Form FEMA Form 080-0-2 FEMA Form 080-0-2 AFG Application (General Questions and Narrative)

2012

Assistance to Firefighters Grants Program

Application

The electronic application period is from Monday, June 11, 2012, beginning at 8:00 am EDT to Friday, July, 6 ending at 5:00 pm EDT. It does not matter how early you submit your application, as long as it is prior to the deadline. All paper applications must be postmarked by July 16, 2012, or otherwise received prior to the deadline.

The Assistance to Firefighters Grant Program Office and USFA has established a help desk to assist you during the application period. Technical assistance with completion of the application will be available by phone on our toll free hotline at (866) 274-0960 during the following hours:

• Monday - Friday from 8:00 a.m. to 5:00 p.m. EDT

In addition to the toll free hotline (866-274-0960) applicants can e-mail questions to [email protected].

For more information about this program, visit http://www.fema.gov/firegrants/

AFG Program Office

(866) 274 – 0960

Overview

The Assistance to Firefighters Grants Program's objective is to provide funding directly to fire departments and non-affiliated EMS organizations for the purpose of protecting the health and safety of the public and first responder personnel against fire and fire-related hazards. Please review the program guidance for information on available program areas and for more information on the evaluation process and conditions of award.

*Did you attend one of the workshops conducted by DHS’s regional fire program specialist?

○ Yes, I have attended workshop

○ No, I have not attended workshop

*Was a workshop within two hours drive?

○ Yes

○ No

○ Do Not Know

* Are you a member, or are you currently involved in the management, of the fire department or non-affiliated EMS organization applying for this grant with this application?

○ Yes, I am a member/officer of this applicant

○ No, I am a grant writer or otherwise not affiliated with this applicant

If you answered No, please complete the information below. If you answered Yes, please skip the Preparer Information section. Fields marked with an * are required.

Preparer Information
* Preparer’s Name
* Address 1
Address 2
* City
* State
* Zip

In the space below please list the person your organization has selected to be the primary point of contact for this grant. This should be a Chief Officer or long time member of the organization who will see this grant through completion. Reminder: if this person changes at any time during the period of performance please update this information. Please list only phone numbers where we can get in direct contact with the POC.

Primary Point of Contact
* Title
Prefix (check one)	○ N/A ○ Dr. ○ Mr. ○ Mrs. ○ Ms.
* First Name
Middle Initial
* Last Name
* Business Phone (e.g. 123-456-7890)	Ext.
* Home Phone (e.g. 123-456-7890)	Ext.
Mobile Phone/Pager (e.g. 123-456-7890)
Fax (e.g. 123-456-7890)
* Email (e.g. [email protected])

Alternate Contact Information

In addition to yourself, please provide two additional points of contact for this application. Between all of the contact information provided, one set of contact information should be for the Chief Officer of the applicant. Due to the complete grant cycle being as much as two years, please consider only listing permanent or long term members of the organization.

Note: Fields marked with an * are required.

Alternate Contact Information Number 1
* Title
Prefix (check one)	○ N/A ○ Dr. ○ Mr. ○ Mrs. ○ Ms.
* First Name
Middle Initial
* Last Name
* Business Phone (e.g. 123-456-7890)	Ext.
* Home Phone (e.g. 123-456-7890)	Ext.
Mobile Phone/Pager (e.g. 123-456-7890)
Fax (e.g. 123-456-7890)
* Email (e.g. [email protected])

Alternate Contact Information Number 2
* Title
Prefix (check one)	○ N/A ○ Dr. ○ Mr. ○ Mrs. ○ Ms.
* First Name
Middle Initial
* Last Name
* Business Phone (e.g. 123-456-7890)	Ext.
* Home Phone (e.g. 123-456-7890)	Ext.
Mobile Phone/Pager (e.g. 123-456-7890)
Fax (e.g. 123-456-7890)
* Email (e.g. [email protected])

Applicant Information

Please complete the following information regarding your department.

Note: Fields marked with an * are required.

