HomeMy WebLinkAbout20042463.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 24,2004, and ending May 31,2005,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 18th day of August, A.D., 2004.
BOARD OF COUNTY COMMISSIONERS
WE COUNTY, COLORADO
EL
Je4 14
1aw�. .' Robert D. Masden, Chair
1861 ' ' ` Clerk to the Board
On kiew William H. J e, Pro-Tem
reputy Clerk o the Board
M. J. 'le
PRO D AS TO F
David ong
ounty Attorne et) Gf
Glenn Vaad
Date of signature: *ACC
2004-2463
AM0018
(+(� ' 41Y\ COQ
STATE OF COLORADO
Bill Owens,Governor
Douglas H.Benevento,Executive Director .oeco.t6�
Dedicated to protecting and improving the health and environment of the people of Colorado
4300 Cherry Creek Dr.S. Laboratory Services Division t
Denver,Colorado 80246-1530 8100 Lowry Blvd. r laze"`
Phone(303)692-2000 Denver,Colorado 80230-6928
TDD Line(303)691-7700 (303)692-3090 Colorado Department
Located in Glendale,Colorado of Public Health
http://www.cdphe.state.co.us and Environment
MEMORANDUM
To: EMS Grant Award Recipient
fifer—
From: Moira Ivey, dministrative Assistant, Prehospital Care Program, EMS Section
Date: August 4,2004
Re: Contract for your grant award
Enclosed are three copies of your contract from the State of Colorado EMS Provider Grants Program for your FY05 EMS
Grant Award. All three copies of this contract need to be signed by two persons at your agency. The first signature should
be by the person who is authorized to sign legal documents for your agency;the second signature should be by a person who
can attest to the validity of the first signature. Please have all three copies signed and mailed back to me by August 13,2004.
After all three copies have been signed and returned to me,the contracts will be routed for State signatures. After the State
Controller or his designee has signed, I will return one signed copy to you. You may begin work at that time. PLEASE
NOTE: Your agency is not authorized to incur obligations under the grant until the State Controller or his designee
has signed this contract.
Please mail all three copies back to me at: Moira Ivey, Administrative Assistance
Colorado Dept.of Public Health&Environment
HFEMSD-A2
4300 Cherry Creek Drive South
Denver, CO 80246-1530
by August 13`".
Please look the contract over carefully. If you have any questions,you may contact me at: 303.692.2443
2004-2463
DEPARTMENT OR AGENCY NAME
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
Emergency Medical Services Program
DEPARTMENT OR AGENCY NUMBER
FMA
CONTRACT ROUTING NUMBER
05-00016
APPROVED PHASE 1 WAIVER#69
GRANTS PROGRAM
POLITICAL SUBDIVISION CONTRACT
This Contract is made this 1st day of July, 2004, 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 AMBULANCE SERVICE (a political subdivision of the State of Colorado), whose address or
principal place of business is 1121 NI Street,Greeley CO 80631,hereinafter referred to as "the Contractor".
WHEREAS, section 25-3.5.101, et seq., 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)(1),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 FMA EMS0500016; 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 24,2004.
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 May 31,2005,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.
Page 3 of 12
H. The Contractor shall repair or replace all purchased equipment which is damaged,
destroyed, lost, stolen,or involved in any other form of casualty.
1. 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 shall cause to be paid to the Contractor an amount not to exceed SEVENTY-
FIVE THOUSAND DOLLARS, ($75,000.001. Of the total financial obligation of the State
referenced above,$75,000.00 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$75,000.00. The Contractor shall provide matching funds in the amount of
$75.000.00. 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:
Moira Ivey
Administrative Assistant
EMS Provider Grants Program
Health Facilities& Emergency Medical Services Division
Colorado Department of Public Health and Environment
Mail Code A-2
4300 Cherry Creek Drive South
Denver, CO 80246-1530
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
Page 4 of 12
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.
D. GENERAL PROVISIONS.
1. 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 wan-ants 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 wan-ants 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.3999
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 fmancial
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 fmal audit report. This requirement is in addition to any other audit
requirements contained in other paragraphs of this Contract.
Page 5 of 12
8. Unless otherwise provided for in this Contract, for all contracts with terms longer than three(3)
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 hinds;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 fmal 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
Page 6 of 12
•
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 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 personal/purchased 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
Page 7 of 12
Contractor for those services or goods. However, if less than sixty percent(60%)of the services
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, fire, 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
maybe 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
Page 8 of 12
the change as if that change was fully set forth herein. Except as provided above, no modification
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 first above written.
