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Home My WebLink About20010721.tiff Application Cover Sheet GRANT ABSTRACT Agency Name E4 icayS ho lo.-- E akc '-' County lu el ct PROJECT AREA(Mark all that apply): _Communications _Medical/Rescue Equipment _Manual_Automated Defibrillator Extrication )C Training 10 Continuing Education )6 Training Equipment _Public Education _Injury Prevention/Pier Projects _Other(can include County planning grant request,data collection,etc.) EMERGENCY VEHICLE: Ambulance _Quick Response Rescue Total dollar amount requested from the State $ 4637- 5C-7) Total cash match provided by applicant $ t(L'3? 50 Total In-Kind match provided by the applicant $ Summarize in one paragraph: 1. The need for this project(for instance- Our county wide ambulance service has been BLS since its inception. We have become a favorite retirement spot for many Colorado residents in the past 5 years. The complexity of our calls has increased along with the number. We want to upgrade to ALS within the next year. We need to replace our worn out transport ambulance) (( n�1 11 v e.e ) \Ace_ �iv 6c M-S vc, ti CeveP y 1ey u CIL VJIS7r�C�r (Dux ,N-Da 1 5 *0 .\i\Cl v Q. Oki r F 1 v L' b-tp-V. ra vt t c� a \A1/44a ,\er ever E1-lt- J_� , t O1E. pnuw pc,„4,o�. Lct, r Y -equkrn.c. ( U AA- 1\:_ktA q 2.l\ . S �vr rc'ctCV.a•AC'j D- PALS Serlilce • 2. A description of the project(for instance-Priority#1 We would like to upgrade the level of service countywide to 24 hr ALS; a)training for 6 new EMT'I; b)2 manual defibs;c)radios for EMT-Is,Priority#2 ambulance to replace 1980 Type II with 150,000 miles on it, etc.) F \AV-t A-c up vc_\ e 1u v Ova R l G / .3 EMT 'S , It rirxt R.R.* `Q m v. S 1 P ,re. -,1 E C t-11 E. %'r' 4\'-t y-tet.t` , �-Y o. h \ o i Ci o% cD v. L tP Average number of EMS runs yearly 3)G oc>6O consent ciendct, 2001-0721 Attachment A Legal Name Of Agency Federal Tax ID f jL1 - 6-11 Is-69 1 (read instructions carefully on this item) • � ciAoL V ;te. 4O-\-'*L kov-v \S\-rCc* Contact Person Phone (Day) E-mail: n a4 Quw.ak\ <R. ((\\\;C)) - 4,54-2>7S0 Vet'-gakaA(aAoL.cum Agency Mailing Address P. O. 1)Ox Stsi) Street City &a1-ova Zip Solo s----- County/Counties Impacted: LW 2kA. Legal Status Of Agency/ Organization (Mark all that apply): _PRIVATE NOT FOR PROFIT _PRIVATE FOR PROFIT _COUNTY/CITY GOVERNMENT _STATE AGENCY _ __SPECIAL DISTRICT _OTHER PROJECT AREA(Mark all that apply): Communications Training Medical/Rescue Equipment 1 Continuing Education Manual Automated Defibrillator Training Equipment Public Education _ Extrication _ Other _ PIER/Injury Prevention Programs Emergency Vehicle Ambulance_ Quick Response Rescue County Wide Grant _ Regional Grant _ State-wide Grant.. Individual Agency Grant 50% CASH MATCH REQUIREMENT MET _ WAIVER HAS BEEN REQUESTED I,the undersigned,do hereby attest that the information contained within this application is true to the best of my knowledge. I also attest that the County Commissioners from the areas impacted by this project will be provided a copy of this application by no later than 7) 31-C I . I understand that my application will be disqualified should either of these statements be untrue. • L- a-V/kru A. L evi ll 8oatd f'je5 - 1F=,t, zz i4gPRINT NAME TITLE 1 /�/a • y 11/ oo/ SIGNATU E DATE 1 JUSTIFY WHY IS THIS PROJECT NEEDED(see instructions on opposite page) We need continuing medical education for our department, to be provided by Aims Community College, to include 24 hours per year at a cost of $25 per hour, totalling $600. This training is required by the State of Colorado to maintain certifications for EMS. The cost to train four additional EMT' s is $1 , 000 each. The cost to train four additional First Responders is $600 each. The skill meter maniken will be used to develop proficiency at CPR and AED application for the entire department. Our district is approximately 64 square miles and includes the towns of Eaton and Lucerne. The population of our district is approximately 3 , 800 and includes a fairly even split between rural farming area residence and town residence. A large portion of our traffic