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ICR 200906-1660-002 · OMB 1660-0054 · Object 12322001.

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O.M.B. No. 1660-0054
FF 080-4

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 2 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting the form. You are not required to respond to this collection of information unless it displays a valid OMB control number. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (1660-0054) NOTE: Do not send your completed form to this address.

Activity Specific Questions for AFG Operations and Safety Applications

Operations and Firefighter Safety – Equipment

Please provide the following information about the equipment you want funded. Only whole dollar amounts are acceptable.

Note: For each piece of equipment, attach an additional sheet.
Note: Fields marked with an * are required.
Equipment Details
* 1. Are all of your active firefighters trained to NFPA 1001 or equivalent (Firefighter I/Firefighter II, or essentials)?
○ Yes ○ No
If not, will you be asking for training funds for this purpose with this application or will you obtain the appropriate training through other sources (if not, please address this training issue in your narrative)?
○ Yes ○ No
* 2. What equipment will your organization purchase with this grant? (select one from Equipment List on page 17)

Please provide further description of the item selected above or if you selected Other above, please specify.

* 3. Number of units: (whole number only)

* 4. Cost per unit: (whole dollar amounts only)

* 5. Generally the equipment purchased under this grant program is: (select one)
○ The equipment is necessary for the organization’s basic mission, but has never been owned before
○ The equipment will replace old, obsolete, or substandard equipment currently owned by your organization
○ The equipment will increase your organization’s capabilities within existing mission areas or to address a new risk
○ The equipment will expand the capabilities of your organization into a new mission area
○ The equipment will increase your organization’s available supply of this equipment to meet basic mission
If you selected "replacing equipment" (from Q5) above, please specify the age of equipment in years.
○ 1 year
○ 2 years
○ 3 years
○ 4 years
○ 5 years
○ Over 5 years

(continued on next page)

(continued from previous page)

* 6. Generally the equipment purchased under this grant program: (select one)
○
Will bring the organization into statutory compliance.
Please explain how this equipment will bring the organization into statutory compliance in the space provided to the right.

○
Will bring the organization into voluntary compliance with a national standard, e.g. compliance with NFPA, OSHA, etc.
Please explain how this equipment will bring the organization into voluntary compliance in the space provided to the right.

○
Bring us into state or local compliance
* 7. Does this equipment provide a health and safety benefit to the members of your organization? If yes, please fully explain in the narrative section.
○ Yes ○ No
* 8. Will the item requested benefit other organizations or otherwise be available for use by other organizations?
○ Yes ○ No
If you answered Yes in the question above, please explain:

* 9. Will this equipment be used for wildland firefighting purposes?
○ Yes ○ No
* 10. Is your department trained in the proper use of the equipment being purchased with grant funds?
○ Yes ○ No
If not, will you be asking for training funds for this purpose with this application, or will you obtain the appropriate training through other sources?
○ Yes ○ No
Equipment List (select one to answer Equipment Details Q1)
Basic Equipment
Adapters, Wyes, & Siamese
Portable Deluge Sets
Foam Eductors and foam concentrate
Power Saws
Hose- (3½ inches or less)
Ropes, Harnesses, Carabiners, Pulleys, etc.
Hose- Large Diameter (LDH 4 inches or larger)
RIT Pack
Hydrant and Spanner Wrenches
Wildland
Ladders
Complete air-fill system
Nozzles
Generator - Mobile
Other Basic Equipment (explain)
Communications
Base Station
Mobile Date Terminal (MDT)
Computer Aided Dispatch (CAD)
Pagers
Computers
Two-Way Pagers
Headsets
Portable Radios
Mobile Radios
Repeaters
Other Communications (explain)
EMS
ALS Airway Equipment
Pulse Oximeters
BLS Airway Equipment
Stethoscopes
Suction
Thermometers
Automated External Defibrillators (AEDs)
Backboards
Defibrillator/Monitor
Cervical Collars
Blood Pressure Cuffs
Splints
Pen Lights
Vest Extrication Devices
Other EMS (explain)
EMS/Rescue
AEDs
Technical Rescue Equipment
Powered/Mechanical Extrication Tools/Equipment
Various Supplies
Stretchers, Backboards, Splint, etc.
Other EMS/Rescue (explain)
Haz-Mat
Decon, Clean-Up, Containment and Packaging Equipment
Spark Proof Tools
Monitoring and Sampling Devices
Suppression
Reference Library
Other Haz-Mat (explain)

(continued on next page)
Investigation
Cameras
Lights, Portable
Hand Tools
Monitoring and Sampling Devices
Other Investigation (explain)
Specialized
All-Terrain Vehicles
Thermal Imaging Devices
Compressors/Cascade/Fill Station (Fixed)
Washer/Extractor
Compressors/Cascade/Fill Station (Mobile)
Cascade
Portable/Mobile Generator
Compressor
Portable Pump
Fill-station
Rehab Equipment
Complete air-fill system
Skid Unit
Other Specialized (explain)
CBRNE Equipment
Real-time X-ray
Auto-injectors
Biological Detection
Other CBRNE-related Pharmaceuticals
Mini-cams
Other CBRNE-related Equipment
Firefighting Equipment - Additional Funding (optional)

Enter any additional funding for your grant in the space provided below. You will need to explain the additional costs. Please note that this section is optional.

