HomeMy WebLinkAbout951805.tiffRESOLUTION
RE: APPROVE CONTRACT FOR EMERGENCY MEDICAL SERVICES WITH COLORADO
DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 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 a Contract for Emergency Medical Services
between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, and the Colorado Department of Public Health and Environment,
commencing September 15, 1995, and ending June 30, 1996, 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 Contract for Emergency Medical Services between the County of Weld,
State of Colorado, by and through the Board of County Commissioners of Weld County, and the
Colorado Department of Public Health and Environment be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chairman 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 30th day of August, A.D., 1995.
BOARD OF COUNTY COMMISSIONERS
LD COUNTY, CO O' iO
74
~, y LU`NY:-
donpty Clerk to the Board
...,NlDlx L x29,1,
• Deputy Clero the Board
AmisM
Dal= K. Hall, Chairman
eorge . Baxter
Constance L. Harbert
W. H.17Vebster
951805
AM0009
X ---)e-17/2.0 voc5 (AJ4,volc—
26000 -- FAA
Contract Routing Number
960371
CONTRACT
THIS CONTRACT, made this 15th day of September 1995, by and
between the State of Colorado for the use and benefit of the
Department of PUBLIC HEALTH AND ENVIRONMENT, 4300 Cherry Creek
Drive South, Denver, CO 80222, hereinafter referred to as the
State, and Weld County, 915 10th Street, P.O. Box 758, Greeley, CO
80632hereinafter referred to as the Contractor.
WHEREAS, 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
960371 ; and
WHEREAS, required approval, clearance and coordination has been
accomplished from and with appropriate agencies; and
WHEREAS, the Division of Emergency Medical Services ("EMS
Division") was created to administer the Local Emergency Medical
Services program created by Title 25, Article 3.5, Part 6, C.R.S.
("Part 6"); and
WHEREAS, the Emergency Medical Services Account within the
Highway Users Tax Fund was created by Title Sec. 25-3.5-603,C.R.S.
to fund grants for the enhancement of emergency medical services
("EMS") statewide; and
WHEREAS, the State wishes to fund the Contractor as a provider
of EMS for this purpose; and
WHEREAS, the Contractor has been licensed, to the extent
required by law, to provide services in the State of Colorado; and
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 EMS; and
WHEREAS, the EMS Division deems the Contractor's application or
request for use of the grant funding justified under EMS Division
Rules Section 3.4.
Page 1 of 8 Pages
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 use the funding provided herein by the
State to administer a program to purchase equipment or obtain
training or education listed in Attachment A, Multi -Agency Grant
Application, attached and incorporated herein by reference. All
such equipment, training or education shall be used for the purposes
of providing emergency medical services.
2. The Contractor will use the Single Agency Assurances form,
Attachment B, attached and incorporated herein, as a means of
assuring each subcontracting agency's participation in this project.
The State agrees to accept the agencies listed in Attachment A, as
subcontractors of the Contractor, and recognizes the signed Single
Agency Assurances form as a written letter of agreement between the
subcontracting agency and the Contractor.
3. If this contract involves training or education, the Contractor
shall submit evidence of certification or other appropriate evidence
of satisfactory completion along with the invoice requesting
reimbursement.
4. If this contract involves acquisition of equipment, the
Contractor shall provide the State with documentation of purchase of
the equipment specified and comply with the following State
requirements:
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) emergency vehicles, with the exception of ambulances, will
be required to go through an informal competitive bidding process.
The specifications for these emergency vehicles must be approved by
the EMS Division in advance. The Contractor will purchase the
vehicle from the low responsible bidder;
c) 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;
d) the Contractor must maintain equipment in good working
order and provide maintenance in accordance with manufacturer's
specifications and any manufacturer's warranty requirements, and
keep detailed records of maintenance;
e) the Contractor will provide insurance for the replacement
value of the equipment for its useful life;
f) the Contractor shall repair or replace equipment, as
necessary, due to damage or loss from theft or casualty;
d) the Contractor will keep inventory control records on the
equipment and must receive approval from the EMS Division for any
relocation of this equipment or reallocation of its use;
Page 2 of 8 Pages
e) the Contractor will provide the EMS Division with a
picture of the equipment purchased. This picture must be submitted
with the final program report; and
f) should the Contractor or its subcontractors cease to
provide EMS in the State of Colorado, the equipment must, with the
prior approval of the State, either be placed with another operating
EMS provider in the state or sold at public auction for fair market
value and the proceeds, consistent with the states percent of
contribution to the original purchase price, from that sale returned
to the State.
5. Any training or education specified in Attachment A, will be
subject to the following:
a) 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;
b) a Contractor providing a training or education program
shall acknowledge the Emergency Medical Services Account Grant Funds
established by the Legislature and managed by the Emergency Medical
Services Division of the Department of Public Health and the
Environment, 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; and
c) a Contractor providing a training or education program
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.
6. The Contractor assures and guarantees that it possesses the
legal authority to enter into the Contract. The person or persons
signing and executing this contract on behalf of the Contractor do
hereby warrant and guarantee that they have full authorization to
execute this Contract.
7. The Contractor may not assign its rights or duties under this
Contract without the prior written consent of the State.
8. The Contractor will provide the EMS Division with quarterly
progress reports for the program and its subcontractors, in the
format required by the State.
9. Anything herein to the contrary notwithstanding, the parties
understand and agree that all terms and conditions of this contract
and the exhibits and attachments hereto which may require continued
performance or compliance beyond the termination date of the
contract shall survive such termination date and shall be
enforceable by the State as provided herein in the event of such
failure to perform or comply by the Contractor.
Page 3 of 8 Pages
10. The Contractor will comply with the Americans with Disabilities
Act at all times during the performance of this contract. The
Contractor certifies that no qualified individual with a disability
shall, by reason of such disability, be excluded from participation
in, or be denied the benefits of the services, programs, or
activities performed by the Contractor, or be subjected to any
discrimination by the Contractor upon which assurance the State
relies.
11. For and in consideration of the Contractor's performance
described herein the State shall pay an amount not to exceed
$53,007, Fifty Three Thousand Seven dollars, as follows:
a. for equipment the Contractor shall receive an amount not
to exceed $53,007. The Contractor will provide matching
funds in the amount of $53,008. Any costs in excess of
$53,007 (State Share) shall be the responsibility of the
Contractor; and.
b. for training the Contractor shall receive an amount not to
exceed $N/A. The Contractor will provide matching funds
in the amount of $N/A. Any costs in excess of $N/A (State
Share) shall be the responsibility of the Contractor.
In either case payment will
signed request for reimbursement
invoice, submitted in duplicate.
made payable to the Contractor.
affirmation by the EMS Division of
with the terms of this contract.
be made upon the receipt of a
along with a copy of• a paid
The State will issue a warrant
Payment will be contingent upon
full and satisfactory compliance
12a. 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.
b. If the Contractor is a "public entity" within the meaning of
the Colorado Governmental Immunity Act, C.R.S. 24-10-101, et seq.,
as amended ("Act"), the Contractor shall at all times during the
term of this Contract maintain such liability insurance, by
commercial policy or self-insurance, as is necessary to meet its
liabilities under the Act. The Contractor must provide the State
with proof of such insurance.
13. The term of this contract shall be from September 15, 1995 to
June 30, 1996.
Page 4 of 8 Pages
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
}seep in force workers' 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 co 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
surcoa
ct
contingent upon continued availability of federal funds for payment pursuant to
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.
276A -276A-5). This act requires that all laborers
contractors or sub -contractors to work on construction
assistance must be paid wages not less than those est
project by the Secretary of Labor;
d) 42 USC 6101 et seq, 42 USC 2000d, 29 USC 794.
person shall, on the grounds of race, color, national origin,
excluded from participation in or be subjected to discrimination
activity funded, in whole or in part, by federal funds; and
Page 5
Rev. 06/01/92
of
8
Pages
is
the
3, 1921, Chap. 411, 40 USC
and and mechanics employed by
projects financed by federal
ablished for the locality of the
These acts require that no
age, or handicap, be
in any program or.
GENERAL PR0V SIONS--Page 2 of 2 pages
e) the Americans with Disabilities Act (Public Law 101-336; 42 USC 12101, 12102,
12111 - 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
Uniform 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
department or agency.
7. 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
the column provided, as required by the funding source.
9. If Contractor receives $25,000.00 or more per year in federal funds in the
aggregate 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
an annual indirect cost proposal to Health for review and approval, Contractor's auditor
will audit the proposal in accordance with the requirements of OMB Circular A-87, A-21
or A-122. Contractor agrees to furnish one copy of the audit reports to the Health
Department Accounting Office within 30 days of their issuance, but not later than nine
months 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.
Page 6 of 8 Pages
Rev. 06/01/92
CONTROLLER'S APPROVAL
SPECIAL PROVISIONS
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 are 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 sufficient bond or other acceptable surety to be approved by
said official in a penal Sam 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 35-26-106.
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 respecting
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:
(al 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.
(CI 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.
Id) The contractor and labor unions will furnish all information and reports required by Executive Order, Equal Opportunity and Affirmative Action of April
lb. 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.
le) 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 race, creed, color,
sex. national origin, or ancestry.