accident calls are due to local resident commutes on Colorado Highway 85 , Weld County Road 74 , and Colorado Highway 392 , We also service a large population of retirees both in town and on farms. District residents and residents in adjoining districts benefit greatly from having trained responders who can administer a higher level of care, perform better EMS communication, and perform assessment and patient "packaging" prior to ALS arrival. Some areas of our district can be up to 8 minutes from ALS. Training above the first aide level is mandatory for the number of farm accidents, traffic accidents and heart 'and breathing problems we encounter. County Plan Reference(see Instructions on opposite page): 2 DESCRIPTION OF THE PROJECT AND HOW YOUR PROJECT UPGRADES EMS (See instructions on opposite page) Our goal is to provide at least First Responder level care on all EMS calls within one year. Due to our volunteer status we need to increase the number of trained people to insure the presence of at least one First Responder or EMT B on every call. We have commitments from four members to complete EMT B and four members to complete First Responder in the next twelve months. We are working with Aims Community College to schedule classes that will fit everyone ' s schedule. Aims also provides State approved instructors for our CME training hours and teaches these classes one night per month for 2 hours each. Aims currently charges $25 per hour X 24 hours = $600 per year. Cost for 4 EMT' s is $4 , 000 and 4 First Responders is $2 , 400. The skill meter maniken will be used for initial CPR classes, refresher CPR classes, AED training, AED 90-day re-certification, and patient assessment training. The cost is $1, 075. 00. 3 Bow will the project provide for a long-term solution to the current problem? With the completion of this training and the purchase of the maniken, we will be able to provide a consistently higher level of care. With continued CME and refresher course work every three years we can expect to train 2 to 4 individuals per year from now on. If this project is funded,how will the project be sustained in subsequent years? Future CME, EMT, and First Responder training will be provided by the District with 50% grant applications to be submitted each year to HPDP. List other any options you have researched to meet the need,and provide dollar amounts of other options you have explored. We have not found any other resources for financial aide for these needs. Explain why this is the most cost-effective way of meeting the need. Any assistance provided for training and equipment costs helps to insure our ability to train the necessary number of people, 4 EQUIPMENT LIST(Listing brands will not preclude applicant from having to obtain bids for the generic equipment types) (see instruction on opposite page) tion Cost Priority Quantity Description sedmiamtamosi Cl �AY-04.91 i i J wit ar:t-ra-rvrriar{ imitirtios 'war-rr:oar_ 1 ''.ns zi'�r111p�tt' 11rhwru.ra=riM+na tsissom.arAw't'ii tr+rranaetarrrwrrw rFlralrYlrJrUl�rlM 7wwtMMww+�w� lownswaisinaS, pir1.11MaKMrfI141vI1t1 Yrraram r— I . Other lemeernmompane rr- saa1wr; TOTAL t t©1 4. s e ulow t tS 1.s cl .,. DyV.ca lrv.a..kl CC\A0,A O8_ m .� . Nu cAN. .\- s Cm ,,AA lo Q._ acv c� • 5 TRAINING LIST Fill in this form if this application is requesting training. TITLE OF TRAINING COURSE: 'E M T--g) . 1 A 'fa)v..1\e`r t C M �. TYPE OF TRAINING: T-1/4.i% (.CU Jw Has your agency been approved by the HPDP Division to cvduct this program? _Yes XC No If No,name the agency/training officer/coordinator who will conduct the training: a\vvt w‘u ((Q It I 341. • COST OF PROJECT: How much of the total CASH cost of training project will be paid by: The EMS GRANT The Agency Cash Match The Student Cash Match $ �J ,SO O . O O S 3 S& for each training list the following information: Training Type #of Persons Course Cost Travel Cost Per Total Cost Per ' To be Trained Per Person Person type of course EMT Basic i k,Obk) OCR LIiQtt?.UO . "'.. . eahwrr!rRw�e+w EMT-I EMT-P sswaraar�ar� First Resp. `'1 L(50.O G a O O.0O Cont.Ed. (..t) SOqCIGS5 