* Organization Name
* Type of Applicant		○ Fire Department/Fire District ○ Non-Affiliated EMS Organization ○ Regional Request
* Type of Jurisdiction Served (list of eligible organizations on page 5)		○ Airport/Port Authority ○ City ○ County ○ Indian Tribe ○ Parish ○ Private/for-profit Company ○ Town ○ Township ○ Unincorporated Community ○ Village ○ Other (explain)
If other, please enter the type of Jurisdiction
* Employer Identification Number (e.g. 12-3456789)
* What is your organization’s DUNS number?		(call 1-866-705-5711 to get a DUNS number)
Headquarters or Main Station Physical Address
* Physical Address 1
Physical Address 2
* City
* State
* Zip
○ Mailing Address is the same as the Physical Address
* Mailing Address 1
Mailing Address 2
* City
* State
* Zip
* Please describe all grants that you have received from DHS, for example, 2002 AFG grant for vehicle or 2010 HSGP grant for exercises. (Enter "N/A" if Not Applicable)

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Account Information
* Type of bank account	○ Checking ○ Savings
* Bank routing number - 9 digit number on the bottom left hand corner of your check	(numbers only, no dashes)
* Your account number	(numbers only, no dashes)
Additional Information
* For this fiscal year (Federal) is your organization receiving Federal funding from any other grant program that may duplicate the purpose and/or scope of this grant request?	○ Yes ○ No
* If awarded the AFG grant, will your organization expend more than $500,000 in Federal funds during your organization’s fiscal year in which this AFG grant was awarded?	○ Yes ○ No
* Is the applicant delinquent on any Federal debt? (This question applies to the applicant's organization, not the person who signs as the authorized representative. Categories of debt include delinquent audit disallowances, loans, and taxes.)	○ Yes ○ No
If you answered yes to any of the additional questions above, please provide an explanation in the space provided below:

Type of Organization

Eligible Organizations

• Airport/Port Authority if they also have first-due area of responsibility off airport property

• City

• County

• Fire District

• Indian Tribe

• Parish

• Town

• Township

• Unincorporated community

• Village

• Volunteer Fire Company

Ineligible Organizations

• Auxiliary organizations

• Federal Fire Department

• Fire Buff Group or Museum

• Fire Chiefs, Fire Training, or Firefighters Association

• Fire Marshal's Office not affiliated with an organized fire department

• State Agency: Forest Service, Training, Fire Marshal, Correctional, University, Hospital, etc.

• For-profit fire departments

• EMS organizations affiliated with hospitals

• For-profit EMS organizations

Budget Object Class Definitions

The following definitions will allow you to complete your budget items appropriately.

Personnel	The costs in this area will cover salaries or wages of personnel that will work on the activity for which you are applying.
Fringe Benefits	Fringe benefits in the form of regular compensation paid to employees during periods of authorized absences from the job, such as vacation leave, sick leave, military leave, and the like, are allowable, provided such costs are absorbed by all organization activities in proportion to the relative amount of time or effort actually devoted to each. Fringe benefits in the form of employer contributions or expenses for social security, employee insurance, workmen's compensation insurance, pension plan costs and the like, are allowable, provided such benefits are granted in accordance with established written organization policies. Such benefits whether treated as indirect costs or as direct costs, shall be distributed to particular awards and other activities in a manner consistent with the pattern of benefits accruing to the individuals or group of employees whose salaries and wages are chargeable to such awards and other activities.
Travel	The costs in this area are for any allowed travel, example airfare, mileage, lodging, etc. The rates must be in accordance with your written department policy and cannot exceed the government-authorized rates.
Equipment	"Equipment" means an article of nonexpendable, tangible personal property having a useful life of more than one year.
Supplies	Supplies are expendable items with a useful life of less than one year. The costs of materials and supplies necessary to carry out an award are allowable. Such costs should be charged at their actual prices after deducting all cash discounts, trade discounts, rebates, and allowances received by the organization. Incoming transportation charges may be a proper part of material cost. Materials and supplies charged as a direct cost should include only the materials and supplies actually used for the performance of the contract or grant, and due credit should be given for any excess materials or supplies retained, or returned to vendors.
Contractual	The costs in this area should cover any contracts that you issue that are not already covered under equipment or supplies. For example, the costs incurred if you hire a grant writer or contractor to handle your Fire Prevention Program.
Construction	Construction is the creation of a new structure or any modification to the footprint or profile of an existing structure. Changes or renovations to an existing structure that do not change the footprint or profile of the structure but exceeds either $10,000 or 50 percent of the value of that structure, is also considered construction.
Other	This area is for a cost that will not fit into the other areas, (e.g., administrative costs). If you put a cost in this category you must describe it in your program.
Indirect Costs	Indirect costs are those incurred for common or joint objectives and cannot be readily identified with a particular final cost objective. A cost may not be allocated to an award as an indirect cost if any other cost incurred for the same purpose, in like circumstances, has been assigned to an award as a direct cost. Typical examples of indirect costs may include depreciation or use allowances on buildings and equipment, the costs of operating and maintaining facilities, general administration, and other general expenses such as the salaries and expenses of executive officers, personnel administration, and accounting.
State Taxes	Please add state sales tax in this area if your state’s sales tax is not reimbursed under another program.