If; 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
page % of $ pages
(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 include the provisions of paragraphs (a) through (h) in every sub -contract and subcontractor purchase order unless exempted by
rules, regulations, or orders issued pursuant to Executive Order, Equal Opportunity and Affirmative Action of April 16, 1975, so -that such provisions will
be binding upon each subcontractor or vendor. The contractor will take such action with respect to any sub -contracting or purchase order as the contracting
agency may direct, es 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 an undertaken hereunder and
are 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
eliminate the inconsistency with Federal requirements (CRS 8-19-101 and 102)
GENERAL
7. The laws of the State of Colorado and rules end regulations issued pursuant -thereto shall be applied in the interpretation, execution, and enforcement of this
contract. Any prevision 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 pen shall be valid or enforceable or available in any action at law whether by way of complaint.
defence. or otherwise. Any prevision rendered null and void by the operation of this provision will notinvalidate 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
been or may hereafter be established.
9. The signatones aver that they are familiar with CRS 18.8-301, et. seq.. (Bribery sod Corrupt Influences) and CRS 18-8-401. et. seq.. (Abuse of Public Office),
and 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 or property described herein:
IN WITNESS WHEREOF, the parties hereto have executed this Contract on the day first above written.
Contractor: Weld County
(Full Legal Name)
ATTORNEY GENERAL
Weld County, Colorado
Board o Co missioners
i.Tman 08/
-1 O'1Q813
By
Form 6 -AC -02C
Revised 1/93
395.53.81.1130
C
STATE OF COLORADO
ROY ROMER, GOVERNOR
for
DIRECTOR
DEPARTMENT HEALTH
OF
APPROVALS
CONTROLLER
By
STATE CONTROLLER
QUEFQJRD W. HALL
Page 8 which is the last of 8
*See instructions on reverse side
pages
PROGRAM APPROVAL:
Grants Manage
PART 1 - OF MULTI -AGENCY GRANT APPLICATION
EMS APPLICATION # (EMS Division Use Only): Attachment A
LEGAL NAME OF AGENCY ACCEPTING GRANT FEDERAL TAX ID NUMBER (read instructions carefully
on this item)
Weld County Government Federal Tax I.D. # 84-6000-813
CONTACT PERSON
PHONE (DAY) PHONE (NIGHT)
Lyle Achziger (303) 339-5823 (303) 330-8048
AGENCY MAILING ADDRESS
1121 M Street Greeley, Colo. R0691
STREET CITY ZIP
Weld and Larimer Counties
COUNTY/COUNTIES IMPACTED
LIST OF AGENCIES PARTICIPATING:
ATTACH AN ADDITIONAL PAGE IF NECESSARY
NAME OF AGENCY
AMT. REQUESTED
FROM EMS GRANT
AGENCY
MATCH
NO. OF EMS
RUNS ANNUALLY
Ault -Pierce Fire Dept.
$4,077.50
$4,077.50
N U
125 0
Eaton Fire Protection
$4,077.50
$4,077.50
180
Fort Lupton Fire
Protection District
$4,077.50
$4,077.50
300 I --
Greeley Fire Department
$24,465.00
$24,465.00
2859 IL —
Hudson Fire
Protection District
$4,077.50
$4,077.50
300
XX 50% CASH MATCH REQUIREMENT MET _ WAIVER HAS BEEN REQUESTED BY APPROPRIATE AGENCIES
Lem undersigned, do hereby attest
tint the information contained within this application la true to the best of my knowledge. I nso attest that the Cougy Comninionms from the as impacted
by this project urn be provided a copy or this sppiralion by no War then E e h 1 5 . I understand that my eppicetion rd be damnified should either
of these statements be untrue.
FMS rnnrrllnatrn-
TITLE
February 13, 1995
DATE
PART 1 PAGE 1
PART 1 - OF MULTI -AGENCY GRANT APPLICATION
EMS APPLICATION # IEMS Division Use Only): Attachment A
LEGAL NAME OF AGENCY ACCEPTING GRANT FEDERAL TAX ID NUMBER (read instructions carefully
on this item)
Weld County Government Federal Tax I.D. # 84-6000-813
CONTACT PERSON
Lyle Achziger
PHONE (DAY) PHONE (NIGHT)
(303) 339-5823 (303) 330-8048
AGENCY MAILING ADDRESS
1121 M Street Greeley, rnlo
STREET
80.631
CITY ZIP
Weld and Larimer Cn1lnriaa
COUNTY/COUNTIES IMPACTED
LIST OF AGENCIES PARTICIPATING:
ATTACH AN ADDITIONAL PAGE IF NECESSARY
NAME OF AGENCY
AMT. REQUESTED
FROM EMS GRANT
AGENCY
MATCH
NO. OF EMS
RUNS ANNUALLY
Johnstown Fire
Protection District
$4,077.50
$4.077.50
17n
$4,077.50
$4,077.50
LaSalle Fire Department
170
Windsor Fire
Protection District
$4,077.50
$4,077 sI1
inn
XX 50% CASH MATCH REQUIREMENT MET WAIVER HAS BEEN REQUESTED BY APPROPRIATE AGENCIES
I.rtr tna.nlg .d. do hereby attest
that the Munn Lion coeaiad whin ee aggfufiort la ma to the best of my Irrowlad a. I m dso attest that the County Confront issione s the areas impacted
by this project wit be provided a copy of the appiratiot by no later ,tenFeb . 15 . I aderstund that my appication a be dsgtoflied should either
of these statements be untrue.
Lyle Achziger, EMT -P
• INT AME
i
S ...i �.• E
EMS Coordinatnr
LE
FeUruary 13, 1995
DATE
PART 1 PAGE 1 A
USE BRIEF STATEMENTS TO DESCRIBE THE PRIORITIES FOR EACH AGENCY BELOW
H
N
O
U
$8155.00
$0.00
$8155.00
$0.00
$8155.00
$0.00
o
O
o
m o
al o
m
a o
N4 64
DESCRIPTION OF PROJECT AND TIME LINES
Purchase an Automatic External Defibrillator and the necessary
adjunctive equipment to properly operate, train, and maintain same.
This project to be completed prior to Jan.1, 1996 in order to
implement the AED in our fire district as training is completed
in January of 1996. This is a necessary project to the citizens
of our fire protection district that may become victims of cardiac
arrest and it is consistent with the forthcoming EMT curriculum.
Initial and continuing training will be provided by Aims College.
Purchase an Automatic External Defibrillator and the necessary
adjunctive equipment to properly operate, train, and maintain same.
This project to be completed prior to Jan. 1, 1996 in order to
implement the AED in our fire district as training is completed
in January of 1996. This is a necessary project to the citizens
of our fire protection district that may become victims of cardiac
arrest and it is consistent with the forthcoming EMT curriculum.
Tnitial and continuina trainina will be provided by Aims Colleae.
Purchase an Automatic External Defibrillator and the necessary
adjunctive equipment to properly operate, train, and maintain same.
This project to be completed prior to Jan. 1, 1996 in order to
implement the AED in our fire district as training is completed
in January of 1996. This a necessary project to the citizens of
the fire protection district that may become victims of cardiac
arrest and it is consistent with the forthcoming EMT curriculum.
Initial and continuing training will be provided by Aims College.
Greeley # 1 Purchase 6 Automatic External Defibrillators and the necessary
Fire adjunctive equipment to properly operate, train, and maintain same.
Department This project to be completed prior to Jan.1, 1996 in order to
implement the AED in the city as training is completed in January
of 1996. This is a necessary project to the citizens of the city
that may become victims of cardiac arrest and it is consistent
with the forthcoming EMT curriculum.
Initial and continuing training will be provided by Aims College.
PRIORITY
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PART 1 PAGE 2
USE BRIEF STATEMENTS TO DESCRIBE THE PRIORITIES FOR EACH AGENCY BELOW
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Purchase an Automatic External Defibrillator and the necessary
adjunctive equipment to properly operate, train, and maintain same.
This project to be completed prior to Jan. 1, 1996 in order to
implement the AED in the fire district as training is completed
in January of 1996. This is a necessary project to the citizens of
the fire protection district that may become victims of cardiac
arrest and it is consistent with the forthcoming EMT curriculum.
Initial and continuing training will be provided by Aims College.
Purchase an Automatic External Defibrillator and the necessary
adjunctive equipment to properly operate, train, and maintain same.
This project to be completed prior to Jan. 1, 1996 in order to
implement the AED in the fire district as training is completed
in January of 1996. This is a necessary project to the citizens of
the fire protection district that may become victims of cardiac
arrest and it is consistent with the forthcoming EMT curriculum.
Initial and continuing training will be provided by Aims College.
Purchase an Automatic Exter___t__ illator and the necessary
adjunctive equipment - • operate, train, and maintain same.
- •'ect t• .-- ed prior to Jan. 1, 1996 in order to
imp - - -- n the facility as training is completed in Januat
-
•-cessary project to the employees of the
ity that may • ims of cardiac arrest and it is
consistent with the fort - rriculum.