CONTRACTOR: STATE:
WELD COUNTY AMBULANCE SERVICE STATE OF COLORADO
(a political subdivision of the State of Colorado) Bill Owens,Governor
By: Y V tl( _ By:
Name: Robert 1) Ma cden OR/1 R/7004 For the Exe99 rtiv Director
Title: Chair DEPARTMENT F PUBLIC HEALTH
F jaa� 846000813 A AND ENVIR MENT
art
`1 Alatailleadietaff PROGRAM APPROVAL:
18,1 t', CZ\_�/•�3a ,7
4
iGc_ T /zL By:
,e and County,County,
%asn.ladtct, or Town Clerk or Equivalent
APPROVALS:
COLORADO DEPARTMENT OF LAW
OFFICE OF THE ATTORNEY GENERAL
Ken Salazar,Attorney General
By:
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
r—
By:
Date: Ri&04/
Revised: 12/12/03
Page 12 of 12
O2€9154/-c1PWAS
ATTACHMENT A
Colorado EMS
ri
ti Provider Grant
Application /S ) F_ 9
Colorado Department of Public Health &Environment /V
PCP—HFEMSD—A2
4300 Cherry Creek Drive South ' \ r 61 ix
Denver,CO 80246-1530 CDPHE Use Only
Date received Stamp
1. Legal Name of Agency 2. Federal Tax ID Number
Weld County Paramedic Services 84-6OOO813
DBA(Doing Business As—If Applicable)
3. Grant Contact Person 4. Phone Numbers
Mr. Ted Beckman Day:970-506-4033 Pager:97O-346-3415
(Title) (First) (Last) Fax: - - E-mail: bgt207@hotmail.com
5. Agency Mailing Address 6. Agency Street Address(Required for contract,P.O. Box not
1121 M Street accepted) 1121 M Street
City: Zip Code: City: Zip Code:
Greeley 80631- Greeley 80631-
7. Legal Status of Agency/Organization (Mark all that apply:)
❑Private Not For Profit ❑ Private for Profit ® County/City Government
❑State Agency ❑ Special District ❑ Other:
8. Is this a RETAC or statewide grant project? No 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 current grant requests to other agencies for the current budget year? 9a. List your RETAC
Yes Describe:DOJ grant to supplement equipment for MCI's Northeast
10. Multi-Agency Application—must read and follow multi-agency instructions _ - New—Your RETAC will score your
application for 50%of 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 %
The values for the project area summary below will auto-populate from the request sections of the application.
PROJECT AREA SUMMARY: CDPHE Use
No more than 2 categories of request per Total Category Only
application are allowed Cost Agency 50% State 50% Amt Funded
Section III—EMS Training $0.00 0.00 0.00
Section IV-Ambulance,Other Vehicle $150,000.00 75,000.00 75,000.00
75,003—
Section V- Communications $0.00 0.00 0.00
Section VI- EMS Equipment $0.00 0.00 0.00
Section VII—Defibrillation/Cardiac
Monitor $200,000.00 100,000.00 100,000.00
❑ PA. Signature included
Section VII-Extrication Equipment $0.00 0.00 0.00
Section VIII - Data Collection $0.00 0.00 0.00
Section VIII- Injury Prevention $0.00 0.00 0.00
Section VIII- Other $0.00 0.00 0.00
Total Grant Request: $350,000.00 $175,000.00 $175,000.00 1 51 SOD--
1 of 16 pages
State Fiscal Year 2005 Application
Section I - Financial Information
All applicants must complete this section.
Balance Sheet
for entire Agency listed on page 1, box 1
For 12 months ending: 12/31/2002 +Enter the date of your most current financials here -this date is a
default value,change if it does not match your record year
Note: Use this same accounting period throughout the financial information section.