Additional Funding
a. Personnel
$
b. Fringe Benefits
$
c. Travel
$
d. Equipment
$
e. Supplies
$
f. Contractual
$
g. Construction
$
h. Other
$
i. Indirect Charges
$
Explanation (Attach an additional sheet if necessary)

Operations and Firefighter Safety - Modify Facilities
Please provide the following information about the Modify Facilities you want funded. Only whole dollar amounts are acceptable.

Reminder: You may be required to provide documentation about the nature of the facility, historical review, EPA review, flood plains, etc. prior to being considered for award.

Modifications are intended to mean changes within the existing structure or to existing props. Funding may not be used to change the existing exterior footprint of the building or add additional stories to the building. The original profile of the facility will remain essentially unchanged.

Note: Fields marked with an * are required.
Note: For each request, attach an additional sheet.
Modify Facilities Details
* 1. Are all of your active firefighters trained to NFPA 1001 or equivalent (Firefigher I/Firefighter II, or essentials)?
○ Yes ○ No
If not, will you be asking for training funds for this purpose with this application or will you obtain the appropriate training through other sources (if not, please address this training issue in your narrative)?
○ Yes ○ No
* 2. On what type of modification will the funds be spent?
○ Exhaust System(s) ○ Sprinkler System(s)
○ Alarm System(s) ○ Smoke Detector
○ Fixed station generator(s)
Please provide further description of the item selected above.

* 3. What is the age of the facility that is being modified?
___________ years
* 4. What type of facility will be modified?
○ Station(s) with sleeping quarters
○ Station(s) without sleeping quarters
○ Training
○ Dispatch
○ Other: _________________________________________
If you answered other, above, please specify.

* 5. What is the level of occupancy for the facility you wish to modify? Note: The occupancy is defined by the number of hours the facility is used within a single 24 hour time period.
○ Full-Time
○ Part-Time
○ Occasional
* 6. Select Object Class
○ Personnel ○ Supplies
○ Fringe Benefits ○ Contractual
○ Travel ○ Construction
○ Equipment ○ Indirect Charges
○ Other
If you selected other above, please specify:

(continued on next page)
Modify Facilities (continued)

Modify Facilities – Add Budget Item
* Item:

Select Object Class:
○ Personnel
○ Fringe Benefits
○ Travel
○ Equipment
○ Supplies
○ Contractual
○ Construction
○ Indirect Charges
○ Other
If you selected other above, please specify:

* Number of units: (whole number only)

* Cost per unit: (whole dollar amounts only)
$

Operations and Firefighter Safety - Personal Protective Equipment
Please provide the following information about the personal protective equipment you want funded. Only whole dollar amounts are acceptable.
Note: For each piece of equipment, attach an additional sheet.

Note: Fields marked with an * are required.
Personal Protective Equipment Details
* 1. Are all of your active firefighters trained to NFPA 1001 or equivalent (Firefigher I/ Firefighter II, or essentials)?
○ Yes ○ No
If not, will you be asking for training funds for this purpose with this application or will you obtain the appropriate training through other sources?
○ Yes ○ No
* 2. Select the PPE that you propose to acquire (select one from PPE list on page 25)

Please provide further description of the item selected above or if you selected Other above, please specify.

* 3. Number of units: (whole number only)

* 4. Cost per unit: (whole dollar amounts only)
$
* 5.
• For turnout requests, what percentage of your on-duty active members have PPE that meets current applicable NFPA and OSHA standards in effect at the time of application?
• If you are requesting new SCBA, what percentage of your seated riding positions have compliant SCBA assigned to it?
• If you are asking for specialized PPE (e.g., HazMat), what percentage of applicable members have this specialized PPE that meets the established standards?

* 6.
• For turnout requests, what percentage of your on-duty active members will have PPE that meets current applicable NFPA and OSHA standards if this grant is awarded?
• If you are requesting new SCBA, what percentage of your seated riding positions will have specialized PPE that meets established standards if this grant is awarded?
• If you are asking for specialized PPE (e.g., HazMat), what percentage of applicable members will have specialized PPE that meets established standards if this grant is awarded?

