80631
Authorized Agent
The individual whose name and signature appear below, has been designated by the agency/organization listed above as the
Authorized Agent to complete and submit this grant application on its behalf. The agency/organization agrees to comply with the
rules and regulations governing the State of Colorado EMS Grants Program concerning grant requests.
Financial Information
1. The Authorized Agent attests to the agency or organization's ability to provide the matching funds (50%,40%, 30%,20%or
10%)to complete the purchase of the grant award,should the agency be awarded state funds.
2. The Authorized Agent is aware that EMS vehicles and equipment purchased must be without any financial liens and
without the item being used as collateral to secure a loan of any kind.
3. The Authorized Agent attests that,to the best of his/her knowledge,the information contained herein,with regard to the
Agency's financial condition, is true,accurate and correctly reflects the financial condition of the agency/organization.
Notification of Affected Entities
By signing below, the Authorized Agent also attests to the fact that:
4. The agency(ies)/organization(s) affected by the possible outcome of this grant request, including but not limited to
agencies/organizations listed in this application if it is a multi-agency application, has(have) been notified and has(have)
agreed to its submission.
21 of 23 pages
State Fiscal Year 2007 Application
Applicant Duties and Obligations Should Funding be Awarded
Should the agency/organization listed in this application receive funding under this grant application, the agency/organization
(hereinafter referred to as"grantee")shall,and affirmatively promises to,comply with all of the provisions set forth in items 5-8
below.
5. The grantee shall use grant funds received under this grant to complete all aspects of its grant application, and shall not
use such funds for purposes other than this.
6. The grantee shall submit quarterly progress reports to the Colorado Department of Public Health and Environment, EMS
Category(hereinafter referred to as"the State").
7. Requirements for Training and Education Grants
For any training or education requests funded from this application the grantee shall comply with the following terms and
conditions:
A. Reimbursement for all travel expenses associated with the training or education program shall be made in accordance
with the then current state of Colorado reimbursement rates for travel as specified in the Fiscal Rules of the state of
Colorado.
B. Written proof of the successful completion of any training or educational program shall be submitted at the same time
as the invoice requesting reimbursement for that training or educational program.
C. If the grantee provides a training or educational program,then the grantee shall acknowledge the use of emergency
medical and trauma services account grant funds in all public service announcements, program announcements,or
any other printed material used for the purpose of promoting or advertising the training or educational program.
D. If the grantee provides a training or educational program,then the grantee shall develop and utilize a course
evaluation tool to measure the effectiveness of that training or educational program. The grantee shall submit a copy
of all evaluation reports to the State upon completion of the training or educational program.
8. Requirements for Equipment Grants
For any equipment purchases funded from this application,the grantee shall comply with the following requirements.
A. The grantee shall provide the state with written documentation of the purchase of the specified equipment.
B. All communications equipment shall be purchased from the State award for communications equipment, or from
another vendor for a comparable price and quality. If the grantee desires to purchase communications equipment
which is not listed on the State award then the grantee must complete,with the State's assistance if needed, an
informal competitive solicitation process before purchasing that equipment. If a competitive solicitation process is
used,then the grantee shall purchase the communications equipment from the lowest bidder whose bid meets the
bid specifications.
C. If the grantee desires to purchase emergency vehicles other than ambulances,then the grantee must complete,with
the State's assistance if needed, an informal competitive solicitation process before purchasing that equipment. The
proposed specifications for these emergency vehicles must be approved by the State prior to the initiation of the
informal competitive solicitation process. If a competitive solicitation process is used,then the grantee shall purchase
the emergency vehicles from the lowest bidder whose bid meets the bid specifications.
D. If the grantee desires to purchase medical equipment,then the grantee must complete,with the State's assistance if
needed, an informal competitive solicitation process before purchasing that equipment. If a competitive solicitation
process is used,then the grantee shall purchase the medical equipment from the lowest bidder whose bid meets the
bid specifications.
E. During the initial term and any renewal or extension term of the contract or purchase order issued to convey funding
to the grantee,and after the cancellation, termination, or expiration date of said contract or purchase order,the
grantee shall acquire and maintain personal property casualty insurance for the replacement value of all equipment it
purchases under this grant for the useful life of that purchased equipment.
22 of 23 pages
State Fiscal Year 2007 Application
F. The grantee shall keep inventory control records for all equipment it purchases. The grantee shall obtain the prior,
express,written consent of the State before relocating or reallocating any equipment it purchases.
G. The grantee shall provide the State with a picture of each piece of equipment it purchases. The grantee may submit
a picture of a piece of purchased equipment at any time, but in no event no later than the date the grantee's final
progress report is due to the State.
