HomeMy WebLinkAboutItem #05 Approval of Florida Deptartment of Health EMS Matching Grant SubmissionAGENDA ITEM COVER SHEET
Meeting Date: February 20, 2018
Item # 5
Reviewed By.-
Contact
y.Contact Name: John Miller, Fire Chief Department Director:
Contact Number: 407-905-3140 City Manager:
Subject: Florida Department of Health EMS Matching Grant Submission
Background Summary:
The fire department would like to submit a matching (75%/25%) grant through the Florida Department of Health.
The grant request is for three (3) U-CAPIT CAP 5 Standard EMS Machines, w/Controllers, Bar
Code/Pin/Parrot Doors, and 36 -month software service contract. The U-CAPIT EMS machine is critical
to the tracking of EMS supplies and pharmaceuticals. The tracking capabilities of the U-CAPIT EMS
machine meet the State of Florida Department of Health requirements for pharmaceutical/narcotics
tracking.
Issue:
Commission approval is required for grant submission.
Recommendations
Staff recommends the approval to submit the grant.
Attachments:
Florida Department of Health EMS Matching Grant Application
Financial Impact:
The total cost of the (3) U-CAPIT CAP 5 Standard EMS Machine is $42,839.97. The State of Florida
Department of Health Matching Grant would provide 75% (32,129.98) of the total cost. If successful,
the financial impact on the city would be the remaining 25% ($10,709.99). The grant funding process
allows for city's contribution to be budgeted in the 2018-2019 fiscal year.
Type of Item:
(please mark with an 'Y)
Public Hearing
Ordinance First Reading
Ordinance Second Reading
Resolution
Commission Approval
Discussion & Direction
For Cleric's Dept Use:
Consent Agenda
Public Hearing
Regular Agenda
Original Document/Contract Attached for Execution by City Clerk
Original Document/Contract Held by Department for Execution
Reviewed by City Attorney N/A
Reviewed by Finance Dept. Yiglne o��. N/A
Reviewed by () N/A
EMS MATCHING GRANT APPLICATION
FLORIDA DEPARTMENT OF HEALTH
Emergency Medical Services Program
HEALTH Complete all items unless instructed differently within the application
Type of Grant Requested: ❑ Rural ® Matching
ID. Code (The State Bureau of EMS will assign the ID Code — (leave this blank)
1. Organization Name: Ocoee Fire Department
2. Grant Signer. (The applicant signatory who has authority to sign contracts, grants, and other legal
documents. This individual must also sign this application)
Name: John Miller
Position Title: Fire Chief
Address: 563 S. Bluford Ave
City: Ocoee County: Orange
State: Florida Zip Code: 34761
Telephone: 407-905-3140 Fax Number:
E -Mail Address: imiller@ocoee.org
3. Contact Person: (The individual with direct knowledge of the project on a day-to-day basis and
responsibility for the implementation of the grant activities. This person may sign project reports and may
request project changes. The signer and the contact person may be the same.)
Name: Corey Bowles
Position Title: EMS/Training Officer
Address: 563 S. Bluford Ave
City: Ocoee County: Orange
State: Florida Zip Code: 34761
Telephone: 407-202-8189 Fax Number:
E -Mail Address: cbowles ocoee.or
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64J-1.015, F.A.C.
1
4
(1) ❑ Private Not for Profit (Attach d
(2) ❑ Private for Profit
(3) ® City/Municipality/TownNillage
(4) ❑ County
(5) ❑ State
(6) ❑ Other (specify):
(3) Oc l
5. Federal Tax ID Number (Nine Digit Number). VFQQ6Q1_9ZC24___
6. EMS License Number: 4819 Type: []Transport ❑Non -transport ®Both
7. Number of permitted vehicles by type: BLS; 3 ALS Transport; 8 ALS non -transport.
8. Type of Service (check one): ® Rescue; ® Fire; ❑ Third Service (County or City Government,
nonfire); ❑ Air ambulance; ❑ Fixed wing; ❑ Rotowing; ❑ Both; ❑Other (specify)
9. Medical Director of licensed EMS provider: If this project is approved, I agree by signing below that I
will affirm my authority and responsibility for the use of all medical equipment and/or the provision of all
continuing EMS education in this project. [No signature Is needed if medical equipment and
professional EMS education are not in this project.]