(continued on next page)
(continued from previous page)

* 7. What is the purpose of this request?
(select one)
○ to buy equipment for the first time
○ to meet new risk
○ to replace old/obsolete equipment
○ to replace torn/tattered/damaged equipment
○ to replace contaminated equipment
○ to replace worn, but usable equipment
○ to replace used equipment
○ to replace new equipment
○ to equip first responders to handle a new mission
○ to increase the department’s available supply of this equipment
If you have indicated you are replacing PPE (any PPE other than SCBA) in Question 1 above, what are the specific ages of your equipment in years? If requesting SCBA, please select “N/A”, do not provide PPE ages here but continue on to the next question. Please assure that you’ve accounted for all members as declared in Department Characteristics.
○ N/A

Age (in years)
Number of Items

Less than 1 year

1 year

2 years

3 years

4 years

5 years

6 years

7 years

8 years

9 years

10 years

11 years

12 or more

Number of members with no gear _______
If you have indicated you are requesting SCBA in the question above, to which edition(s) of NFPA are your SCBA compliant? If not requesting SCBA, please clicked on “N/A” and continue on to the next question.
○ N/A

Year
Number of NFPA Compliant SCBA

2007 standard

2002 standard

1997 standard

Older Standards

(continue on next page)

(continued from previous page)

* 8. If purchasing a PASS device, what type of PASS device will you be purchasing?
○ Integrated/Automatic PASS devices without accountability sys
○ Integrated/Automatic PASS devices with accountability sys
○ Not Applicable
* 9. Is this PPE:
○ For protection use against fire
○ For use in Haz-mat incidents
○ For use in Rescue incidents
○ For some other use
If you selected Other above, please specify______________________________________________________
* 10. Will this equipment be used for wildland firefighting purposes?
○ Yes
○ No
* 11. Is your department trained in the proper use of the equipment being purchased with grant funds?
○ Yes
○ No
If not, will you be asking for training funds for this purpose with this application or will you obtain the appropriate training through other sources?
○ Yes
○ No

Personal Protective Equipment List (select one to answer Q1)

Structural
Helmets
Hoods
Coats
Accountability Systems
Pants
Flashlights
Goggles
Boots
Gloves
Hearing Protection
PASS Devices
Respiratory
SCBA-30 minutes with face piece-No extra bottle
Spare Cylinders-30 minutes
SCBA-30 minutes with face piece-With extra bottle
Spare Cylinders-45 minutes
SCBA-45 minutes with face piece-No extra bottle
Spare Cylinders-60 minutes
SCBA-45 minutes with face piece-With extra bottle
Face Pieces
SCBA-60 minutes with face piece-No extra bottle
Respirators
SCBA-60 minutes with face piece-With extra bottle
Air-Line Units
Wildland
Jumpsuits/Coveralls
Canteens
Shelters
Other CBRNE-related PPE
Other PPE
EMS Turnout
Wet and Dry Suits
Encapsulated Suits
Infection Control
Tyveck Suits
Extrication Clothing/Rescue Clothing
Splash Suits
ANSI Traffic Vests
Escape Masks
SCBA/CBRN
Proximity and Entry Suits
Chemical/Biological Suits (Must conform to NFPA 1994, 2001 edition)
Other PPE (explain)

PPE - Additional Funding (optional)

Enter any additional funding for your grant in the space provided below. You will need to explain the additional costs. Please note that this section is optional.

Firefighter Training Program
The Department of Homeland Security provides CBRNE training at the Awareness, Performance, Planning and Management levels FREE OF CHARGE for eligible applicants. This training is listed in the DHS Course Catalog and it may be obtained at http://www.ojp.usdoj.gov/odp/training_catalog.htm or by calling the DHS Help-line at 1-800-368-6498.

Please provide the following information about the training you want funded.
Note: For each program, attach an additional sheet.
Note: Fields marked with an * are required.
Training Details
* 1. Are all of your active firefighters trained to NFPA 1001 or equivalent (Firefigher I/Firefighter II, or essentials)?
○ Yes ○ No
If not, will you be asking for training funds for this purpose with this application or will you obtain the appropriate training through other sources?
○ Yes ○ No
* 2. Which title most closely describes your requested program? (select one from Training Titles list on page 28)

Please provide further description of the item selected above or if you selected Other above, please specify.