1p 06.00 sawr�rsa4t� First Resp. List any training equipment on Equipment List on page 5. A DETAILED BUDGET BREAKDOWN IF THIS IS A MAJOR TRAINING PROJECT 6 COMMUNICATIONS IF YOUR APPLICATION IS REQUESTING RADIO EQUIPMENT,THIS SECTION MUST BE COMPLETED.LIST FREQUENCY AND RADIO SERVICE OF THE SYSTEM BEING DEVELOPED,MODIFIED OR UPGRADED. If frequencies are UHF MED channels,put"Med Channels". If repeater operation,list both frequencies. FREQUENCY RADIO SERVICE If the communications system is shared with other public safety services,please indicate which service(mark all that apply) Police Fire_ Highway Maintenance_ Other Major communications projects must provide a separate sheet of paper,with a functional diagram of the proposed system. Major communications projects-IF A COMMUNICATIONS PLAN HAS BEEN DEVELOPED,PROVIDE A COPY OF THIS PLAN WITH THE APPLICATION (THE NEW SYSTEM MUST HAVE, AT A MINIMUM, A CONCEPTUAL PLAN PROVIDED WITH THIS APPLICATION) New or upgraded communications system must provide technical engineering information. 1. Name and telephone number of individual providing technical specifications or responsible for answer questions regarding specifications.. Name Phone E-Mail 2.If technical engineering has not been completed,please provide the name,telephone and cost quoted for the individual or agency you will be using. Name Phone E-Mail 3.Will you need to bid for development of technical specification for the system? Yes No Estimated Cost 7 FILL IN THIS SECTION ONLY IF REQUESTING EXTRICATION EQUIPMENT Location and type(RS-10,Hurst,etc.)Of nearest extrication equipment(place, distance in miles,travel time): Do you have a written_or verbal_agreement to share extrication equipment? If so,name of agency with whom you share: Do any other agencies (i.e.,fire,police,rescue)plan to share in the use of equipment bought with funding from this grant?_Yes No If Yes,please list names: How many of your agency's EMS runs required extrication equipment in the past year?_ Average time of extrication DEFIBRILLATION INFORMATION SECTION The following information should be available from your physician advisor. Number of EMS runs in the past 2 years that were cardiac arrests _ Number of EMS runs in the past 2 years that were witnessed arrests _ Number of CPR starts that took place on your EMS runs in the past 2 years BLS avg Response Time ALS Avg Response Time Telephone CPR Yes_ No_ Citizen CPR Program_ Agencies required to have medical oversight for the use of Defibrillation must have the approval signature of their Physician Advisor here Date OR attach a letter from their Physician Advisor approving their request as page 8a of this application. 8 PROJECT FUNDING A)EMS Fund Request $ 14°37 SC) B)Local Government Share-Cash $ (List source) C) Other Cash $ D)Total Cash Proj.Cost(A+B+C) $ E)Dollar Estimate of In-kind match $ C' 3 1 . ;5 C F)Total Program Cost(D+E) $ 07 S. v O Describe the in-kind match you can provide: 9 Applicants Budget EMS PORTION -Cash flow projection for next full Fiscal Year(this section is solely for theEMSportion of the budget). Anticipated Anticipated Revenue Expenditures Cash Balance at start of 11 q i I / Operating Costs your Fiscal Year J. ,4U�.GC� A 5(u, goo. CO Donations — (rt) — Salaries 75, 0C)0 CO Special Dist Funding Capital Improvement Mil Levy '1,0% Li43, OC.U0 6e.1`> 0O City/County Funding Loans(Explain) Investment Income �S t, C t� Other(Explain) U G -.j.‘ lr,nivAv„4..,.(e. 7. 0 ec' . c o Run Revenue Other:(Explain) FvvA g,S,a00. ego Total 7 t , Mak 430 Total 5- 6, 3eO Anticipated Cash Balance at the end of the FY 4 6S, -)(p 4 II \ 1` I I Explain the purpose of the cash balance(i.e.reserve,building fund,etc.)[calkia to v.