Accounting Method: Cash
Assets Liabilities
1. Unreserved Cash Accounts 37,859,773 12. Accounts Payable 5,405,312
2. Reserved Cash Accounts 3,307,949 13. Short Term Notes and Loans 0
3. Unreserved Investments 0 14. Long Term Notes and Loans 7,126,956
4. Reserved Investments 0 15. Taxes payable 0
5. Held in trust for Pension Benefits 0 16. Payable Payroll Expenses 1,793,900
6. Real Estate and Buildings 44,087,813 17. Prepaid and Deferred Revenue 52,017,639
7. Equipment
❑ market value ®depreciated 47,790,552 Total Liabilities $66,343,807.00
value
8. Accounts Receivable 54,588,399 18. Define accounting method for Depreciation and Capital(Hit
9. Prepaid Expenses 0
Fl for help.): straight line
10. Inventory 1,357,920 19. List new Capital items purchased: 5969655
11.Other Assets 480,825
Total Assets $189,473,231.00 Net Worth $123,129,424.00
Profit and Loss
for entire Agency listed on page 1, box 1
For 12 months ending: 12/31/2002 +For the financial period listed at the start of this section
Income/Revenues Expenses
20. Government 38,039,636 29. Operational Expense 103,300,186
21. Mil Levy%= 33 enter dollar
revenues 45,233,546 30. Personnel Costs—salaries, benefits,etc. 14,807,083
22. Donations,Contnbutions,Bequests 0 31. Depreciation Expense 4,341,732
23. EMS Fee for Service 6,808,797 32. Debt Service 406,155
24. Fund Raising 0 33. Capital Expenditures 5,969,655
25. Interest& Dividends 2,052,594 34. Other Expenses 0
26. Grants—list sources: 26,163,342 Define:
27. Subscription Program 0
28. Other Income: 10,030
Total Income $118,307,945.00 Total Expenditures
$128,824,811.00
35. List new capital items purchased: 0
Profit or(Loss)
($10,516,866.00)
Rates and Collection
36. Does your agency charge for Yes 37.Who processes this agency's billing and accounting?
service? ®Agency ❑ Contract Service O No billing/accounting
Service
Base Rate Medicare Allowable
38. BLS (Basic Life Support)non-emergent 966.00 238.47
2 of 16 pages
State Fiscal Year 2005 Application
Section I - Financial Information
All applicants must complete this section.
39. BLS-Emergent 966.00 279.62
40.ALS1 (Advanced Life Support-Level 1)Non-emergent 966.00 252.19
41.ALS1 —Emergent 966.00 300.19
42.ALS2- non-emergent 1,200.00 358.49
43. SCT(Specialty Care Transport)non-emergent 0.00 0.00
44.SCT(Specialty Care Transport)emergent 0.00 0.00
45. PI (Paramedic ALS Intercept)non-emergent 0.00 0.00
46. FW (fixed Wing)—non-emergent 0.00 0.00
47. FW(fixed Wing)—emergent 0.00 0.00
48. RW(Rotary Wing)—non-emergent 0.00 0.00
49. RW (Rotary Wing—emergent 0.00 0.00
50.Treat and Release 150.00 ■
51. Mileage Rate—Urban 15.00
52. Mileage Rate—Rural 1 to 17 miles 15.00
53. Mileage Rage Rural 18 to 50 miles 15.00
54. Overall collection rate(Percentage): 43.00 %
EMS Portion of the Agency Budget
for the Agency listed on page 1, box 1, detail the budget allocated to EMS
For 12 months ending: 12/31/2002 (—For the financial period listed at the start of this section
Income/Revenues Expenses
55. Government 0.00 64. Operational Expense I 1,047,223.00
56. Mil Levy%= 0.00 enter dollar
revenues 0.00 65. Personnel Costs—salaries, benefits,etc. 3,029,540.00
57. Donations,Contributions,Bequests 0.00 66. Debt Service 1,506,063.00
58. EMS Fee for Service 6,391,000.00 67. Capital Expenditures 405,298.00
59. Fund Raising 0.00 68. Depreciation Expense 189,644.00
60. Interest&Dividends 0.00 69. Other Expenses 0.00
61. Grants—list sources: 0.00 Define:
62 Subscription Program 0.00
63. Other Income: 0.00.
Total Income $6,391,000.00 Total Expenditures $6,177,768.00
70. List new capital items to be purchased:
Projected Profit or(Loss) I $213,232.00
3 of 16 pages
State Fiscal Year 2005 Application
Section I - Financial 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.
(Form will expand as you type)
(The numbers provided throughout section I are based on the fiscal year 2002. These facts have
been audited and are accurate. The 2003 financial records have been completed but have not
been audited.)
Weld County Paramedic Services (WCPS) is owned and operated by the Board of County
Commissioners of Weld County. The agency serves over 4000 square miles of north / north
eastern Colorado. Operating as an enterprise of Weld County Government since 1989, WCPS is
required to bill and collect all of their operational costs of providing advanced life support
treatment and transportation. The service area and customer base include a population that is
over 50% Medicare, Medicaid and medically indigent.