Initial and continuing training - rovided by Aims Colle
Purchase an Automatic External Defibrillator and the necessary
adjunctive equipment to properly operate, train, and maintain same.
This project to be completed prior to Jan. 1, 1996 in order to
implement the AED in the fire protection district as training is
completed in January of 1996. This project is necessary to the
citizens of the districtthat may become victims of cardiac arrest
and it is consistent with the forthcoming EMT curriculum.
Initial and continuing training to be provided by Aims College.
PRIORITY 77
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PART 1 PAGE 2 A
USE BRIEF STATEMENTS TO DESCRIBE THE PRIORITIES FOR EACH AGENCY BELOW
COST I
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DESCRIPTION OF PROJECT AN TIME LINES
e an Automatic Ex a1 Defi ator and the necessary
' ment erl rate, train, and maintain same.
This p lets or to Jan. 1, 1996 in order to
implement e district as training is completed
in Januar .5— ssary project to the citizens
of th ric at e cardiac arrest and it is
c nt the forthc c
In ial ' continuing training ovide y Aims College.
Purchase an Automatic External Defibrillator and the necessary
adjunctive equipment to properly operate, train, and maintain same.
This project to be completed prior to Jan. 1, 1996 in order to
implement the AED in the fire district as training is completed
in January of 1996. This is a necessary project to the citizens
of the district that may become victims of cardiac arrest and it is
consistent with the forthcoming EMT curriculum.
Initial and continuing training to be provided by Aims College.
PRIORITY
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PART 1 PAGE 3
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PART 1 PAGE 3 A
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PART 1 PAGE 4
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EMS Service Area and Geographic Description:
In the space below, please describe your service area:
ATTACH PART 2 OF MULTI AGENCY PAGES AFTER THIS PAGE
PART 1 PAGE 4 A
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ATTACH PART 2 OF MULTI AGENCY PAGES AFTER THIS PAGE
PART 1 PAGE 4 AA
t
EMS Service Area and Geographic Description:
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ATTACH PART 2 OF MULTI AGENCY PAGES AFTER THIS PAGE
PART 1 PAGE 4A AA
PART 2 - OF MULTI -AGENCY APPLICATION
For use by Individual Agency Participating in a Combined grant
INDIVIDUAL AGENCY NAME
AGENCY ADDRESS
COUNTY
PHONE
Ault -Pierce Fire Protection
106 Main St. Ault,Co 80610
Weld
(303)
834-7875
District
LEGAL STATUS OF AGENCY/ORGANIZATION (Mark all that apply):
_ PRIVATE NOT FOR PROFIT _ PRIVATE FOR PROFIT _ COUNTY/CITY
GOVERNMENT
STATE AGENCY xx SPECIAL DISTRICT _OTHER
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 limn the areas impacted by this project will be provided
a copy of this application by no later than Feb. 15 ' 95 I understand that my application will be disqualified
should either of these statements be untrue.
$pith Kanneny
PRINT NAME
SI ATURE
Fire rhief
TITLE
February 13, 1995
DATE
WHY IS THIS PROJECT NEEDED
In the space below, write a concise statement describing the need(s) addressed by this
project. The fire department rescue personnel need an AED. A population
base of 3000 people are served and mutual aid is provided to other
surrounding districts as needed. 2100 of these citizens live in
town, the rest are rural. The population increases seasonally with
the influx of migrant labor. A large number of the citizens are
retired. A senior citizen housing complex has increased the number
of older residents. An AED would benefit the citizens by providing
rescue personnel with a tool that will provide definitive care to
arrest victims. Area is agricultural based. Response time averages
-5 minutes. ALS via Weld County and Air Life.
COUNTY PLAN REFERENCE4
List the goals and objectives identified in your county EMS plan that are associated
with this funding application.
Section II.11 Initiated AED study among first responders. Upon
completion of the study, the physician advisor and EMS council
recommended implementation of an AED program.
If your funding application is not identified in your county EMS plan, explain why
it is not.
PART 2 PAGE 1
PART 2 - OF MULTI -AGENCY APPLICATION
For use by Individual Agency Participating in a Combined grant
INDIVIDUAL AGENCY NAME
AGENCY ADDRESS
COUNTY
PHONE
Ault -Pierce Fire Prot. Dist
LEGAL STATUS OF AGENCY/ORGANIZATION (Mark all that apply):
PRIVATE NOT FOR PROFIT _ PRIVATE FOR PROFIT _ COUNTY/CITY
GOVERNMENT
STATE AGENCY SPECIAL DISTRICT OTHER
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 . I understand that my application will be disqualified
should either of these statements be untrue.
PRINT NAME TITLE
SIGNATURE DATE
WHY IS THIS PROJECT NEEDED
In the space below, write a concise statement describing the need(s) addressed by this
project.
The average number of cardiac arrests is 5 to 6 per year with the
majority of them ocurring within the city limits This number is anticipated
to increase with the increase in population and the aging of our senior and
retired citizens.
COUNTY PLAN REFERENCE
List the goals and objectives identified in your county EMS plan that are associated
with this funding application.
If your funding application is not identified in your county EMS plan, explain why
it is not.
PART 2 PAGE ''
EQUIPMENT LIST (listing brands will not preclude you from having to obtain bids for the generic equipment
types)
In the space provided, please list the EMS equipment or training equipment for which funding
is being requested, and explain whether or not you currently have equipment that serves this
purpose, its age, and serviceability. When requesting extrication equipment tell where the
nearest extication equipment is both is time and distance. When requesting defibrillators,
please list what you currently have and how many times you use it in the last two years.
Include as much information as possible.
Prior
-ity
#_
List the type of
equipment you me
requesting.
Total
Price
What equipment are you
currently using for this tea,
,1,
Purpose? Moor Pvi Yo1Li;4.
How many runs a
year require this
equipment?
# 1
Physio-Control
Lifepak 300 and
adjunctive equip-
ment
$8155
None
8 -10
TYPE
# OF PERSONS
TO BE TRAINED
COST PER
PERSON
TRAVEL COST
PER PERSON
TOTAL COST PER
TYPE OF COURSE
EMT -B
10
0
0
0
EMT -I
EMT -P
CONTIN. ED
OTHER
COST OF PROJECT:
How much of the total CASH cost of the TRAINING will be paid by the state $
How much of the total CASH cost of the TRAINING will be paid by the student $
How much of the total CASH cost of the TRAINING will be paid by your agency $
ATTACH A DETAILED BUDGET BREAKDOWN
IF THIS IS A MAJOR TRAINING PROJECT
Arrangements have been made for initial and continuing
training to be provided by Aims Community College at
no cost to the fire district or the student.
PART 2 PAGE 2
0
n
0
COMMUNICATIONS
IF YOU ARE 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
1. Name and telephone number of individual or agency providing technical specifications.
Name
( )
Telephone
PROJECT FUNDING
A) EMS Fund Request
B) Local Gvmt. Share - Cash
(list source) •
C) Other Cash
(list source)
$ $4,077 50
$ $4,077.50 Local oov't.
source
$ 0
D) Total Cash Proj. Cost (A+B+C) $
$8.155 00
E) Dollar Estimate of In -Kind Match S 0
(In -Kind cannot be counted as port of you, 50% cash match)
F) Total Program Cost (D+E)
$ $8.155.00
Describe the in -kind match you can provide:
source
PART 2 PAGE 3
AGENCY'S FINANCIAL INFORMATION
Cash Flow Projection for Next Full Fiscal Year
Year: 1995 to 19 96
Cash Balance at the
at the start of year
Anticipated Revenues
Local Government
Private Contributions
Investment Income
Other
Anticipated Expenditures
Salaries
Operating
Capital Improvement
Loans
Other
Anticipated Cash Balance
For the end of next FY
Agency Projection
$ 1RR,681
$ 101,00
$ 0
$ 3,000
$ 1,077.50
$ 0
$ 67,327
$ 363,010
$ 39,000
$ 1 .6R1
$ 14,883
EMS Portion of
Agency Projection
S
0
$ 4,077.50
$
$ 1,077.50
$
S
S-84.5&,00-
$ 0
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 reserve for coinsurance and large repair items.
Loan payments of $39,000 per year on a new fire truck/
pumper. This item and the AED comprise our capital
improvements.
Other expenditure is Amendment 12 cash reserve.
PART 2 PAGE 4
EMS PROVIDER INFORMATION
Years in Operation 91
TYPE OF SERVICE:
_ ALS (EMT -P & EMT -I) xx BLS _ Combination
•4- Fire/Rescue Service
Transport OR xx Non -transport
Other (i.e. Air, etc...)
Name of physician advisor (if agency has one) David Cl aman . M n,
PERSONNEL BY TRAINING LEVEL (number of each):
Volunteer Full -Time Paid Part-time Paid
First Responder 6
EMT -Basic
(certified)
EMT -Intermediate
(certified)
EMT -Paramedic
(certified)
Other
(CPR certified,
basic first -aid, R.N.)