Signature: Date:
Print/Type: Name of Director Christian Zuver
FL Med. Lic. No. ME97144
Note: All organizations that are not licensed EMS providers must obtain the signature of the medical
director of the licensed EMS provider responsible for EMS services in their area of operation for projects
that involve medical equipment and/or continuing EMS education.
If your activity is a research or evaluation project, omit Items 10, 11, 12, 13, and skip to Item
Number 14. Otherwise, proceed to Item 10 and the following items.
10. Justification Summary: Provide on no more than three one sided, double spaced pages a summary
addressing this project, covering each topic listed below.
A) Problem description (Provide a narrative of the problem or need);
B) Present situation (Describe how the situation is being handled now);
C) The proposed solution (Present your proposed solution);
D) Consequences if not funded (Explain what will happen if this project is not funded);
E) The geographic area to be addressed (Provide a narrative description of the geographic area);
F) The proposed time frames (Provide a list of the time frame(s) for completing this project);
G) Data Sources (Provide a complete description of data source(s) you cite);
H) Statement attesting that the proposal is not a duplication of a previous effort (State that this project
doesn't duplicate what you've done on other grant projects under this grant program).
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10. Justification Summary
A. Problem Description
Pharmaceutical accountability is critical for the monitoring for compliance of local protocols and
state/federal tracking requirements. The Ocoee Fire Department is still utilizing a paper based tracking
system which is time-consuming and error prone. The use of a Controlled Medical Supply Dispensing
System (UCaplt) provides the ability to catalog, time stamp, and regulated the supply chain. Personnel
will be able to restock their units without the need to leave their jurisdiction will providing real-time
usage and inventory tracking of pharmaceuticals and medical supplies. The Controlled Medical Supply
Dispensing System has the ability to regulate the inventory of narcotics through multiple forms of checks
and balances. Administrator can be notified when abnormalities occur. The Controlled Medical Supply
Dispensing System will aide administrator with:
• Avoiding shortages and waste
• Quality assurance
• Audit Capabilities
• Medical provider accountability
• Complies with records/tracking regulations
B. Present Situation
The Ocoee Fire Department has historically utilized a third -party ambulance service to provide
emergency transportation services. The agency has shifted to provide fire -based medical transport
services on a regular basis and will be assuming the complete emergency transport service from the
third -party ambulance service by October 1, 2018. With the increase to service demands, the agency
would like to expand its pharmaceutical and medical supply accountability system.
In 2017, the Ocoee Fire Department responded to 3,874 emergency medical calls. The Ocoee Fire
Department has experienced a 16% increase in emergency medical calls for service since 2016.
Currently, all apparatus have to return to a single hub at the agency's headquarters to replace narcotics,
pharmaceuticals, and medical supplies. The agency does not have dedicated EMS supervisors on each
shift to deliver medical supplies. Apparatus must travel outside of its jurisdiction to retrieve the
replacement supplies. This results in excessive trips outside of their first due response districts and
additional wear on the apparatus.
C. Proposed Solution
The use of a Controlled Medical Supply Dispensing System (UCaplt) has been utilized by the agency at it
main hub for inventory control and accountability of narcotics, pharmaceuticals, and other medical
supplies. The system has proven to be critical asset in the record management of narcotics. The current
Controlled Medical Supply Dispensing System (UCaplt) has been used for tracking other pharmaceutical
and medical supplies. If the agency is successful in acquiring this grant funding, all medical supplies and
pharmaceutical will be inventoried, track/monitored for usage and expiration, and a supply chain will be
established through accurate data obtained from the Controlled Medical Supply Dispensing System
(UCaplt).
D. Consequences If not funded
In the event that Ocoee Fire Department does not receive funding towards the purchase of the
Controlled Medical Supply Dispensing System, personnel will have to continue current practice of paper
documentation and frequently traveling outside of jurisdiction to resupply. If this project is not funded
the risk of pharmaceutical and medical supply inventory mistakes increase. In addition the increased
time outside of first due response zones to resupply will lead to an increase in response time
capabilities.
E. Geographic area to be addressed
Ocoee Fire Department provides fire suppression and emergency medical services from 4 fire
stations to more than 40,000 permanent residents over 15 square miles.
F. Proposed Timeframes
With approved funding, Ocoee Fire Department is committed to the proposed timeline:
• Ordering the (3) Controlled Medical Supply Dispensing Systems (UCaplt) once
notification of funding has been received.