Critical Infrastructure

Critical infrastructure includes any system or asset that if attacked would result in catastrophic loss of life or catastrophic economic loss. Critical infrastructure also includes the following:

• Public water systems serving large population centers.

• Primary data storage and processing facilities, stock exchanges, or major banking centers.

• Chemical facilities located in close proximity to large population centers.

• Major power generation facilities that exceed 2,000 MW and support the regional electric grid.

• Hydroelectric facilities and dams that produce power in excess of 2,000 MW or could cause catastrophic loss of life if breached.

• Nuclear power plants.

• Electric substations 500 KV or larger, and substations 345 KV or larger, that are part of a critical system supporting populations in excess of one million.

• Rail and highway bridges over major waterways that, if destroyed, would cause catastrophic loss of life or catastrophic economic impact.

• Major natural gas transmission pipelines in excess of 3,000 bcf.

• Natural gas and liquid natural gas storage facilities.

• Major petroleum handling facilities such as pipelines, ports, refineries, and terminals.

• Telecommunications, Internet and cyber facilities.

• Facilities that support large public gatherings such as sporting events or concerts.

If your organization is applying as a Non-Affiliated EMS Organization, please skip ahead to page 52. If this is a Regional Request, please skip ahead to page 87.

Fire Department Characteristics (Part I)

If you are applying on behalf of a Non-Affiliated EMS Organization go directly to page 52.

If you are applying with a Regional Request go directly to page 87.

Please provide the following additional information regarding your organization.

Note: Fields marked with an * are required.

* Are you a member of a Federal Fire Department or contracted by the Federal government and solely responsible for suppression of fires on Federal property?	○Yes ○ No
* What kind of organization do you represent? Career – An agency or organization in which all members receive financial compensation for their services. Combination – An agency or organization in which at least one member receives financial compensation for their services and/or at least one member does not receive financial compensation for their services, except as defined below. Volunteer – (Reserve) An agency or organization in which no member receives financial compensation for their services other than life/health insurance, workmen’s compensation insurance. Paid on Call/Stipend – An agency or organization in which members receive a nominal fee based on per event basis.	○ All Paid/Career ○ Combination ○ All volunteer ○ Paid On Call/Stipend
If you answered combination, above, what is the percentage of career members in your organization? (number only)	%
If you answered volunteer or combination or paid on-call, how many of your volunteer firefighters are paid members from another career department? (number only)
* What type of community does your organization serve?	○ Urban ○ Suburban ○ Rural
* Is your Organization considered a Metro Department? (Over 400 paid career Firefighters)	○ Yes ○ No
* What is the square mileage of your first-due response area? (number only)
* What percentage of your response area is protected by hydrants? (number only)	%
* In what county/parish is your organization physically located? If you have more than one station, in what county/parish is your main station located?
* Does your organization protect critical infrastructure of the state? (definitions on page 7)	○ Yes ○ No
Percentages in three answers below must sum up to 100%:
* How much of your jurisdiction’s land use is for agriculture, wildland, open space, or undeveloped properties?	%
* What percentage of your jurisdiction’s land use is for commercial and industrial purposes?	%
* What percentage of your jurisdiction’s land is used for residential purposes?	%