10
PRIMARY Hospital transported to: North Colorado Medical renter
Distance to PRIMARY Hospital: 15 miles
Average number of EMS Runs Annually: 1 9
Average number of Runs Annually: 143
PART 2 PAGE 5
PART 2 - OF MULTI -AGENCY APPLICATION
For use by Individual Agency Participating in a Combined grant
INDIVIDUAL AGENCY NAME
AGENCY ADDRESS
COUNTY
PHONE
Eaton Fire Protection Dist.
224 1st St. Eaton,Co 80615
Weld
(303)
454-3374
LEGAL STATUS OF AGENCY/ORGANIZATION (Mark all that apply):
_ PRIVATE NOT FOR PROFIT _ PRIVATE FOR PROFIT _ COUNTY/CITY
GOVERNMENT
STATE AGENCY SPECIAL DISTRICT _OTHER
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 Feb 1 c ' 95. I understand that my application will be disqualified
should either of these statements be untrue.
flonalr1 R Carlwallaier
PRINT NAME
SIGNATURE
Firp rhipf
TITLE
February FR. , 1995
DATE
WHY IS THIS PROJECT NEEDED
In the space below, write a concise statement describing the need(s) addressed by this
project. The needs of the residents of the district include the availability
of an AED in order to maximize the survivability potential of cardiac
arrest victims. Citizens number approx. 3600, 2400 urban, 1200 rural.
Seasonal increase of migrants. Large percentage of senior citizens.
District is 60 square miles, largely agricultural. The number of
cardiac arrests is increasing as population and age of citizens does.
The average over 2 years is 6 arrests per year ALS is provided from
Greeley with an avg. response time of 5 minutes. Air Life also
responds. Mutual aid from Greeley and Ault is back up.
COUNTY PLAN REFERENCE
List the goals and objectives identified in your county EMS plan that are associated
with this funding application.
Section II.11 Initiated AED study among first responders. Upon
completion of the study, the physician advisor and EMS council
recommended implementation of an AED program.
If your funding application is not identified in your county EMS plan, explain why
it is not.
PART 2 PAGE 1
EQUIPMENT LIST (listing brands will not preclude you from having to obtain bids for the generic equipment
types)
In the space provided, please list the EMS equipment or training equipment for which funding
is being requested, and explain whether or not you currently have equipment that serves this
purpose, its age, and serviceability. When requesting extrication equipment tell where the
nearest extication equipment is both is time and distance. When requesting defibrillators,
please list what you currently have and how many times you use it in the last two years.
Include as much information as possible.
Prior
-ity
#
List the type of
equipment you me
requesting_
Total
Price
What equipment are you
currently using for this/. 2,
purpose? uv..r^eeig, I ivn-,
How many runs a
year require this
equipment?
# 1
Physio-Control
Lifepak 300 and
adjunctive
equipment
$8155
None
6 - 8
TYPE
It OF PERSONS
TO lIE TRAINED
COST PER
PERSON
TRAVEL COST
PER PERSON
TOTAL COST PER
TYPE OF COURSE
EMT -B
8
0
0
0
EMT -I
EMT -P
CONTIN. ED
OTHER
COST OF PROJECT:
How much of the total CASH cost of the TRAINING will be paid by the state $ n
How much of the total CASH cost of the TRAINING will be paid by the student $ 0
How much of the total CASH cost of the TRAINING will be paid by your agency $ 0
ATTACH A DETAILED BUDGET BREAKDOWN
IF THIS IS A MAJOR TRAINING PROJECT
Initial and continuing training will be provided by Aims Community
at no cost to the fire district or the student. This training will
be a part of the required curriculum by the state.
PART 2 PAGE 2
COMMUNICATIONS
IF YOU ARE 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
1. Name and telephone number of individual or agency providing technical specifications.
(
Name
Telephone
PROJECT FUNDING
A) EMS Fund Request $ 4,077.50
B) Local Gvmt. Share - Cash
(list source)
C) Other Cash
(list source)
$ 4,077.50 local gov't
$ 0
D) Total Cash Proj. Cost (A+B+C) $
E) Dollar Estimate of In -Kind Match $
On -Kind cannot be counted as part of your 50% cash match)
8155.00
0
F) Total Program Cost (D+E) $ R195 nn
Describe the in -kind match you can provide:
source
source
PART 2 PAGE 3
AGENCY'S FINANCIAL INFORMATION
Cash Flow Projection for Next Full Fiscal Year
Year: 19gsto 1936
Cash Balance at the
at the start of year
Anticipated Revenues
Local Government
Private Contributions
Investment Income
Other
Anticipated Expenditures
Agency Projection
$103,086
$n
$5,000
$4 .n7, 50 $ 4,077.50
EMS Portion of
Agency Projection
$0
$4,077.50
Salaries $ 0 $
Operating $ 100, 757
Capital Improvement $ 8155.00 $ 8,155 AO
Loans $ $
Other $ $
Anticipated Cash Balance
For the end of next FY $ 162.324
$
$ 0
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.
Balance of funds is designated for building fund and
emergency reserve.
A loan payment of $35,600 is included in the operating
budget. This payment is for a pumper purchased two years ago.
Our only expected capital outlay is for the AED in 1995.
PART 2 PAGE 4
EMS PROVIDER INFORMATION
Years in Operation 7f1
TYPE OF SERVICE:
ALS (EMT -P & EMT -I) Rx— BLS _ Combination
xx Fire/Rescue Service
Transport OR Non -transport
Other (i.e. Air, etc...)
Name of physician advisor (if agency has one) Da vi ri rt aman M n
PERSONNEL BY TRAINING LEVEL (number of each):
Volunteer Full -Time Paid Part-time Paid
First Responder 1'1
EMT -Basic
(certified)
EMT -Intermediate
(certified)
EMT -Paramedic
(certified)
Other
(CPR certified,
basic first -aid, R.N.)
8
PRIMARY Hospital transported to: North Colorado Me,ira1 roptar
Distance to PRIMARY Hospital: 8 Miles
Average number of EMS Runs Annually: 145
Average number of Runs Annually: 260
PART 2 PAGE 5
PART 2 - OF MULTI -AGENCY APPLICATION
For use by Individual Agency Participating in a Combined grant
INDIVIDUAL AGENCY NAME
AGENCY ADDRESS
COUNTY
PHONE
Fort Lupton Protection Dist.
Colo. 80621
LEGAL STATUS OF AGENCY/ORGANIZATION (MarkEFORPROFIT COUNTY/CITY
alt that apply):
_ PRIVATE NOT FOR PROFIT _ -
GOVERNMENT
STATE AGENCY xx SPECIAL DISTRICT —OTHER
1121 Denver Ave Ft. Lupton
NIP Id
(303)
57_4Fn.
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 Fro-, t 5 1 951 understand that my application will be disqualified
should either of these statements be untrue.
Larry K. Richardson nictrict Administrator
11TLE
PRINT NAME
7
n )jinn:vCi-fl,�
SIGNATURE
February 13. 1995
DATE
WHY IS THIS PROJECT NEEDED
In the space below, write a concise statement describing the need(s) addressed by this
project. Equipment necessary to optimum medical care by the district is an
AED. The district covers 76 square miles with a population of 10000.
One half of the population is rural. Rapid growth is anticipated with
DIA opening. Agriculture, oil and gas production predominate industry.
Increased population with migrant workers. Highway 85 is a major
commuter route. The district population has a high rate of cardiac arree
victims per capita averaging 12 - 14 per year. Average response time 01
the department is 5 minutes. We are supported by three ALS services an(
Air Life of Greeley as well as Air service from Denver. Platte Valley
COUNTY PLAN REFERENCE Medical Center is within 7 minutes by ground.
List the goals and objectives identified in your county EMS plan that are associated
with this funding application.
Section II.11 Initiated AED study among first responders. Upon
completion of the study, the physician advisor and EMS council
recommended implementation of an AED program.
If your funding application is not identified in your county EMS plan, explain why
it is not.
PART 2 PAGE 1
EQUIPMENT LIST (rusting brands will not preclude you from having to obtain bids for the generic equipment
types)
In the space provided, please list the EMS equipment or training equipment for which funding
is being requested, and explain whether or not you currently have equipment that serves this
purpose, its age, and serviceability. When requesting extrication equipment tell where the
nearest extication equipment is both is lime and distance. When requesting defibrillators,
please list what you currently have and how many times you use it in the last two years.
Prior
-ity
#_
List the type of
equipment you are
requesting.
Total
Price
What equipment are you
currently using for this i ;
purpose? Naar, Pf /n%n.
How many runs a
year require this
equipment?
* 1
Physio-Control
Lifepak 300 and
adjunctive
equipment
$8155
None
12 -14
• I -tuna r -Y .-. .
TYPE
# OF PERSONS
TO BE TRAINED
COST PER
PERSON
TRAVEL COST
PER PERSON
TOTAL COST PER
TYPE OF COURSE
EMT -B
5
0
0
0
EMT -I
EMT -P
CONTIN. ED
OTHER
COST OF PROJECT:
How much of the total CASH cost of the TRAINING will be paid by the state So
How much of the total CASH cost of the TRAINING will be paid by the student S 0
How much of the total CASH cost of the TRAINING will be paid by your agency S n
ATTACH A DETAILED BUDGET BREAKDOWN
IF THIS IS A MAJOR TRAINING PROJECT
Aims Community College will provide the initial training for our
fire district personnel beginning January 1996 with the implementation
of the new EMT -B curriculum. They will also provide the continuing
AED education each 90 days all at no cost to the district or EMTs.
