KANSAS BOARD OF EMERGENCY MEDICAL SERVICES REVOLVING AND ASSISTANCE FUND GRANT (KRAF) GRANT APPLICATION INSTRUCTIONS Applicatin Frm is t be filled ut by the Nn-prfit Licensed EMS Service wh is submitting data in KEMSIS r actively pursuing submissin. Cmplete the Applicatin Frm in its entirety using Internet Explrer. Step 1. Agency Infrmatin Agency Name Enter the name f the applying agency/rganizatin. Email Address Enter a current and valid email address fr cntact and applicatin cmpletin. EMS Agency License Number Enter yur EMS agency number. Level f Care Prvided - Licensed EMS agencies hld a certificatin at either the BLS r ALS level f care. % at each Level Enter the % f calls care is prvided at the BLS and ALS level. Address, City, State, Zip, Cunty, Telephne # - Address at which the agency receives its mail. This address cannt be an individual member s hme address. Reginal Cuncil - All areas f the state are serviced by a reginal EMS cuncil ffice. Federal ID Number (FIN) - Each agency must have an individual Federal Identificatin Number. Auditing requirements will nt allw payments t be made t any rganizatin that des nt have a FIN. The use f anther rganizatin s FIN is nt acceptable. Received KRAF Funding Previusly Indicate if KRAF funding had been received previusly and list each fiscal year (FY). (July 1-June 30) Step 2. Persnnel Data Current KBEMS Certificatin - List each member nly nce. FR/EMR - Thse prviders hlding the certificatin f FR r EMR. EMT - Thse prviders hlding the certificatin f EMT-B r EMT. AEMT Thse prviders hlding the certificatin f AEMT. Paramedic - Thse prviders hlding the certificatin f Paramedic. Ttal number f persnnel (calculates autmatically) IC Thse prviders hlding the certificatin f Instructr/Crdinatr. Member Status Full-time - The number f certified persnnel that are cnsidered full-time (paid persnnel). Part-time The number f certified persnnel that are cnsider part-time (paid and wrking < 999 hurs annually). Vlunteer - The number f certified persnnel that are vlunteers. (Receive nly reimbursement fr expenses.) Other Supprt Staff Ttal members - The ttal number f members in yur rganizatin. (calculates KBEMS KRAF Grant Prgram Page 1
autmatically) Step 3. Operatinal Activity (methd/s by which the service is funded). Operatinal Activity Check all that apply Type f EMS Service - Indicate which best describes yur agency: full-time, vlunteer, r a cmbinatin. Hw many licensed ambulances The number f units (ambulances) perated by the service (licensed r stand-by) Hw many staff vehicles Hw many staff vehicles are wned/perated Ttal EMS Calls BLS Calls (including stand-bys) - Ttal number f calls recrded as Basic Life Supprt call. ALS Calls - Ttal number f calls recrded as Advanced Life Supprt call. Ttal Number f Calls - The ttal f BLS and ALS calls frm abve. (calculates autmatically) Number f calls yur agency was UNABLE t respnd t, fr any reasn - This ttal shuld include thse related t mechanical failure, lack f equipment, lack f certified attendants, etc. Demgraphics Square Miles f Service Area - Ttal square miles f service area cvered by yur agency. Ppulatin f Service Area - Ttal ppulatin f service area cvered by yur agency. Ttal Number f Statins - Ttal number f statins perated by yur agency including sub-statins. Number f calls yur agency respnded t OUTSIDE f yur jurisdictin This ttal shuld include calls fr mutual aid, etc. Cmments - Use this sectin t briefly describe any infrmatin that was requested abve. Step 4. Request Page (NOTE: Yu will have a chance t add additinal item requests after yu finish up the first item and the rest f the applicatin and hit submit.) Item Cde (see bttm f this page fr listing f item cdes) Enter item cde fr the item being requested. Other If yu pick Other in Item Cde, specify what the ther item is. Funding Level - Indicate at what level yur agency is seeking funding frm the state fr each item requested. State % is first percent number, Lcal % is secnd percent number. Pririty fr funding may cnsider funding matches, but will be reviewed n a case-by-case basis. AGAIN THIS YEAR: All mnitr requests have a minimum 25% lcal match with a maximum state share f $20,000. AGAIN THIS YEAR: Ct and CPR devices will have a minimum 25% lcal match requirement. (Pwerlad systems will nt be cnsidered.) Add/Replace - Indicate if the item that is being requested is a replacement, r additinal equipment. KBEMS KRAF Grant Prgram Page 2
Quantity - Indicate quantity being requested. Current Inventry - Indicate the number f items being requested that are currently wned by the agency. This number will include items that are similar t thse items being requested. (Example: An agency requesting 2 - Zll X Series Mnitr/Defibrillatr yet has 1 - LifePak 1000 and 1- LifePak 500 in their inventry wuld place a 2 in this blck.) Item Requested - Prvide a brief descriptin f the item being requested. Ttal Purchase Price - Indicate the ttal amunt f the item(s) being requested. Descriptin Shuld include any accessries requested, identified individually with cst. Justificatin - The narrative sectin prvides the agency with the pprtunity t explain their agency s need fr the item(s) requested and the impact it will have n their agency and/r service area. D nt frget t include the need fr hardship funding, if s requested. Where equipment will be placed Be specific t identify where the requested equipment will reside. If it will nt be n the first ut vehicle, please give an explanatin. Step 5. Affirmatin The