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Home My WebLink About20052102.tiff RESOLUTION RE: APPROVE POLITICAL SUBDIVISION CONTRACT FOR EMERGENCY MEDICAL AND TRAUMA SERVICES GRANT 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 Political Subdivision Contract for the Emergency Medical and Trauma Services Grant 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 Paramedic Services,and the Colorado Department of Public Health and Environment,commencing August 1, 2005, and ending June 30,2006,with further terms and conditions being as stated in said contract, and WHEREAS,after review, the Board deems it advisable to approve said contract, 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 Political Subdivision Contract for Emergency Medical and Trauma Services Grant 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 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 contract. The above and foregoing Resolution was,on motion duly made and seconded,adopted by the following vote on the 25th day of July, A.D., 2005. BOARD OF COUNTY COMMISSIONERS Erc a WELD COUNTY, COLORADO 1861 ; EXCUSED William H. J e, Chair r. �a�' • o 7 ty Clerk to the Board �®UY`I, 42,/ J. le, Pro-Tem • (/ Deputy Clerk to the Board s C o Da APPR AST vid Rob\e� Mas en 0 ty or- Glenn Vaa Let- Date of signature: x- 2005-2102 AM0018 DEPARTMENT OR AGENCY NAME COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT HFEMSD • DEPARTMENT OR AGENCY NUMBER FMA CONTRACT ROUTING NUMBER 06-00016 APPROVED PHASE 1 WAIVER#69 GRANTS PROGRAM POLITICAL SUBDIVISION CONTRACT This Contract is made this 11th day of July,2005,by and between: the state of Colorado acting by and through the DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT,whose address or principal place of business is 4300 Cherry Creek Drive South,Denver,CO 80246,hereinafter referred to as"the State";and, Weld County Paramedic Services(a political subdivision of the State of Colorado},whose address or principal place of business is 1121 M Street,Greeley,CO 80631, ,hereinafter referred to as"the Contractor". WHEREAS,section 25-3.5.101,et seg.,C.R.S., as amended,creates the"Colorado Emergency Medical Services and Trauma Act"; WHEREAS,section 43-4-201,C.R.S., as amended,creates the"Highway Users Tax Fund"; WHEREAS,section 25-3.5-603,C.R.S.,as amended,creates the"Emergency Medical Services Account" within the Highway Users Tax Fund; WHEREAS,section 25-3.5.603(3)(a)(I), C.R.S.,as amended,states that funds in the Emergency Medical Services Account shall be used,in part,for distribution as grants to local emergency medical and trauma service providers pursuant to the emergency medical and trauma services grant program; WHEREAS,section 25-3.5-604,C.R.S.,as amended,creates the emergency medical and trauma services grant program; WHEREAS,the Contractor is licensed,to the extent required by law,to provide emergency medical and trauma services in the state of Colorado; WHEREAS,the Contractor has filed a timely application for grant funds with the State; WHEREAS,the State has reviewed the Contractor's grant application and determined that the Contractor's grant application establishes a substantiated need for grant funds from the State; WHEREAS,section 29-1-203,C.R.S.,as amended,encourages governments to make the most efficient and effective use of their powers and responsibilities by cooperating and contracting with each other to the fullest extent possible to provide any function,service,or facility lawfully authorized to each of the cooperating or contracting entities; WHEREAS,all contracts between the State of Colorado and its political subdivisions are exempt from the State of Colorado's personnel rules and procurement code; WHEREAS,as of the effective date of this Contract,the State has a currently effective Group II purchasing delegation agreement with the division of finance and procurement within the Colorado Department of Personnel and administration; Page 1 of 12 WHEREAS,as of the effective date of this Contract,the Contractor meets all other qualifications for funding under the emergency medical and trauma services grants'program to provide local emergency medical and trauma services; WHEREAS,as to the State,authority exists in the Law and Funds have been budgeted,appropriated,and otherwise made available, and a sufficient uncommitted balance thereof remains available for subsequent encumbering and payment of this Contract in Fund Number 409 Appropriation Account 845,and Organization Number 8305,under Contract Encumbrance Number PO FLA EMS06-00016;and, WHEREAS,all required approvals,clearances,and coordination have been accomplished from and with all appropriate agencies. NOW THEREFORE,in consideration of their mutual promises to each other,hereinafter stated,the parties hereto agree as follows: A. EFFECTIVE DATE AND TERM. The proposed effective date of this Contract is August 1,2005. However, in accordance with section 24-30-202(1),C.R.S.,as amended,this Contract is not valid until it has been approved by the State Controller,or an authorized designee thereof. The Contractor is not authorized to, and shall not,commence performance under this Contract until this Contract has been approved by the State Controller. The State shall have no financial obligation to the Contractor whatsoever for any work or services or,any costs or expenses, incurred by the Contractor prior to the effective date of this Contract. If the State Controller approves this Contract on or before its proposed effective date,then the Contractor shall commence performance under this Contract on the proposed effective date. If the State Controller approves this Contract after its proposed effective date,then the Contractor shall only commence performance under this Contract on that later date. The initial term of this Contract shall commence on the effective date of this Contract and continue through and including June 30,2006,unless sooner terminated by the parties pursuant to the terms and conditions of this Contract. Unless otherwise modified by this Contract,the total term of this Contract, including any renewals or extensions hereof,may not exceed the term authorized by the original procurement method used to select the Contractor, or in no case longer than five(5)years. B. DUTIES AND OBLIGATIONS OF THE CONTRACTOR. 1. The Contractor shall use grant funds it receives from the St ate under this Contract to complete all aspects of its grant application. The Contractor's grant application is incorporated herein by this reference,made a part hereof,and attached hereto as"Attachment A". 2. Any training or education requirements that are identified in Attachment A are subject to 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. The Contractor shall submit written proof of the successful completion of any training or educational program at the time it submits an invoice requesting reimbursement for that training or educational program. C. If the Contractor provides a training or educational program under this Contract,then the Contractor 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. Page 2 of 12 • D. If the Contractor provides a training or educational program under this Contract,then the Contractor shall develop and utilize a course evaluation tool to measure the effectiveness of that training or educational program. The Contractor shall submit a copy of all evaluation reports to the State upon completion of the training or educational program. 3. If this Contract involves the purchase of equipment,then the Contractor shall provide the State with written documentation of the purchase of the specified equipment,and shall comply with the following State requirements: A. 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 Contractor desires to purchase communications equipment which is not listed on the State award,then Contractor 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 Contractor shall purchase the communications equipment from the lowest bidder. B. If the Contractor desires to purchase emergency vehicles other than ambulances,then the Contractor 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 Contractor shall purchase the emergency vehicles from the lowest bidder. C. If the Contractor desires to purchase medical equipment,then the Contractor 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 Contractor shall purchase the medical equipment from the lowest responsive and responsible bidder. D. During the initial,and any renewal or extension,term of this Contract,and as may be required after the cancellation,termination,or expiration date of this Contract,the Contractor shall acquire and maintain personal property casualty insurance for the replacement value of all equipment it purchases under this Contract for the useful life of that purchased equipment. E. The Contractor shall keep inventory control records for all equipment it purchases under this Contract. The Contractor shall obtain the prior,express,written consent of the State before relocating or reallocating any equipment it purchases under this Contract. F. The Contractor shall provide the State with a picture of each piece of equipment it purchases under this Contract. The Contractor may submit a picture of a piece of purchased equipment at any time during the term of this Contract,but in no event no later than the date the Contractor's final progress report is due to the State. G. The Contractor shall maintain all equipment it purchases under this Contract in good working order,normal wear and tear excepted. The Contractor shall perform all necessary maintenance services for all equipment it purchases under this Contract in a timely manner and in accordance with all manufacturer's specifications and all manufacturer's warranty requirements. The Contractor shall keep detailed and accurate records of all maintenance services it performs on all equipment it purchases under this Contract. H. The Contractor shall repair or replace all purchased equipment which is damaged, destroyed,lost,stolen, or involved in any other form of casualty. Page 3 of 12 I. If the Contractor ceases to provide emergency medical and trauma services in the state of Colorado,then all equipment purchased under this Contract 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 Contractor. The Contractor shall obtain the prior,express written consent of the State prior to any relocation or sale of any purchased equipment. 