PART 2 PAGE 2
COMMUNICATIONS
IF YOU ARE 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
1. Name and telephone number of individual or agency providing technical specifications.
( 1
Name
Telephone
PROJECT FUNDING
A) EMS Fund Request
B) Local Gvmt. Share - Cash
(list source)
C) Other Cash
(list source)
$ $4,077.50
$ $4,077.50
D) Total Cash Proj. Cost (A+B+C) $ $8,155.00
E) Dollar Estimate of In -Kind Match $
On -Kind cannot be counted as pan of your 50% cash match)
F) Total Program Cost (D+E) $ $8,155.00
Describe the in -kind match you can provide:
local oov't
source
source
PART 2 PAGE 3
AGENCY'S FINANCIAL INFORMATION
Cash Flow Projection for Next Full Fiscal Year
Year: 19_95to 199
Cash Balance at the
at the start of year
Anticipated Revenues
EMS Portion of
Agency Projection Agency Projection
$25,000 $ 0
Local Government $371,095
$
Private Contributions $3,000
Investment Income
Other
Anticipated Expenditures
$14,500
$4343.50
$
$ 4077.50
Salaries $ R2 , c 3F $
Operating $ 214.990 $
Capital Improvement $84002 $ 8155.951
Loans $ p $
Other $ 0 $
Anticipated Cash Balance
For the end of next FY $4n,4R2
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.
The excess reserve will go toward future capital expenditures as approv
by the taxpayers in May, 1994. The capital expenditures are as follows
$21,700 for improvements to the building and grounds; $6,300 for rural
land improvements; $5,000 for vehicle improvements; $4,300 for furnitur
and fixture improvements; and $38, 547 for equipment improvements
including AED matching funds.
PART 2 PAGE 4
EMS PROVIDER INFORMATION
Years in Operation 43
TYPE OF SERVICE:
ALS (EMT -P & EMT -I) x BLS _ Combination
x Fire/Rescue Service
Transport OR x Non -transport
Other (i.e. Air, etc...)
Name of physician advisor lif agency has one) Dr. David Claman, MD
PERSONNEL BY TRAINING LEVEL (number of each):
Volunteer Full -Time Paid Part-time Paid
First Responder 25
EMT -Basic 5
(certified)
EMT -Intermediate 0
(certified)
EMT -Paramedic
(certified)
Other
(CPR certified,
basic first -aid, R.N.)
0
30
PRIMARY Hospital transported to:
Northern Colorado Mediral ranrar
Distance to PRIMARY Hospital: 25 miles
Average number of EMS Runs Annually: 300
Average number of Runs Annually: 528
PART 2 PAGE 5
PART 2 - OF MULTI -AGENCY APPLICATION
For use by Individual Agency Participating in a Combined grant
INDIVIDUAL AGENCY NAME
AGENCY ADDRESS
COUNTY
PHONE
GREELEY FIRE DEPARTMENT
919 7th St.,Greeley, CO
WELD
303-
150-951
LEGAL STATUS OF AGENCY/ORGANIZATION (Mark all that apply):
_ PRIVATE NOT FOR PROFIT _ PRIVATE FOR PROFIT x COUNTY/CITY
GOVERNMENT
STATE AGENCY SPECIAL DISTRICT _OTHER
t, 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 Feb. 15, '9 9 understand that my application wiU be disqualified
should either of these statements be untrue.
Gary W. Novinger Fire Chief
TITLE
?HINT NAME
SIGtIIATURE
c'2 i3
/DATE
WHY IS THIS PROJECT NEEDED
In the space below, write a concise statement describing the need(s) addressed by this
project. Having automatic external defibrillators on the front line apparatus of The
Greeley Fire Deparment will allow the Greeley Fire Department to provide a higher level
of BLS service to the citizens of and the visitors to the City Of Greeley. It will
provide a greater chance of survival to a patient with their heart in ventricular
fibrillation. It could save lives if it is available to be used by well trained EMT -Bs
who arrive quickly to aid the patient. The citizens of and visitors to the City Of
Greeley need to have this level of BLS service. Greeley fire department
responds to over 50 cardiac arrests within the city each year with an
daft Y PLAN Kt gRtNCE minutes.
List the goals and objectives identified in your county EMS plan that are associated
with this funding application.
Section II.11 Initiated AED study among first responders. Upon
completion of the study, the physician advisor and EMS council
recommended implementation of an AED program.
If your funding application is not identified in your county EMS plan, explain whY
it is not.
PART 2 PAGE 1
EQUIPMENT LIST (listing brands will not preclude you from having to obtain bids for the generic equipment
types)
In the space provided, please list the EMS equipment or training equipment for which funding
is being requested, and explain whether or not you currently have equipment that serves this
purpose, its age, and serviceability. When requesting extrication equipment tell where the
nearest extication equipment is both is time and distance. When requesting defibrillators,
please list what you currently have and how many times you use it in the last two years.
Include as much information as possible.
Prior
-ity
# 1
List the type of
equipment you are
requesting.
Total
Price
What equipment are you
currently using for this
Purpose? lam r fig;',412-c; tn., nsequipment?
How many runs a
year require this
6
Six (6) Auto
External Defibrillator
Physio-Control
@ $8155 ea.
48,930
None
51
TYPE
it OF PERSONS
TO BE TRAINED
COST PER
PERSON
TRAVEL COST
PER PERSON
TOTAL COST PER
TYPE OF COURSE
EMT -B
68 •
0
0
0
EMT -I
EMT -P
CONTIN. ED
OTHER
COST OF PROJECT:
How much of the total CASH cost of the TRAINING will be paid by the state $
How much of the total CASH cost of the TRAINING will be paid by the student $ n
How much of the total CASH cost of the TRAINING will be paid by your agency $ o
ATTACH A DETAILED BUDGET BREAKDOWN
IF THIS IS A MAJOR TRAINING PROJECT
Aims Community College Emergency Services will provide at no cost to the
department the initial and ongoing training necessary to implement the
use of the AED and comply with the new state EMT -B curriculum.
PART 2 PAGE 2
COMMUNICATIONS N/A
IF YOU ARE 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
1. Name and telephone number of individual or agency providing technical specifications.
Name
( 1
Telephone
PROJECT FUNDING
A) EMS Fund Request
B) Local Gvmt. Share - Cash
(list source)
C) Other Cash
(list source)
$ 24:465
$ 24,465 Approved Budget
source
D) Total Cash Proj. Cost IA+B+C) $ 48,930
E) Dollar Estimate of In -Kind Match $
(In -Kind cannot be counted as part of your 50% cash match)
F) Total Program Cost (D+E) $ 48,930
Describe the in -kind match you can provide:
source
PART 2 PAGE 3
AGENCY'S FINANCIAL INFORMATION
Cash Flow Projection for Next Full Fiscal Year
Year: 1995 to 1996
EMS Portion of
Agency Projection Agency Projection
Cash Balance at the
at the start of year $ 4.110.746 $
Anticipated Revenues
Local Government $ 4,110,746 $ 32,740**
Private Contributions $ 0 $
Investment Income $ 0 $
Other $ 74 465 $
94,465
Anticipated Expenditures
Salaries $
Operating $
Capital Improvement $
Loans $
Other $
Anticipated Cash Balance
3,740,778
S
445.500 $ 8,275
LA 94n $ 48,930
o S
0 $
For the end of next FY $ 0 $
0
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.
* EMS portion of salaries is not budgeted separtely.
** EMS portion of projection includes normal medical supply expenditures plus
capital outlay for AEDs..
PART 2 PAGE 4
EMS PROVIDER INFORMATION
Years in Operation 95
TYPE OF SERVICE:
ALS (EMT -P & EMT -I)
X Fire/Rescue Service
_ Transport OR _Non -transport
Other (i.e. Air, etc...)
x BLS
Combination
Name of physician advisor (if agency has one) David Cl aman, M.D.
PERSONNEL BY TRAINING LEVEL (number of each):
Volunteer Full -Time Paid Part-time Paid
First Responder
EMT -Basic
(certified)
EMT -Intermediate
(certified)
EMT -Paramedic
(certified)
Other
(CPR certified,
basic first -aid, R.N.)
3
68
0
0
0
PRIMARY Hospital transported to: North Colorado Medi cal Center
Distance to PRIMARY Hospital: Two (2) miles or less
Average number of EMS Runs Annually:
2,767 (Last 3 yr. avg.)
Average number of Runs Annually: 3,853 (Last 3 yr. avg.)