With the recent required changes placed on ambulance services in the Medicare / Medicaid fee
schedules and forced acceptance of assignment, coupled with the evolving effect of the changes
in the Colorado No Fault automobile insurance on collection rates, WCPS has experienced a
decrease in their collection rates from 50% to close to 40% percent in the last year. Field
personnel levels have been reduced by seven FTE's, along with a substantial mid year increase in
the ambulance service fee structure, in an attempt to address the revenue shortfall created by
these changes.
The result being a negative impact on our scheduled replacement of ambulances, along with our
diagnostic equipment. WCPS has had to lengthen the service life of our ambulances and
diagnostic equipment beyond previous schedules for replacment.
4 of 16 pages
State Fiscal Year 2005 Application
Section II - Agency Information
All applicants must complete this section.
1. Is EMS coverage included in your district 2. Type of service: 0 ALS ❑ BLS D Fire/Rescue
coverage? Yes ❑ Training ❑ Other
Number of years this agency has provided EMS
service? 29
3. Does this agency transport?Yes 4. Primary mode of patient transport: Ambulance
Number of transports for the last year? 11,283
Operational Activity
5. Type of EMS Service:Career 6. Demographics of Service Area:
Number of paid employees? 83 3,999.00 Square Miles 207,000.00 Population
Number of volunteer employees? 0
3 #of Stations for this agency
7. Total EMS calls for the last record year? 8. Average BLS call time: 5 minutes
0 BLS calls 10,659 ALS calls 9. Average ALS call time:8 minutes
10,659 = Total all calls 10. Average mileage to nearest Hospital: 5
Date ending of record year: 12/31/2003 11. Average round trip mileage per call: 10
12. Number of calls your agency was UNABLE to respond to,for any reason:0
List any explanations for being unable to respond(i.e.equipment failure, staffing,call volume):
Personnel
Responder Full-time Part-time Volunteer AED Approved
13. EMT-Basic 5 20
14. EMT-Intermediate 3 6
15. EMT-Paramedic 29 15
16. First Responder
17. Nurse
18. Other
Vehicle Inventory
19. Bought with Replacing
Make/Model Type EMS Grant this
Unit# Chassis/Box Year Mileage (Ex: Ford/E-350) 4WD Code Funds? Vehicle
08 1999 / 1999 171,312 Ford I E350 DYes 3 ['Yes DYes
10 1999 / 1999 84,373 Ford I E350 DYes 3 DYes Dyes
16 1999 / 1999 173,204 Ford 1E450 Dyes 3 Dyes Dyes
17 1999 / 1999 165,657 Ford 1 E450 DYes 3 DYes Dyes
18 1999 / 1999 172,269 Ford/E450 DYes 3 DYes Dyes
19 1999 / 1999 160,974 Ford/E450 DYes 3 Dyes DYes
20 2001 / 2001 114,854 Ford/E450 DYes 3 Dyes Dyes
21 2002 / 2002 81,729 Ford/E450 Dyes 3 DYes Dyes
22 2002 / 2002 61,780 Ford 1 E450 Dyes 3 DYes Dyes
23 2003 / 2003 35,250 Ford I E450 Dyes 3 Dyes Dyes
/ / Dyes Dyes Dyes
/ / Dyes Dyes Dyes
If you need more space for vehicle inventory. Please fill out Vehiclelnventory.dot and mail it in with your attest form.
frttp://www.cdphe.state.co.us/em/Grants/PCPGrantsProviderasp#Useful%20Files°/020and%20Downloads Useful Files
Type Codes: 6. Medium Duty Rescue Vehicle
1. Type I Ambulance 7. Heavy Duty Rescue Vehicle
2. Type 11 Ambulance 8. Search & Rescue
3. Type Ill Ambulance 9. Pumper
4. Any vehicle used for first 10. Ladder Truck
response-Licensed as Class"A"
(Chase, Rapid or first Response)
5. Light Duty Rescue Vehicle 11. Utility(Chiefs Car, Sedans, Brush Trucks, etc.)
5 of 16 pages
State Fiscal Year 2005 Application
Section II - Agency Information
All applicants must complete this section.
20. Extrication Equipment
#of RS 10 Kits #Spreaders #Cutters #Rams #Air Bags
1 to 5 yrs 0 0 0 0 0
6yrs+ 0 0 0 0 0
21. Emergency Medical Equipment owned by your agency
How many manual defibrillators does your agency own? 10 1-3 years 4 years or older
How many semi-automatic defibrillators does your agency own? 0 1-3 years 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
250 your agency own? 0 agency own?13
Narrative describing your Agency's Structure and Service Area
72. Please use this area to describe your agency to someone from outside your area. Include a description of your district
proper, response area and the number of residents. Assume that the reader does not know the structure and staffing of
your agency,the terrain and roads of your area,and any special circumstances your agency contends with.