4. During the initial,and any renewal or extension,term of this Contract,the Contractor shall provide quarterly progress reports to the State as provided in the applicable rules of the State. C. DUTIES AND OBLIGATIONS OF THE STATE. In consideration for those services satisfactory and timely performed by the contractor under this Contract,the State hall cause to be paid to the Contractor an amount not to exceed Seventy Nine Thousand One Hundred Eighty Nine Dollars,($79,189). Of the total financial obligation of the State referenced above,$79,189 are identified as attributable to a funding source of the state of Colorado. 2. The funding provided to the Contractor by State under this Contract shall be utilized as follows: A. For equipment purchased under this Contract,the Contractor shall receive an amount not to exceed$79.189. The Contractor shall provide matching funds in the amount of $79,189. All costs in excess of the State's share for this class of purchases shall be the sole responsibility of the Contractor. 3. To receive compensation under this Contract,the Contractor shall submit a signed"Payment Request Statement". A sample Payment Request Statement is incorporated herein by this reference,made a part hereof,and attached hereto as"Attachment B". The Contractor shall submit a Payment Request Statement to the State no later than thirty(30)calendar days after the date the Contractor makes a purchase, or incurs an expense,under this Contract. Expenditures shall be made in accordance with those items identified in Attachment A hereto. Each Payment Request Statement shall have a copy of any invoice the Contractor paid and for which the Contractor requests reimbursement from the State. Each Payment Request Statement shall: reference this Contract by its contract routing number,which number is located on page one of this Contract; state the applicable performance dates,the names of payees; a brief description of the goods purchased or services performed during the relevant performance dates;the incurred expenditures;and,the total requested reimbursement. Payment Request Statements shall be sent to: EMS Grants Manager EMS&T Section Health Facilities and Emergency Medical Services Division Colorado Department of Public Health and Environment Mail Code HF-EMS-A2 4300 Cherry Creek Drive South Denver,CO 80246 Payment of all,or any part,of any Payment Request Statement shall be contingent upon verification by the State that the Contractor made the purchase(s),or incurred the expense(s),and is otherwise in compliance with the terms and conditions of this Contract. The State shall issue a warrant payable to the Contractor only after the State has verified the Contractor's Payment Request Statement. Page 4 of 12 • Request Statement. D. GENERAL PROVISIONS. Because this Contract involves the expenditure of federal, state,or private funds,this Contract is subject to, and contingent upon,the continued availability of those funds for payment pursuant to the terms and conditions of this Contract. If those funds, or any part thereof,become unavailable as determined by the State,then the State may immediately terminate this Contract. 2. The Contractor warrants that it possesses actual,legal authority to enter into this Contract. The Contractor further warrants that it has taken all actions required by its applicable laws,procedures, rules, or bylaws to exercise that authority, and to lawfully authorize its undersigned signatory to execute this Contract and bind it to its terms and conditions. The person or persons signing this Contract,or any attachment(s)or amendment(s)hereto, also warrant(s)that such person(s) possess(es)actual,legal authority to execute this Contract, and any attachment(s)or amendment(s) hereto, on behalf of the Contractor. 3. The Contractor is a"public entity"within the meaning of the Colorado Governmental Immunity Act(CGIA), section 24-10-101,et seq., C.R.S.,as amended. Therefore,the Contractor shall at all times during the initial term of this Contract,and any renewals or extensions hereof,maintain such liability insurance,by commercial policy or self-insurance,as is necessary to meet its liabilities under the CGIA. On or before the effective date of this Contract,the Contractor must provide the State with written proof of such insurance coverage. 4. The Contractor certifies that,as of the effective date of this Contract,it has currently in effect all required licenses,certifications,approvals,insurance,permits,etc.,if any,that are necessary to properly perform the services and/or deliver the products specified in this Contract. The Contractor also warrants that it shall maintain all required licenses,certifications, approvals, insurance,permits,etc., if any,that are necessary to properly perform this Contract,without reimbursement by the State or other adjustment in the Contract price. Additionally,all employees or subcontractors of the Contractor performing services under this Contract shall hold,and maintain in effect,all required licenses,certifications, approvals,insurance,permits,etc.,if any, that are necessary to perform their duties and obligations under this Contract. Any revocation, withdrawal or nonrenewal of any required licenses,certifications,approvals,insurance,permits, etc., if any,that are necessary for the Contractor,or its employees and subcontractors,to properly perform its duties and obligations under this Contract shall be grounds for termination of this Contract by the State for default without further liability to the State. 5. To be considered for payment,billings for payments pursuant to this Contract must be received within a reasonable time after the period for which payment is requested;but in no event no later than sixty(60)calendar days after the relevant performance period has passed. Final billings under this Contract must be received by the State within a reasonable time after the expiration or termination of this Contract;but in no event no later than sixty(60)calendar days from the effective expiration or termination date of this Contract. 6. Unless otherwise provided for in this Contract,"Local Match"shall be included on all billing statements, in the column provided therefore,as required by the funding source. 7. The Contractor shall grant to the State, or its authorized agents,access to the records and financial statements of the Contractor that directly relate to its performance under this Contract. The Contractor shall retain all such records and financial statements for a period of six(6)years after the date of issuance of a final audit report. This requirement is in addition to any other audit requirements contained in other paragraphs of this Contract. 8. Unless otherwise provided for in this Contract, for all contracts with terms longer than three(3) Page 5 of 12 months,the Contractor shall submit a written progress report specifying the progress made for each activity identified in this Contract. These progress reports shall be submitted in accordance with any applicable procedures developed and prescribed by the State. The preparation of progress reports in a timely manner is the responsibility of the Contractor. If the Contractor fails to comply with this provision,then the failure:may result in a delay of payment of funds;or,termination of this Contract. 9. The Contractor shall maintain a complete file of all records,documents,communications,and other materials that directly relate to this Contract. These materials shall be sufficient to properly reflect all direct and indirect costs of labor,materials,equipment, supplies,and services,and other costs of whatever nature for which a contract payment was made. These records shall be maintained according to generally accepted accounting principles and shall be easily separable from other records of the Contractor. Copies of all such records, documents,communications,and other materials shall be the property of the State and shall be maintained by the Contractor, in a central location as custodian for the State, on behalf of the State, for a period of six(6)years from the date of final payment under this Contract, or for such further period as may be necessary to resolve any pending matters, including,but not limited to,audits performed by the federal government. 10. The Contractor authorizes the State,or its authorized agents or designees,to perform audits or make inspections of those records that directly relate to its performance under this Contract. Audits and inspections may be made at any reasonable time during the term of this Contract and for a period of three(3)after the termination or expiration date of this Contract. The Contractor shall permit the State,or any other duly authorized governmental agent or agency,to monitor all activities conducted by the Contractor pursuant to the terms of this Contract. Monitoring may include,but is not limited to: internal evaluation procedures,examination of program data, special analyses,on-site checks,formal audit examinations,or any other reasonable procedures. All monitoring shall be performed by the State in a manner that does not unduly interfere with the work of the Contractor. 11. Subject to the Public(Open)Records Act,section 24-72-101,et seq.,C.R.S., as amended, if the Contractor obtains access to any records,files,or other information of the State in connection with, or during the performance of,this Contract,then the Contractor shall keep all such records,files, or other information confidential and shall comply with all laws and regulations concerning the confidentiality of all such records,files,or information to the same extent as such laws and regulations apply to the State. Any breach of confidentiality by the Contractor,or third party agents of the Contractor,shall constitute good cause for the State to cancel this Contract,without liability to the State. Any State waiver of an alleged breach of confidentiality by the Contractor,or third party agents of the Contractor,does not constitute a waiver of any subsequent breach by the Contractor,or third party agents of the Contractor. 