PART 2 PAGE 5
PART 2 - OF MULTI -AGENCY APPLICATION
For use by Individual Agency Participating in a Combined grant
INDIVIDUAL AGENCY NAME
AGENCY ADDRESS
COUNTY
PHONE
Hudson Fire Protection District
PO Box 7 Hudson Colorado 80642
Weld
536-4740
LEGAL STATUS OF AGENCY/ORGANIZATION (Mark all that apply):
_ PRIVATE NOT FOR PROFIT _ PRIVATE FOR PROFIT COUNTY/CITY
GOVERNMENT
STATE AGENCY XX SPECIAL DISTRICT _OTHER
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 Feb 15, '95 I understand that my application will be disqualified
should either of these statements be untrue.
4.eigkc72-Z flee /k) S /ec71
TITLE
RINT NAME
l
cL'
February 6. 1995
SIGNATURE DATE
WHY IS THIS PROJECT NEEDED
In the space below, write a concise statement describing the need(s) addressed by this
project. To provide the citizens of the Hudson Fire Protection District as well as
interstate travelers throughout our district with the best of patient care. The
number of cardiac arrest calls that Hudson responds to has been high in the past
and with the growing population has the potential to go higher. We want to be able
to provide out citizens with early defibrillation so as to hopefulle make a dif-
ference with their outcome should they or their family members be in an arrest
situation. Hudson has a number of EMT -B's interested in becoming certified to
use AED's with an additional three first responders that will be enrolled in an
EMT class be the end of 1995.
COUNTY PLAN REFERENCE
List the goals and objectives identified in your county EMS plan that are associated
with this funding application.
Section II.11 Initiated AED study among first responders. Upon
completion of the study, the physician advisor and EMS council
recommended implementation of an AED program.
If your funding application is not identified in your county EMS plan, explain why
it is not.
PART 2 PAGE 1
PART 2 - OF MULTI -AGENCY APPLICATION
For use by Individual Agency Participating in a Combined grant
INDIVIDUAL AGENCY NAME
AGENCY ADDRESS
COUNTY
PHONE
Hudson Fire Protection Dist.
LEGAL STATUS OF AGENCY/ORGANIZATION (Mark all that apply):
_ PRIVATE NOT FOR PROFIT _ PRIVATE FOR PROFIT _ COUNTY/CITY
GOVERNMENT
STATE AGENCY _ SPECIAL DISTRICT _OTHER
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 . I understand that my application will be disqualified
should either of these statements be untrue.
PRINT NAME TITLE
SIGNATURE
WHY IS THIS PROJECT NEEDED
In the space below, write a concise statement
project.
Hudson fire and rescue personnel respon
per year. This number is expected to i
with .the increase in growth in the dist
area. The majority of cardiac arrests
of Hudson. We also serve the town of L
DATE
describing the need(s) addressed by this
d to 10 to 15 cardiac arrest patients
ncrease to approximately 20 per year
rict and the impact of DIA on our
ocurr within or near the city limits
ochbuie in southern Weld County.
COUNTY PLAN REFERENCE
List the goals and objectives identified in your county EMS plan that are associated
with this funding application.
If your funding application is not identified in your county EMS plan, explain why
it is not.
PART 2 PAGE 1 A
EQUIPMENT LIST listing brands will not preclude you from having to obtain bids for the generic equipment
types)
In the space provided, please list the EMS equipment or training equipment for which funding
is being requested, and explain whether or not you currently have equipment that serves this
purpose, its age, and serviceability. When requesting extrication equipment tell where the
nearest extication equipment is both is time and distance. When requesting defibrillators,
please list what you currently have and how many times you use it in the last two years.
Include as muchinformation as possible.
Prior
-ity
#
List the type of
equipment you are
requesting.
Total
Price
What equipment are you
currently using for this/_,,
purpose? N mdf, Yy i.e e.
How many runs a
year require this
equipment?
# 1
Physio-Control
Lifepak 300 and
adjunctive
equipment
$8155
None
20
TYPE
# OF PERSONS
TO BE TRAINED
COST PER
PERSON
TRAVEL COST
PER PERSON
TOTAL COST PER
TYPE OF COURSE
EMT -B
4
0
0
0
EMT -I
0
EMT -P
0
CONTIN. ED
OTHER
COST OF PROJECT:
How much of the total CASH cost of the TRAINING will be paid by the state $ n
How much of the total CASH cost of the TRAINING will be paid by the student $ c
How much of the total CASH cost of the TRAINING will be paid by your agency $ 0
ATTACH A DETAILED BUDGET BREAKDOWN
IF THIS IS A MAJOR TRAINING PROJECT
Initial and continuing training for use of the AEDs and implementation
of the new state EMT -B curriculum will be provided at no cost to the
fire district or personnel by Aims Community College with training
beginning January of 1996.
PART 2 PAGE 2
COMMUNICATIONS
IF YOU ARE 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
1. Name and telephone number of individual or agency providing technical specifications.
( )
Name
Telephone
PROJECT FUNDING
A) EMS Fund Request $ 4 , 077.50
B) Local Gvmt. Share - Cash
)list source)
C) Other Cash
(list source)
$4,077.50 budget
DI Total Cash Proj. Cost (A+B+C) $ 8,155.00
E) Dollar Estimate of In -Kind Match $
(In -Kind cannot be counted as part of your 50% cash match)
F) Total Program Cost (D+E) $ 8,155.00
Describe the in -kind match you can provide:
source
source
PART 2 PAGE 3
AGENCY'S FINANCIAL INFORMATION
Cash Flow Projection for Next Full Fiscal Year
Year: 19 95to 1996
EMS Portion of
Agency Projection Agency Projection
Cash Balance at the
at the start of year
Anticipated Revenues
Local Government
Private Contributions
Investment Income
Other
Anticipated Expenditures
Salaries
Operating
Capital Improvement
Loans
Other
Anticipated Cash Balance
$ 144,585
$ 134,100
$ -0-
$ 4000
$ 4,n77 sn $ 4,077 c0
$
$
S 6850
$ 66,300
$ 11,000
$ 39,100
$ 15,000
For the end of next FY $ 144,435
$
$ 2500 medical supplies
$ 8155.
$
$
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.
1) Cash balance in reserve for future operations and equipment replacement.
2) Loan payments are annual lease payments on two fire trucks.
3) Capital improvement payment for the year will be an AED, bunker gear, and
landscaping.
4) The EMS portion of the agency does not generate income. The only budget
item specifically set aside for EMS is medical supplies. However, it is
estimated that approximately 82% of all calls in the district are medical.
PART 2 PAGE 4
EMS PROVIDER INFORMATION
Years in Operation 44
TYPE OF SERVICE:
ALS (EMT -P & EMT -I) x BLS _ Combination
X Fire/Rescue Service
Transport OR X Non -transport
Other (i.e. Air, etc...)
Name of physician advisor (if agency has one) David Claman
PERSONNEL BY TRAINING LEVEL (number of each):
Volunteer Full -Time Paid Part-time Paid
First Responder 15
EMT -Basic
(certified)
EMT -Intermediate
(certified)
EMT -Paramedic
(certified)
Other
(CPR certified,
basic first -aid, R.N.)
c,
PRIMARY Hospital transported to: NCMC
Distance to PRIMARY Hospital: 35 miles
Average number of EMS Runs Annually:
240
300
Average number of Runs Annually:
PART 2 PAGE 5
PART 2 - OF MULTI -AGENCY APPLICATION
For use by Individual Agency Participating in a Combined grant
INDIVIDUAL AGENCY NAME
Johnstown Fire Protection Distriol P.O. Box F
AGENCY ADDRESS
PHONE
((
Weld I58Z-4043
COUNTY
LEGAL STATUS OF AGENCY/ORGANIZATION (Mark all that apply):
_ PRIVATE NOT FOR PROFIT _ PRIVATE FOR PROFIT _ COUNTY/CITY
GOVERNMENT
STATE AGENCY X SPECIAL DISTRICT OTHER
t, 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 Feb 15 , ' 95 I understand that my application will be disqualified
should either of these statements be untrue.
/l,':Ch-c(r:5 14. 5icro F�
PRINT NAME
r,rf chi -cc
TITLE
�e l --F b 3 —
SIGNATURE DATE
WHY IS THIS PROJECT NEEDED
In the space below, write a concise statement describing the need(s) addressed by this
project.
The Johnstown Fire Protection District responds to approximately 120 medical
calls per year. Of the 120 medical calls, about .25 are cardiac arrest patients.
Many of the cardiac arrest patients are from the Senior Citizen Center or from
private residences in our district.
COUNTY PLAN REFERENCE
List the goals and objectives identified in your county EMS plan that are associated
with this funding application.
Section II.11 Initiated AED study among first responders. Upon
completion of the study, the physician advisor and EMS council
recommended implementation of an AED program.
If your funding application is not identified in your county EMS plan, explain why
it is not.
PART 2 PAGE 1
EQUIPMENT LIST (listing brands will not preclude you from having to obtain bids for the generic equipment
types)
In the space provided, please list the EMS equipment or training equipment for which funding
is being requested, and explain whether or not you currently have equipment that serves this
purpose, its age, and serviceability. When requesting extrication equipment tell where the
nearest extication equipment is both is time and distance. When requesting defibrillators,
please list what you currently have and how many times you use it in the last two years.
Include as much information as possible.
Prior
-ity
#
List the type of
equipment you are
requesting.