• Personnel have already been trained on the system but new training will include a
review of the Standard Operating Procedures for UCaplt machines at the stations.
• Implementation of the devices will be within 2 weeks of receipt of the equipment.
• Collect data on narcotic, pharmaceutical, and medical supply usage for determining a
reliable and efficient supply chain.
• Compliance with state/federal accountability regulations.
G. Data Source
N/A
H. Statement the proposal is not a duplication of previous effort
This is not a duplication of other grant projects under this grant program.
Next, only complete one of the following: Items 11, 12, or 13. Read all three and then select and
complete the one that pertains the most to the preceding Justification Summary. Note that on all
three, that before -after differences for emergency victim data are the highest scoring items on the
Matching Grants Evaluation Worksheet used by reviewers to evaluate your application form.
11. Outcome For Projects That Provide or Effect Direct Services To Emergency Victims: This may
include vehicles, medical and rescue equipment, communications, navigation, dispatch, and all other
things that impact upon on-site treatment, rescue, and benefit of emergency victims at the emergency
scene. Use no more than two additional one sided, double-spaced pages for your response. Include the
following.
A) Quantify what the situation has been in the most recent 12 months for which you have data (include
the dates). The strongest data will include numbers of deaths and injuries during this time.
B) In the 12 months after this project's resources are on-line, estimate what the numbers you provided
under the preceding "(A)" should become.
C) Justify and explain how you derived the numbers in (A) and (B), above.
D) What other outcome of this project do you expect? Be quantitative and explain the derivation of your
figures.
E) How does this integrate into your agency's five-year plan?
12. Outcome For Training Projects: This includes training of all types for the public, first responders, law
enforcement personnel, EMS and other healthcare staff. Use no more than two additional one sided,
double-spaced pages for your response. Include the following:
A) How many people received the training this project proposes in the most recent 12 -month time period
for which you have data (include the dates).
B) How many people do you estimate will successfully complete this training in the 12 months after
training begins?
C) If this training is designed to have an impact on injuries, deaths, or other emergency victim data,
provide the impact data for the 12 months before the training and project what the data should be in
the 12 months after the training.
D) Explain the derivation of all figures,
E) How does this integrate into your agency's five-year plan?
13. Outcome For Other Projects: This includes quality assurance, management, administrative, and
other. Provide numeric data in your responses, if possible, that bear directly upon the project and
emergency victim deaths, injuries, and/or other data. Use no more than two additional one sided, double-
spaced pages for your response. Include the following.
A) What has the situation been in the most recent 12 months for which you have data (include the
dates)?
B) What will the situation be in the 12 months after the project services are on-line?
C) If this project is designed to have an impact on injuries, deaths, or other emergency victim data,
provide the impact data for the 12 months before the project and what the data should be in the 12
months after the project.
D) Explain the derivation of all numbers.
E) How does this integrate into your agency's five-year plan?
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13. Outcomes
A. What has the situation been In the most recent 12 months for which you have data
(including dates)?
Based on the Ocoee Fire Departments NIFRS data, the agency has completed 3,874 calls for
emergency medical service in 2017. This is a 16% increase from year 2016. The currently utilizes
a third -party ambulance service who provides primary transport services and resupplies the
Ocoee Fire Department with ems supplies and pharmaceuticals used. The Ocoee Fire
Department has begun the transition to take on all emergency transport services including the
need for a supply chain with medical supply vendors. The current system does not provide the
Ocoee Fire Department administration with the ability to completely and accurately track the
use of all medical supplies. The complete utilization of the Controlled Medical Supply Dispensing
Systems (UCaplt) in all stations will incorporate all pharmaceutical and medical supplies use by
the agency. This will allow administration to conduct frequent analysis of supply usage and cost.
B. What will the situation be in 12 months after the project services are on-line?
The Controlled Medical Supply Dispensing Systems (UCaplt) will allow the ability to
interface/link with the Ocoee Fire Department primary medical supply vendor all the way down
to the paramedic on the apparatus. The supply/tracking chain will begin with the agency
administrators ordering supplies and filling the Controlled Medical Supply Dispensing Systems
(UCaplt) with the inventory. The paramedic end users will document medical supply,
pharmaceutical, and narcotic use through the Controlled Medical Supply Dispensing Systems
(UCaplt). The Controlled Medical Supply Dispensing Systems (UCaplt) then has the ability to
automate the ordering of supplies based "system rules" established by administration.