(Form will expand as you type)
Weld County Paramedic Services (WCPS) provides advanced life support response, evaluation,
treatment and transport to the 207,000 citizens and numerous visitors throughout the 4000
square miles of Weld County Colorado. This service is provided in coorperation with surrounding
ALS providers via mutual aid agreemnts along with the tiered response of first responders from
the fire departments operating throughout Weld County. Of the near 11,000 calls for service,
over 60% of the calls for service fall into the rural / frontier areas, county roads and highways of
Weld County. The other 40% of calls occur within the city of Greeley.
Advanced Life Support coverage is provided through the fluid deployment of five ambulances
during the day and four ambulance from midnight to 0600 hours, via fixed station and system
status placement of resources throughout Weld County. Operating with 35 full time field staff
and an office and administrative staff of 7 Weld County operates as a enterprise of Weld County
government, billing and collecting all cost of operation.
6 of 16 pages
State Fiscal Year 2005 Application
Section III - EMS Training Request
Complete this section if your grant request includes EMS training.
EMS Training Request Section
Course/Class Name #of Tuition cost Total Agency State share CDPHE Use Only
students per student Cost share 50% 50% Amount Funded
0.00 0.00
What are the proposed dates of the above course/class?
Where will the class be offered?
Who will conduct the training?
How did you determine the number of students per class?
What costs other than tuition did you include in the class cost. Itemize and explain how you determined these.
Course/Class Name #of Tuition cost Total Agency State share CDPHE Use Only
students per student Cost share 50% 50% Amount Funded
0.00 0.00
What are the proposed dates of the above course/class?
Where will the class be offered?
Who will conduct the training?
How did you determine the number of students per class?
What costs other than tuition did you include in the class cost. Itemize and explain how you determined these.
Course/Class Name #of Tuition cost Total Agency State share CDPHE Use Only
students per student Cost share 50% 50% Amount Funded
0.00 0.00
What are the proposed dates of the above course/class?
Where will the class be offered?
Who will conduct the training?
How did you determine the number of students per class?
What costs other than tuition did you include in the class cost. Itemize and explain how you determined these.
Course/Class Name #of Tuition cost Total Agency State share CDPHE Use Only
students per student Cost share 50% 50% Amount Funded
0.00 0.00
What are the proposed dates of the above course/class?
Where will the class be offered?
Who will conduct the training?
How did you determine the number of students per class?
What costs other than tuition did you include in the class cost. Itemize and explain how you determined these.
Course/Class Name #of Tuition cost Total Agency State share CDPHE Use Only
students per student Cost share 50% 50% Amount Funded
0.00 0.00
What are the proposed dates of the above course/class?
Where will the class be offered?
Who will conduct the training?
How did you determine the number of students per class?
What costs other than tuition did you include in the class cost. Itemize and explain how you determined these.
Course/Class Name #of Tuition cost Total Agency State share CDPHE Use Only
students per student Cost share 50% 50% Amount Funded
0.00 0.00
What are the proposed dates of the above course/class?
Where will the class be offered?
Who will conduct the training?
How did you determine the number of students per class?
What costs other than tuition did you include in the class cost. Itemize and explain how you determined these.
Course/Class Name #of Tuition cost Total Agency State share CDPHE Use Only
students per student Cost share 50% 50% Amount Funded
0.00 0.00
7 of 16 pages
State Fiscal Year 2005 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 costs other than tuition did you include in the class cost. Itemize and explain how you determined these.
Course/Class Name #of Tuition cost Total Agency State share CDPHE Use Only
students per student Cost share 50% 50% Amount Funded
0.00 0.00
What are the proposed dates of the above course/class?
Where will the class be offered?
Who will conduct the training?
How did you determine the number of students per class?
What costs other than tuition did you include in the class cost. Itemize and explain how you determined these.
Course/Class Name #of Tuition cost Total Agency State share CDPHE Use Only
students per student Cost share 50% 50% Amount Funded
0.00 0.00
What are the proposed dates of the above course/class?
Where will the class be offered?
Who will conduct the training?
How did you determine the number of students per class?
What costs other than tuition did you include in the class cost. Itemize and explain how you determined these.
Course/Class Name #of Tuition cost Total Agency State share CDPHE Use Only
students per student Cost share 50% 50% Amount Funded
0.00 0.00
What are the proposed dates of the above course/class?
