HomeMy WebLinkAbout940189.tiff RESOLUTION
RE: APPROVE EMS GRANT CONTRACT BETWEEN COLORADO DEPARTMENT OF HEALTH AND
AMBULANCE SERVICE AND AUTHORIZE CHAIRMAN 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 an EMS (Emergency Medical
Services) Grant Contract 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 Ambulance Service, and the Colorado Department of Health, commencing
October 20, 1993, and ending June 30, 1994, 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 EMS Grant Contract 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 Ambulance Service, and the Colorado Department of
Health be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chairman be, and hereby is,
authorized to sign said contract and any other necessary documents.
The above and foregoing Resolution was, on motion duly made and seconded,
adopted by the following vote on the 16th day of February, A.D. , 1994, nunc pro
tunc October 20, 1993.
�Pla,1 �(,,���� BOARD OF COUNTY COMMISSIONERS
ATTEST: WELD COUNTY,f C LORADO
/
Weld County Clerk to the Board , j)
Weld ((\\}}��II ,, nn �j �( } y� W H. Webster, Cha' rman�' —
BY: \JVL1X��/ FBIlUxtc'L,
Deputy CleUc to the Board DaleKHall, Pr em
UV 7
APPROVED AS TO FORM: '„I/ >; ,
eorge Fri Baxter //
ount Attorn4.-- 7.---,.. ((91z-i ,�t0rsP , W-7/42
y yQon tance L. Harbert
Barbara J. Kirkmeyey
q } 940189
11IIA /1/'1 'i V' .?,' ?.1/ 1
Form 6-AC-02A Department or Agency Number
260000 -- FAA
Contract Routing Number
940346
Approved Waiver Form
CONTRACT
THIS CONTRACT, made this 20th day of October, 1993,by and between the State of Colorado for the use and
benefit of the Department of HEALTH , 4300 Cherry Creek Drive South, Denver, CO 80222-1530 hereinafter referred
to as the State and County of Weld, Ambulance Service, 1121 M Street, Greeley, CO 80631 hereinafter referred to as
the contractor.
WFFREAS, authority exists in the Law and Funds have been budgeted, appropriated and otherwise made
available and a sufficient unencumbered balance thereof remains available for payment in Fund Number 409 . APPR
code 845, Contract Encumbrance Number FAA, EMS 940346 ; and
WHEREAS, required approval, clearance and coordination has been accomplished from and with appropriate
agencies: and
WHEREAS the purpose of the Division of Emergency Medical
Services (EMS) grants program is to improve statewide emergency
medical services in the State of Colorado pursuant to CRS Sec. 25-
3 . 5-601;
WHEREAS the State wishes to fund the Contractor as a provider
of EMS for this purpose;
WHEREAS the Contractor has been licensed to provide services in
the State of Colorado or the Contractor is a provider of emergency
medical services in the State of Colorado;
WHEREAS as of the date of execution of this contract, the
Contractor meets all other qualifications for funding under the EMS
grants program and for provision of emergency medical services; and
WHEREAS the Contractor has been selected in accordance with the
State of Colorado Procurement Code.
NOW THEREFORE, it is hereby agreed that for and in
consideration of their mutual promises to each other, hereinafter
stated, the parties hereto agree as follows:
1 . The Contractor will accomplish the performance described in
attachment A, EMS grant application attached and incorporated
herein by reference.
2 . Any equipment purchases specified in Attachment A will be
subject to the following:
Page 1 of 7
.9401_149
a. All communications equipment must be purchased from the
state bid award for communications equipment or from
another vendor for a comparable price and quality. Any
communications equipment not listed on the state bid award
will be required to go through an informal competitive bid
process. The Contractor will be required to purchase the
equipment from the lowest responsible bidder.
b. Any new ambulances must be purchased from the state
ambulance bid award or, with EMS Division approval, from
another vendor for comparable price and quality.
c. Any other emergency vehicles, with the exception of used
ambulances, will be required to go through a competitive
bidding process. The specifications for the vehicle bid
must be approved by the EMS Division in advance. The
Contractor will purchase the vehicle from the low
responsible bidder.
d. Any medical equipment will be required to go through an
informal competitive bidding process. The Contractor will
be required to purchase from the lowest responsible
bidder.
3 . Any training or education programs specified in Attachment A
will be subject to the following:
a. The Contractor shall acknowledge the Emergency Medical
Services Account Grant Funds established by the
Legislature and managed by the Emergency Medical Services
Division on all public service announcements, program
announcements, and all other printed material used for the
purpose of promoting or advertising the training program
or course.
b. The Contractor will develop and utilize a course
evaluation tool to measure the effectiveness of the
program. A copy of the evaluation reports must be
submitted to the EMS Division.
c. All travel expenses associated with the training or
education program will be in accordance with the current
State of Colorado reimbursement rates for travel as
specified in the State Fiscal Rules.
4 . a. Except as to public entities described below, during the
term of this contract and any renewal hereof, the Contractor agrees
that it will keep in force a policy or policies of comprehensive
general liability insurance, issued by a company authorized to do
business in Colorado in an amount not less than $500, 000 combined
single limit for total injuries or damages arising from any one
incident (for bodily injuries or damages). The Contractor shall
provide the State with a Certificate of Insurance as evidence that
such insurance is in effect at the inception of this contract.
Page 2 of 7
940189
b. If the contractor is a "public entity" within the meaning of
the Colorado Governmental Immunity Act, sections 24-10-101, et seq. ,
as amended ("Act") , contractor shall carry such general liability
insurance, by commercial policy or self-insurance, as is necessary
to meet its liabilities under the Act. Proof of such insurance
shall be provided upon request by the State.