C. If the project is designed to have an impact on injuries, deaths, or other emergency victim
data, provide the impact data for the 12 months before the project and what the data should
be in the 12 months after the project.
As part of the Ocoee Fire Department CPSE accreditation process a formal and documented
appraisal of the agency's response times and deployment were analyzed. The agency's current
baseline for response times to calls for emergency medical services is 9 minutes and 10 seconds.
A benchmark goal of 8 minutes has been established. One of the factors leading to unit
availability in first due response districts was the time it took for units to report to the main
station EMS hub for resupplying. The use of the Controlled Medical Supply Dispensing Systems
(UCaplt) will eliminate the need for the resupply trips, thus increasing the unit availability in
first -due response districts. The increased unit availability will have a direct and positive impact
on the Ocoee Fire Department's ability to meet the benchmark of 8 minute response time to
emergency medical calls.
D. Explain the derivation of all numbers
The data utilized in the justify this grant was derived from the Ocoee Fire Department NIFRS
data, Computer Aided Dispatch (CAD) data, and the agency's recent continuous improvement
process through the Center of Public Safety of Excellence(CPSE). The Ocoee Fire Department
recently completed CPSE accreditation process which included a strategic plan, community risk
assessment, and standards of cover. Each of these documents required a thorough analysis
including but not limited to the agency's administrative procedures, deployment analysis, and
response times.
E. How does this integrate into your agency's five year plan?
The Ocoee Fire Department completed it strategic plan for 2017-2021. In the strategic plan were
a number of goals which included providing emergency medical transport services. Traditionally
the Ocoee Fire Department has relied on a third party ambulance service to provide emergency
medical transport services. These contracts also included the supplementing of all medical
supplies used by the Ocoee Fire Department. Starting October 1, 2018, that Ocoee Fire
Department will be taking over the full responsibility of emergency medical transport for the
40,000 residents and visitors to the City of Ocoee. The initial plan is to utilize two full-time
transport capable rescues and one peak -time transport capable rescue to provide emergency
medical transport services. All engine companies within the City of Ocoee are also registered
through the Florida Department of Health as ALS non -transport. The acquisition of the
Controlled Medical Supply Dispensing Systems is critical to the success of this transition since
system will reduce units down time for resupply.
Skip Item 14 and go to Item 15, unless your project is research and evaluation and you have not
completed the preceding Justification Summary and one outcome item.
14. Research and Evaluation Justification Summary, and Outcome: You may use no more than three
additional one sided, double spaced pages for this item.
A) Justify the need for this project as it relates to EMS.
B) Identify (1) location and (2) population to which this research pertains.
C) Among population identified in 14(B) above, specify a past time frame, and provide the number of
deaths, injuries, or other adverse conditions during this time that you estimate the practical application
of this research will reduce (or positive effect that it will increase).
D) (1) Provide the expected numeric change when the anticipated findings of this project are placed into
practical use.
(2) Explain the basis for your estimates.
E) State your hypothesis.
F) Provide the method and design for this project.
G) Attach any questionnaires or involved documents that will be used.
H) If human or other living subjects are involved in this research, provide documentation that you will
comply with all applicable federal and state laws regarding research subjects.
1) Describe how you will collect and analyze the data.
ALL AF'NLIGAN 1 5 M ti I GUMNLt I t I I tIVI lb.
15. Statutory Considerations and Criteria: The following are based on s. 401.113(2)(b) and 401.117, F.S.
Use no more than one additional double spaced page to complete this item. Write N/A for those things in
this section that do not pertain to this project. Respond to all others.
Justify that this project will:
A) Serve the requirements of the population upon which it will impact.
B) Enable emergency vehicles and their staff to conform to state standards established by law or rule of
the department.
C) Enable the vehicles of your organization to contain at least the minimum equipment and supplies as
required by law, rule or regulation of the department.
D) Enable the vehicles of your organization to have, at a minimum, a direct communications linkup with
the operating base and hospital designated as the primary receiving facility.
E) Enable your organization to improve or expand the provision of:
1) EMS services on a county, multi county, or area wide basis.
2) Single EMS provider or coordinated methods of delivering services.
3) Coordination of all EMS communication links, with police, fire, emergency vehicles, and other
related services.