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* How many occupied structures (commercial, industrial, residential, or institutional) in your jurisdiction are more than three stories tall? Do not include structures which are not regularly occupied such as silos, towers, steeples, etc. (whole numbers only)
* What is the permanent resident population of your Primary/First Due Response Area or jurisdiction served? (whole numbers only) Primary/First Due Response Area is a geographical area proximate to a fire or rescue facility and normally served by the personnel and apparatus from that facility in the event of a fire or other emergency and does not include daily or seasonal population surges. Population shall be based upon the most recent official census and shall include only those individuals who permanently reside within the jurisdiction served.
* Do you have a seasonal increase in population?		○ Yes ○ No
If "Yes" what is your seasonal increase in population?
* How many active firefighters does your department have who perform firefighting duties? (whole numbers only) Active Firefighter – A member in good standing who is qualified to respond to and extinguish fires and has actively participated in firefighting in the past year.
* How many ALS level trained members do you have in your department/organization? (whole numbers only)
* How many stations are operated by your organization? (whole numbers only)
* Is your department compliant to your local Emergency Management standard for the National Incident Management System (NIMS)?		○ Yes ○ No
* Do you currently report to the National Fire Incident Reporting System (NFIRS)?		○ Yes ○ No
If you answered yes above, please enter your FDIN/FDID
* What percent of your active firefighters are trained to the level of Firefighter I? (numbers only)
* What percent of your active firefighters are trained to the level of Firefighter II? (numbers only)
If you answered less than 100% to either question above, are you requesting for training funds in this application to bring 100% of your firefighters into compliance with NFPA 1001?		○ Yes ○ No
If you indicated that less than 100% of your firefighters are trained to the Firefighter II level and you are not asking for training funds in this application, please describe in the box to the right your training program and your plans to bring your membership up to Firefighter II.

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* What services does your organization provide?
○ Structural Fire Suppression ○ Emergency Medical Responder ○ Haz-Mat Operational Level ○ Wildland Fire Suppression ○ Basic Life Support ○ Haz-Mat Technical Level ○ Airport Rescue Firefighting (ARFF) ○ Advanced Life Support ○ Rescue Operational Level ○ Occasional Fire Prevention ○ Formal/Year-Round Fire ○ Rescue Technical Level Program Prevention Program ○ Maritime Operations/Firefighting
* Please describe your organization and/or community that you serve. Use additional sheet if necessary.

Bottom of Form

Fire Department Characteristics (Part II)

Please provide the following additional information regarding your organization.

Note: Fields marked with an * are required.

* What is the total number of fire-related civilian fatalities in your jurisdiction over the last three years? (whole numbers only)		2011	2010	2009
* What is the total number of fire-related civilian injuries in your jurisdiction over the last three years? (whole numbers only)		2011	2010	2009
* What is the total number of line of duty member fatalities in your jurisdiction over the last three years? (whole numbers only)		2011	2010	2009
* What is the total number of line of duty member injuries in your jurisdiction over the last three years? (whole numbers only)		2011	2010	2009
* Over the last three years, what was your organization’s average operating budget? (number only)
* What percentage of your TOTAL budget is dedicated to personnel costs (salary, overtime and fringe benefits)?		%
* What percentage of your annual operating budget is derived from: (Enter numbers only; percentages must sum up to 100%)
Taxes?		%
EMS Billing? (Recoverable funds from billing the insurance agencies or the patient for emergency medical service and/or transport.)		%
Grants?		%
Donations?		%
Fund drives?		%
Fee for Service? If your department or agency is billing for services such as vehicle extrication or charging any other fees for your service please enter it here. If your department or agency is billing insurance companies for service other than EMS billing list them here.		%
Other?		%
If you entered a value into Other field (other than 0), please explain:
* Please describe your organization’s need for Federal financial assistance. Use additional sheet if necessary.