H. The grantee shall maintain all equipment it purchases in good working order,normal wear and tear excepted. The
grantee shall perform all necessary maintenance services for all equipment it purchases in a timely manner and in
accordance with all manufacturer's specifications and all manufacturer's warranty requirements. The grantee shall
keep detailed and accurate records of all maintenance services it performs on all equipment it purchases.
I. The grantee shall repair or replace all purchased equipment which is damaged, destroyed, lost,stolen, or involved in
any other form of casualty.
J. If the grantee ceases to provide emergency medical and trauma services in the state of Colorado,then all equipment
purchased under this grant shall either be placed with another operating emergency medical services provider in the
state of Colorado, or be sold at public auction for its then fair market value. That portion of the sale proceeds which
equals the State's initial financial contribution towards the purchase of that equipment shall be refunded to the State
by the grantee. The grantee shall obtain the prior, express written consent of the State prior to any relocation or sale
of any purchased equipment.
First Name: M. :J. Last Name: Geile Chair, Board of County CommissionE rs
Print Na of Authorized Agent Title
(970) 356-4000 X4200
Daytime Phone Number
///AY 02/15/2006
Si nature of Authorized Agent Date
❑Are you requesting a defibrillator or a cardiac monitor?
First Name: Last Name:
Print Name of Medical Director Physician License Number
Signature of Medical Director Date
ATTESTING TO BOARD OF COUNTY
COMMISSIONER SIGNATURES ONLY E P7
it
ATTEST: Ldikat t8�t ��,
WEL COUNTY CLERK TO THE BOARD zek
BY: ti's , C1 ail to L v ' '
DEP TY CLE TO THE ARO e
23 of 23 pages
State Fiscal Year 2007 Application
���� 0 99?'
NAME AND TAX IDENTIFICATION NUMBER (TIN)
INDIVIDUALS: Enter First and Last name EXACTLY as it appears on your Social Security Card.However,if you have changed
your last name, for instance,due to marriage,without informing the Social Security Administration of the name
change,please enter your first name and both the last name shown on your social security card and your new last
t— name(IN THAT ORDER).For your TIN,enter your Social Security Number(SSN).
¢ SOLE PROPRIETORSHIPS: Enter the owner's name on the first line;on the second name line you may enter the business name.YOU
a MAY NOT ENTER ONLY THE BUSINESS NAME.For the TIN,enter both the owner's Social Security
Number and the Federal Employer Tax Identification Number(EIN)if you are required to have one.
ALL OTHER ENTITY'S: Enter the name of the owner of the EIN or SSN exactly as originally registered with the IRS.The correct
TIN is the Employer Identification Number(ELN).
• N•T ENTE AN SSN • E!N THAT WAS N•T ASSIGNEr T+ THE LEG L NAME • F THIS F• • M
HOW TO OBTAIN A TIN
If you do not have a TIN,you should apply for one immediately.To apply for the number,obtain Form S5-05,Application for a Social Security Number
Card(for individuals),or Form 55-4,Application of Employer Identification Number(for businesses and all other entities),at your local office of the
Social Security Administration or the Internal Revenue Service.Complete and file the appropriate form according to its instructions.
To complete Form W-9 if you do not have a TIN,check"Applied For"box in the space indicated on the front,sign and date the form,and give it to the
requester. For payments that could be subject to backup withholding,you will then have 60 days to obtain a TIN and furnish it to the requester.During
the 60-day period,the payments you receive will not be subject to the 31%backup withholding.unless you make a withdrawal.However if the requester
does not receive your TIN from you within 60 days,backup withholding,if applicable,will begin and continue until you furnish your TIN to the requester.
Note: Writing "Applied For"on the form means that you have already applied for a TIN OR that you intend to apply for one in the near future.
As soon as you receive your TIN,complete another Form W-9,include your new TIN,sign and date the form,and give it to the requester.
FOR PAYEES EXEMPT FROM BACKUP WITHHOLDING
— Individuals (including sole proprietors)are not exemp• from backup withholding.Corporations are exempt from backup withholding for
certain payments,such as interest and dividends.
•
¢ If you are exempt from backup withholding,you should still complete this form to avoid possible erroneous backup withholding.Enter
< your correct TIN in Part I, write 'Exempt'in Part II,and sign and date the form.
Il If you are a nonresident alien or a foreign entity not subject to backup withholding,give the requester a completed Form W-8,
Certificate of Foreign Status.
CE'TIFICATI+
(I)Interest,Dividend,and Barter Exchange Accounts Opened Before 1984 and Broker Accounts That Were Considered Active During 1983.
-You are not required to sign the certification; however,you may do so.You are required to provide your correct TIN.
(2)Interest,Dividend,Broker and Barter Exchange Accounts Opened After 1983 and Broker Accounts That Were Considered Inactive During 1983.
- -You must sign the certification or backup withholding will apply.If you are subject to backup withholding and you are merely
providing your correct TIN to the requester,you must cross out item(2)in the certification before signing the form.