Where will the class be offered?
Who will conduct the training?
How did you determine the number of students per class?
What costs other than tuition did you include in the class cost. Itemize and explain how you determined these.
Combined cost of all requested classes Total Agency State Share CDPHE Use Only
Share 50% 50% Amount Funded
Total Training Request $0.00 0.00 0.00
Training Request Narrative—
Please use the narrative section to describe your agency's method of determining who is elegible for training tuition assistance.
Describe any agreement you have with students in order to be eligible for tuition assistance. Explain how your agency will
sustain a training program in future years. Include any other specifics that would help an outside person understand the needs
of your agency's training request. (Form will expand as you type.)
8 of 16 pages
State Fiscal Year 2005 Application
Section IV - Ambulance, Other Vehicle Request
Complete this section if your grant request includes an ambulance or other vehicle.
Request for Ambulance
1. 2.Type 3. Description-Press F1 key for 4.Total$ 5.Agency 6. State Share CDPHE Use
Qty Code listing of fixed ambulance award Request Share 50% 50% Only
amounts. Amount Funded
0.00 0.00
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?
Request for Ambulance
1. 2.Type 3. Description-Press Ft key for 4.Total$ 5.Agency 6. State Share CDPHE Use
Qty Code listing of fixed ambulance award Request Share 50% 50% Only
amounts. Amount Funded
0.00 0.00
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?
Request for non ambulance •
1. 2.Type 3. Description 4.Total$ 5.Agency 6. State Share CDPHE Use
Qty Code Request Share 50% 50% Only
Amount Funded
2 3 Re-chassis 150,000.00 75,000.00 75,000.00 -Isom-
7. Is the vehicle requested above: O New addition to inventory? O Replacement vehicle?
7a. If this is a replacement vehicle,which unit number does it replace? 16,17,18
8. If the requested vehicle(s)is a replacement(s):
• What was the number of calls your agency was unable to respond to due to mechanical unavailability of the emergency
vehicle to be replaced? 0
• What will be done with the unit that is replaced?
Type Codes: 6. Medium Duty Rescue Vehicle
1. Type I Ambulance - 7. Heavy Duty Rescue Vehicle
2. Type II Ambulance 8. Search&Rescue
3. Type Ill 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.
Qty Description Price Total Request Agency State Share CDPHE Use
Each Share 50% 50% Only
Amount Funded
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
Total related equipment cost 0.00 0.00 0.00
Total Vehicle Request—vehicle cost plus $150,000.00 75,000.00 $75,000.00 15000equ equipment
10. What is the average length of service in miles and or years of vehicles operated by your agency?
11. Please describe your agency's vehicle replacement program:
(Form will expand as you type.)
Weld County Paramedic Services (WCPS) has initiated a re-chassis program in which chassis
would be replaced and patient modules would be remounted. The first re-chassis will occur in
April of 2004 at a savings of$68,000 over the purchase of a new ambulance. This project will
continue until each of the 9 type III ambulances have been remounted 3 times each. The
9 of 16 pages
State Fiscal Year 2005 Application
Section IV - Ambulance, Other Vehicle Request
Complete this section if your grant request includes an ambulance or other vehicle.
ambulances being rechassised this year will be #16,17, tk 18. These ambulances are not being
replaced. The entire program is described in detail in the following narrative.
12. Vehicle request narrative
(Form will expand as you type.)
Weld County Paramedic Services is an agency of Weld County government 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 increasing costs are some of the major factors that
have negatively affected WCPS. Significant mandatory budget cuts have been met. The
management of WCPS continues to search for methods to operate more efficiently and
effectively.
In 1998 a decision was made to establish a program that would save an estimated $2.5 million
over the next 12 years. A re-chassis program was undertaken in which ambulances chassis
would be replaced and patient modules would be remounted. The first rechassis will occur in
April of 2004 at a savings of$68,000 over the purchase of a new ambulance. This project will
continue until each of the 9 Type III ambulances have been remounted 3 times.
This project will require the remounting of 3 units this fiscal year. With considerations for
inflation and variation in the requirements of each specific unit it is estimated that the cost of
remounting 3 chassis this year will be $150,000.
WCPS respectfully requests matching funds from the state for our rechassis project.
This program of remounting ambulances is a responsible and effective utilization of funds that
are increasingly difficult to obtain. It is but one of many methods by which WCPS strives to
maintain the highest quality emergency service with less financial resources.