affirmatin is a statement that indicates that the Authrized Agent and Financial Officer have truthfully, and t the best f his/her knwledge, cmpleted this applicatin accurately. Print the Affirmatin page, get the required signatures and send the signed frm t the bard ffice. Business Name The licensed ambulance service. Business Name (if different) If DBA, the name f the licensed ambulance service. Address Address f licensed ambulance service. City, State, Zip The City, State, and zip cde f the licensed ambulance service. FIN Federal Identificatin Number assciated with the licensed ambulance service thrugh the Operatr. Agency/Organizatin Authrized Agent - The authrized agent is the persn respnsible fr the peratin f the service (persn r municipality wh has a permit t perate an ambulance service). Service Directr The service directr is the persn respnsible fr the service. Medical Directr Name f the Medical Directr. Printed name f the Authrized Agent, Service Directr, and Medical Directr - Print the name f the authrized agent, service directr and OMD. Title - Prvide the title f the authrized agent, service directr, and OMD Phne Phne number f the authrized agent, service directr, and OMD Email address: A current and valid email address f the authrized agent, service directr, and OMD. Pint f Cntact fr Grant Management. Name, Agency (licensed service), phne, and email address f an individual t be utilized as the cntact by KBEMS regarding questins f the grant applicatin. KBEMS KRAF Grant Prgram Page 3
Step 8. Befre clicking submit, Print a cpy fr yur recrds Submit Click t submit yur applicatin. Yes N Cancel Click if yu need t request additinal items n the Request Frm Click if yu are nly requesting 1 (ne) item and are submitting with n additinal items Click if yu wish t remain in the current applicatin Once selected, yu certify that all infrmatin is crrect subject t false infrmatin, perjury, and disqualificatin f applicatin Reset Please click t erase the ENTIRE applicatin and re-enter all applicable infrmatin Failure t submit all applicable infrmatin by the deadline will result in disqualificatin f the applicatin. CHECKLIST Cmplete entire KBEMS Applicatin Frm and submit electrnically required AGAIN THIS YEAR: KBEMS secured qutes frm varius vendrs fr cts/stretchers, cardiac mnitrs, stair chairs, RAD-57, and autmatic CPR devices. Please use these qutes and select the accessries that meet yur needs t frm yur ttal request per item. Submit Vendr Qute fr all requested items nt listed abve and send t: kraf@ks.gv required Please prvide n the Subject Line: Service name and individual submitting dcument Each qute must break ut accessries separately. Each qute must be valid fr at least six (6) mnths. required Submit Request fr Mdificatin fr Used/Refurbished Equipment t: kraf@ks.gv if applicable Please prvide n the Subject Line: Service name and individual submitting dcument KBEMS KRAF Grant Prgram Page 4
If requesting t purchase an item that is nt new, a request fr mdificatin must be submitted in writing. Used/Refurbished must be shwn n the qute and KBEMS and the bard address must be included in the purchaser name. Submit KRAF New Vendr Prduct Request Frm (see KSBEMS.rg website) and qute t: kraf@ks.gv if applicable Please prvide n the Subject Line: Service name and individual submitting dcument If requesting t purchase an item thrugh YOUR vendr, yu will need t cmplete this frm. Prvide the vendr qute n vendr letterhead. Each qute must break ut accessries separately. Each qute must be valid fr at least six (6) mnths. Submit KRAF Agreement f Service (see KSBEMS.rg website) t: kraf@ks.gv required Please prvide n the Subject Line: Service name and individual submitting dcument Als, send an email t suzette.smith@ks.gv t verify yur submissin was received. Review Prcess 1. Applicatins will be initially reviewed by KBEMS Staff fr cmpleteness. Items will be reviewed t ensure cmpliance with the grant pririties fr funding, i.e., cmputer requests will be reviewed t verify that Service has agreed t submit data via the Kansas Emergency Medical Services Infrmatin System (KEMSIS). 2. KBEMS will prvide all dcumentatin t the Assistance Review Cmmittee (ARC) members fr review. The ARC will grade each request and prepare their prpsal fr apprval. 3. The ARC will prvide cmments and grades fr each requested item and return this dcumentatin t KBEMS. Data is then entered int the ffice database fr tabulatin. The ARC will cnduct a public meeting befre the regular April KBEMS meeting t review the requests that received a viable funding grade. Infrmatin may be prvided r requested cncerning requests annunced fr funding frm thse attending the meeting. 4. The Cmmittee reserves the right t recmmend a request be partially funded r t place a cnditin f funding n any award. 5. A reprt f the requests that are recmmended fr funding will be submitted t the KBEMS Executive Directr t be presented t the full Bard fr ratificatin. 6. Fllwing the regular April KBEMS Bard Meeting, KBEMS will mail written ntificatin t thse agencies wh were apprved fr funding and thse wh were nt apprved. Awardee respnsibility Thse agencies receiving ntice f awarded funds will be required t ntify KBEMS f the acceptance f the award, submit the rder fr the equipment, and submit the invice t KBEMS upn receipt f the equipment. Once the equipment is received and KBEMS receives the invice, KBEMS will issue a check t the service fr the state prtin f the grant award. KBEMS KRAF Grant Prgram Page 5