�Qgip g Z•SCvwvaa, }1/4)et....) S`\ t rv.A f 6- Explain any anticipated capital improvement expenditures: 1G�� fr, �s Y1y��P v`vt (Qs`v`^^4`.0 Vzw`tAQ idea1/41e. Number of EMS runs per year 3.)01 Number of Transports per year — 0— Fee Structure Information: Does your agency bill for services Yes_ No)( (if not,please explain): Rates: Basic Life Support Advanced Life Support _ Charge per patient Mile Charge for Unloaded Mile If your charges are much lower than other EMS providers in your area-please explain If there are barriers to Increasing your rates: 10 Agency Portion of Budget - See instructions on opposite page Anticipated Anticipated Revenue Expenditures Cash Balance at start of Operating Costs your fiscal year Donations Salaries Special Dist Funding Capital Improvement Mil Levy City/County Funding Loans(Explain) Investment Income Other(Explain) other:(Explain) Total Total Anticipated Cash Balance at the end of the FY Explain the purpose of the cash balance(i.e.reserve,building fund,etc.) Explain any anticipated capital improvement expenditures: 11 EMS PROVIDER INFORMATION All of the information in this section is mandatory for your application to be considered complete.Please list only the personnel that are trained or certified.Persons currently in training should not be listed in this section.If the number of persons currently in training is pertinent to your application,list them in the project description narrative. Years in Operation ��' �[�'Clr 3 Qv- ' .a VkA tv.. l9 t4 ._ tv%(or•pQ,r0.rU �.,� 1 t 1t Li") TYPE OF SERVICE: I `ALS(EMT-P&EMT-I) X BLS Combination Fire/Rescue service Transport OR )(Non-transport _Other(i.e.,Air,etc.) Name of physician advisor(if agency has one) 01 • a t,t.e'.› (a tip, )a v,,(..), PERSONNEL BY TRAINING LEVEL(number of each): Level of Training Number of Full Time Paid Number of Part Time Paid Number of Volunteers F EMT-B 1 EMT-I EMT-P First Responder Cert. -7 CPR,Other,etc. -; 3 PRIMARY Hospital transported to: N C`t \i"\ CoUV C+4'u VtiNt L` C(L L. 't%."--&t"r Distance to PRIMARY Hospital: t c, tA,-*\1Q `j Average number of EMS Runs Annually: —2),'O Average number of Runs Annually: •-• Ct i 12 EMS Provider Information(cont'd) EMS Service Area and Geographic Description: (See Instructions) 1 CVO-4Y UQ)e r eNciR,.Se �\�v. � � cv 4vu -K. \lav‘,-rti 5Ya'I,u, 72, . �e �, v, �c e_s `r v a w. �'� \\,„.E .'v.e ca (I . C� v 0.t\ � � I: Z 1t� a� ks--1 \ L\aAt0""•..- 'CO M1.42 �\U (0LA, 1S 11w XS- . 3 r c\\s v \CA is \OOLAv.S44. \ m ‘,‘ AA.4e v\rl• lay w41\1 (O . Q —, , "1/4A\ st„x`\yL. \)y we_la cc k 64, or N W-e sA Co kc a\AA a, , A1.\ L tas.* tat Li et l C6 led t4 :� � Qti�ly � CC UC� CLGC C1ve cC lS U1iYUk 64 Slic. Mils Wcclh' W C P\ � I E.04€'11W CIS ti \uct e • Vc 13 EMS PROVIDER INFORMATION CONTINUED EMS VEHICLES OWNED BY YOUR AGENCY Write in the number of vehicles owned of each type in the age group.If your agency does not own vehicles please check here N/A Type of Vehicle 1 to 3 yrs old 4 to 7 yrs old 8 to 11 yrs old 11 years or>Number& Number&Mileage Number&Mileage Number&Mileage Mileage Typel Type II I / I / Type III Rescue Vehicle j / t(yL(l-1 First Response / / / f / '3 7)L j1-4 Extrication Equipment Age It of RS 10 Kits 0 Spreaders 0 Cutters 0 Rams 0 Air Bags I to S yrs 6 yrs-older — — _ Q EMERGENCY MEDICAL EQUIPMENT OWNED BY YOUR AGENCY Defibrillators: Manual 1-3 years old _ 4 years or older Semi-automatic or automatic 1-2 years old 1 3 years or older Suction(electric/battery): 1-2 years old — 3 years or older Back Boards(number owned): YO — Stretchers: 4 Scoop ( Wire 14 COMMUNICATIONS EQUIPMENT Mobile Radios(VHF): Pleasq,check all agencies who use this equipment: _✓Fire EMS __Police List the number of mobile radios(VHF)equipment you have in the correct age group: 0-5 years old 7 6-10 years old _ 11 years or older Mobile Radios(UHF): Please check all agencies who use this equipment: _Fire _EMS _Police . List the number of mobile radios(UHF)equipment you have in the correct age group: 0-5 years old _ 6-10 years old 11 years or older Portables: Please check all agencies which use this equipment: ✓Fire ✓EMS _Police List the number of Portables you have in the correct age group: _0-5 years old 3 6-10 years old _11 years or older Pagers: Please check all agencies this equipment is used by: -"fire=EMS_Police List the number of pagers you have in the correct age group: 0-5 years old a Cc 6-10 years old )23 11 years or older TRAINING EQUIPMENT OWNED BY YOUR AGENCY Please list the equipment on the following lines: 1" 0b\t 15 Hello