5 . Should the Contractor cease to provide emergency medical
services in the State of Colorado any equipment purchased through
the grant must be placed with EMS Division approval with another EMS
provider or sold at public auction and the percent provided by the
State towards the original purchase cost returned to the State.
6 . The Contractor shall provide the State with documentation of
all purchases specified and comply with the following State
reporting requirements:
a. the Contractor will keep applicable records of the numbers
of EMT's trained, documentation of course completion, and
their levels of certification; and
b. the Contractor will keep records of any reduced response
times and increased service capacity; and
c. the Contractor will maintain detailed maintenance records
on any equipment purchased;and
d. the Contractor will maintain proof of any vehicle
licensure, the vehicle serial number and ownership papers
for review by the State; and
e. the Contractor will supply the State with quarterly
progress reports in the format specified by the State.
This information must be available to the EMS Division upon request.
7 . For and in consideration of the Contractor's performance of its
obligations under this contract, the State will provide up to 100%
of the actual cost of this project, but in no event to exceed
$38 , 532 . 00, Thirty Eight Thousand Five Hundred Thirty Two Dollars .
Any costs in excess of $38, 532 . 00 shall be the responsibility of the
Contractor. The total cost of the project is estimated to be
$38,532 . 00, in the event actual costs are less, State and Contractor
costs shall be reduced proportionately.
8 . The Following Payment Method will be Used:
Payment will be made upon receipt of a signed request for
reimbursement, submitted in duplicate. A copy of an invoice marked
paid from the vendor must accompany the request.
9 . The term of this contract shall be from October 20, 1993 to
June 30 , 1994 .
Page 3 of 7 Pages .
310183
COLORADO DEPARTMENT OF HEALTH hereinafter, under the General Provisions referred to as
"Health" .
GENERAL PROVISIONS -- page 1 of 2 pages
1. 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 withholding, shall provide and
keep in force worker's compensation (and show proof of such insurance) and unemployment
compensation insurance in the amounts required by law. Contractor will be solely
responsible for its acts and the acts of its agents, employees, servants and
subcontractors during the performance of this contract.
2. Contractor authorizes Health, or its agents, to perform audits and to make
inspections for the purpose of evaluating performance under this contract.
3. Either party shall have the right to terminate this agreement by giving the other
party thirty days notice by registered mail, return receipt requested. If notice is so
given, this agreement shall terminate on the expiration of the thirty days, and the
liability of the parties hereunder for the further performance of the terms of this
agreement shall thereupon cease, but the parties shall not be relieved of the duty to
perform their obligations up to the date of termination.
4. This agreement is intended as 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 contract executed and approved pursuant
to the State Fiscal Rules.
5. If this contract involves the expenditure of federal funds, this contract is
contingent upon continued availability of federal funds for payment pursuant to the
terms of this agreement. Contractor also agrees to fulfill the requirements of:
a) Office of Management and Budget Circulars A-87, A-21 or A-122, and A-102 or
A-110, whichever is applicable;
b) the Hatch Act (5 USC 1501-1508) and Public Law 95-454 Section 4728. These
statutes state that federal funds cannot be used for partisan political purposes of any
kind by any person or organization involved in the administration of federally-assisted
programs;
c) the Davis-Bacon Act (40 Stat. 1494, Mar. 3 , 1921, ' Chap. 411, 40 USC
276A-276A-5) . This act requires that all laborers and and mechanics employed by
contractors or sub-contractors to work on construction projects ' financed by federal
assistance must be paid wages not less than those established for the locality of the
project by the Secretary of Labor;
d) 42 USC 6101 et seq, 42 USC 2000d, 29 USC 794. These acts require that no
person shall, on the grounds of race, color, national origin, age, or handicap, be
excluded from participation in or be subjected to discrimination in any program or
activity funded, in whole or in part, by federal funds; and
of 7_. Pages • '4°1 ;roc,
: ENERAL PROVISIONS--Page 2 of 2 pages
e) the Americans with Disabilities Act (Public Law 101-336; 42 USC 12101, 12102,
_2111 - 12117, 12131 - 12134, 12141 - 12150, 12161 - 12165, 12181 - 12189, 12201 - 12213
and 47 USC 225 and 47 USC 611.
f) if the contractor is acquiring real property and displacing households or
businesses in the performance of this contract, the contractor is in compliance with the
?niform Relocation Assistance and Real Property Acquisition Policies Act, as amended
(Public Law 91-646, as amended and Public Law 100-17, 101 Stat. 246 - 256) ;
g) when applicable, the contractor is in compliance with the provisions of the
Uniform Administrative Requirements for Grants and Cooperative Agreements to State and
Local Governments (Common Rule) .
6. By signing and submitting this contract the contractor states that:
a) the contractor is in compliance with the requirements of the Drug-Free
Workplace Act (Public Law 100-690 Title V, Subtitle D, 41 USC 701 et seq. ) ;
b) the contractor is not presently debarred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded from covered transactions by any federal
9epartment or agency.
To be considered for payment, billings for payment pursuant to this contract must
be received within 60 days after the period for which payment is being requested and
final billings on the contract must be received by Health within 60 days after the end
of the contract term.
8. If applicable, Local Match is to be submitted on the monthly payment statements, in
.he column provided, as required by the funding source.