10 of 16 pages
State Fiscal Year 2005 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: O Trunking -list system: ❑ Other- describe:
Pager and Alerting Information (required for all requests for pagers,paging portables,and alerting monitors)
2. Does your agency use a commercial service to provide paging? If yes, list service:
3a. If your agency does not use a commercial paging service, check the box that describes service provider:
❑ Government ❑ Agency Owned ❑ Other:
3b. Receiver Frequency Used to Receive Pages: MHZ
Communications Equipment Inventory—list number of units by type
UHF VHF 800 MHZ
0-5 years 6-10 years 11+years 0-5 years 6-10 years 11+years 0-5 years 6-10 years
4. Portables
5. Mobiles
6. Pagers
7. Request for Communications Equipment
For communications systems requests,provide the name and contact information for the individual responsible for answering
_ questions regarding specifications.
Communications Contact Name Phone Number E-mail
8.Qty 9. Description 10. Price Each 11. Total 12.Agency 13. State CDPHE Use Only
Request Share 50% Share 50% Amount Funded
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
Total Communications Request $0.00 0.00 0.00
Communications Narrative
Note: For major communications projects, insert separate page or pages that include a functional diagram of the proposed
system and a copy of the communications plan if one exists. If you have vendor quotes that you have used to prepare this
request, please include those following this page.
(Form will expand as you type.)
11 of 16 pages
State Fiscal Year 2005 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
0.00 0.00 0.00
` �� - -`---- 0.00 0.00 0.00
0.00 - 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 - 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
•
TOO 0.00 0.00
0.00 0.00 0.00 -
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 • 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
Total EMS Equipment Request $0.00 0.00 0.00
7. EMS Equipment Request Narrative
(Form will expand as you type.)
Note:
12 of 16 pages
State Fiscal Year 2005 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: 408
2. Number of EMS runs in the past 2 years that were witnessed arrests: 152
3. Number of CPR starts that took place on your EMS runs in the past 2 years: 144
4. BLS average response time to scene:Unkminutes 5. ALS average response time to scene: 7minutes
6. Telephone CPR? ® Yes 0 No 7. Citizen CPR Program? ® Yes 0 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% Amount Funded
50%
10 Zoll M Series 20,000.00 200,000.00 100,000.00 100,000.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
Total Defibrillation Request $200,000.00 100,000.00 100,000.00 C�
15. Defibrillation Narrative:
(Form will expand as you type.)
(The facts presented in section VII question 1, 2, 8s 3 are an estimate based on three random
months multiplied by 4 to get the year total and then multiplied by two to get the two year
total. These numbers were obtained by counting the number of cardiac arrests and
determining if it was witnessed and/or if there was CPR initiated.)
With coronary artery disease becoming the #1 killer in the U.S., it has become increasingly
important that the definitive care provided at the hospital be given an accurate assessment of
the patient as soon as possible to plan for treatment. As EMS providers it is our duty to the
public to provide the highest quality care and best treatment possible. This is all within
reach with an upgrade to 12 lead monitors and biphasic delivery of defibrillation.
Currently our service has the capability to monitor patients with 5 leads and we can not
provide a true diagnostic level interpretation of ECG's to convince hospitals of our diagnosis.
There has been many studies proving the accuracy of Paramedics in the field to interpret 12
lead ECG's. Early identification enables the Paramedic to alert the ED to their arrival and
give adequate time to prepare for treatment. The adage of" Time is Muscle" becomes
important and early notification could save 20 minutes or more in providing thrombolytic
therapy or cardiac cathiterization.
The field of paramedice is evolving and gaining respect. We can affect the outcomes of many
patients with our knowledge and the use of 12 lead ECG. A proper patient evaluation and in
depth history taking are still of paramount importance, but the 12 lead is certainly of more
diagnostic value than anything we have used in the past.
WCPS respectfully requests assistance in upgrading from our ECG monitors / defibrillators to
those machines with the modern essentials to provide the optimal care for the citizens and
visitors in our county. With the addition of 12 leads we will institute a cardiac alert program
and cut the time from door the definitive care significantly.
Extrication Equipment Information
13 of 16 pages
State Fiscal Year 2005 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.
16. List the location, distance,travel time and type(RS-10, Hurst,etc.)of nearest extrication equipment: O
17. Do you have a written or verbal agreement to share extrication equipment? O
18. List any other agencies that plan to share in the use of equipment bought with funding from this grant:O
19. How many of your agences EMS runs required extrication equipment in the past year?0
20.Average time of extrication:Ominutes
Extrication Equipment Request Information
21. 22. Description 23. Price Each 24.Total 25. Agency 26. State Share CDPHE Use
Qty Request Share 50% 50% only
Amount Funded
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
Total Extrication Request $0.00 0.00 0.00
27. Extrication Narrative
(Form will expand as you type.)