12. Unless otherwise provided for in this Contract,or in a written amendment executed and approved pursuant to the Fiscal Rules of the state of Colorado,all material, information, data,computer software, documentation,studies,and evaluations produced in the performance of this Contract for which the State has made a payment under this Contract are the sole property of the State. 13. If any copyrightable material is produced under this Contract,then the State shall have a paid in full,irrevocable,royalty free,and non-exclusive license to reproduce,publish,or otherwise use, and authorize others to use,the copyrightable material for any purpose authorized by the Copyright Law of the United States as now or hereinafter enacted. Upon the written request of the State, the Contractor shall provide the State with three(3)copies of all such copyrightable material. 14. If required by the terms and conditions of a state grant,the Contractor shall obtain the prior approval of the State and all necessary third parties prior to publishing any materials produced under this Contract. If required by the terms and conditions of a state grant,the Contractor shall Page 6 of 12 4 also credit the State and all necessary third parties with assisting in the publication of any materials produced under this Contract. 15. If this Contract is in the nature of personaVpurchased services,then the State reserves the right to inspect services provided under this Contract at all reasonable times and places during the term of this Contract. "Services", as used in this clause,includes services performed or written work performed in the performance of services. If any of the services do not conform with the terms of this Contract,then the State may require the Contractor to perform the services again in conformity with the terms of this Contract,with no additional compensation to the Contractor for the reperformed services. When defects in the quality or quantity of the services cannot be corrected by reperformance, then the State may:require the Contractor to take all necessary action(s)to ensure that the future performance conforms to the terms of the Contract; and,equitably reduce the payments due to the Contractor under this Contract to reflect the reduced value of the services performed by the Contractor. These remedies in no way limit the other remedies available to the State as set forth in this Contract. 16. If,through any cause attributable to the action(s)or inaction(s)of the Contractor,the Contractor: fails to fulfill, in a timely and proper manner, its duties and obligations under this Contract; or, violates any of the agreements, covenants,provisions,stipulations, or terms of this Contract,then the State shall thereupon have the right to cancel this Contract,in whole or in part, for cause by giving written notice thereof to the Contractor. The written notice shall be given to the Contractor no less than thirty(30)calendar days before the proposed cancellation date and shall afford the Contractor the opportunity to cure the default or state why cancellation is otherwise inappropriate. If this Contract is cancelled for default,then all finished or unfinished data,documents,drawings, evaluations,hardware,maps,models,negatives,photographs,reports, software,studies, surveys, or any other material,medium or information,however constituted,which has been or is to be produced or prepared by the Contractor under this Contract shall,at the option of the State, become the property of the State. The Contractor shall be entitled to receive just and equitable compensation for any services or supplies delivered to, and accepted by,the State. If applicable, the Contractor shall return any unearned advance payment it received under this Contract to the State. Notwithstanding the above,the Contractor is not relieved of liability to the State for any damages sustained by the State because of the breach of this Contract by the Contractor. The State may withhold any payment due to the Contractor under this Contract to mitigate the damages of the State until such time as the exact amount of those damages is determined. If, after canceling this Contract for default, it is determined for any reason that the Contractor was not in default,or that the action(s)or inaction(s)of the Contractor was excusable,then such cancellation shall be treated as a termination for convenience,and the respective rights and obligations of the parties shall be the same as if this Contract had been terminated for convenience as described below. 17. The State may,when the interests of the State so require,terminate this Contract,in whole or in part,for the convenience of the State. The State shall give written notice of termination to the Contractor. The written notice shall specify the part(s)of the Contract terminated. The written notice shall be given to the Contractor no less than thirty(30)calendar days before the effective date of termination. If this Contract is terminated for convenience, then all finished or unfinished data,documents,drawings,evaluations,hardware,maps,models,negatives,photographs,reports, software,studies, surveys,or any other material,medium or information,however constituted, which has been or is to be produced or prepared by the Contractor under this Contract shall,at the option of the State,become the property of the State. The Contractor shall be entitled to receive just and equitable compensation for any services or supplies delivered to,and accepted by,the State. If applicable,the Contractor shall return any unearned advance payment it received under this Contract to the State. This paragraph in no way implies that a party has breached this Contract by the exercise of this paragraph. If this Contract is terminated by the State as provided for herein, then the Contractor shall be paid an amount equal to the percentage of services actually performed for,or goods actually delivered to,the State,less any payments already made by the State to the Contractor for those services or goods. However, if less than sixty percent(60%)of the services Page 7 of 12 4 • or goods covered by this Contract have been performed or delivered as of the effective date of termination,then the Contractor shall also be reimbursed(in addition to the above payment) for that portion of those actual"out-of-pocket"expenses(not otherwise reimbursed under this Contract)incurred by the Contractor during the term of this Contract that are directly attributable to the uncompleted portion of the services, or the undelivered portion of the goods,covered by this Contract. In no event shall reimbursement under this clause exceed the total financial obligation of the State to the Contractor under this Contract. If this Contract is canceled for default because of a material breach of this Contract by the Contractor,then the above provisions for cancellation for default shall apply. 18. Neither the Contractor nor the State shall be liable to the other for any delay in,or failure of performance of,any covenant or promise contained in this Contract to the extent that the delay or failure is caused by a supervening cause. As used in this Contract, `supervening cause"is defined to mean: an act of God,fue,explosion,action of the elements, strike,interruption of transportation,rationing, court action,illegality,unusually severe weather,war,or any other cause which is beyond the control of the affected party and which,by the exercise of reasonable diligence,could not have been prevented by the affected party. A delay or failure to perform that is caused by a supervening cause shall not constitute a material breach of this Contract or give rise to any liability for damages therefore under this Contract. 19. The enforcement of the terms and conditions of this Contract,and all rights of action related to that enforcement,shall be strictly reserved to the State and the Contractor. Nothing contained in this Contract shall give rise to,or allow,any claim or right of action whatsoever to or by any third person. Nothing contained in this Contract shall be construed as a waiver of any provision of the Colorado Governmental Immunity Act, section 24-10-101 et seq.,C.R.S.,as amended. Any person or entity,other than the State or the Contractor,who may receive services or benefits under this Contract shall be deemed an incidental beneficiary only. 20. To the extent that this Contract may be executed and performance of the obligations of the parties may be accomplished within the intent of this Contract,the terms of this Contract are severable. If any term or provision of this Contract is declared invalid by a court of competent jurisdiction,or becomes inoperative for any other reason,then that invalidity or failure shall not affect the validity of any other term or provision of this Contract. 21. The waiver of a breach of a term or provision of this Contract shall not be construed as a waiver of a breach of any other term or provision of this Contract or, as a waiver of a breach of the same term or provision upon subsequent breach. 22. If this Contract is in the nature of personal/purchased services,then,except for accounts receivable,the rights,duties,and obligations of the Contractor shall not be assigned,delegated,or otherwise transferred,except with the prior,express,written consent of the State. 23. Unless otherwise provided for in this Contract,this Contract shall inure to the benefit of,and be binding upon,the parties hereto and their respective successors and assigns. 24. Unless otherwise provided for in this Contract,the Contractor shall notify the State,within five(5) working days after being served with a summons,complaint, or other pleading in any case that involves any services provided under this Contract and which has been filed in any federal or state court or administrative agency.The Contractor shall deliver copies of any documents that it was served with to the State within five working(5)days of the date of service. 