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15. Statutory Considerations and Criteria
A. Serve the requirements of the population upon which it will impact.
The City of Ocoee is experience tremendous growth in both infrastructure and population. At
the same time the Ocoee Fire Department is preparing to take over all emergency medical
transport services for the City of Ocoee. This is a major shift since the department has only ever
utilized a third party agency. The addition of providing emergency transport services means that
the Ocoee Fire Department will have to manage a higher call load, more equipment, and more
supplies. The Controlled Medical Supply Dispensing Systems will aide administrators/personnel
with tracking of high value equipment, live tracking of narcotics, inventory tracking of supplies
making the transition efficient and accountable. The use of the Controlled Medical Supply
Dispensing Systems will also reduce the lost, damage, and expiration of medical supplies and
pharmaceuticals which ultimately results in more responsible spending of the community tax
dollars.
B. Enable emergency vehicles and their staff to conform to state standards established by law
or rule of the department.
The utilization of the Controlled Medical Supply Dispensing Systems at each station will ensure
that all apparatus will remain in compliance with the minimum equipment and supplies
established in (64J-1.003).
C. Enable the vehicles of you organization to contain at least the minimum equipment and
supplies as required by law, rule or regulation of the department.
The utilization of the Controlled Medical Supply Dispensing Systems at each station will ensure
that all apparatus will remain in compliance with the minimum equipment and supplies
established in (64J-1.003).
D. Enable the vehicles of your organization to have, at a minimum, a direct communications
linkup with the operating base and hospital designated as the primary receiving facility.
N/A
E. Enable your organization to improve or expand the provisions of:
1) The Ocoee Fire Department provides and has automatic/mutual response
agreements with Winter Garden Fire Rescue, Orange county Fire Rescue, and Apopka
Fire Department. The acquisition of the Controlled Medical Supply Dispensing Systems
at each station will allow units to resupply and return to service. The ability to get units
returned to service efficiently will positively impact the entire Orange County EMS
systems since any delay in unit availability will have to be unnecessary supplemented by
automatic aid agreements with other agencies.
2) As the Ocoee Fire Department works towards becoming the primary emergency
transport provider for the City of Ocoee, the use of the Controlled Medical Supply
Dispensing Systems will positively impact the unit availability and reliability to respond
to emergencies within their designated response districts. The ability to resupply at the
stations will ensure that units remain in their first due jurisdictions, thus reducing
response times to the next emergency ca►I and ensuring that the units have the
appropriate equipment (64J-1.003) for each emergency.
3) N/A
16. Work activities and time frames: Indicate the major activities for completing the project (use only the
space provided). Be reasonable, most projects cannot be completed in less than six months and if it is a
communications project, it will take about a year. Also, if you are purchasing certain makes of
ambulances it takes at least nine months for them to be delivered after the bid is let.
Work Activity
Number of Months After Grant Starts
Becin End
Units Ordered
10/01/2018 10/15/2018
Delivery/Installation of Units
10/15/2018 12/15/2018
Units Inservice Training and put into service
12/15/2018 12/31/2018
17. County Governments: If this application is being submitted by a county agency, describe in the space
below why this request cannot be paid for out of funds awarded under the state EMS county grant
program. Include in the explanation why any unspent county grant funds, which are now in your county
accounts, cannot be allocated in whole or part for the costs herein.
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18. Budget:
Salaries and Benefits: For each
position title, provide the amount of
salary per hour, FICA per hour,
fringe benefits, and the total
number of hours.
Costs
Justification: Provide a brief justification
why each of the positions and the numbers
of hours are necessary for this project.
TOTAL:
0.00
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"Update Field" to calculate Total
Expenses: These are travel costs
and the usual, ordinary, and
incidental expenditures by an
agency, such as, commodities and
supplies of a consumable nature,
excluding expenditures classified
as operating capital outlay (see
next category).
Costs: List the price
and source(s) of the
price identified.
Justification: Justify why each of the
expense items and quantities are
necessary to this project.
TOTAL:
0.00
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DH FORM 1767 [2013]
Vehicles, equipment, and other
operating capital outlay means
equipment, fixtures, and other
tangible personal property of a non
consumable and non expendable
nature, and the normal expected
life of which is 1 year or more.
Costs: List the price
of the item and the
source(s) used to
identify the price.
Justification: State why each of the items
and quantities listed is a necessary
component of this project.
Software Service per CAP 5 for 36
months, PAID IN FULL covers
Service, Training, Support DS
12239.97
Software utilized to track inventory.