If Contractor receives $25,000.00 or more per year in federal funds in the
!;gregate from Health, Contractor agrees to have an annual audit, by an independent
certified public accountant, which meets the requirements of Office of Management and
Budget Circular A-128 or A-133, whichever applies. If Contractor is required to submit
,n annual indirect cost proposal to Health for review and approval, Contractor's auditor
11 audit the proposal in accordance with the requirements of OMB Circular A-87, A-21
A-122. Contractor agrees to furnish one copy of the audit reports to the Health
apartment Accounting Office within 30 days of their issuance, but not later than nine
;onths after the end of Contractor's fiscal year. Contractor agrees to take appropriate
corrective action within six months of the report's issuance in instances of
noncompliance with federal laws and regulations. Contractor agrees to permit Health or
its agents to have access to its records and financial statements as necessary, and
further agrees to retain such records and financial statements for a period of three
years after the date of issuance of the audit report. This contract does not
contain federal funds as of the date it is signed. This requirement is in addition to
any other audit requirements contained in other paragraphs within this contract.
10. Contractor agrees to not use federal funds to satisfy federal cost sharing and
matching requirements unless approved in writing by the appropriate federal agency.
5
Page of Pages
nA/niin-> 9-7.01.139
SPECIAL PROVISIONS •
CONTROLLER'S APPROVAL -
I.This contract shall not be deemed valid until it shall have been approved by the Controller of the State of Colorado or such assistant as he may designate.This
provision is applicable to any contract involving the payment of money by the State.
FUND AVAILABILITY
2.Financial obligations of the State of Colorado payable after the current fiscal year arc contingent upon funds for that purpose being appropriated,budgeted,
and otherwise made available.
BOND REQUIREMENT
•
3. If this contract involves the payment of more than fifty thousand dollars.for the construction,erection,repair,maintenance,or improvement of any building,
road, bridge,viaduct,tunnel,excavation or other public work for this State,the contractor shall.before entering upon the performance of any such work included
in this contract,duly execute and deliver to the State official who will sign the contract_a good and,suffcient bond or other acceptable surety to be approved by
said official in a penal sum not less than one-half of the total amount payable by the terms of this contract.Such bond shall be duly executed by a qualified corporate
surety conditioned upon the faithful performance of the contract and in addition,shall provide that if the contractor or his subcontractors fail to duly pay for any
labor,materials,team hire,sustenance,provisions,provendor or other supplies used or consumed by such contractor or his subcontractor in performance of the work
contracted to be done or fails to pay any person who supplies rental machinery,tools,or equipment in the prosecution of the work the surety will pay the same in
an amount not exceeding the sum specified in the bond,together with interest at the rate of eight per cent per annum.Unless such bond is executed,delivered and
filed,no claim in favor of the contractor arising under such contract shall be audited,allowed or paid.A certified or cashier's check or a bank money order payable
to the Treasurer of the State of Colorado may be accepted in lieu of a bond.This provision is in compliance with CRS 38-26-106.
INDEMNIFICATION
4. To the extent authorized by law, the contractor shall indemnify, save, and hold harmless the State, its employees and agents,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:
•
DISCRIMINATION AND AFFIRMATIVE ACTION
•
5. The contractor agrees to comply with the letter and spirit of the Colorado Antidiscrimination Act of 1957. as amended, and other applicable law respectine
discrimination and unfair employment practices(CRS 24-34-402), and as required by Executive Order,Equal Opportunity and Affirmative Action.dated April 16,
1975.Pursuant thereto.the following provisions shall be contained in all State contracts or sub-contracts.
•
During the performance of this contract,the contractor agrees as follows: •
(a) The contractor will not discriminate against any employee or applicant for employment because of race, creed, color, national origin, sex,
marital status, religion,ancestry,mental or physical handicap.or age.The contractor will take affirmative action to insure that applicants are employed,and that
employees are treated during employment,without regard to the above mentioned characteristics.Such action shall include,but not be limited to the following:
employment upgrading,demotion,or transfer,recruitment or recruitment advertisings:lay-offs or terminations:rates of pay or other forms of compensation: and
selection for training, including apprenticeship.The contractor agrees to post in conspicuous places,available to employees and applicants for employment,
notices to be provided by the contracting officer setting forth provisions of this non-discrimination clause.
(b)The contractor will,in all solicitations or advertisements for employees placed by or on behalf of the contractor,state that all qualified applicants will
receive consideration for employment without regard to race,creed,color,national origin,sex,marital status,religion,ancestry,mental or physical handicap.
or age.
(c)The contractor will send to each labor union or representative of workers with which he has a collective bargaining agreement or other contract or
understanding,notice to be provided by the contracting officer,advising the labor union or workers'representative of the contractor's commitment under the
Executive Order.Equal Opportunity and Affirmative Action,dated April 16. 1975.and of the rules,regulations.and relevant Orders of the Governor.
(d)The contractor and labor unions will furnish all information and reports required by Executive Order,Equal Opportunity and Affirmative Action of April
16. 1975. and by the rules,regulations and Orders of the Governor,or pursuant thereto, and will permit access to his books,records, and accounts by the
contracting agency and the office of the Governor or his designee for purposes of investigation to ascertain compliance with such rules,regulations and orders.
(e)A labor organization will not exclude any individual otherwise qualified from full membership rights in such labor organization.or expel any such individual
from membership in such labor organization or discriminate against any of its members in the full enjoyment of work opportunity because of sere,creed-color.
sex,national origin.or ancestry.
•
•
(f) A labor organization.or the employees or members thereof will not aid, abet,incite, compel or coerce the doing of any act defined in this contract to be
discriminatory or obstruct or prevent any person from complying with the provisions of this contract or any order issued thereunder,or attempt,either directly
or indirectly,to commit any act defined in this contract to be discriminatory. •
•
Form 6-AC-02B
Revised 1/93 •
395-53-01-1022
pact 6 of 7 paces
9 ()1.89
•
(g) In the event of the contractor's non-compliance with the non-discrimination clauses of this contract or with any of such rules,regulations,or orders,
this contract may be canceled, terminated or suspended in whole or in part and the contractor may be declared ineligible for further State contracts in
accordance with procedures, authorized in Executive Order, Equal Opportunity and Affirmative Action of April 16. 1975 and the rules, regulations, or
orders promulgated in accordance therewith,and such other sanctions as may be imposed and remedies as may be invoked as provided in Executive Order.