25. This Contract is subject to such modifications as may be required by changes in applicable law,or the implementing rules,regulations,or procedures of that law. Any required modification(s)shall be automatically incorporated into, and be made a part of,this Contract as of the effective date of the change as if that change was fully set forth herein. Except as provided above,no modification Page 8of12 • of this Contract shall be effective unless that modification is agreed to in writing by both parties in the form of a written amendment to this Contract that has been previously executed and approved in accordance with the Fiscal Rules of the state of Colorado. 26. Unless otherwise provided for in this Contract, all terms and conditions of this Contract,and the attachments or exhibits hereto,that may require continued performance or compliance beyond the termination or expiration date of this Contract shall survive that termination or expiration date and shall be enforceable as provided for herein. 27. Unless otherwise provided for in this Contract,no term or condition of this Contract shall be construed or interpreted as a waiver, express or implied, of any of the immunities,rights,benefits, protections,or other provisions of the Colorado Governmental Immunity Act(CGIA), section 24- 10-101,et seq.,C.R.S.,as amended. Liability for claims for injuries to persons or property arising out of the alleged negligence of the State or the Contractor,their departments, institutions, agencies,boards,officials,and employees is controlled and limited by the provisions of section 24- 10-101 et seq.,C.R.S., as amended. 28. The captions and headings used in this Contract are for identification only,and shall be disregarded in any construction of the terms,provisions, and conditions of this Contract. 29. The venue for any action related to this Contract shall be in the City and County of Denver, Colorado. 30. All attachments or exhibits to this Contract are incorporated herein by this reference and made a part hereof as if fully set forth herein. In the event of any conflict or inconsistency between the terms of this Contract and those of any attachment or exhibit to this Contract,the terms and conditions of this Contract shall control. 31. This Contract is the complete integration of all understandings between the parties. No prior or contemporaneous addition,deletion,or other amendment hereto shall have any force or effect whatsoever,unless embodied herein in writing. No subsequent novation,renewal,addition, deletion,or other amendment hereto shall have any force or effect unless embodied in a written amendment to this Contract executed and approved in accordance with applicable law. 32. Contract Renewal,Extension,and Modification. The State,with the concurrence of the Contractor,may prospectively renew or extend the term of this Contract,or increase or decrease the amount payable under this Contract through a"Limited Amendment"that is substantially similar to the sample form Limited Amendment that is incorporated herein by this reference and identified as Attachment C.To be effective,this Limited Amendment must be signed by the State and the Contractor,and be approved by the State Controller or an authorized delegate thereof. The parties understand that this Limited Amendment shall be used only for the following: A. To increase or decrease the level of funding during the current term of the Original Contract due to an increase or decrease in the amount of goods and/or level of services being provided based upon the existing Scope of Work and/or established pricing and/or established Budget/pricing; B. To revise specifications within the current Scope of Work and/or Budget that increase/decrease the level of funding during the current term of the Original Contract; C. To renew or extend the term of the contract with appropriate changes in the amount of funding that results in a new total financial obligation of the State based upon: a. the same Scope of Work and pricing,or b. revised specifications to the previously defined Scope of Work. Page 9 of 12 D. To make changes to the specifications to the original Scope of Work,project management/manager identification,notice address or notification personnel,or the period of performance,that result in"no cost"changes to the Budget. Upon proper execution and approval,this Limited Amendment shall become a formal amendment to this Contract. 33. Other Contract Modifications. If either the State or the Contractor desires to modify the terms and conditions of this Contract other than as provided for in paragraph 32 above,then the parties shall execute a standard written amendment to this Contract initiated by the State. The standard written amendment must be executed and approved in accordance with all applicable laws and rules by all necessary parties including the State Controller or delegate. E. SPECIAL PROVISIONS. 1. CONTROLLER'S APPROVAL.CRS 24-30-202(1) This contract shall not be deemed valid until it has been approved by the Controller of the State of Colorado or such assistant as he may designate. 2. FUND AVAILABILITY.CRS 24-30-202(5.5) Financial obligations of the State of Colorado payable after the current fiscal year are contingent upon funds for that purpose being appropriated,budgeted,and otherwise made available. 3. INDEMNIFICATION. To the extent authorized by law,the Contractor shall indemnify, save,and hold harmless the State against any and all claims,damages,liability and court awards including costs, expenses, and attorney fees incurred as a result of any act or omission by the Contractor, or its employees, agents, subcontractors,or assignees pursuant to the terms of this contract. No term or condition of this contract shall be construed or interpreted as a waiver,express or implied,of any of the immunities,rights,benefits,protection,or other provisions for the parties,of the Colorado Governmental Immunity Act,CRS 24-10-101,et seq.,or the federal tort claims act, 28 U.S.C.2671 et seq.,as applicable as now or hereafter amended. 4. INDEPENDENT CONTRACTOR.4 CCR 801-2 THE CONTRACTOR SHALL PERFORM ITS DUTIES HEREUNDER AS AN INDEPENDENT CONTRACTOR AND NOT AS AN EMPLOYEE.NEITHER THE CONTRACTOR NOR ANY AGENT OR EMPLOYEE OF THE CONTRACTOR SHALL BE OR SHALL BE DEEMED TO BE AN AGENT OR EMPLOYEE OF THE STATE. CONTRACTOR SHALL PAY WHEN DUE ALL REQUIRED EMPLOYMENT TAXES AND INCOME TAX AND LOCAL HEAD TAX ON ANY MONIES PAID BY THE STATE PURSUANT TO THIS CONTRACT.CONTRACTOR ACKNOWLEDGES THAT THE CONTRACTOR AND ITS EMPLOYEES ARE NOT ENTITLED TO UNEMPLOYMENT INSURANCE BENEFITS UNLESS THE CONTRACTOR OR THIRD PARTY PROVIDES SUCH COVERAGE AND THAT THE STATE DOES NOT PAY FOR OR OTHERWISE PROVIDE SUCH COVERAGE.CONTRACTOR SHALL HAVE NO AUTHORIZATION, EXPRESS OR IMPLIED,TO BIND THE STATE TO ANY AGREEMENTS,LIABILITY,OR UNDERSTANDING EXCEPT AS EXPRESSLY SET FORTH HEREIN.CONTRACTOR SHALL PROVIDE AND KEEP IN FORCE WORKERS' COMPENSATION(AND PROVIDE PROOF OF SUCH INSURANCE WHEN REQUESTED BY THE STATE)AND UNEMPLOYMENT COMPENSATION INSURANCE IN THE AMOUNTS REQUIRED BY Page 10 of 12 LAW,AND SHALL BE SOLELY RESPONSIBLE FOR THE ACTS OF THE CONTRACTOR, ITS EMPLOYEES AND AGENTS. 5. NON-DISCRIMINATION. The contractor agrees to comply with the letter and the spirit of all applicable state and federal laws respecting discrimination and unfair employment practices. 6. CHOICE OF LAW. The laws of the State of Colorado and rules and regulations issued pursuant thereto shall be applied in the interpretation,execution,and enforcement of this contract.Any provision of this contract,whether or not incorporated herein by reference,which provides for arbitration by any extra-judicial body or person or which is otherwise in conflict with said laws,rules,and regulations shall be considered null and void.Nothing contained in any provision incorporated herein by reference which purports to negate this or any other special provision in whole or in part shall be valid or enforceable or available in any action at law whether by way of complaint,defense,or otherwise.Any provision rendered null and void by the operation of this provision will not invalidate the remainder of this contract to the extent that the contract is capable of execution.At all times during the performance of this contract,the Contractor shall strictly adhere to all applicable federal and State laws,rules,and regulations that have been or may hereafter be established. 7. SOFTWARE PIRACY PROHIBITION GOVERNOR'S EXECUTIVE ORDER No State or other public funds payable under this Contract shall be used for the acquisition, operation or maintenance of computer software in violation of United States copyright laws or applicable licensing restrictions.The Contractor hereby certifies that, for the term of this Contract and any extensions,the Contractor has in place appropriate systems and controls to prevent such improper use of public funds. If the State determines that the Contractor is in violation of this paragraph,the State may exercise any remedy available at law or equity or under this Contract, including,without limitation, immediate termination of the Contract and any remedy consistent with United States copyright laws or applicable licensing restrictions. 8. EMPLOYEE FINANCIAL INTEREST.CRS 24-18-201 &CRS 24-50-507 The signatories aver that to their knowledge,no employee of the State of Colorado has any personal or beneficial interest whatsoever in the service or property described herein. Page 11 of 12 IN WITNESS WHEREOF,the parties hereto have executed this Contract on the day fun above written. CONTRACTOR: STATE: Weld County Paramedic Service STATE OF COLORADO (a political subdivision of the State of Colorado) Bill Owens,Governor By: By: Name: M. . Geile, 07/25/2005 For the Execu veDirector Title: Chair Pro—Tern DEPARTMENT OF PUBLIC HEALTH FEIN: 84-6000813 AND ENVIRONMENT \ I /(��1 r ATTESTQ /J A/��I//v �(ROGRAM APPROVAL: ,.. " ttitt;ML. ,►,ten r. purr ,. and I nty,County, a/ v • or Town Clerk or Equivalent Nati,= 00.1I APPROVALS: COLORADO DEPARTMENT OF LAW OFFICE OF THE ATTORNEY GENERAL By: N ! 