* 3. Generally, this program can best be categorized as: (select one)
○ Training that is tested and results in a nationally sanctioned or State certification
○ Training on new equipment provided by an AFG grant
○ Training that results in certification of the trainee without testing
○ Training that does not lead to the certification of the trainee
○ Other training
If you answered other above, please specify:

* 4. What percentage of applicable personnel will be trained by this program?
%
* 5. Generally, the training program provided under this grant: (select one)
○ Will bring your department into compliance with applicable NFPA or other standards, please specify:

○ Will bring your department into compliance with federal or state mandated training requirements, please specify:

○ Will address a specific, identified risk for your department or community, please specify:

○ Has no statutory requirement

* 6. Will this training enhance your ability to perform mutual aid?
○ Yes ○ No
If you answered Yes to the question above, please explain

* 7. Will this training be instructor led?
○ Yes ○ No
Training Program Titles List (select one to answer Q1)
Operations (NFPA 472)
Firefighter I, Firefighter II (NFPA 1001)
Instructor Training (NFPA 1041)
Driver/Operator (NFPA 1002)
Officer Training (NFPA 1021)
Basic Wildland Firefighting
Wildland Firefighter Certification
Airport Rescue Firefighting (ARFF) (NFPA 1003)
RIT Training
Confined Space Rescue – Awareness level
Vehicle Rescue
Technical Rescue/Urban Search and Rescue – Awareness level (NFPA 1670/1006)
Technical Rescue/Urban Search and Rescue – Operations level (NFPA 1670/1006)
Technical Rescue/Urban Search and Rescue – Technician level (NFPA 1670/1006)
Hazmat – Technician/Specialist level
Infection Control (NFPA 1581)
Medical First Responder Training
Emergency Medical Technician – Basic (EMT B)
Emergency Medical Technician – Intermediate (EMT I)
Paramedic Training (EMT-P)
Mass Casualty Incident Training (MCI)
NIIMS (Unified Command)
Incident Management Course (IMC)
Integrated Emergency Management Course (IEMC)
Fire Inspector (NFPA 1031)
Fire Investigator (NFPA 1033)
Fire Educator (NFPA 1035)
Telecommunications/Dispatcher
Weapons of Mass Destruction – Awareness level (CBRNE)
Safety Officer
First Responder
Firefighter Safety and Survivor Training

(continued on next page)

(continued from previous page)

Officer
Weapons of Mass Destruction Technician Level for Rural
Other/Specialized Weapons of Mass Destruction Training
Weapons of Mass Destruction Operations
Weapons of Mass Destruction Training Technician Level for Urban/Suburban
Fire Prevention
CBRNE Training
Operations-level Training
Technician-level Training
Other Specialized CBRNE Training
Specialist
EMS for Incidents Involving CBRNE
ICS for Terrorism
Mass Decontamination
Live Agent
Explosives and Secondary Device Awareness
Seaport
Environmental
Exercises/Preparedness
Other CBRNE-related Training
Other Training
Training Program (continued)

Please provide the following information about the programs you want funded. Only whole dollar amounts are acceptable.

Note: For each item, attach an additional sheet.
* Item: (select one)
-- Equipment --
○Basic Training PPE ○CPR Manikins
○Basic Training FFE ○Library
○Audio-Visual ○Reference Texts
○Classroom ○Supplies
○Media ○Other Equipment
○Rescue
-- Programs & Contract Instruction --
○Firefighter I ○Public Educator
○Firefighter II ○Hazmat
○Driver/Operator ○Marine
○EVOC ○Aircraft
○EMT ○Wildland
○Paramedic ○Officer I-IV
○Inspector ○Specialized
○Other Programs & Contract Instruction ○Investigator
-- Props: Non-Construction --
○Simulators
○Flashover Simulators
○Other Props: Non-Construction
Please provide further description of the item selected above or If you selected other above, please specify.

* Number of units: (whole number only)

* Cost per unit: (whole dollar amounts only)
$
Firefighter Wellness and Fitness Program
Please provide the following information about the program you want funded.

Note: For each program, attach an additional sheet.

Note: Fields marked with an * are required.

Program Area
Does your organization currently offer this activity?
Will your organization fund with grant?
Will the activity be mandatory?
Will this activity be offered to all members?
* Initial Physical Exam
○ Yes ○ No
○ Yes ○ No
○ Yes ○ No
○ Yes ○ No
* Job Related Immunization Program
○ Yes ○ No
○ Yes ○ No
○ Yes ○ No
○ Yes ○ No
* Periodic Physical Exam/Health Screening
○ Yes ○ No
○ Yes ○ No
○ Yes ○ No
○ Yes ○ No
Wellness and Fitness Program (continued)

Please provide the following information about the programs you want funded. Only whole dollar amounts are acceptable. You must have at least one item for each new Wellness program area being requested.