Equal Opportunity'and Affirmative Action of April 16. 1975, or by rules, regulations, or orders promulgated in accordance therewith, or as otherwise
provided by law.
(h The contractor will -I rte the provisions of paragraphs (a) through(h) in every sub-contract and subcontractor purchase order unless exempted by
rules.regulations.or ore: •ssued pursuant to Executive Order,Equal Opportunity and Affirmative Action of April I6, 1975.so that such provisions will
be binding upon each su`_- ;ntractor or vendor.The contractor will take such action with respect to any sub-contracting or purchase order as the contracting
agency may direct,as a means of enforcing such provisions, including sanctions for non-compliance: provided,however,that in the event the contractor
becomes involved in.or is threatened with,litigation,with the subcontractor or vendor as a result of such direction by the contracting agency,the contractor
may request the State of Colorado to enter into such litigation to protect the interest of the State of Colorado.
COLORADO LABOR PREFERENCE
•
6a.Provisions of CRS 8-17-101 & 102 for preference of Colorado labor are applicable to this contract if public works within the State are undertaken hereunder and
ire financed in whole or in part by State funds.
b. When a construction contract for a public project is to be awarded to a bidder,a resident bidder shall be allowed a preference against a non-resident bidder from
a state or foreign country equal to the preference given or required by the state or foreign country in which the non-resident bidder is a resident.If it is determined by
the officer responsible for awarding the bid that compliance with this subsection.06 may cause denial of federal funds which would otherwise be available or would
otherwise be inconsistent with requirements of Federal law,this subsection shall be suspended,but only to the extent necessary to prevent denial of the moneys or to
'',minate the inconsistency with Federal requirements(CRS 8-19-101 and 102)
GENERAL
7. 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
otherwise in conflict with said laws.rules,and regulations shall be considered null and void.Nothing contained in any provision incorporated herein by reference
huh 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 o f complaint,
ec fence.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.
8. 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
'v:en or may hereafter be established.
9. The signatories aver that they are familiar with CRS 18-8-301,et.seq.,(Bribery and Corrupt Influences)and CRS 18.8-401,et.seq.,(Abuse of Public Office),
that no violation of such provisions is present.
10.The signatories aver that to their knowledge,no state employee has any personal or beneficial interest whatsoever in the service orproperty described herein:
?ITNESS WHEREOF,the parties hereto have executed this Contract on the day first above written.
Convector
7,111 Legal Name) WELD COUNTY BOARD OF COMMISSIONERS STATE OF COLORADO
/p \1 /li )-/�^(/,,. :0fbMtG00R
W. H. WEBSTER /94 {0r
•5 EXECUTIVE DIRECTOR
,ition(Title) CHAIRMAN
84-6 003
Socialc h Nu Tq�dd 1 /; aer DEPARTMENTf Corparation:j // (//,� OF HEALTH
eh
Vmst(Seal)
lv DONALD D. WARDEN
4[j c)SJJ .g} paAiJ ,33 ouu y clerk TO BOARD •
Y: R1
DPPUTY CLERK T APPROVALS
.1TORNEY GENERAL CONTROLLER
By
•
inn O-AC-02C 7 7
•viscd 497 Page which is the last of pages
i.53-01-1030 'Sec masrucnons on reverse vac, �
9 0, RAM APPROVAL: A -YXPe% (j )
a �
Atarh eat i sec 0654EMS APPLICATION It ( S Division Use Only): (- /CI?
LEGAL NAME OF AGENCY FEDERAL TAX ID NUMBER (read instructions carefully on this item)
Weld County Ambulance Service
County of Weld , Colorado � Q35.51 g0`"-6e.a.°3-‘3
CONTACT PERSON PHONE (DAY) PHONE (NIGHT)
Gahy M . McCabe 303-353 -5700 303-353-5700
•
AGENCY MAILING ADDRESS
1121 M Street Greeley , CO 80631
STREET CITY ZIP
COUNTY/COUNTIES IMPACTED
Weld
LEGAL STATUS OF AGENCY/ORGANIZATION (Mark all that apply):
_ PRIVATE NOT FOR PROFIT PRIVATE FOR PROFIT X COUNTY/CITY GOVERNMENZ
STATE AGENCY _ SPECIAL DISTRICT OTHER
PROJECT AREA (Mark all that apply): PROJECT AREA - TRAINING SPECIFIC:
Communications
Training
_x._ Medical/Rescue Equipment
Manual —Automated Defibrillator — Continuing Education
Extrication
Training Equipment
Emergency Vehicle
Ambulance QRT
Rescue
Public Education
Other
X COUNTY WIDE GRANT REGIONAL GRANT _STATE-WIDE GRANT INDIVIDUAL AGENCY GRANT
` 5O% CASH MATCH REQUIREMENT MET X WAIVER HAS BEEN REQUESTED
940-1 R9
WHY IS THIS PROJECT NEEDED
In the space below, write a concise statement describing the need(s) addressed by this project.
Infection control guidelines promulgated by OSHA and CDC dictate
the need to replace equipment that tends to harbor infectious
materials ( ie ; wooden backboards ) . EMS agencies in Weld County
use wooden backboards .