4 Date: ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS 24-30-202 requires that the State Controller approve all state contracts.This contract is not valid until the State Controller,or such assistant as he may delegate,has signed it.The contractor is not authorized to begin performance until the contract is signed and dated below.If performance begins prior to the date below,the State of Colorado may not be obligated to pay for the goods and/or services provided. STATE CONTROLLER: Leslie M. Shenefelt By: i t. Date: 0 Revised: 12/12/03 Page 12 of 12 lPEC I CTEACHMENT A t; a EHSU Colorado EMS FED i � � • Provider Grant C .;_C PUBLIC ti r• rrrlr�i-� �. Application �;��ii t� Ei tl;li; �1Ed1 Colorado Department of Public Health&Environment HFEMSD—A2 4300 Cherry Creek Drive South Submit /Sj E+ 4 Denver,CO 80246-1530 1 Reset Form 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) —T 3. Grant Contact Person 4. Phone Numbers MR DA VI:. BRESSLER Day:9703535700 Pager: (Title) (First) (Last) Fax: 9703046r4M E-mail: dbresslcr+Pco.wetd.cn.us — 5. Agency Mailing Address 6. Agency Street Address(Required for contract,P.O.Box not 1121 Nt S1'Rl I i accepted) 112.1 M STREET City: Zip Code: City: Zip Code: GREELEY 80637. - GREELEY 80631 - 7. Legal Status of Agency/Organization(Mark all that apply:) ❑ Private Not For Profit O Private for Profit O County/City Government O State Agency 0 Special District ❑ Other: 8. Is this a RETAC or statewide grant project? No 1 8a. List the county your agency is Note: Grants for RETAC or statewide projects will be reviewed by the SEMTAC only. licensed in: WELD 9. Do you have any citi#4 narMrpiliers f to other agencies for the current budget year? 9a. List your RETAC ycs 'Describe: (Northeast I New—Your RETAC w 10.Multi-Agency Application—must read and follow multi-agency instructions score your application for 50%of l your total []Yes—This is a multi-agency application. score. See instructions for details. FUNDING REQUEST 11.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 cYo • The values for the project area summary below will auto-populate from the request sections of the application. PROJECT AREA SUMMARY: Agency 50 % State S0 % CDPHE Use No more than 2 categories of request per Total Category Only application are allowed Cost Amt Funded Section III—EMS Training 0 0 0 Section 1V-Ambulance,Other Vehicle 168628 84314 84314 )/`a)11,OD Section V-Communications 0 0 0 Section VI-EMS Equipment 4750 2375 2375 eD 375E CO_ Section VII-Defibrillation/Cardiac Monitor 0 0 0 O P.A.Signature included — Section VII-Extrication Equipment 0 0 0 __ Section VIII-Data Collection 0 _ o 0 Section VIII- Injury Prevention 0 0 0 _ Section VIII-Other 0 a 0 1 Total Grant Request: 173378 86689 86689 ITII in.oD . 1 of 24 pages State Fiscal Year 2006 Application Section II - Agency Information All applicants must complete this section. Balance Sheet for entire Agency listed on page 1, box 1 For 12 months ending: 12131/2003 EEnter 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 section. Accounting Method: Cash Assets Liabilities 1. Unreserved Cash Accounts 16_203 12. Accounts Payable i 3002 2. Reserved Cash Accounts 0 13. Short Term Notes and Loans 93;tltltl 3. Unreserved Investments 0 14. Long Term Notes and Loans tl 4. Reserved Investments it 15. Taxes payable t1 5. Held in trust for Pension Benefits o 16. Payable Payroll Expenses 22,;332 6. Real Estate and Buildings 7611529 17. Prepaid and Deferred Revenue 0 7. Equipment ❑market value []depreciated value 73751. Total Liabilities 1226334 8. Accounts Receivable S3,137t1 18. Define accounting method for Depreciation and Capital 9. Prepaid Expenses Help CASH 10. Inventory 0 1Rti flei t �lem�flu{.ctt}Psed: 11.Other Assets 0 Total Assets 1689858 Net Worth 463524 Profit and Loss for entire Agency listed on page 1, box 1 For 12 months ending: 12/31/2004 f—For the financial period listed at the start of this section Income/ Revenues Expenses 20. Government 29. Operational Expense 21. Mil Levy% _� J enter dollar 0 30. Personnel Costs—salaries,benefits, etc. 2898010 revenues-� 22. Donations,Contributions,Bequests 0 31. Depreciation Expense 216652 23. EMS Fee for Service 8503174 32. Debt Service 0 24. Fund Raising 0 33. Capital Expenditures 114960 25. Interest&Dividends 1; 3D 4..fOtther Expenses 5x,67360 26. Grants—list sources: BAU EBT,SUPPLIES,PUR. SER,MISC 27. Subscription Program 0 28. Other income: 15115 Total Income 8518304 Total Expenditures 8896982 35. List new capital items purchased: TYPE 111 AMBULANCE,SERVER Profit or(Loss) -378678 2 of 24 pages Slate Fiscal Year 2006 Application Section II - Agency Information All applicants must complete this section. Rates and Collection 37. Who processes this agency's billing and accounting? 36. Does your agency charge for service? Ye. M Agency ❑Contract Service ❑ No billing/accounting Service Base Rate Medicare Allowable 38. BLS(Basic Life Support)non-emergent 966 232.27 39. BLS- Emergent 966 2F9.i0 40.ALS1 (Advanced Life Support-Level 1)Non-emergent 966 255.60 41.ALS1 -Emergent 966 315.20 42.ALS2- non-emergent 12_0(1 5:,4.57 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 966 51. Mileage Rate-Urban 1s 52. Mileage Rate-Rural 1 to 17 miles 53. Mileage Rage Rural 18 to 50 miles J5 54.Overall collection rate(Percentage): I 39 I% 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:-t2/31/2003 (-For the financial period listed at the start of this section Income/Revenues Expenses 55. Government 64. Operational Expense 367207 56. Mil Levy%= enter dollar 0 65. Personnel Costs-salaries,benefits,etc. 309.4039 revenues-. 57. Donations,Contributions,Bequests 0 66. Debt Service o 58. EMS Fee for Service ;,10000 67. Capital Expenditures 174000 59. Fund Raising 0 68. Depreciation Expense 2(10000 60. Interest& Dividends 0 69. Other sLE t Expenses, 1 tiK SFRV Flxr.f)('HAR(;)..:S 33468`f3 61. Grants—list sources: Define: 62. Subscription Program 0 63. Other Income: Total Income 7510000 Total Expenditures 7182129 70. List new capital items to be purchased:l�1"t 1t:1Stb O1 1l l'L 1u AMBULANCE. . Projected Profit or(Loss) f 327871 3 of 24 pages State Fiscal Year 2006 Application Section II - Agency Information All applicants must complete this section. Financial Narrative 71. Please summarize below: o Any other 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 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. (If you need more room,please attach extra pages) (The numbers provided throughout section I are based on the fiscal year 2003.These facts have been audited and are accurate. The 2u)04 financial records have been completed but have not been audited.) %Veld County Paramedic Services(WCPS)is owned and operated by the Board of County Commissioners of Weld County.'flir agency being a enterprise tunes is sole'responsible for its budget and finacial well being within the county.The agency serves over 4,0(kt square miles of north/ norhteastern Colorado.Operating as an enterprise of Weld County Goverment since 1989, WCPS is required to bill and collect all of their gyrational costs of providing advanced life support treatment and transportation.'I he 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 assingment,coupled with the changes in the Colorado No Fault automobile insurance on collection rates,WCPS has experienced a decrease in their collection rates from 43%to 39%in the last year.Field personnel levels have been reduced by seven F t F's,along,with a decrease in Medicare; Medicaid allowable reimbursement, WCPS has decreased certain budgeted items and initiated a electronic billing software to address the revenue shortfall crated by these changes. i he result being a negative impact on our shceduled replacement of ambulances,along with inability to purchase EMS training equipment.WCPS has had to lengthen the serVice life of our ambulances and been unable to provied equipment during CAW and training increase knowledge in ALS skills. 4 of 24 pages State Fiscal Year 2006 Application Section 11 - Agency Information All applicants must complete this section. 1.Is EMS coverage included in your district coverage? 2. Type of service: ® ALS ❑ BLS O Fire/Rescue Yes O Training ❑ Other: Number of ears this agency has provided EMS service? 3. Does this agency transport?yes 4.Primary mode ofpatient trans ort:++ Number of transports for the last year? 121841 p 1�lmbutaru e Operational Activity 5. Type of EMS Service:ICareer 6. Demographics of Service Area: 3'io`iI Square Miles t�nnnn1Population Number of paid employees? 77 Number of volunteer employees? 3 #of Stations for this agency 7. Total EMS calls for the last record year? 8. Average BLS call time:r 5 minutes Date ending of record year:Ii 2/31/2004 j 9. Average ALS call time:( 8 minutes 10. Average mileage to nearest Hospital:1 1 f 01 BLS calls L1o9741 ALS calls I Total 10978 11. Average round trip mileage per call: 10 12.Does your agency participate in the CDPHE EMS Data Collection Project? Yes 13.If applicable, is your agency in compliance with NFIRS,the national fire center reporting system?No 14. Does your agency profile exist in the Colorado Emergency Resources Mobilization Project? Ix u 1 For Fire? For EMS? Agency Information? Resource Information?' 15.Is your agency National Incident Command System(NIMS)compliant? No 16.Number of calls your agency was UNABLE to respond to,for any reason: 01 List any explanations for being unable to respond(i.e.equipment failure,staffing,call volume): Personnel Responder Full-time Part-time Volunteer AED Approved 17.EMT-Basic 5 21 0 26 18.EMT-Intermediate n 0 9 19.EMT-Paramedic 15 0 42 _20.First Responder 0 0 t) 0 21.Nurse 0 0 0 0 22.Other 0 c? 0 0 5 of 24 pages State Fiscal Year 2006 Application Section II - Agency Information All applicants must complete this section. Vehicle Inventory _ 23. Bought with Replacing Make/Model Type EMS Grant this Unit# Chassis/Box Year Mileage (Ex:Ford/E-350) 4WD Code Funds? Vehicle Ill 1999 / 1999 97072 FORD / F-350 EYes 3 DYes Elves 17 1999 / 1999 170392 I ORD I 1=-450 DYes 3 Dyes DYes 19 1999 / 1999 183354 FORD / F-450 DYes 3 DYes Dyes 20 2001 / 2(101 151681 FORD / f:-4;o DYes 3 DYes Dyes 21 2002 / 2002 _ 119942 FORD I F-450 DYes 3 DYes Dyes 22 200"2' / 2002 104711 FORD) 1 F.