Note: For each item, attach an additional sheet.
* Item (select one):
-- Physicals/Medical Examinations --
○Entry ○Immunizations
○Annual ○Rehab and Therapy
○Health Screenings
○Other Physicals/Medical Examinations
-- Wellness –
○Exercise Equipment ○Aerobic Instructors
○Nutrition ○Physical Trainers
○Diet Programs ○CISD Programs
○Smoking Cessation ○EAP Programs
○Fitness Assessments and Counseling
○Other Wellness
If you selected other above, please specify.

Select Object Class:
○ Personnel
○ Fringe Benefits
○ Travel
○ Equipment
○ Supplies
○ Contractual
○ Construction
○ Indirect Charges
○ Other
If you selected other, above, please specify:

* Number of units: (whole number only)

* Cost per unit: (whole dollar amounts only)
$

Please go directly to page 74 and Budget
EMS Request Information

Program Selection
Please use this section to select the program for which you want to apply and provide the additional information requested.
* 1. Select a program for which you are applying. You can apply for as many activities within a program as you need. If you are interested in applying under both Vehicle Acquisition and EMS Operations and Safety, and/or regional application you will need to submit separate applications.
Program Name
Activities Available
○ EMS Operations and Safety (page 43)
[Equipment] [Modify Facilities] [Personal Protective Equipment] [Training] [Wellness and Fitness Programs]
○ Vehicle Acquisition (page 56)
[Vehicle Acquisition]
* 2. Will this grant benefit more than one organization?
○ Yes ○ No
If you answered Yes to Question 2 above, please explain. (attach additional sheet if necessary)

* 3. Enter Grant-writing fee associated with the preparation of this request. Enter 0 if there is no fee.
(This amount will be included under Other Budget Object Class section of Budget)

Operations and Safety – EMS Equipment

Please provide the following information about the equipment you want funded. Only whole dollar amounts are acceptable.

Note: For each piece of equipment, attach an additional sheet.
Note: Fields marked with an * are required.

Equipment Details
* 1. What equipment will be purchased with grant funds?
(select one)
○Defibrillators
○BLS/ALS equipment
○Mobile Radios
○Portable Radios
○Computers
○Other
○ALS Airway Equipment
○BLS Airway Equipment
○Suction
○Automated External Defibrillators (AEDs)
○Defibrillator/Monitor
○Blood Pressure Cuffs
○Pulse Oximeters
○Backboards
○Other EMS (explain)
○AEDs
○Powered/Mechanical Extrication Tools/Equipment
○Stretchers, Backboards, Splint, etc.
○Technical Rescue Equipment
○Various Supplies
○Other EMS/Rescue (explain)
○Decon, Clean-Up, Containment and Packaging Equipment
○Monitoring and Sampling Devices
○Reference Library
○Suppression
○Other Haz-Mat (explain)
If you answered other, above, please specify

* 2. Number of units: (whole number only)

* 3. Cost per unit: (whole dollar amounts only)
$

(continued on next page)
(continued from previous page)

* 4. What is the reason for this equipment purchase?
○ Upgrade service
○ New service
○ Expanded service
○ To meet new risk
○ Replace used or obsolete equipment
* 5. Will this equipment bring you into compliance with State or Federal or local protocols, standards/regulations?

○ Yes ○ No ○ N/A
*6. Up to what level of patient care will this equipment bring your department?
○ First Responder
○ EMT-B
○ EMT-I
○ EMT-P
○ Physicians Assistant
○ Hazmat Ops
○ Rescue Ops
*7. Is your department trained in the proper use of the equipment being purchased with grant funds?
○ Yes ○ No
If not, will you be asking for training funds for this purpose with this application or will you obtain the appropriate training through other sources?
○ Yes ○ No
EMS Equipment - Additional Funding (optional)

Enter any additional funding for your grant in the space provided below. You will need to explain the additional costs. Please note that this section is optional.

EMS Operations and Safety - Modify Facilities

Please provide the following information about the Modify Facilities you want funded. Only whole dollar amounts are acceptable.

Reminder: You may be required to provide documentation about the nature of the facility, historical review, EPA review, flood plains, etc. prior to being considered for award.

Note: Fields marked with an * are required.

Note: For each request, attach an additional sheet.
Modify Facilities Details
* 1. On what type of modification will the funds be spent?
○ Exhaust System(s) ○ Sprinkler System(s)
○ Alarm System(s) ○ Smoke Detector
○ Fixed Station Generator(s)
Please provide further description of the item selected above.