State and County goals and objectives identify need for standard-
ization , interagency cooperation ,and backup capabilities .
Current supply and construction of spinal immobilization equipment
in Weld County EMS agencies do not meet these needs .
The 27 EMS agencies represented by the Weld County Emergency Medical
Services Council serve a population of approximately 140 , 000 people .
The majority of the population is located in the western 1/3 of the
county . Weld County is approximately 4 ,004 square miles in size !
It is about 79 miles wide and 70 miles long ! Transport times can
be in excess of one hour ! Two interstate highways ( I -25 and I -76 )
and two U . S . highways traverse the county . There are hundreds of
miles of paved and unpaved county roads .
List the goals and objectives identified in your county EMS plan that are associated
with this funding application.
1 . Regionalize efforts to fund rural EMS needs .
2 . Enhance existing mutual aid agreements and stimulate new ones .
3 . Provide adequate supply of long spine boards , C-collars , straps ,
Headbeds , etc .
List the goals and objectives identified in the state EMS plan that are associated
with this funding application.
1 . ( 5 . 3 ) Facilitate cooperation between agencies
2 . ( 5 . 4 ) Standardization/ adequate equipment
3 . ( 1 . 5 . 1 ) Reduce on scene time
If your fundinq application is not identified in your county EMS plan, explain why
it is not.
Not applicable
2
9'10189
DESCRIPTION OF PROJECT
In the space provided, please outline the project. Include planned expenditures, the timeframe, and
any other information that will assist in understanding the nature of the request.
As stated in the Weld County EMS Plan : " In order to provide a more
consistent approach to the treatment of trauma patients , a concert-
ed effort will be made to acquire an adequate supply of long spine-
boards , C-collars , Headbeds , and straps for all first responder
agencies in Weld County. "
The cost for meeting this important goal is estimated at approxi -
mately $77 ,000. See page 9 for details . By purchasing these items
all at once on a "group" basis , a substantial economy of scale can
be realized , and all agencies involved will receive their equipment
at the same time . Once distribution has been accomplished , each
agency will be able to exchange and interact with one another on
a uniform basis .
The timeframe for accomplishing this project is September 1 , 1993 .
Once the initial supply is distributed , records will be kept to
establish replacement needs and future supply increase needs .
3
How will the project provide for a long term solution to the current problem?
The backboards and straps requested are constructed from materials
designed to give long term ( 5 or more years ) service , resist bac-
terial transfer , provide higher load limits , faciltate easy clean-
ing , provide speed and safety of use .
By having all spinal immobilization equipment uniform throughout
our system , interagency cooperation , use , and exchange will be
facilitated . Future joint efforts should be enhanced .
t, '
If this project is funded in July, 1993, how will the project be sustained in subsequent years?
Nonexpendible Equipment :
Records will be kept by the Weld County EMS Coordinator . Preventive
maintenance , repairs , and replacement needs will be communicated
to member agencies . Sharing of expenses will be proportionate to
call volumes .
Expendible Equipment :
Transporting agencies in Weld County that charge for their services
will replace items used by fire rescue agencies .
4
9 :0189
EQUIPMENT LIST (listing brands will not preclude you from having to obtain bids for the generic equipment typos)
In the space provided, please list the EMS equipment or training equipment for which funding is
being requested. Include as much information as possible.
PRIORITY QUANTITY DESCRIPTION VENDOR COST
1 • 250 Plastic Backboards Safe-T-Lite $40, 000
2. 750 Nylon restraints ALS Med Prod 12 , 525
3. 250 Stiffneck Bags ALS Med Prod 4 ,987 . 50
4 . 1,000 Stiffneck C-collars ALS Med Prod 15 ,000
5 . 1 ,000 Stiffneck Headbeds ALS Med Prod 4 , 550
OTHER:• TOTAL COST $77 ,062 . 50
5
940189
TRAINING LIST
Fill in this form if this application is for training.
TITLE OF TRAINING COURSE: N/A
TYPE OF TRAINING:
Has your agency been approved by the EMS Division to conduct this program?
Yes No
If No, name the agency/training officer/coordinator who will conduct the Training?
COST OF PROJECT:
How much of the total CASH cost of the project will be paid by the state $
How much of the total CASH cost of the project will be paid by the student $
How much of the total CASH cost of the project will be paid by your agency $
For each type of training list the following information:
Travel Total Cost
# of persons Cost per Costs Per Per Type of
Type To be Trained Person Person Course
EMT-B
EMT-1
EMT-P
Contin. ethic.
Other
List any training equipment on equipment list on page 5.
ATTACH A DETAILED BUDGET BREAKDOWN IF THIS IS A MAJOR TRAINING
PROJECTS
6 940'189
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
Wfrt
If the communications system is shared with other public safety services, please indicate which
service: (mark all that apply)
Police _ Fire Highway Maintenance Other
ON A SEPARATE SHEET OF PAPER, PROVIDE A FUNCTIONAL DIAGRAM OF THE PROPOSED
SYSTEM.
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 or agency providing technical specifications.
Name Telephone
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 Telephone
3. Will you need to bid for development of technical specification for the system?
Yes No_ Estimated Cost
7
0,'f FE! Pnl
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): N/A
Do you have a written - or verbal_ agreement to share extrication equipment. If so, name
of agency:
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 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. Nfr
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
FOR AUTOMATED DEFIBRILLATOR REQUESTS -
Quality assurance standards from your physician advisor must be submitted to the EMS office
by JANUARY 16, 1993 or your request for an automated external defibrillator is disqualified.