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*How many vehicles does your organization have in each of the types or class of vehicle listed below? You must include vehicles that are leased or on long-term loan as well as any vehicles that have been ordered or otherwise currently under contract for purchase or lease by your organization but not yet in your possession. (Enter numbers only and enter 0 if you do not have any of the vehicles below)
Type or Class of Vehicle	Number of Front line Apparatus	Number of Reserve Apparatus	Number of Seated Riding Positions
Engines or Pumpers (pumping capacity of 750 gpm or greater and water capacity of 300 gallons or more): Pumper, Pumper/Tanker, Rescue/Pumper, Foam Pumper, CAFS Pumper, Type I Engine or Type II Engine Urban Interface
Ambulances for transport and/or emergency response
Tankers or Tenders (pumping capacity of less than 750 gallons per minute (gpm) and water capacity of 1,000 gallons or more):
Aerial Apparatus: Aerial Ladder Truck, Telescoping, Articulating, Ladder Towers, Platform, Tiller Ladder Truck, Quint
Brush/Quick Attack (pumping capacity of less than 750 gpm and water carrying capacity of at least 300 gallons): Brush Truck, Patrol Unit (Pick up w/ Skid Unit), Quick Attack Unit, Mini-Pumper, Type III Engine, Type IV Engine, Type V Engine, Type VI Engine, Type VII Engine
Rescue Vehicles: Rescue Squad, Rescue (Light, Medium, Heavy), Technical Rescue Vehicle, Hazardous Materials Unit
Additional Vehicles: EMS Chase Vehicle, Air/Light Unit, Rehab Units, Bomb Unit, Technical Support (Command, Operational Support/Supply), Hose Tender, Salvage Truck, ARFF (Aircraft Rescue Firefighting), Command/Mobile Communications Vehicle

Fire Department Call Volume

Please provide the total number of incidents that your department responded to for each of three year periods (Jan – Dec). Include only those alarms which your department was a primary responder and not second due on giving mutual aid.

Note: Each incident must be counted only once regardless of the number of units or agencies that responded to that incident. (e.g. a vehicle fire with entrapment and injuries may be counted as a vehicle fire or a rescue call or an EMS call, but not all three.)

How many responses per year by category? (Enter whole numbers only: If you have no calls for any of the categories, enter 0)
Working Structural Fires - includes cooking fires, chimney fires, smoke odor calls, unauthorized burning calls, and trash and rubbish fires that spread to a structure(s).	2011	2010	2009
False Alarms/Good Intent Calls Good Intent Calls - includes canceled enroute, authorized burning calls, prescribed fire calls, smoke scares. False Alarms: making a false report of a fire or other emergency via telephone to 911 or other emergency number, the false activation of a manual or automatic fire alarm system, and/or the transmission of a malicious false alarm via a dedicated public alarm system (telephone, telegraph, or radio call box).	2011	2010	2009
Vehicle Fires- includes all vehicle fires except those that were inside a structure.	2011	2010	2009
Vegetation Fires- includes wildland fires, brush fires, and grass fires.	2011	2010	2009
EMS-BLS Response Calls- includes medical assists, EMS calls, vehicle accident EMS calls, sickness/injuries, vehicle/pedestrian EMS calls, etc.	2011	2010	2009
EMS-ALS Response Calls- calls that require an advanced level of treatment typically provided by an Advanced Life Support Provider (EMT-I or EMT-P). Examples: cardiac/respiratory arrest/distress, traumatic injury, I.V. treatment, trouble breathing, chest pains, unconscious/unresponsive, cardiac monitoring, intubation.	2011	2010	2009
EMS-BLS Scheduled Transports- non-critical patient transports, ALS/critical transports, transports from one medical facility to another, etc.	2011	2010	2009
EMS-ALS Scheduled Transports- pre-scheduled transports of patients to or from a medical facility that requires monitoring or treatment typically administered by an Advanced Life Support Provider (EMT-P or EMT-I). Examples: cardiac/respiratory distress, traumatic injury, I.V. treatment, trouble breathing, chest pains, unconscious/unresponsive, cardiac monitoring, intubation.	2011	2010	2009
Vehicle Accidents w/o Extrication- response to incidents involving any motorized vehicle (automobiles, motorcycles, trucks, etc…) with or without injury, where there is no entrapment of the occupants.	2011	2010	2009
Vehicle Extrications- vehicle extrication is the process of removing a person(s) from a vehicle that has been involved in an accident which has resulted in making ordinary means of exit impractical. Vehicle extrication is typically accomplished by utilizing hydraulic cutting, spreading, and stabilization tools.	2011	2010	2009