(3)Real Estate Transactions-You must sign the certification.You may cross out time(2)of the certification if you wish.
< (4) Other Payments-You are required to furnish your correct TIN,but you are not required to sign the certification unless you have
been notified of an incorrect TIN. Other payments include payments made in the course of the requester's trade or business for rents.
royalties,goods(other than bills for merchandise), medical and health care services,payments to a nonemployee for services(including
attorney and accounting fees),and payments to certain fishing boat crew members.
(5)Mortgage Interest Paid by You,Acquisition or Abandonment of secured Property,or IRA Contributions. -You are required to
furnish your correct TIN, but you are not required to sign the certification.
Signature.- The signature should be an authorized signature,generally the person whose name is on the top tine of the form,a partner
in the partnership,or an officer of the corporation.For a joint account,only the person whose TIN is shown in LEGAL
¢ BUSINESS DESIGNATION should sign the form.
W
= Privacy Act Notice.- Section 6109 requires you to furnish your correct taxpayer identification number(TIN)to persons who must tile information
returns with IRS to report interest,dividends.and certain other income paid to you,mortgage interest you paid,the acquisition or abandonment of secured
O property.or contributions you made to an individual retirement arrangement(IRA).IRS uses the numbers for identification purposes and to help verify the
accuracy of your tax return.You must provide your TIN whether or not you are required to tile a tax return. Payers must generally withhold 31%of
taxable interest.dividend,and certain other payments to a payee who does not furnish a TIN to a payer.Certain other penalties may also apply.
Substitute Form REQUEST FOR TAXPAYER IDENTIFICATION State of Colorado
W-9 NUMBER (TIN) VERIFICATION Do NOT send to IRS
PRINT OR TYPE
Legal Name (OWNER OF THE EIN OR SSN AS NAME APPEARS ON IRS OR SOCIAL SECURITY ADMINISTRATION RECORDS) RETURN TO ADDRESS BELOW
DO NOT ENTER THE BUSINESS NAME OF A SOLE PROPRIETORSHIP ON THIS LINE•See Reverse for Important Information
•
Trade Name COMPLETE ONLY IF DOING BUSINESS AS(Lv0/A)
Remit Address
•
Purchase Order Address—Optional PART II See Part II Instructions on Back of Form
•
Check legal entity type and enter 9 digit Taxpayer Identification Number(TIN)below: Do Not enter an SSN or EIN that was not
(SSN=Social Security Number EIN=Employer Identification Number) assigned to the Zeal name entered above.
Individual (Individual's SSN)
NOTE:If no nurse is circled on a loins Account when there is more than nog name.the number will be considered to be that of the first name listed ————
Sole Proprietorship(Owner's SSN or Business FEIN) SSN
NOTE:Envy both theowner's SSN and to business EIN(if you an required to haeonel --- -- —'---
EIN
Partnership n General n Limited (Partnership's EIN)
Estate/'Dust (Legal Entity's EIN)
NOTE:Do not furnish the identification number of personal representative or trustee unless the legal entity itself is not designated in ——
the account title.Lin and circle the name of the legal num.omre lention trust.
Other ► (Entity's EIN) _
Limited Liability Company.Joint Venture.Club.etc. ——
Corporation Do you provide legal or medical services? n Yes n No (Corp's EN)
Includes corporations providing medical billing services ——
Government(or Government Operated)Enity (Entity's EN)
nOrganization Exempt from Tax under Section 501(a) (Org's EIN) _
Do you provide medical services? ❑Yes O No
Check Here if you do not have a SSN or EIN,but have applied for one. See reverse for information on How to Obtain A TIN.
Licensed Real Estate Broker? O Yes ❑ No
Under Penalties of perjury,I certify that:
(I) The number listed on this form is my correct Taxpayer Identification Number(or I am waiting for a number to be issued to me)AND
(2) I am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue
Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends'or(c)the IRS has notified me that I
am no longer subject to backup withholding(does not apply to real estate transactions, mortgage interest paid,the acquisition of abandonment of
secured property,contribution to an individual retirement arrangement(IPA),and payments other than interest and dividends).
CERTIFICATION INSTRUCTIONS — You must cross out item(2)above if you have been notified by the IRS that you are currently subject to backup
withholding because of under reporting interest or dividends on your tax return.(See Signing the Certification on the reverse of this form.)
THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS
• DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP WITHHOLDING
NAME (Print or Type) TITLE (Print or Type)
AUTHORIZED SIGNATURE DATE PHONE(
DO NOT WRITE BELOW THIS LINE RETURN BOTH COPIES TO ADDRESS ABOVE
AGENCY USE ONLY
Agency _ _ Approved By Date
1099 Y_ N
VEND Addition _ Change _ Action Completed By Date
61542-S0-7093 IR 11/981
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