-458 [Yes 3 DYes Dyes 23 2003 / _2003 76657 FORD / l*-4itt Dyes 3 Dyes DYes 24 2003 / 2003 • 36898 FOR() / F-4311 Dyes 3 EYes Dyes 25 2003 / 1999 37361 1(1R17 / F-150 DYes 3 JYes Dyes 26 2005 / 1999 8239 FORD I E.-450 Dyes 3 [Des Dyes / I Dyes Dyes Dyes / I Dyes Dyes Dyes / I Eves Dyes Elves / I DYes Dyes EYes / 1 Dyes DYes DYes / I Dyes DYes Dyes / I DYes Oyes [Yes / I Dyes DYes DYes / I Dyes DYes DYes / I Dyes Dyes Elves / 1 Dyes Dyes DYes / i Dyes [hies DYes / / DYes Dyes Dyes I 1 Dyes Dyes DYes / 1 Dyes DYes Dyes I I DYes DYes Dyes / I Dyes Dyes Dyes / I Dyes ales Dyes / I Dyes Dyes DYes / I DYes Dyes Dyes If you need more space for vehicle inventory. Please fill out a Vehiclelnventory form and mail it in with your attest form. Type Codes: 6. Medium Duty Rescue Vehicle 1. Type I Ambulance 7. Heavy Duty Rescue Vehicle 2. Type II Ambulance 8. Search 8 Rescue 3. Type III Ambulance 9. Pumper 4. Any vehicle used for first response 10 Ladder Truck -Licensed as Class"A" (Chase, Rapid or first Response) 5. Light Duty Rescue Vehicle 11.Utility(Chiefs Car,Sedans,Brush Trucks,etc.) 6 of 24 pages State Fiscal Year 2006 Application Section II - Agency Information All applicants must complete this section. 24. Extrication Equipment , #of RS 10 Kits #Spreaders #Cutters # Rams #Air Bags 1 to 5 yrs 0 0 (1 0 0 6yrs+ 0 0 0 0 0 25. Emergency Medical Equipment owned by your agency How many manual defibrillators does your agency own? 10 1-3 years n 4 years or older How many semi-automatic defibrillators does your agency own?I 0 1 1-3 years [7 4 years or older How many suction units(battery or electric)does your agency own? 20 How many backboards does your agency own? How many stretchers does How many cots does your 2Sl _ your agency own? 0 _ agency own?! 11 _1 Narrative describing your Agency's Structure and Service Area 26. 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. (If you need more room,please attach extra pages) Weld County I'aTorne.tii Services(1 VPS)provides advanced life support response,evaluation,treatment and transport to the ?I(I,n(N)citi,cns and numernms visitors throughout the i,000 square rinks of Weld County Colorado.This service is provided iii coorper.ation with surrounding A15)providers via mutual aid.agreements along with the tiered response of first responders from the fire departments operating throughout Weld County.OI the near 12,00X)calls for smv ice,over NI°,%of the calls for service(all 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 amhulancers from midnight to(1600.via fixed station and system status placement of resources thnnughout Weld County. Operating with 15 full time.field staff and an office and administrative staff of t Weld County operates as and enterprise of Weld County Goverment,billing and collecting all costs of operation. 7 of 24 pages State Fiscal Year 2006 Application Section III - EMS Training Request Complete this section if your grant request includes EMS training. EMS Training Request Section Course I Class Name #of Cost per Total Agency State share CDPHE Use Only students student Cost share 50% 50 % Amount Funded 0 0 0 What are the proposed dates of the above course/class? Where will the class be offered? Who will conduct the training? How did you determine the number of students per class? What is the tuition cost per student'? 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 so% so % Amount Funded 0 0 0 What are the proposed dates of the above course/class? Where will the class be offered? Who will conduct the training? How did you determine the number of students per class'? What is the tuition cost per student? 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 0 0 What are the proposed dates of the above course/class? Where will the class be offered'? Who will conduct the training? How did you determine the number of students per class? What is the tuition cost per student? 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% so% Amount Funded 0 0 0 What are the proposed dates of the above course/class? Where will the class be offered'? Who will conduct the training? How did you determine the number of students per class? What is the tuition cost per student? 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 so% 50% Amount Funded 0 0 0 8 of 24 pages State Fiscal Year 2006 Application Section III - EMS Training Request Complete this section if your grant request includes EMS training. What are the proposed dates of the above course/class? Where will the class be offered? Who will conduct the training? How did you determine the number of students per class? What is the tuition cost per student? 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 0 0 What are the proposed dates of the above course/class? Where will the class be offered? Who will conduct the training? How did you determine the number of students per class? What is the tuition cost per student? 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 0 0 What are the proposed dates of the above course/class? Where will the class be offered? Who will conduct the training? How did you determine the number of students per class? What is the tuition cost per student? 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 0 0 What are the proposed dates of the above course/class? Where will the class be offered? Who will conduct the training? How did you determine the number of students per class? What is the tuition cost per student? 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 0 0 What are the proposed dates of the above course/class? Where will the class be offered? Who will conduct the training? How did you determine the number of students per class? What is the tuition cost per student? What costs other than tuition did you include in the class cost. Itemize and explain how you determined these. 9 of 24 pages State Fiscal Year 2006 Application Section III - EMS Training Request Complete this section if your grant request includes EMS training. Course/Class Name #of Cost per Total Agency State share CDPHE Use Only students student Cost share 50% 50 % Amount Funded 0 0 0 What are the proposed dates of the above course/class? Where will the class be offered? Who will conduct the training? How did you determine the number of students per class? What is the tuition cost per student'? 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 5o% 50 % Amount Funded Total Training Request 0 0 l 0 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. 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. (If you need more room,please attach extra pages) 10 of 24 pages State Fiscal Year 2006 Application Section IV - Ambulance, Other Vehicle Request Complete this section if your grant request includes an ambulance or other vehicle. Request for Ambulance 1. 2.Type 3. Description- 4.Total$ 5.Agency 6.State Share CDPHE Use Qty Code Request o % • only Share 50 /0 50 Amount Funded 2 RFCHASSI5OF2 BRAUN 1YPF.III ,0 153628 76814 76814 71, IL1 7.Is the vehicle requested above: ❑new addition to inventory? Q Replacement vehicle?-+ 7a. If this is a replacement vehicle,which unit number does it replace'? 17.19 Request for Ambulance 1. 2.Type 3. Description- 4.Total$ 5.Agency 6.State Share CDPHE Use Qty Code Request Share 50% S0 % Only Amount Funded 1 Rescue QRV-h1F.1)1(.-A}_GATOR 015000 7500 7500 7.Is the vehicle requested above: Q new addition to inventory? ❑ Replacement vehicle?—* 7a. If this is a replacement vehicle,which unit number does it replace? Request for non ambulance 1. 2.Type 3.Description 4.Total $ 5.Agency 6.State Share CUVHE Use - Qty Code Request Share 50% 50 7° AmountOnly Funded 0 0 0 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? 8.if the requested vehicle(s)is a replacement(s): ▪ What was the number of calls our 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? THE OI.1)CIlAssis tvir I BE 5O1 I)BY 7 HF vFNUOK. Type Codes: _ 6. Medium Duty Rescue Vehicle 1. Type I Ambulance 7. Heavy Duty Rescue Vehicle 2. Type Il Ambulance 8. Search& Rescue 3. Type III Ambulance 9. Pumper 4. Any vehicle used for first response—Licensed as 10. Ladder Truck Class"A" (Chase, Rapid or first Response) 5. Light Duty Rescue Vehicle 11. Utility(Chiefs Car, Sedans, Brush Trucks,etc.) 9. Request for Related Equipment for Vehicle—Include the cost of radios or equipment specific to stock a new ambulance separately from the vehicle here. The updated fixed prices for 2004 include lightbar, running boards,mud flaps, paint package and stretcher. Price Agency State Share CDPHE Use Qty Description Each Total Request Share 50 % 50 % AmountOnly Funded O 0 0 O 0 0 0 0 0 0 0 0 0 0 0 Total related equipment cost 0 0 0 Total Vehicle Request—vehicle cost plus 168628 84314 84314 -46 91.1 CD equipment 10. What is the average length of service in miles and or years of vehicles operated by your agency? 4YEAR OR 180,000 NIP '11, Please describe your agency s vehicle replacement program: (If you need more room,please attach extra pages) 1.1`cld County Paramedic Services(l1'CPS)has initiated a re-chassis pm}rarn in t,Rich chassis would be replaced and patient module,W1)111 be n:•mcncnted.The first re-chassis oicured in 200{,)rid was a great success at an average savings of over x'8.(11)0 over tlu'purchase of a rove ambulance.This project will continue until each nl the 9 typo 111 ambulances have been remounted 3 limes each.The ambulances that were re-chassisecl in 20(14 were 16.18.The nett scheduled tti,tt ambulance to be to 11 of 24 pages State Fiscal Year 2006 Application Section IV - Ambulance, Other Vehicle Request Complete this section if your grant request includes an ambulance or other vehicle. 12. Vehicle request narrative (If you need more room,please attach extra pages) Weld County Paramedic Services is an agency of Weld County goverment that operates as an enterprise fund.Funding is provided through fees for service only.The economy.Medicare,and Medicaid cuts,tort law auto insurance and inr reasinl, c .. are some of the major factors that have negatively affected WCPS. Signficanl mandator Ibudgt't cuts have been met.The management of WCI'S continues to search for methods to operate more efficiently and effectively. in 199$a decision was made to establis a program that would save and estimated S25 million over the next 12 ,•e ars. A re-chassis program was undertaken in which ambulances chassis would be replaced and patient modules would be remounted 1.1u•first rechassis will of c tired in 2004.at a saving,.of approximately(.