SDML Workers Compensation Fund EMS Equipment 2018 Grant Application

Transcription

1 SDML Workers Compensation Fund EMS Equipment 2018 Grant Application In partnership with Stryker EMS equipment *The SDML WC FUND GRANTS will be awarded on a first come first received basis.

2 Power-PRO /Stair-PRO /Power-LOAD Grant Application Program Information: Background: The SDML Workers Compensation Fund (SDML WCF) has funds available to grant to EMS services that have their workers compensation coverage through the SDML WC Fund, for the purchase of Stryker Power-PRO Model 6506 ambulance cot, Stryker Stair-PRO Model 6252 tracked chair, or a Stryker Power-LOAD system Model 6390 (The grant does not include the Power-Load Cot Compatibility Upgrade). For the Stryker Power-PRO Model 6506 and Stryker Stair-PRO Model 6252 only: Funds will be distributed in a 60/40 matching grant with the SDML WCF/Stryker EMS providing 40%. This 40% includes the discount of the negotiated pricing and payment made by the SDML WC Fund (off of list price) for the purchase of either one of the following: 1 Stryker Power-PRO Model 6506 and 1 Stryker Stair-PRO Model 6252 (if funds permit) 1 Stryker Power-PRO Model 6506 only 1 Stryker Stair-PRO Model 6252 only Stryker Power-LOAD System Model 6390 only: Funds will be distributed in a 67/33 matching grant with the SDML WCF/Stryker EMS providing 33%. This 33% includes the discount of the negotiated pricing and payment made by the SDML WC Fund (off of list price). The grant does not include the Power-Load Cot Compatibility Upgrade. In an effort to aid services who wish to acquire more than the allotted equipment in this grant (i.e. additional Power-PRO cots or Stair-PRO tracked chairs or additional accessories not listed below for equipment) the SDML WC has negotiated a discount available only for SDML WC Fund members. The SDML WC Fund will not provide additional funds for these items. Please reference your affiliation with the SDML WC Fund to Stryker to obtain this discount. The Power-PRO Model 6506/Stair-PRO /Stryker Power-LOAD grant is only for products with the following accessories: Power-PRO : IV Pole, Head-End Stair-PRO : Foot Rest and Stryker Power-LOAD : Storage and Fowler O2 holder Head Support Option Not included: Power Load Cot Compatibility Upgrade Purpose: To provide EMS services with ergonomically beneficial equipment in an effort to reduce risk and injury to the EMS caregiver during patient handling and transport. 2

3 Deadline of Applications: Grants will be awarded on a first come, first received basis until the grant funds are exhausted. If grant funds are available, the final deadline to submit an application is 5:00 P.M., Dec. 31 st 2018, CST. Applications must be received or postmarked by this date to be considered for the grant and if you receive a grant your order must be placed prior to Jan 31 st, Applications should be delivered to: SDML WC Fund c/o Insurance Benefits, Inc S. Isabel Pl #110 Sioux Falls, SD info@sdmlwcfund.com Fax: It is recommended that the application be sent by or certified mail to receive an acknowledgement of receipt of the application. Applications will be accepted in electronic form at the address above. Applicants that file applications electronically will receive an confirmation from the SDML WC Administrator. Application Availability: Applications are available by contacting Insurance Benefits, Inc., Brad Wilson at or brad@sdmlwcfund.com. Award Notification Date: All applicants will be notified of their receipt or non-receipt of awards by Jan. 12 st Selection Criteria: Applications will be reviewed and funds will be awarded using the following selection criteria: Presentation of a logical needs statement Member s compliance with previous loss control recommendations Member s financial hardship In depth description of the availability of your out-of-pocket funds Grant funds availability Eligibility Requirements: Eligibility: Applicant must be a current member of the SDML Workers Compensation Fund as of the date that the application for the Grant is being made, and in the year the Grant will be distributed. Application Guidelines: The SDML Workers Compensation Fund has the discretion in approving or denying any, all, or a portion of the grant applications. All applications must include the following completed sections: Organization information (page 4) Narrative (page 5) Signature page (page 6) 3

4 Organization Information: Applicant/Member: Address: Department Involved: Project Contact: Phone: Fax: Alternate Contact (if any): Phone: Fax: # Full-time staff: # Volunteer staff: #/Year(s) of primary response unit(s): #(s)/year(s) of backup unit(s): Ambulance Call volume per year: # of emergency calls: # of transfer calls: Service area size and description: 4

5 Narrative (use additional pages as necessary) Part I. Needs Statement: a) How many cots and stair chairs does your service currently have, please describe (type/brand) of equipment, age and serial number on cot/chair. b) Explain how receiving this new Power-PRO, Stair-PRO or a Stryker Power-LOAD system will improve caregiver safety and prevent injuries within your organization. Also, describe your lift-assist protocol if lift-assist is needed on a call: c) Please include any unique personnel data or information that you would like the SDML WC Fund to know about your service when considering this grant application (i.e. staffing description): Part II. Explanation for lack of available funds: a) Explain why your agency needs assistance with funding to purchase this equipment. Please include an overview of the current budget and planned expenditures in FY 2018 and for FY 2019: Please describe (in depth) what your plans are to generate your service s portion of funds for this equipment purchase : Part III. Please circle which item you are applying for: 1 Stryker Power-PRO Model 6506 and 1 Stryker Stair-PRO Model 6252 (if funds permit) 1 Stryker Power-PRO Model 6506 only 1 Stryker Stair-PRO Model 6252 only 1 Stryker Power-LOAD Model 6390 (The grant does not include the Power-Load Cot Compatibility Upgrade) *If benefits of this project will aid or involve other departments, members or organizations, please describe: 5

6 Total budget for project: Portion funded by applicant: Total from other source: Additional Information: Signature of applicant: Date: Project and application authorized by: (governing body) Signature (Authorizing Person): Date: Print Name (Authorizing Person): Title: *All Stryker EMS Power-PRO, Stair-PRO and Power-LOAD equipment pricing quotes may be obtained by contacting: Nicole Wood. (please reference that you are applying for the SDML WC grant)* Nicole Wood Regional Manager SD/ND EMS Equipment M / (314) F / (636) E / nicole.wood@stryker.com Website / 6