Total
Price
What equipment are you
currently using for this ),;
w.
purpose? Nrmdff4t .4
How many runs a
year require this
equipment?
4 1
Physio-Control
Lifepak 300 and
adjunctive
equipment
$8155
None
25
TYPE
# OF PERSONS
TO BE TRAINED
COST PER
PERSON
TRAVEL COST
PER PERSON
TOTAL COST PER
TYPE OF COURSE
EMT -B
6 .
0
0
0
EMT -I
EMT -P
CONTIN. ED
OTHER
COST OF PROJECT:
How much of the total CASH cost of the TRAINING will be paid by the state S 0
How much of the total CASH cost of the TRAINING will be paid by the student $ 0
How much of the total CASH cost of the TRAINING will be paid by your agency $ 0
ATTACH A DETAILED BUDGET BREAKDOWN
IF THIS IS A MAJOR TRAINING PROJECT
Aims Community College will provide all training related to the AED
prggram at no cost to the fire district or fire personnel.
PART 2 PAGE 2
COMMUNICATIONS
IF YOU ARE 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
1. Name and telephone number of individual or agency providing technical specifications.
Name
(
Telephone
PROJECT FUNDING
A) EMS Fund Request $ 4,077.50
B) Local Gvmt. Share - Cash
(list source)
C) Other Cash
(list source)
$ 4.n77.n F!vS h„nget
$
source
D) Total Cash Proj. Cost (A+B+C) $8155.00
E) Dollar Estimate of In -Kind Match $
On -Kind cannot be counted as part of your 50% cash match)
F) Total Program Cost (D+E) $ 8155.00
Describe the in -kind match you can provide:
source
PART 2 PAGE 3
AGENCY'S FINANCIAL INFORMATION
Cash Flow Projection for Next Full Fiscal Year
Year: 1 95 to 1996
Cash Balance at the
at the start of year
Anticipated Revenues
Local Governmentt axes
Private Contributions
Investment !Tome
e T
Other la I�
Anticipated Expenditures
Agency Projection
$ 146,654
EMS Portion of
Agency Projection
$24,931
$106,793 $4077.50
$400 $200
$$4077.50 $4.077.50
Salaries $
Operating
Capital Improvement
Loans $
Other $ $
$ -0-
$/500
$114,948
$
$8155.ou
$
Anticipated Cash Balance
For the end of next FY
$30,000
$5100.00
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.
The general fund moneys will be used for pension, operating costs, insurance,
building maintenance, and truck maintenance.
The 1995 building plan includes building an addition to the fire station
and remodeling the existing station.
Capital expenditures include the purchase of an AED.
PART 2 PAGE 4
EMS PROVIDER INFORMATION
Years in Operation 71 years
TYPE OF SERVICE:
ALS (EMT -P & EMT -I) X BLS _ Combination
X Fire/Rescue Service
Transport OR X Non -transport
Other (i.e. Air, etc...)
Name of physician advisor (if agency has one) David C'laman, M.D.
PERSONNEL BY TRAINING LEVEL (number of each):
Volunteer Full -Time Paid Part-time Paid
First Responder -5-
EMT-Basic
(certified)
EMT -Intermediate
(certified)
- 6-
NA
NA
NA
NA
- 0- NA NA
EMT -Paramedic -0-
(certified)
Other
(CPR certified,
basic first -aid, R.N.)
- 1-
NA NA
NA NA
PRIMARY Hospital transported to: North Colorado Medical Center
Distance to PRIMARY Hospital: 20 Mi 1 es
Average number of EMS Runs Annually:
Average number of Runs Annually:
120
200
PART 2 PAGE 5
PART 2 - OF MULTI -AGENCY APPLICATION
For use by Individual Agency Participating in a Combined grant
INDIVIDUAL AGENCY NAME
aSalle Fire Department
IAGENCY ADDRESS COUNTY PHONE
IP.O. Box 245 LaSalle, Co. 80645 Weld (303)
284-6336
LEGAL STATUS OF AGENCY/ORGANIZATION RIVATE all that apply):
PROFIT COUNTY/CITY
_ PRIVATE NOT FOR PROFIT - -
GOVERNMENT
STATE AGENCY SPECIAL DISTRICT _OTHER
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 Feb. 15, '95 . I understand that my application will be disqualified
should either of these statements be untrue.
Bruce Sandau
PRINT -NAME /
SIGNATURE
Fire Chief
TITLE
FahrnAry 13, 1095
DATE
WHY IS THIS PROJECT NEEDED
In the space below, write a concise statement describing the need(s) addressed by this
project.To provide the citizens of Weld County whomay become victims of cardiac arrest
accessibility to AED, through first responding fire departments. The purpose is to
significantly shorten the time span from arrest to definitive defibrillation. The result
will be a higher survivability ratio of cardiac arrest victims. This project will give
the EMTs the tools with which to utilize andmake effective the training they will recei\
as part of the forthcoming new state EMT -B curriculum. The district serves 5000 resident:
2/3 of which are urban. It covers 83 sq. miles. Farming, oil/gas exploration, railways,
recreational lakes, Platte river, irrigation ditches, schools, recreational facilities,
Airports, chemical companies, trailer parks and the town of LaSalle comprise the district
ALS is 6 minutes away via Weld County and Air Life.
COUNTY PLAN REFERENCE
List the goals and objectives identified in your county EMS plan that are associated
with this funding application.
Item # 11, Section II: Plan completed the study among first responders. Upon completior
the physician advisor and the North Colorado Emergency Physicians and the Weld County
EMS Council support this project and have recommended implementation of an AED program
195 'vour {undinn application is not identified in your county EMS plan. explain why
it is not.
PART 2 PAGE 1
PART 2 - OF MULTI -AGENCY APPLICATION
For use by Individual Agency Participating in a Combined grant
INDIVIDUAL AGENCY NAME
AGENCY ADDRESS
COUNTY
PHONE
LaSalle Fire Department
LEGAL STATUS OF AGENCY/ORGANIZATION (Mark all that apply):
_ PRIVATE NOT FOR PROFIT _ PRIVATE FOR PROFIT
GOVERNMENT
STATE AGENCY
SPECIAL DISTRICT
OTHER
COUNTY/CITY
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 . I understand that my application will be disqualified
should either of these statements be untrue.
PRINT NAME
SIGNATURE
TITLE
DATE
WHY IS THIS PROJECT NEEDED
In the space below, write a concise statement describing the need(s) addressed by this
project.
Our Fire Department responds to an average of15 cardiac arrests per year
with an average response of 4 to 5 minutes. This number of calls is expected
to increase as our population increases.
COUNTY PLAN REFERENCE
List the goals and objectives identified in your county EMS plan that are associated
with this funding application.
If your funding application is not identified in your county EMS plan, explain why
it is not.
PART 2 PAGE 1 A
1
EQUIPMENT LIST (listing brands will not preclude you from having to obtain bids for the generic equipMent
types)
In the space provided, please list the EMS equipment or training equipment for which funding
is being requested, and explain whether or not you currently have equipment that serves this
purpose, its age, and serviceability. When requesting extrication equipment tell where the
nearest extication equipment is both is time and distance. When requesting defibrillators,
please list what you currently have and how many times you use it in the last two years.
Include as much information as possible.
Prior
-ay
# 1
List the type of
equipment you are
requesting.
Physio-Control
Lifepak 300 and
adjunctive
equipment
TRAINING LIST
TYPE
EMT -B
EMT -1
Total
Price
$8155
What equipment are you
currently using for this?
purpose? No -.r nd) Nt 1.M""
None
How many runs a
year require this
equipment?
15
# OF PERSONS
TO BE TRAINED
6
EMT -P
CONTIN. ED
OTHER
COST PER
PERSON
N/A
TRAVEL COST I TOTAL COST PER
PER PERSON TYPE OF COURSE
N/A
N/A
COST OF PROJECT:
How much of the total CASH cost of the TRAINING will be paid by the state $ N/A
How much of the total CASH cost of the TRAINING will be paid by the student $ N/A
How much of the total CASH cost of the TRAINING will be paid by your agency $ N/A
ATTACH A DETAILED BUDGET BREAKDOWN
IF THIS IS A MAJOR TRAINING PROJECT
Aims Community College will provide the necessary training to support the county wide
AED program. There will be no cost to the participating fire districts.
PART 2 PAGE 2
COMMUNICATIONS
IF YOU ARE REQUESTING RADIO EQUIPMENT, TFIIS 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 ___
1. Name and telephone number of individual or agency providing technical specifications.
Name
( )
Telephone
PROJECT FUNDING
A) EMS Fund Request $4,077.50
B) Local Gvmt. Share - Cash
(list source)
C) Other Cash
(list source)
D) Total Cash Proj. Cost (A+B+C) $ 8,155.00
$4,077.50
Budget
source
$
E) Dollar Estimate of In -Kind Match $
(In -Kind cannot be counted as pan of your 50% cash match)
F) Total Program Cost (D+E) $ 8,155.00
Describe the in -kind match you can provide:
source
PART 2 PAGE 3
AGENCY'S FINANCIAL INFORMATION
Cash Flow Projection for Next Full Fiscal Year
Year: 1995 to 19_96
Cash Balance at the
at the start of year
Anticipated Revenues
EMS Portion of
Agency Projection Agency Projection
$ 105,316
Local Government $ 188,636
Private Contributions $ -0-
Investment Income $ 6,050
EMS rant $ 4,D77.50
Other
Anticipated Expenditures
Salaries
Operating
Capital Improvement
Loans
Other
Anticipated Cash Balance
For the end of next FY
$ 49,655
$ 95,408
S 57 155
$ 28,357
$ -0-p
$ 80,987
S
-0-
$ 4.077.50
S
S
$4,U//.5U
S
$ 8155
$
$
S
-0-
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.