-ti'rli.00tl over the purchase of a new ambulance.This pre•je.-i will continue until each of the 9'Eypc•Ill ambulances have been remounted 3 times.This project will require the remounting of 2 units this,fiscal t•ear.With considerations for inflation and variations in the requirements of each specific unit it is estimated that the cuss of renumntin,;2 chassis this year will be Sl;tt,00t). WCPS has also been laced with a mounting problem during the multiple standbys and extreme terrain ot Weld County.Patient nwvennent has become a challenge within its self.]he addition of QRV-medical gator would alleviate many of the problems we are facing with patient movement.WC:PS covers events from highschool actives,college events,Greeley independence Stampede, motorcross,demolition derbies,to mass casualty/ major incident response withing the entire county and into other iuutle•s with OUT mutual aid agreements.The terrain of Weld County is mainly agriculhtral which make ambulance access a difficult undertaking at the least.The QRV would allow safe and timely patient movement in an emergency situation.The QRV would be located on our MCI trailer and would be available 24/7 via the on duty Medical Operations Supervisor. WCPS respectfully request s matching funds from they state for our rechassis project and Our QRV vehicle.This program of remounting ambulances is a responsible and effective utilization of funds that are increasingly difficult too obtain.It is but our of n►anv methods by which WCPS strive to maintain the highest quality emergency servic with less financial reseruces. 12 of 24 pages State Fiscal Year 2006 Application Section V - Communications Request Complete this section if your grant request includes communication equipment. 1. EXISTING COMMUNICATIONS SYSTEM PROFILE Agency Primary Operational Frequencies_ Purpose Transmit Receive CTCSS(Hz)or Name or Use of Channel (Dispatch,Fire,EMS. (MHZ) (MHZ) DPL(Code) FCC Call 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: ❑ Trunking -list system: J❑ Other- describe: 1 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: ❑ Government ❑ Agency Owned ❑ Other: 3b. Receiver Frequency Used to Receive Pages: 1MHZ 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 0 0 0 0 0 0 0 0 O 0 0 O 0 0 0 0 0 O 0 0 0 0 0 Total Communications Request 0 0 0 13 of 24 pages State Fiscal Year 2006 Application Section V - Communications Request Complete this section if your grant request includes communication equipment. Communications Request 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. (If you need more room, please attach extra pages) 14 of 24 pages State Fiscal Year 2006 Application Section VI - EMS Equipment Request Complete this section if your grant request includes EMS equipment. EMS Equipment Request Section 1. Qty 2. Description 3. Price Each 4.Total 5.Agency 6. State Share CDPHE Use Only Request Share 50 % 50 % Amount Funded 1l S IN roll;\l u)V 0 140(1 1400 700 700 1aD►C0 I iNFANt 1\7GliArlo Silt) 500 250 250 asp.w 1 MA'AM.II)lNltc:o 550 550 275 275 01-rjinD 1 1.hNSH)N PNI:U\1<'. 500 500 250 250 40saco 1 AMA"' ntR►AAY a10 900 900 450 450 Li GO.CD 1 c1tlt.0 AIRWAY M. 900 900 , 450, 450 450,CO O 0 0 O 0 0 O 0 0 0 0 0 O 0 0 0 0 0 I 0 0 0 O 0, 0 0 0 0 O 0 0 O 0 0 0 0 0 0 0 0 o , 0 0 O 0 _ 0 0 0 0 1 0 . 0 0 ____i0 0 . 0 _ 0 0 0 O 0 0 O 0 04 0 0 0 , 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 O 0 0 o 0 0 Total EMS Equipment Request 4750. 2375 2375 a396,ao 15 of 24 pages State Fiscal Year 2006 Application Section VI - EMS Equipment Request Complete this section if your grant request includes EMS equipment. 7. EMS Equipment Request Narrative (If you need more room,please attach extra pages) 11414 County Paramedic Services(WCPS)is an agency of Weld County gc+vennent that operates as an enterprise fund. Finding is provided through fees for service only.'Ihe economy, Medicare j Medicaid cuts. tort law auto insurance and increasing costs arc some of the major far tuns that WCPS is doing more in house training and CAW to keep are employees at the highest level if care.WCPS mandates that are employees maintain and also increase medieval knowledge throughout their career at tkCPS.WCPS has a very serious need for EMS training equipment to compliment our instructors that provide the ( \IF and training.This equipment will help premole keeping skills and confidence at a high level due to its ayailabilty to our stall.Thr•agency will otter its ecfnipment to any ai•cnc y that has a need for it during training classes 41'C:PS will maintian and assure proper care of all equipment funded. WCPS respectfully requests matching funds from the state for out FMS training equipment.This need of maintaining skills and medical knowledge is a responsible and effective use of funds that are increasingly difficult In obtain. 16 of 24 pages State Fiscal Year 2006 Application Section VII — Defibrillation / Cardiac Monitor and Extrication Request Complete the defibrillation section 1 —15 if your grant request includes defibrillation, and 16-27 if your grant request includes extrication equipment. 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 Physician Advisor/Medical Direction on the attest form to be mailed in,or attach a letter from their Physician Advisor approving their request. Defibrillation Request Information 9. Qty 10. Description 11. Price Each 12. Total 13 Agency 14. State Share CDPHE Use Only Request Share 50% 50 % Amount Funded O 0 0 0 0 0 O 0 0 O 0 0 0 0 0 Total Defibrillation Request 0 0 0 15. Defibrillation Request Narrative: (If you need more room, please attach extra pages) 17 of 24 pages State Fiscal Year 2006 Application Section VII — Defibrillation / Cardiac Monitor and Extrication Request Complete the defibrillation section 1 —15 if your grant request includes defibrillation, and 16-27 if your grant request includes extrication equipment. Extrication Equipment Information 16. List the location,distance,travel time and type(RS-10, Hurst,etc.)of nearest extrication equipment: 17. Do you have a written or verbal agreement to share extrication equipment? 18. List any other agencies that plan to share in the use of equipment bought with funding from this grant: 19. How many of your agency's EMS runs required extrication equipment in the past year? 20.Average lime of extrication: minutes Extrication Equipment Request Information 21. 22. Description 23. Price Each 24. Total 25.Agency 26. State Share COPHE Use Qty Request Share 50% 50 % only Amount Funded 0 0 0 0 0 0_ 0 0 0 0 0 0 0 0 0 Total Extrication Request 0 0 0 27. Extrication Request Narrative (If you need more room,please attach extra pages) 18 of 24 pages State Fiscal Year 2006 Application Section VIII - Data Collection, Injury Prevention, Other Request Complete this section if your grant request includes data collection, injury prevention or any other project. Data Collection 1.Qty 2. Description 3. Price Each 4. Total 5.Agency 6. State Share CDPHE Use only Request Share 50% 50 % Amount Funded 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Total Data Collection Request 0 0 7. Data Collection Request Narrative. (If you need more room,please attach extra pages) 19 of 24 pages State Fiscal Year 2006 Application Section VIII - Data Collection, Injury Prevention, Other Request Complete this section if your grant request includes data collection, injury prevention or any other project. Injury Prevention 1. Qty 2. Description 3. Price Each 4. Total 5.Agency 6. State Share CDPHE Use Only Request Share 50% 50 % Amount Funded 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Total Injury Prevention Request 0 0 0 7. Injury Prevention Request Narrative: (If you need more room,please attach extra pages) 20 of 24 pages State Fiscal Year 2006 Application Section VIII - Data Collection, Injury Prevention, Other Request Complete this section if your grant request includes data collection, injury prevention or any other project. Other Request Section 1. Qty 2. Description 3. Price Each 4.Total 5.Agency 6. State Share CDPHE Use Only Request Share 50% 50% Amount Funded 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Total Other Request 0 0 0 7. Other Request Narrative: (If you need more room, please attach extra pages) 21 of 24 pages State Fiscal Year 2006 Application Colorado EMS IMPORTANT-If submitting via email-this page, Provider Grant along with the W-9 must be printed,signed and Mailed to: Attest Form CDPHE Attention:FY05 EMS Grants Colorado Department of Public Health& Environment HFEMSD-A2 HFEMSD—A2 4300 Cherry Creek Drive South Denver,Co 80246-1530 4300 Cherry Creek Drive South Denver, CO 80246-1530 If delivering your application as a paper copy, include this page with original signatures. 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) 3. Grant Contact Person 4. Phone Numbers MR DAVE BRESSI ER Day97n.,,,,00 Pager: (Title) (First) (Last) Fax-9�03o4619a E-mail:EmI dbresslergco.weld.co.us 5. Agency Mailing Address 6. Agency Street Address(Required for contract,P.O.Box not 1121 NI STREET accepted) 1121 M STREET City: Zip Code: City: Zip Code-. GRE.ELEY 80531 GREE.I EY S0631.- 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. 22 of 24 pages State Fiscal Year 2006 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 Section(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. I II 23 of 24 pages State Fiscal Year 2006 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: DAVE Last Name:BRESSLER DIRECTOR Print Name of Authorized Agent Title 9703535700 X 32_11. Daytime Phone Number 02/13/2005 Signature of Authorized Agent Date DAre you requesting a defibrillator or a cardiac monitor? First Name: IIM Last Name: CAMPAIN CO32697 Print Name of Physician Advisor/Medical Direction Physician License Number 02/13/2005 Signature of Physician Advisor/Medical Direction Date 24 of 24 pages State Fiscal Year 2006 Application Z Cia a)Z / E V 2 ta k CO ikaal CSE $ I cc , _ « s \ 2 f Ts 004 .Ck WTo k o 4.) \ 2 \ 0 K , 4.4 ^ a o o E C N c 2 .23 c / so 7 k 0 / ■ a E J 2 0 CD . CU \ \ § k / co _ 2 [ 4-0 § 0 0 § J C . 