* 2. What is the age of the facility that is being modified?
___________ years
* 3. What type of facility will be modified?
○ Station(s) with sleeping quarters
○ Station(s) w/o sleep quarters
○ Training
○ Dispatch
○ Other (explain)
If you answered other, above, please specify

* 4. What is the level of occupancy for the facility you wish to modify? Note: The occupancy is defined by the number of hours the facility is used within a single 24 hour time period.
○ Full-Time
○ Part-Time
○ Occasional
* 5. Select Object Class
○ Personnel ○ Supplies
○ Fringe Benefits ○ Contractual
○ Travel ○ Construction
○ Equipment ○ Indirect Charges
○ Other
If you selected Other above, please specify:

(continued on next page)
EMS Modify Facilities (continued)

Modify Facilities – Add Budget Item
* Item:

* Number of units: (whole number only)

* Cost per unit: (whole dollar amounts only)
$

EMS Operations and Safety - Personal Protective Equipment
Please provide the following information about the personal protective equipment you want funded. Only whole dollar amounts are acceptable.

Note: For each piece of equipment, attach an additional sheet.
Note: Fields marked with an * are required.
Personal Protective Equipment Details
* 1. Select the PPE that you propose to acquire
○ Hearing Protection
○ Respirators
○ Helmets
○ Boots
○ Goggles
○ Gloves
○ Pants
○ Coats
○ Jumpsuits/Coveralls
○ Accountability Systems
○ Encapsulated Suits
○ Tyveck Suits
○ Splash Suits
○ Escape Masks
○ Infection Control
○ ANSI Traffic Vests
○ Suspenders
○ Other PPE (explain)
Please provide further description of the item selected above or if you selected other above, please specify.

* 2. Number of units: (whole number only)

* 3. Cost per unit: (whole dollar amounts only)
$
* 4.
• For EMS protective clothing requests, what percentage of your on-duty active members have PPE that meets current applicable NFPA and OSHA standards in effect at the time of application?
• If you are requesting new SCBA, what percentage of your seated riding positions have compliant SCBA assigned to it?
• If you are asking for specialized PPE (e.g., HazMat), what percentage of applicable members have this specialized PPE that meets the established standards?

(continued from previous page)
* 5.
• For turnout requests, what percentage of your on-duty active members will have PPE that meets current applicable NFPA and OSHA standards if this grant is awarded?
• If you are requesting new SCBA, what percentage of your seated riding positions will have compliant PPE that meets established standards if this grant is awarded?
• If you are asking for specialized PPE (e.g., HazMat), what percentage of applicable members will have specialized PPE that meets established standards if this grant is awarded?

* 6. What is the purpose of this request? (select one)
○ to buy equipment for the first time
○ to meet new risk
○ to replace old/obsolete equipment
○ to meet regional interoperability
○ to replace torn/tattered/damaged equipment
○ to replace contaminated equipment
○ to replace worn, but usable equipment
○ to replace used equipment
○ to replace new equipment
○ to equip first responders to handle a new mission
○ to increase the department’s available supply of this equipment
If you have indicated you are replacing PPE (any PPE other than SCBA) in the Question above, what are the specific ages of your equipment in years? If requesting SCBA, please select “N/A”, do not provide PPE ages here but continue on to the next question. Please assure that you’ve accounted for all members as declared in Department Characteristics.
○ N/A

Age (in years)
Number of Items

Less than 1 year

1 year

2 years

3 years

4 years

5 years

6 years

7 years

8 years

9 years

10 years

11 years

12 or more

Number of members with no gear ____________

(continued from previous page)

If you have indicated you are requesting SCBA in Question 1 above, to which edition(s) of NFPA are your SCBA compliant? If not requesting SCBA, please clicked on “N/A” and continue to next question.
○ N/A

Year
Number of NFPA Compliant SCBA

2007 standard

2002 standard

1997 standard

Older Standards

* 7. Is this PPE:
○ Against Blood borne pathogens or other contaminants
○ For use in Haz-mat incidents
○ For use in Rescue incidents
○ For some other use
If you selected Other above, please specify:
* 8. Will this equipment be used for wildland firefighting purposes?
○ Yes ○ No
* 9. Is your department trained in the proper use of the new equipment being purchased with grant funds?
○ Yes ○ No
If not, will you be asking for training funds for this purpose with this application, or will you obtain the appropriate training through other sources?
○ Yes ○ No

EMS PPE - Additional Funding (optional)

Enter any additional funding for your grant in the space provided below. You will need to explain the additional costs. Please note that this section is optional.

EMS Training Program

The Department of Homeland Security (DHS) provides CBRNE training at the Awareness, Performance, Planning and Management levels FREE OF CHARGE for eligible applicants. This training is listed in the DHS Course Catalog and it may be obtained at http://www.ojp.usdoj.gov/odp/training_catalog.htm or by calling the DHS Help-line at 1-800-368-6498.