Balance = Operating Reserve and Lease Payment Fund.
We make two lease payments per year @ $14,276 each. We do not anticipate any
capital improvement purchases in the next three years except for the
AED.
PART 2 PAGE 4
EMS PROVIDER INFORMATION
Years in Operation 53
TYPE OF SERVICE:
ALS (EMT -P & EMT -I) _ BLS x Combination
X Fire/Rescue Service
Transport OR x Non -transport
Other (i.e. Air, etc...)
Name of physician advisor (if agency has one) _PR. DAVID CI AKAN
PERSONNEL BY TRAINING
Volunteer LEVEL In Fuber of each):
ll) Time PaidPart-time Paid
First Responder 20
EMT -Basic
(certified)
EMT -Intermediate
(certified)
EMT -Paramedic
(certified)
Other
(CPR certified,
basic first -aid. R.N.)
6
0 0
PRIMARY Hospital transported to: NORTH COLORADO MEDICAL CENTER
Distance to PRIMARY Hospital: 7 miles
Average number of EMS Runs Annually:
Average number of Runs Annually: 275
170
PART 2 PAGE 5
PART 2 - OF MULTI -AGENCY APPLICATION
For use by Individual Agency Participating in a Combined grant
INDIVIDUAL AGENCY NAME
Windsor Fire Protection Dist.
AGENCY ADDRESS
728 Main St. Windsor, Co 80550
COUNTY
Weld
PHONE
(303)
686-4287
LEGAL STATUS OF AGENCY/ORGANIZATION (Mark all that apply):
_ PRIVATE NOT FOR PROFIT _ PRIVATE FOR PROFIT
GOVERNMENT
STATE AGENCY SPECIAL DISTRICT OTHER
COUNTY/CITY
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 Feb. 15. '95 . I understand that my application will be disqualified
should either of these statements be untrue.
Dave Vohs
PRINT NAME
SIGNATURE
Fire Chief
TITLE
February 13, 1995
DATE
WHY IS THIS PROJECT NEEDED
In the space below, write a concise statement describing the need(s) addressed by this
project. Windsor fire district has its roots in agriculture but is rapidly becoming a
large residential area with a 25% per year increase in population. There has been a
tremendous growth in industry as well. The current population of the district is in
excess of 10,000 with a large number of residents commuting to surrounding Greeley, Ft.
Collins, Loveland, Cheyenne, and even to Denver. The District serves a part of Larimer
County along the I-25 corridor. It covers approximately 150 sq. miles. With the large
number of residents, a large number of them being senior citizens and the standard of
medical care becoming the use of AEDs, the district needs to purchase an AED and have.
their rescue personel trained in its use. We respond and are supported with ALS from
COUNTY PLAN REFERENCE Greeley and Ft. Collins as well as Air Life.
List the goals and objectives identified in your county EMS plan that are associated
with this funding application.
Section II.11: Initiated AED study among first responders. Upon completion
of the study, thephysicianadvisor and the EMS council recommended implementation
of an AED program in 1995.
If your funding application is not identified in your county EMS plan, explain why
it is not.
PART 2 PAGE 1
EQUIPMENT LIST (listing brands will not preclude you from having to obtain bids for the generic equipMent
types)
In the space provided, please list the EMS equipment or training equipment for which funding
is being requested, and explain whether or not you currently have equipment that serves this
purpose, its age, and serviceability. When requesting extrication equipment tell where the
nearest extication equipment is both is time and distance. When requesting defibrillators,
please list what you currently have and how many times you use it in the last two years.
1r1G1uue as u.u..n newel ••••••••••• ....
r-_-.--_
Prior
-ity
#_
List the type of
equipment you are
requesting.
Total
Price
What equipment are you
currently using for this i..:
purpose? Mr-c.r and ;,} too,.
How many runs a
year require this
equipment?
# 1
Physio-Control
Lifepak 300 and all
adjunctive equipment
$8155
None
20
TYPE
# OF PERSONS
TO BE TRAINED
COST PER
PERSON
TRAVEL COST
PER PERSON
TOTAL COST PER
TYPE OF COURSE
EMT -B
12
-0-
-0-
-0-
EMT-I
EMT -P
CONTIN. ED
OTHER
COST OF PROJECT:
How much of the total CASH cost of the TRAINING will be paid by the state $
How much of the total CASH cost of the TRAINING will be paid by the student $
How much of the total CASH cost of the TRAINING will be paid by your agency $
ATTACH A DETAILED BUDGET BREAKDOWN
IF THIS IS A MAJOR TRAINING PROJECT
Aims Community will provide the training program beginnign January 1996 and will
povide it at no cost to the fire districts and their personnel participating in
the AED program. This includes both the initial and the continuing training.
PART 2 PAGE 2
- 0-
_n_
- 0-
COMMUNICATIONS
IF YOU ARE 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
1. Name and telephone number of individual or agency providing technical specifications.
( )
Name
Telephone
PROJECT FUNDING
A) EMS Fund Request $ 4,077.50
B) Local Gvmt. Share - Cash
(list source)
C) Other Cash
(list source)
$ 4,077 5n B»dgct item
D) Total Cash Proj. Cost (A+B+C) $ 8155
E) Dollar Estimate of In -Kind Match $
On -Kind cannot be counted as part of your 50% cash match)
F) Total Program Cost (D+E) $ 8155
Describe the in -kind match you can provide:
source
source
PART 2 PAGE 3
AGENCY'S FINANCIAL INFORMATION
Cash Flow Projection for Next Full Fiscal Year
Year: 1995 to 1996
Cash Balance at the
at the start of year
Anticipated Revenues
Local Government
Private Contributions
Investment Income
Other
Anticipated Expenditures
Salaries
Operating
Capital Improvement
Loans
Other
EMS Portion of
Agency Projection Agency Projection
$ 376,631
$ 141.096
$ -n-
$ 16.000
$ 4,077.50
$ -0-
$ 112,000
$ 220,155
$ -0-
$ -0-
Anticipated Cash Balance
For the end of next FY $209,727
S -o-
$4,077.50
$
$
$ 4,077.50
S
$
$ 8155
S
$
$ -0-
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 designated for building fund and emergency operations funding.
Capital expenditures anicicpated include a fire truck @ $212,000 and an Automatic
External Defibrillator @ $8155.
PART 2 PAGE 4
EMS PROVIDER INFORMATION
Years in Operation45
TYPE OF SERVICE:
ALS (EMT -P & EMT -I) xx BLS Combination
xx Fire/Rescue Service
Transport OR yx Non -transport
Other (i.e. Air, etc...)
Name of physician advisor (if agency has one) David ('l wan . M.D.
PERSONNEL BY TRAINING LEVEL (number of each):
Volunteer Full -Time Paid Part-time Paid
First Responder 6 -
EMT -Basic
(certified)
EMT -Intermediate
(certified)
EMT -Paramedic
(certified)
Other
(CPR certified,
basic first -aid, R.N.)
15
PRIMARY Hospital transported to: North Coloradn Mediral renter
Distance to PRIMARY Hospital: is
Average number of EMS Runs Annually: 550
Average number of Runs Annually: 430
PART 2 PAGE 5
Attachment B
SINGLE AGENCY ASSURANCES FORM
This form is considered a formal letter of agreement between
(Administering Agency), herein after referred to as "Administering
Agency" and (Agency's Name), hereinafter referred to as
"Subcontractor":
As a subcontractor of (Administering Agency), the (Agency's name)
agrees to comply with the requirements set forth in Contract
# , Attached.
The Subcontractor will provide the Administering Agency with written
or verbal quarterly reports as required by the Administering Agency,
in order to comply with the above referenced contract requirements.
The Subcontractor will purchase any equipment, purchase or provide
training or education as listed in Contract #
Upon completion of the project, the Subcontractor will provide the
Administering Agency with paid invoices so that the Administering
Agency can request reimbursement from the State under Contract
The Administering Agency, agrees to submit quarterly reports to the
state and obtain reimbursement from the state for the program. The
Administering Agency will then provide payment to the Subcontractor.
(Administering Agency) and (Agency's Name) hereby mutually agree
that the State will have no liability for and will be under no
obligation to pay (Agency's Name) for any work performed pursuant to
this agreement. (Agency's Name) hereby agrees to hold
(Administering Agency) solely responsible for payment of all monies
due pursuant to this agreement.
Administer Agency Name:
Legal Signing Authority Date
Subcontracting Agency Name:
Legal Signing Authority Date
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