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Other Rescue- includes lock-outs, lock-ins, searches, rescues and extrications	2011	2010	2009
Hazardous Condition/Materials Calls- includes spills and leaks, chemical releases, electrical transmission and service lines down.	2011	2010	2009
Service Calls- includes persons in distress calls, water problem calls, smoke odor calls, animal rescue calls, public service assist calls, and unauthorized burning calls.	2011	2010	2009
Other Calls and Incidents- anything that doesn't fit in another category.	2011	2010	2009
Total	2011	2010	2009
How many responses per year by category? (Enter whole numbers only: If you have no calls for any of the categories, enter 0)
What is the total acreage of all vegetation fires?	2011	2010	2009
How many responses per year by category? (Enter whole numbers only: If you have no calls for any of the categories, enter 0)
In a particular year, how many times does your organization receive mutual/automatic aid?	2011	2010	2009
In a particular year, how many times does your organization provide mutual/automatic aid? (Please indicate the number of times your department provides or receives mutual aid. Do not include first-due responses claimed above.)	2011	2010	2009
Total Mutual / Automatic Aid (please total the responses from the previous two blocks)	2011	2010	2009
Out of the mutual/automatic aid responses, how many were structure fires?	2011	2010	2009

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. If you are interested in applying under both Vehicle Acquisition and Operations and Safety, and/or regional application you will need to submit separate applications.
Program Name	Activities Available
○ Operations and Firefighter Safety (page 16)	[Equipment] [Modify Facilities] [Personal Protective Equipment] [Training] [Wellness and Fitness Programs]
○ Vehicle Acquisition (page 45)	[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 page)
$ (whole dollar amounts only)
*From the requested activities, what is the total dollar amount requested for EMS equipment, supplies, training, etc in the Request Details of this application? If none of the items requested are for fire-based EMS, then enter $0.		$

EMS Department Characteristics (Part I)

This section is for nonaffiliated EMS organizations only. If you are not applying on behalf of a non-affiliated EMS organization, DO NOT FILL OUT THIS SECTION. Fire department/districts should go directly to page 112, regional applicants go to page 87.

Please provide the following information regarding your organization.

Note: Fields marked with an * are required.

* What kind of organization do you represent? Career – An agency or organization in which all members receive financial compensation for their services. Combination – An agency or organization in which at least one member receives financial compensation for their services and/or at least one member does not receive financial compensation for their services, except as defined below. Volunteer – (Reserve) An agency or organization in which no member receives financial compensation for their services other than life/health insurance, workmen’s compensation insurance. Paid on Call/Stipend – An agency or organization in which member receive a nominal fee based on per event basis.	○ All Paid/Career ○ Combination ○ All volunteer ○ Paid On Call/Stipend
If you answered combination above, what is the percentage of career members in your organization? (number only)	%
* What type of community does your organization serve?	○ Urban ○ Suburban ○ Rural
* Does your department transport?	○ Yes ○ No
* What is the square mileage of your first-due response area? (number only)
* In what county/parish is your organization physically located? If you have more than one station, in what county/parish is your main station located?
* Does your organization protect critical infrastructure of the state? (definitions on page 7)	○ Yes ○ No
Percentages in three answers below must sum up to 100%:
* How much of your jurisdiction’s land use is for agriculture, wildland, open space, or undeveloped properties?	%
* What percentage of your jurisdiction’s land use is for commercial and industrial purposes?	%
* What percentage of your jurisdiction’s land is used for residential purposes?	%