Please provide the following information about the training you want funded.

Note: For each program, attach an additional sheet.

Note: Fields marked with an * are required.

Training Details
* 1. What type of training will this be?

* 2. If awarded these funds, to what level will you be training your personnel?

○ First Responder
○ EMT-B
○ EMT-I
○ EMT-P
○ Physicians Assistant
○ Hazmat Ops
○ Rescue Ops
* 3. Are you asking for the funds for equipment to go with the level of your training?
○ Yes
○ No

Note: Eligible expenses include: instructional costs for EMS training, books and materials, training equipment and supplies, exam and course fees, certification and re-certification expenses and continuing education.
Medications and communications centers constitute ineligible expenses.
EMS Training Program (continued)

Please provide the following information about the programs you want funded. Only whole dollar amounts are acceptable.

Note: For each item, attach an additional sheet.

* Item: (select one)
-- Equipment --
○Basic PPE ○Audio-Visual
○Classroom ○Media
○CPR Manikins ○Library
○Reference Texts ○Supplies
○Other
-- Programs & Contract Instruction --
○Driver/Operator ○EMT
○Paramedic ○Hazmat
○Other
-- Props: Non-Construction --
○Simulators
○Others
Please provide further description of the item selected above or If you selected other above, please specify.

* Number of units: (whole number only)

* Cost per unit: (whole dollar amounts only)
$

EMS Wellness and Fitness Program

Please provide the following information about the program you want funded.

Note: For each program, attach an additional sheet.

Note: Fields marked with an * are required.

Program Area
Does your organization currently offer this activity?
Will your organization fund with grant?
Will this activity be mandatory?
Will this activity be offered to all members?
* Initial Physical Exam
○ Yes ○ No
○ Yes ○ No
○ Yes ○ No
○ Yes ○ No
* Job Related Immunization Program
○ Yes ○ No
○ Yes ○ No
○ Yes ○ No
○ Yes ○ No
* Periodic Physical Exam/Health Screening
○ Yes ○ No
○ Yes ○ No
○ Yes ○ No
○ Yes ○ No

EMS Wellness and Fitness Program (continued)

Note: For each item, attach an additional sheet.

* Item (select one):
Physicals/Medical Examinations

Entry
Immunizations

Annual
Rehab and Therapy

Health Screenings
Other Physicals/Medical Examinations

Wellness

Exercise Equipment
Aerobic Instructors

Nutrition
Physical Trainers

Diet Programs
CISD Programs

Smoking Cessation
EAP Programs

Fitness Assessments and Counseling
Other Wellness
Please provide further description of the item selected above or If you selected other above, please specify.

* Number of units: (whole number only)

* Cost per unit: (whole dollar amounts only)
$

Please continue to Budget on page 74
Regional Request Information

Activity Selection
Please use this section to select the program for which you want to apply and provide some additional information requested. If you intend to request funds for an activity, you must answer all of the activity specific questions and specify at least one budget item. The cost figures you provide do not have to be firm quotes from your vendors, but they should be estimated based on research of current prices (i.e., check with at least two vendors for your estimates) before you submit your estimated costs. If you do not have these estimates, you can come back and modify this area at any point before you submit your application to DHS. Only whole dollar amounts should be provided (no cents please). The Assistance to Firefighters Grant Program does not allow for any grant funds to be used for construction.

* 1. Select a program for which you are applying. Regional applications are not eligible for modification of facilities, wellness and fitness programs, or vehicles. You can apply for as many activities within a program as you need.
Program Name
Activities Available
○ Operations and Safety
[Equipment] [Training]
* 2. Will this grant benefit more than one organization?
○ Yes ○ No
If you answered Yes to Question 2 above, please explain. (attach additional sheet if necessary)

* 3. Enter Grant-writing fee associated with the preparation of this request. Enter 0 if there is no fee.
(This amount will be included under Other Budget Object Class section of Budget)

Regional Operations and Safety - Equipment
Please provide the following information about the equipment you want funded. Note: Fields marked with an * are required.

Note: For each piece of equipment, attach an additional sheet.
Equipment Details
* 1. What equipment will you purchase with this grant? (select one)
-- Communications --
○Base Station ○Computer Aided Dispatch (CAD)
○Mobile Radios ○Mobile Data Terminal (MDT)
○Portable Radios ○Repeaters
○Other Communications (explain)
-- EMS --
○Other EMS (explain)
-- EMS/Rescue --
○Other Haz-Mat (explain)
○Other Investigation (explain)
-- Specialized --
○Other Specialized (explain)
Please provide further description of the item selected above or if you selected Other above, please specify.