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94018.9
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PROJECT FUNDING
A) EMS Fund Request $ 77 ,062 . j& 38)53„ ,0j
B) Local Gvint. Share - Cash $ 0
(list source) o source
C) Other Cash $
(list source)
source
D) Total Cash Proj. Cost (A+B+C) $ 77 ,46-? . 50 ( �' "3*. 00
1
E) Dollar Estimate of In-Kind Match $ 0
(In-Kind cannot be counted as pert of your 60%cash match)
F) Total Program Cost (D+ E) $ 77 ,002 . 50 2 630-00
Describe the in-kind match you can provide:
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94(1159
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APPLICANT'S FINANCIAL INFORMATION
Cash Flow Projection for Next Full Fiscal Year
Year: 1992 to 19 93
EMS Portion of
Agency Projection Agency Projection
Cash Balance at the
at the start of year $ 129 923 . 94 $ 129 , 923 . 94
Anticipated Revenues
Local Government $ 0 $ 0
Private Contributions $ 0 $ 0
Investment Income $ 0 $ 0
Other Fees $ 2 ,241 ,660 $ 2 ,241 ,660
Anticipated Expenditures
Salaries $ (121 ,0,10 ORO $ 921 ,1)20
Operating $ 1 ,320 , 580 $ 1 ,320 , 580
Capital Improvement $ 0 $ 0
Loans $ $
Other $ $
Anticipated Cash Balance 130 ,000 $ 130 , 000
For the end of next FY $
ADDITIONAL INFORMATION
Explain what the purpose of your cash balance; i.e. reserve, building fund, etc....
Explain any loan payments you are currently making; i.e. $ per month on a fire vehicle.
Explain any capital improvement purchases you intend to make.
Cash balance is maintained to offset any interruption in cash
- flow from fees billed.
Weld County Ambulance Service
EMS PROVIDER INFORMATION
Years in Operation 16
TYPE OF SERVICE:
x ALS (EMT-P & EMT-I) ___.. BLS _ Combination
Fire/Rescue Service
Transport OR Non-transport
Other (i.e. Air, etc...)
Name of physician advisor (if agency has one) D r. David Link
PERSONNEL BY TRAINING LEVEL (number of each):
Volunteer . Full-Time Paid Part-time Paid
First Responder 0 0 0
EMT-Basic 0 6 3
(certified)
≤ I
EMT-Intermediate 0 0 0
(certified)
EMT-Paramedic 0 14 3
(certified)
Other
0 D
(CPR certified,
basic first-aid, R.N.) .
PRIMARY Hospital transported to: North Colorado Medical Center
Distance to PRIMARY Hospital: 2 . 5 miles from main station
Average number of EMS Runs Annually: 6 ,4nn
Average number of Runs Annually: 6 ,400
11 910.x_99
L. iS Provider Information (cor.. d)
EMS Service Area and Geographic Description:
In the space below, please describe your service area:
Weld County Ambulance Service is responsible for all 4 , 004 square
miles of Weld County . WCAS works in concert with 26 other EMS •
providers in Weld County . Weld' County is approximately 79 miles
wide and 70 miles long , has a population of about 140 ,000 people .
Most of the population lives in the western 1/3 of the county .
Greeley is the county seat. The Greeley/ Evans population is
approximately 65 ,000 . These two cities account for about 60% of
all EMS runs .
Two interstate highways ( I -25 and I -76 ) and two U . S . highways
( U . S . 34 and U . S . 85 ) traverse the county . There are hundreds of
miles of paved and unpaved county roads . The new Denver Interna -
tional Airport is less than 15 miles from the southern Weld bor-
der .
Population growth and traffic is expected to grow exponen-
tially in that area in the near future . Tourist traffic through
Weld County to and from the mountains is very high .
Infection control guidelines promulgated by OSHA and CDC dictate
the need to replace equipment that tends to harbor infectious
materials ( ie : wooden backboards ) . EMS agencies in Weld County
use wooden backboards .
State and County goals/ objectives have clearly identified the
need for standardization , interagency cooperation , and back-up
capabilities . Current supply and construction of spinal immobil -
ization equipment in Weld County EMS agencies do not meet these
needs .