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* What is the permanent resident population of your Primary/First Due Response Area or jurisdiction served? (whole number only) Primary/First Due Response Area is a geographical area proximate to a fire or rescue facility and normally served by the personnel and apparatus from that facility in the event of a fire or other emergency and does not include daily or seasonal population surges. Population shall be based upon the most recent official census and shall include only those individuals who permanently reside within the jurisdiction served.
* How many active members does your EMS organization have that meet the minimum EMS certification standards as dictated by your jurisdiction or state? (whole number only)
* How many stations are operated by your organization? (whole number only)
* How many personnel are trained to First Responder/Emergency Medical Responder? (whole number only)
* How many untrained members perform other duties, such as only drive? (whole numbers only)
* How many personnel are trained to EMT-B level? (whole numbers only)
* How many personnel are trained to EMT-I level? (whole numbers only)
* How many personnel are trained to EMT-P level? (whole numbers only)
* What services does your organization provide?
○ Medical First Response ○ Advanced Life Support Transport ○ Rescue Operational Level ○ Basic Life Support Transport ○ Advanced Life Support Non-Transport ○ Vehicle Extrication ○ Basic Life Support Non-Transport ○ Haz-Mat Operational Level ○ Swift Water Rescue ○ BLS/ALS Schedule Transport ○ Rescue Technical Level ○ Fire Suppression ○ Maritime Operations
* Please describe your organization and/or community that you serve. Use additional sheet if necessary.

EMS Department Characteristics (Part II)

Please provide the following additional information regarding your organization.

Note: Fields marked with an * are required.

* What is the total number of line of duty member fatalities in your jurisdiction over the last three years? (whole numbers only)			2011		2010				2009
* What is the total number of line of duty member injuries in your jurisdiction over the last three years? (whole numbers only)			2011		2010				2009
* Over the last three years, what was your organization’s average TOTAL operating budget?
* What percentage of your TOTAL budget is dedicated to personnel costs (salary, overtime and fringe benefits)?							%
* What percentage of your annual operating budget is derived from: (Enter numbers only; percentages must sum up to 100%)
Taxes?			%
EMS Billing?			%
Grants?			%
Donations?			%
Fund drives?			%
Fee for Service?			%
Other?			%
If you entered a value into Other field (other than 0), please explain:
* Please describe your organization's need for Federal financial assistance. Use additional sheet if necessary.
*What was the total mileage that your organization drove the vehicles in your fleet last year?						(number only)
*How many vehicles does your organization have in each of the types or classes of vehicle listed below? You must include vehicles that are leased or on long-term loan as well as any vehicles that have been ordered or otherwise currently under contract for purchase or lease by your organization but not yet in your possession. (Enter numbers only and enter 0 if you don't have any of the vehicles below)
Type or Class of Vehicle		Number of Front line Apparatus		Number of Reserve Apparatus				Number of Seated Riding Positions
Ambulances: Ambulance, EMS Transport Unit
Additional Vehicles: EMS Chase Vehicle, Air/Light Unit, Rehab Units, Bomb Unit, Technical Support (Command, Operational Support/Supply), Salvage Truck, ARFF (Aircraft Rescue Firefighting), Command/Mobile Communications Vehicle

EMS Department Call Volume

Please provide the total number of incidents that your department responded to for each of the three year periods (Jan - Dec). Include only those alarms which your department was a primary responder and not second due on giving mutual aid.

Note: Each incident must be counted only once regardless of the number of units that responded to that incident. (e.g. A vehicle fire with entrapment and injuries may be counted as a vehicle fire or a rescue call or an EMS call, but not all three.)