•
14 of 16 pages
State Fiscal Year 2005 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% Amount Funded
50%
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
Total Data Collection Request $0.00 0.00 0.00
7. Data Collection Request Narrative:
(Form will expand as you type.)
Injury Prevention
1. Qty 2. Description 3. Price Each 4.Total 5.Agency 6. State Share CDPHE Use Only
Request Share 50% Amount Funded
50%
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
Total Injury Prevention Request $0.00 $ 0.00 $ 0.00
7. Injury Prevention Request Narrative:
(Form will expand as you type.)
Injury Prevention (background information on planning, implementing and evaluating injury
prevention programs is available at http://www.cdphe.state.co.us/em/SEMTAC/ipac/IP 03-
08finalstrategicplan.pdf and www.cdphe.state.co.us/ps/bestpractices/bestpracticeshom.asp )
Other Request Section
1. Qty 2. Description 3. Price Each 4. Total 5.Agency 6. State Share CDPHE Use Only
Request Share 50% Amount Funded
50%
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
Total Other Request $0.00 $ 0.00 $ 0.00
7. Other Request Narrative:
(Form will expand as you type.)
15 of 16 pages
State Fiscal Year 2005 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 ADPHE ADIE.1
Attention: FY05 EMS Grants
Colorado Department of Public Health& Environment PCP—HFEMSD—A2
4300 Cherry Creek Drive South
PCP-HFEMSD—A2
Denver,Co 8o2as-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. Ted Beckman Day:970-506-4033 Pager:970-346-3415
(Title) (First) (Last) Fax: - - E-mail:bigt207@hotmail.com
5. Agency Mailing Address 6. Agency Street Address(Required for contract, P.O. Box not
1121 M Street accepted) 1121 M Street
City: Zip Code: City: Zip Code:
Greeley __ 80631- Greeley 80631-
The Authorized Agent, whose name and signature appear below, has been designated by the agency/organization to complete
and submit a grant request 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'. In addition,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. 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. By signing below,The
Authorized Agent attests to the fact that:
a) the Agency(ies)that is affected by the possible outcome of the grant request has been notified and has agreed
to its submission.
b) the Regional Emergency&Trauma Advisory Council (RETAC)for the applying agency has been provided with
five copies of this application (waived if this is a RETAC or statewide request).
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.
First Name: Robert Last Name: Masden Chair, BOCC Weld County, Colorado
Print Name of Authorized Agent Title
970 - 356 - 4000 X4200
Daytime Phone Number
02/08/2004
Signature o Authorized Agent Date
-- -®Are you requesting a defibrillator or a cardiac monitor?
First Name:James Last Name: Campain CO32697
Print Name of Physician Advisor/Medical Direction Physician License Number
02/08/2004
Sgnature OT Pj ysitian dvisor/Medical Direction Date
16 of 16 pages
State Fiscal Year 2005 Application
.o?•co<o Attachment B
y=� A A0 Payment Request Statement
* vo
.isle . Date:
Colorado Department Contract/Purchase Order#:
of Public Health
and Environment Federal Tax ID #:
To: The Colorado Department of Public Health and Environment From:
HF and EMS Division, Pre-hospital Care Program, EMS Grants Contractor Name
4300 Cherry Creek Drive South, A235
Denver, Colorado 80246-1530 Contractor Address
(303)692-2985 office (303) 691-7720 fax
Contractor City,State,&Zip Code
Voucher Itemization Table
Note:A separate line for each invoice submitted should be filled out and the back up documentation should be attached in concurrent order.
Description of Activities/Expenses Invoice# Invoice Total Agency Cash Match Total EMS Funds Requested
TOTALS $ $ $
This is to certify that the above expenses were incurred per contract/purchase order number With the State and we, the
contractor, are requesting reimbursement for the same.
Is this the final payment reimbursement request for this contract/purchase order? YES NO
Contractor Signature Date Phone
For State Use Only:
Grant Manager Approval Date
Fiscal Officer Approval Date
1\Prehospi,al CarelGrantsV4od der GIen6\Coni,act Masters\Gary,Newell-(Wormed MaslersSIM9 PI W.EMS Grauer 03-04 anachmen,B revised 12-12-03 doc White&Yellow- Return to Grants Manager
Pink- Contractors Copy
Hello