0 0 0 \ k To E o w e ■ 42.1 / % § 7 k k ( Ce 9 ° - C.) 2 $CO 404. C — f V . = s e co m cx u ca CD E ' / I V ° c u f 3 c v o _ 2o CC Om C E 2 - k v 2G T:1 4,-) \ P 2 § o I0 O - V 22 c t © c. p @ # p a ' 3 Y. ii ■ q U 7 ■ ... 2 ® ' m « » — E 7. ® k � ® E CO • 0 C CO _ � © c a § 2 . C co c) j k e a) \ w I— E .. Cl) � .E § = ■ e' » C.) a) Q_ .- # @ _ J ° Cl) � C q : § , / 2 2 k2 2 O ■ a- C o Co ; I- . ! / @ o ) ® o E - O U f 2 H % 2 _13 @ ® ° ®L. CNJ / crI , r g / © 0. ...rip. �1 § 2 /cip .,:c 2 ■ / & 01( \ u �. u.� o « IiIs c @% q0® 0 0 2 \ ATTACHMENT C DEPARTMENT OR AGENCY NAME COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT (ADD PROGRAM NAME HERE) DEPARTMENT OR AGENCY NUMBER *** CONTRACT ROUTING NUMBER * ***** LIMITED AMENDMENT#* This Limited Amendment is made this**** day of*********,200*,by and between the State of Colorado,acting by and through the DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT whose address or principal place of business is 4300 Cherry Creek Drive South,Denver,Colorado 80246,hereinafter referred to as the "State"; and, LEGAL NAME OF ENTITY,(legal type of entity) whose address or principal place of business is Street Address,City,State& Zip Code hereinafter referred to as the"Contractor". FACTUAL RECITALS The parties entered into a contract dated******** **,**** with contract encumbrance number PO *** **********,and contract routing number** *** *****,whereby the Contractor was to provide to the State the following: 'briefly describe what the Contractor was to do under the original contract—indent this paragraph' [Please choose one of the following four options and then delete this heading and the other three options not selected:[ The State promises to [choose one and delete the other[increase/decrease the amount of funds to be paid to the Contractor by **********Dollars,(5*.**)during the current term of the Original Contract in exchange for the promise of the Contractor to perform the 'choose one and delete the other[increased/decreased work under the Original Contract. The State promises to pay the Contractor the sum of**********Dollars ($*.**)in exchange for the promise of the Contractor to continue to perform the work identified in the Original Contract for the renewal term of**** years/months,ending on******** **,****. The State promises to [choose one and delete the otherlincrease/decrease the amount of funds to be paid to the Contractor by**********Dollars ($*.**)for the renewal term of**** Ichoose one and delete the otherlyears/months,ending on******** **,****,in exchange for the promise of the Contractor to perform the Ichoose one and delete the otherlincreased/decreased specifications to the Scope of Work described herein. The State hereby exercises a"no cost"change to the [insert those that apply and delete those that don'tlbudget, specifications within the Scope of Work,project management/manager identification,notice address or notification personnel,or performance period within the [choose one and delete the otherlcurrent term of the Original Contract or renewal term of the Original Contract. NOW THEREFORE,in consideration of their mutual promises to each other, stated below,the parties hereto agree as follows: 1. Consideration for this Limited Amendment to the Original Contract consists of the payments and services that shall be made pursuant to this Limited Amendment,and promises and agreements herein set forth. 2. It is expressly agreed to by the parties that this Limited Amendment is supplemental to the original Page 1 of 4 contract,contract routing number** *** *****, linsert the following language here if previous amendment(s), change order(s), renewal(s) have been processedlas amended by 'include all previous amendment(s),change order(s), renewal(s)and their routing numbers!, linsert the following word here if previous amendment(s), change order(s), renewal(s) have been processedlcollectively referred to herein as the Original Contract,which is by this reference incorporated herein. All terms, conditions, and provisions thereof,unless specifically modified herein,are to apply to this Limited Amendment as though they were expressly rewritten, incorporated,and included herein. 3. It is expressly agreed to by the parties that the Original Contract is and shall be modified, altered,and changed in the following respects only: A. 'Use this paragraph when changes to the funding level of the Original Contract occur during the current term of the Original Contract]This Limited Amendment is issued pursuant to paragraph*_*.of the Original Contract identified by contract routing number** *** *****. This Limited Amendment is for the current term of********* ** "** through and including ********* ** **** The maximum amount payable by the State for the work to be performed by the Contractor during this current term is [choose one and delete the other]increased/decreased by **********Dollars,f$***1 for an amended total financial obligation of the State of**********DOLLARS ($*.**). 'delete any portion of this sentence that is not applicablelThe revised specifications to the original Scope of Work and the revised Budget, if any,are incorporated herein by this reference and identified as "Attachment*"and "Attachment*". The first sentence in paragraph*_*.of the Original Contract is modified accordingly. All other terms and conditions of the Original Contract are reaffirmed. A. 'Use this paragraph when the Original Contract will be renewed for another termlThis Limited Amendment is issued pursuant to paragraph*_*.of the Original Contract identified by contract routing number** *** *****. This Limited Amendment is for the renewal term of ********* ** **** through and including********* ** ****. The maximum amount payable by the State for the work to be performed by the Contractor during this renewal term is **********Dollars f$*.**)for an amended total financial obligation of the State of********** DOLLARS,($*.**). This is an 'choose one and delete the otherlincrease/decrease of ********** Dollars,($***)of the amount payable from the previous term. (delete any portion of this sentence that is not applicablelThe revised specifications to the original Scope of Work and revised Budget, if any,for this renewal term are incorporated herein by this reference and identified as"Attachment *"and"Attachment*". The first sentence in paragraph*_*.of the Original Contract is modified accordingly. All other terms and conditions of the Original Contract are reaffirmed. A. 'Use this paragraph when there are"no cost changes" to the Budget, the specifications within the original Scope of Work, allowable contract provisions as noted,or performance period.IThis Limited Amendment is issued pursuant to paragraph*_*.of the Original Contract identified by contract routing number** *** *****. This Limited Amendment [choose those that apply and delete those that don'tlmodifies the Budget in 'identify location in contract', modifies the specifications to the Scope of Work in [identify location in contract!,modifies the project management/manager identification in [identify location in contract],modifies the notice address or notification personnel in [identify location in contract],modifies the period of performance in 'identify location in contract! of the Original Contract. The revised 'choose those that apply and delete those that don'tlBudget,specifications to the original Scope of Work,project management/manager identification,notice address or notification personnel,or period of performance is incorporated herein by this reference and identified as "Attachment*". All other terms and conditions of the Original Contract are reaffirmed. 4. The effective date of this Amendment is date,or upon approval of the State Controller,or an authorized delegate thereof, whichever is later. 5. Except for the General Provisions and Special Provisions of the Original Contract,in the event of any Page 2 of 4 ATTACHMENT C conflict,inconsistency,variance, or contradiction between the terms and provisions of this Amendment and any of the terms and provisions of the Original Contract,the terms and provisions of this Amendment shall in all respects supersede, govern,and control. The Special Provisions shall always control over other provisions of the Original Contract or any subsequent amendments thereto. The representations in the Special Provisions to the Original Contract concerning the absence of personal interest of state of Colorado employees is presently reaffirmed. 6. FINANCIAL OBLIGATIONS OF TIIE STATE PAYABLE AFTER THE CURRENT FISCAL YEAR ARE CONTINGENT UPON FUNDS FOR THAT PURPOSE BEING APPROPRIATED,BUDGETED, AND OTHERWISE MADE AVAILABLE. Page 3 of 4 f IN WITNESS WHEREOF,the parties hereto have executed this Form Amendment on the day first above written. CONTRACTOR: STATE: ]LEGAL NAME OF CONTRACTOR] STATE OF COLORADO (legal type of entity) Bill Owens,Governor By: By: Name: For the Executive Director Title: DEPARTMENT OF PUBLIC HEALTH FEIN: AND ENVIRONMENT ATTEST: PROGRAM APPROVAL: If the Contractor is a corporation or governmental entity,then an attestation By: is required. (Seal,if available.) By: City,City and County,County, Special District,or Town Clerk or Equivalent Corporate Secretary or Equivalent I Delere inapplicable language.) ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER CRS 24-30-202 requires that the State Controller approve all state contracts. This limited amendment is not valid until the State Controller,or such assistant as he may delegate,has signed it. The contractor is not authorized to begin performance until the contract is signed and dated below. If performance begins prior to the date below,the State of Colorado may not be obligated to pay for goods and/or services provided. STATE CONTROLLER Leslie M.Shenefelt By: Date: Form:LAT 7-1-04GN Page 4 of 4 Hello