Software provides dual validation options
for narcotics and email notifications when
inventory is low or narcotics are dispensed.
CAP 5 Standard EMS Machine
w/Controller (Bar Code)/Pin
Pad/Prrot Door) BLACK
20700.00
Machine is secured and can be customized
based on each personnels access levels
(i.e. EMT, Medic, Administrator)
CAP 12DL, 12 Door Lockers
Extension for Connection to CAP
5,13LACK
9900.00
Machine is secured and can be customized
based on each personnels access levels
(i.e. EMT, Medic, Administrator)
TOTAL:
$42,839.97
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"Update Field" to calculate Total
State Amount
(Check applicable program)
❑ Matching: 75 Percent
❑ Rural: 90 Percent
Local Match Amount
(Check applicable program)
® Matching: 25 Percent
❑ Rural: 10 Percent
Grand Total
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32129.98 "Update Field" to calculate Total
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0.00 "Update Field" to calculate Total
Right click on 0.00 then left click on
$10,709.99 "Update Field" to calculate Total
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0.00 "Update Field" to calculate Total
LAM Right click on 0.00 then left click on
7
19. Certification:
My signature below certifies the following.
I am aware that any omissions, falsifications, misstatements, or misrepresentations in this
application may disqualify me for this grant and, if funded, may be grounds for termination at a
later date. I understand that any information I give may be investigated as allowed by law. I
certify that to the best of my knowledge and belief all of the statements contained herein and on
any attachments, are true, correct, complete, and made in good faith.
I agree that any and all information submitted in this application will become a public document
pursuant to Section 119.07, F.S. when received by the Florida Bureau of EMS. This includes
material which the applicant might consider to be confidential or a trade secret. Any claim of
confidentiality is waived by the applicant upon submission of this application pursuant to Section
119.07, F.S., effective after opening by the Florida Bureau of EMS.
I accept that in the best interests of the State, the Florida Bureau of EMS reserves the right to
reject or revise any and all grant proposals or waive any minor irregularity or technicality in
proposals received, and can exercise that right.
I, the undersigned, understand and accept that the Notice of Matching Grant Awards will be
advertised in the Florida Administrative Weekly, and that 21 days after this advertisement is
published I waive any right to challenge or protest the awards pursuant to Chapter 120, F.S.
I certify that the cash match will be expended between the beginning and ending dates of the
rant and will be used in strict accordance with the content of the application and approved
budget for the activities identified. In addition, the budget shall not exceed, the department,
approved funds for those activities identified in the notification letter. No funds count towards
satisfying this grant if the funds were also used to satisfy a matching requirement of another
state grant. All cash, salaries, fringe benefits, expenses, equipment, and other expenses as
listed in this application shall be committed and used for the activities approved as a part of this
grant.
Acceptance of Terms and Conditions: If awarded a grant, I certify that I will comply with all of the
above and also accept the attached grant terms and conditions and acknowledge this by signing
below.
�/ ✓�— i / 31 / 1,O 1 a
Signat of Authorized Grant Signer MM/DD/YY
Ind' idual Identified in Item 2
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THE TOP PART OF THE FOLLOWING PAGE MUST ALSO BE COMPLETED AND SIGNED.
FLORIDA DEPARTMENT OF HEALTH
EMS GRANT PROGRAM
REQUEST FOR GRANT FUND DISTRIBUTION
In accordance with the provisions of Section 401.113(2)(b), F. S., the undersigned hereby
requests an EMS grant fund distribution for the improvement and expansion of pre -hospital
EMS.
DOH Remit Payment To:
Name of Agency:Ocoee Fire Department
Mailing Address: 563 S. Bluford Ave
Ocoee FL 34761
Federal Identification Number VF
Authorized Agency Official:
John Miller
9764
Sign and return this page with your application to:
DOH Bureau of Emergency Medical Oversight
EMS Section, Grants Unit
4052 Bald Cypress Way, Bin A-22
Tallahassee, Florida 32399-1722
Do not write below this line. For use by Bureau of Emergency Medical Services personnel on
Grant Amount For State To Pay:
Approved By:
Signature of State EMS Grant Officer
Grant ID Code:
State Fiscal Year: 2017 - 2018
Organization Code € - OCA Object Code Category
64-61-70-30-000 03 SF003 750000 059999
Federal Tax ID: VF_________
Grant Beginning Date: Grant Ending Date:
M