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910189
EMS PROVIDER INFORMATION CONTINUED
Weld County Ambulance Service
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 I Ambulances -
0 1 thru 3 years old 0 4 thru 7 years old
0 8 thru 11 years old O Older than 11 yrs
n/a How many of the above ambulances have more than 70,000 miles on the odometer
Typo II Ambulances -
1 thru 3 years old 1 4 thru 7 years old
0 8 thru 11 years old - Older than 11 yrs
$ How many of the above ambulances have more than 70,000 miles on the odometer
Type III Ambulances -
2 1 thru 3 years old 0 4 thru 7 years old
O 8 thru 11 years old O, Older than 11 yrs
O How many of the above ambulances have more than 70,000 miles on the odometer
First Response Vehicles
0 1 thru 3 years old 0 4 thru 7 years old
0 8 thru 11 years old 0 Older than 11 yrs
0 The number of these vehicles that have more than 70,000 miles on the odometer
Search and Rescue Vehicle
IL 1 thru 3 years old 4 thru 7 years old
0 8 thru 11 years old Older than 11 yrs
0 The number of these vehicles that have more than 70,000 miles on the odometer
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9401E-3
EMS PROVIDER INFORMATION CONTINUED
Weld County Ambulance Service
EXTRICATION EQUIPMENT OWNED BY YOUR AGENCY
Write in the number of extrication devices owned by your agency
None - N/A x
RS 10 Kit
1 thru 5 years old 6 years or older
Spreader
1 thru 5 years old 6 years or older
Cutter
1 thru 5 years old _ 6 years or older
Ram
1 that 5 years old _ 6 years or older
Air Bags
1 thru 5 years old _ 6 years or older
EMERGENCY MEDICAL EQUIPMENT OWNED BY YOUR AGENCY
Defibrillators - I, -
MANUAL2 6
1 thru 3 years old 4 years or older
SEMI-AUTOMATIC OR AUTOMATIC
0 1 thru 2 years old 0 3 years or older
Suction (Electric/Battery)
2 1 thru 2 years old 6 3 years or older
Back Boards (number owned) 32 wooden
Stretchers
8 Scoop 0 Wire
COMMUNICATIONS EQUIPMENT
Mobile Radios (VHF) -
Please check all agencies this equipment is used by: Fire X EMS Police
List the number of mobile radios (VHF) equipment you have in the correct age group:
4 0 thru 5 years old 4 6 thru 10 years old
0 11 years or older
Mobile Radios (UHF) -
Please check all agencies this equipment is used by: Fire x EMS Police
List the number of mobile radios (UHF) equipment you have in the correct age group:
4 0 thru 5 years old __ 6 thru 10 years old
0 11 years or older
14
9101139
EMS PROVIDER INFORMATION CONTINUED
Portables -
Please check all agencies this equipment is used by: Fire x EMS Police
List the number of Portables you have in the correct age group:
5 0 thru 5 years old 5 6 thru 10 years old
0 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:
3 O thru 5 years old 5 6 thru 10 years old
11 years or older
TRAINING EQUIPMENT OWNED BY YOUR AGENCY
Please list the equipment on the following lines:
VCR , TV , Videu Comerd , VCR Tapes , Slide Projector , Overhead Pro-
jector , Screen
FEE STRUCTURE INFORMATION
Does your agency charge for Services? Yes x No
Base Rates: 200
Basic Lite Support
Advanced Life Support 350
Charge per patient mile
Charge for unloaded miles U
Oxygen therapy 40
MAST 45
Extrication 0
Do you charge (or service when you provide treatment but do not transport? Yes X No
If the answer is yes list basic charge 350
•
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
2-16-93 I understand that my application will be disqualified should either of
these statements be untrue.
Weld EMS Council Board Member and
Gary M . McCabe Director , Weld County Ambulance Service
PRINT NAME TITLE
cM/fie .(, � 2-16-93
IGNATURE DATE
15
9 7 1-89
INAME AND TAX IDENTIFICATION NUMBER(FIN)
INDIVIDUALS:Enter First and Last name EXACTLY as it appears on your Social Sentrity Card.However,if you have changed your
last.name,for instance,due to marriage,without informing the Social Security Administration of the name change,please enter your
first name and both the last name shown on your social security card and your new last name(IN THAT ORDER).For your TIN,enter
your Social genirity Number(SSN).
SOLE PROPRIETORSHIPS:Enter the individuals name on the first line;on the second name line you may enter the business name.
YOU MAY NOT ENTER ONLY THE BUSINESS NAME. For the TIN,enter either the Social Cernrity Number or the Federal
Employer Tax Identification Number(FEIN).
ALL OTHER ENTITY'S: Enter the name exactly as originally registered with the IRS.The correct TIN is the Federal Employer Iden-
tification Number(FEIN).
HOW TO OBTAIN A TIN
If you do not have a TIN,you should apply for one immediately.To apply for the number,obtain Form SS-05,Application for a Social
Security Number Card(for individuals).or Form SS-4,Application of Employer Identification Number(for businesses and all other en-
tities), at your local office of the Social Security Administration or the Internal Revenue Service.Complete and file the appropriate
form according to its instructions.
To complete Form W-9 if you do not have a TIN,check"Applied For"box in the space indicated on the front,sign and date the form,
and give it to the requester.For payments that could be subject to backup withholding,you will then have 60 days to obtain a TIN and
furnish it to the requester.During the 60-day period,the payments you receive will not be subject to the 20%backup withholding,un-
less you make a withdrawal. However f the requester does not receive your TIN from you within 60 days,backup withholding,if ap-
plicable,will begin and continue until you furnish your TIN to the requester.
Note: Writing "Applied For"on the form means that you have already applied for a TIN OR that you intend to apply for one in the
near future.
•
As soon as you receive your TIN,complete another Form W-9, include your new TIN,sign and date the form,and give it to the re-
quester.
SIGNING THE CERTIFICATION
(1) Interest,Dividend,and Barter Exchange Accounts Opened Before 1984 and Broker Accounts That Were Considered Active
During 1983.-You art not required to sign the certification;however,you may do so.You are required to provide your correct TIN.
(2)Interest,Dividend,Broker and Barter Exchange Accounts Opened After 1983 and Broker Accounts That Were Considered
Inactive During 1983.-You must sign the certification or backup withholding will apply.If you are subject to backup withholding
and you are merely providing your correct TIN to the requester,you must cross out item(2)in the certification before signing the form.
(3) Real Estate Transactions-You must sign the certification. You may cross out time(2)of the certification if you wish.
(4) Other Payments-You are required to furnish your correct TIN,but you are not required to sign the certification unless you have
been notified of an incorrect TIN.Other payments include payments made in the course of the requester's trade or business for rents,
royalties,goods(other than bills for merchandise),medical and health care services,payments to a nonemployee for services(includ-
ing attorney and accounting fees),and payments to certain fishing boat crew members.
(5) Mortgage Interest Paid by You,Acquisition or Abandonment of secured Property,or IRA Contributions.-You are required
to furnish your correct TIN,but you are not required to sign the certification.