* 2. Number of units: (whole number only)

* 3. Cost per unit: (whole dollar amounts only)

* 4. Generally the equipment purchased under this grant program is: (select one)
○ The equipment is necessary for the region’s basic mission, but has never been owned before
○ The equipment will replace old, obsolete, or substandard equipment currently owned by your region
○ The equipment will increase the region’s capabilities within existing mission areas
○ The equipment will expand the capabilities of your region into a new mission area
○ The equipment will increase your region’s available supply of this equipment to meet basic mission
If you selected "replacing equipment" (from Q4) above, please specify the age of equipment in years.
○ 1 year
○ 2 years
○ 3 years
○ 4 years
○ 5 years
○ Over 5 years

(continued on next page)

(continued from previous page)

* 5. Generally the equipment purchased under this grant program: (select one)
○
Will bring the region into statutory compliance.
Please explain how this equipment will bring the region into statutory compliance in the space provided to the right.

○
Will bring the region into voluntary compliance with a national standard, e.g. compliance with NFPA, OSHA, etc.
Please explain how this equipment will bring the region into voluntary compliance in the space provided to the right.

○
Bring us into State or local compliance
* 6. Does this equipment provide a health and safety benefit to the members of your organization? If yes, please fully explain in the narrative section.
○ Yes ○ No
* 7. Will the item requested benefit other organizations or otherwise be available for use by other organizations?
○ Yes ○ No
If you answered Yes in the question above, please explain:

* 8. Will this equipment be used for wildland firefighting purposes?
○ Yes ○ No
* 9. Is your department trained in the proper use of the equipment being purchased with grant funds?
○ Yes ○ No
If not, will you be asking for training funds for this purpose with this application, or will you obtain the appropriate training through other sources?
○ Yes ○ No
Regional Equipment - Additional Funding (optional)

Enter any additional funding for your grant in the space provided below. You will need to explain the additional costs. Please note that this section is optional.

Regional Training Program

The Department of Homeland Security provides CBRNE training at the Awareness, Performance, Planning and Management levels FREE OF CHARGE for eligible applicants. This training is listed in the DHS Course Catalog and it may be obtained at http://www.ojp.usdoj.gov/odp/training_catalog.htm or by calling the DHS Help-line at 1-800-368-6498.

Please provide the following information about the training you want funded.

Note: For each program, attach an additional sheet.

Note: Fields marked with an * are required.

Training Details
* 1. Which title most closely describes your requested program? (select one)
○ Other Training (explain)
Please provide further description of the item selected above or if you selected other above, please specify.

* 2. Generally, this program can best be categorized as (select one):
○ Training that is tested and results in a nationally sanctioned or State certification
○ Training on new equipment provided by an AFG grant
○ Training that results in certification of the trainee without testing
○ Training that does not lead to certification of the trainee
○ Other training
If you answered other above, please specify:

* 3. What percentage of applicable personnel will be trained by this program?
%

( continued on next page )

( continued from previous page )

* 4. Generally, the training program provided under this grant: (select one)
○ Will bring your region into compliance with recommended applicable NFPA or other standards, please specify:

○ Will bring your region compliance with federal or state mandated training requirements, please specify:

○ Will address a specific, identified risk for your region or community, please specify:

○ Has no statutory requirement

* 5. Will this training enhance your ability to perform mutual aid?
○ Yes ○ No
If you answered Yes to the question above, please explain

* 6. Will this training be instructor-led?
○ Yes ○ No
Training Program (continued)

Please provide the following information about the programs you want funded. Only whole dollar amounts are acceptable.

Note: For each item, attach an additional sheet.

* Item: (see next page for Training Items list)

Please provide further description of the item selected above or If you selected other above, please specify.

* Select Object Class:
○ Personnel
○ Fringe Benefits
○ Travel
○ Equipment
○ Supplies
○ Contractual
○ Construction
○ Indirect Charges
○ Other
If you selected other above, please specify:

* Number of units: (whole number only)

* Cost per unit: (whole dollar amounts only)
$

Training Items List (select one)

Equipment
Basic Training PPE
Basic Training FFE
Audio-Visual
Classroom
Media
Rescue
CPR Manikins
Library
Reference Texts
Supplies
Other Equipment
Programs & Contract Instruction
Firefighter I
Firefighter II
Driver/Operator
EVOC
EMT
Paramedic
Inspector
Investigator
Public Educator
Hazmat
Marine
Aircraft
Wildland
Officer I-IV
Specialized
Other Programs & Contract Instruction
Props: Non-Construction
Simulators
Flashover Simulators
Other Props: Non-Construction