(6) Exempt Payees and Payments.-If you are exempt from backup withholding,you should complete this form to avoid possible er-
roneous backup withholding. Enter your correct TIN in LEGAL BUSINESS DESIGNATION section,and write"EXEMPT"'above
your signature,sign and date the form. If you are a nonresident alien or foreign entity not subject to backup withholding,give the re-
quester a completed Form W-8, Certificate of Foreign Status.
OTHER
Signature.-The signature should be an authorized signature,generally the persons whose name is on the top line of the form,a
partner in the partnership,or an officer of the corporation.For a joint account,only the person whose TIN is shown in LEGAL BUSI-
NESS DESIGNATION should sign the form.
Privacy Act Notice.-Section 6109 requires you to furnish your correct taxpayer identification number(TIN)to persons who must file
information returns with IRS to report interest,dividends,and certain other income paid to you,mortgage interest you paid,the acquisi-
tion or abandonment of secured property,or contributions you made to an individual retirement arrangement(IRA).IRS Ices the num-
bers for identification purposes and to help verify the accuracy of your tax return.You must provide you TIN whether or not you are
required to file a tax return.Payers must generally withhold 20%of taxable interest, dividend,and certain other payments to a payee
who does not furnish a TIN to a payer.Certain penalties may also apply.
•
Substitute Form RE(t, £ST FOR TAXPAYER IDENTIFIC. ZION Colorado Department of Administration
W-9 NUMBER(TIN) VERIFICATION Do NOT send to IRS
PRINT OR TYPE RETURN TO ADDRESS BELOW •
Legal Name WELD COUNTY GOVERNMENT, WELD COUNTY, COLORADO
WELD COUNTY BOARD OF COMMISSIONERS
DO NOT ENTER THE BUSINESS NAME OF A SOLE PROPRIETORSHIP ON THIS UNE-Sec Remise for tmpalent Information
Trade Name
COMPLETE ONLY IF DOING BUSINESS AS(D.B/A1
Primary Address 915 10TH STREET
City,State,Zip, GREELEY, COLORADO 80632
Remit Address-Optional P.0. BOX 758
City,State.Zip. GREELEY, CO 80632
Order Address -Optional
City,State,Zip,
Check legal entity type and enter 9 digit Taxpayer IdentificauerrNmrtbei. ).,below:
(SSN=Social Security Number FEIN=Federal Employer r Ictuiao Numbearill
Individual / � `►..: idual N) —NOTE:If N no tone is circled m a faint Amami eaten thae. time than the nypLoraellneoai .ore dtto 3—'t fined. —— ————
.fs. ,..
Sole Proprietorship(Owner's N°' usineess FEIN; • N\s'
- ... ...•a rCY
Partnership �0 General Limn p
ed • ,(Partriershi 's FEIN}S. _
•
Estate/Trust l �
(Legal Entity's FEIN) E
NOTE Do nor fteshish the identification ember of the pence al representative cc court unless the legal entity awEf is nor dhsiphaled is the ' —
aiesaa t title.List ad dick the area of dun kpl our.wire,or pension rust. ! t
Other Groups of lndividaals . " 1 > (Entity's IEIN)4, - _
(Limited Liability Canpony,Joint vennee A ciMist.d eb)< } y
Corporation Doyou ovide medical�xervicesi, [}Yes:; f No _rpo pr (Carp's FEIN) �,'
• .r>e:.
(Inchhdes cooperations phomidtna medical blab;senilnesl ..,,.�: s . 1 ��—
xxi Government(or Gov Operated)Entity mow (Entity's FEIN,)
Organization Exempt from Tax under 5e lion 5434N- : -tGrgs, EIN)
Do you provide medical services`,„ 0 Yes ,£ 0 No,
nCheck Here if you do not have a SSN or FEIN.biit have applied for carne":See reverse for information on How to Obtain A TIN.
Licensed Real Estate Broker? ❑Yes 0 No
Under Penalties of perjury,I certify that:
(I) The number listed on this form is my correct Taxpayer Identification Number(or 1 am waiting for a number to be issued to me)AND
(2) I am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not ben notified by the Internal Revenue Service(IRS)
that lam subject to backup withholding as a result of a failure to report all interest or dividends'or(c)the IRS has notified me that I am no longer subject to backup
withholding(does not apply to real estate transactions.mortgage interest paid.the acquisition of abandonment of secured property,contribution to an individual
retirement arrangement(IPA).and payments other than interest and dividends).
CERTIFICATION INSTRUCTIONS-You must cross out item(2)above if you have been notified by the IRS that you are currently subject to backup withholding be-
cause or under reporting interest or dividends on your tax return.(Sec Signing the Certification on the reverse of this form.)
NAME(Print or Type) W. H. WEBSTER 'MILE(Print orType) CHAIRMAN
AUTHORIZED SIGNATURE 1/(..) O.
DATE 02/16/94 PHONE( 303 ) 356-4000
DO NOT WRITE BELOW THIS LINE 0 /23/9
•
AGENCY USE ONLY
Agency .,..,. Approved By Date
1099 Y_ N_
VEND Addition Change_ Action Completed By Daze i^� �
c.[�.�tTdhiM6lR
mEmoRAnDum
WITo Don Warden . F=inance Directcro.re. February 11 , 1914
i Att./
COLORADO car •
Fry !'ie ab �mb:1? anr.e Director
Froth_
EMS Grant Contract=/W9
Subject:
WE need to ec'cute the enclosed grant contracts and W9 form in
order to be reimbursed by the State.
Page 7 of the contract requires :
1. . The signature of the authority and typed name under it .
L. Federal Tai: ID number .
`• The signature of a witness and the typed name of the
witness under it .
The W-9 form needs to ?:.,e completed .
Once this is done, I will send them back to the State.
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940189
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