How many responses per year by category? (Enter whole numbers only: If you have no calls for any of the categories, enter 0)
Working Structural Fires - Includes cooking fires, chimney fires, smoke odor calls, unauthorized burning calls, and trash and rubbish fires that spread to a structure(s).	2011	2010	2009
EMS-BLS Response Calls - Includes medical assists, EMS calls, vehicle accident EMS calls, sickness/injuries, vehicle/pedestrian EMS calls, etc.	2011	2010	2009
EMS-ALS Response Calls - Calls that require an advanced level of treatment typically provided by an Advanced Life Support Provider (EMT-I or EMT-P). Examples: cardiac/respiratory arrest/distress, traumatic injury, I.V. treatment, trouble breathing, chest pains, unconscious/unresponsive, cardiac monitoring, intubation.	2011	2010	2009
EMS-BLS Scheduled Transports - Non-critical patient transports, ALS/critical transports, transports from one medical facility to another, etc.	2011	2010	2009
EMS-ALS Scheduled Transports- Pre-scheduled transports of patients to or from a medical facility that requires monitoring or treatment typically administered by an Advanced Life Support Provider (EMT-P or EMT-I). Examples: cardiac/respiratory distress, traumatic injury, I.V. treatment, trouble breathing, chest pains, unconscious/unresponsive, cardiac monitoring, intubation.	2011	2010	2009
Vehicle Extrications - Vehicle extrication is the process of removing a person(s) from a vehicle that has been involved in an accident which has resulted in making ordinary means of exit impractical. Vehicle extrication is typically accomplished by utilizing hydraulic cutting, spreading, and stabilization tools.	2011	2010	2009
Other Rescue - Includes lock-outs, lock-ins, searches and rescues.	2011	2010	2009
Hazardous Condition/Materials Calls - Includes spills and leaks, chemical releases, electrical transmission and service lines down.	2011	2010	2009
Total	2011	2010	2009
How many responses per year by category? (Enter whole numbers only: If you have no calls for any of the categories, enter 0)
Total calls requiring transport, exclusive of scheduled transport declared above - Includes persons in distress calls, water problem calls, animal rescue calls, public service assist calls, and unauthorized burning calls.	2011	2010	2009
All Other Calls and Incidents not declared above, including fire, good-intent, etc. - anything that doesn't fit in another category.	2011	2010	2009

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 57)	[Training] [Modify Facilities] [Personal Protective Equipment] [Wellness and Fitness Programs] [Equipment]
○ Vehicle Acquisition (page 81)	[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)

Regional Characteristics (Part I)

You only need to fill out this part if you are applying with a Regional Request. All other applicants should proceed to page 112 and Total Budget.

Please provide the following information regarding your organization.

Note: Fields marked with an * are required.

* What kind of organization do you represent? Career – An agency or organization in which all members receive financial compensation for their services. Combination – An agency or organization in which at least one member receives financial compensation for their services and/or at least one member does not receive financial compensation for their services, except as defined below. Volunteer – (Reserve) An agency or organization in which no member receives financial compensation for their services other than life/health insurance, workmen’s compensation insurance. Paid on Call/Stipend – An agency or organization in which members receive a nominal fee based on per event basis.	○ All Paid/Career ○ Combination ○ All volunteer ○ Paid On Call/Stipend
If you answered combination, above, what is the percentage of career members in your organization? (number only)	%
*What type of community will your regional project serve (what is the make up of the majority of the region affected by the project)?	○ Urban ○ Suburban ○ Rural
* Is your Organization considered a Metro Department? (Over 400 paid career Firefighters)	○ Yes ○ No
* What is the square mileage of the region affected by the project? (number only)
* In what county/parish is the host applicant physically located? If you have more than one station, in what county/parish is your main station located?
* Does your region protect critical infrastructure of the state? (definitions on page 7)	○ Yes ○ No
Percentages in three answers below must sum up to 100%:
* How much of your region’s land use is for agriculture, wildland, open space, or undeveloped properties?	%
* What percentage of your region’s land use is for commercial and industrial purposes?	%
* What percentage of your region’s land is used for residential purposes?	%
* What is the permanent resident population of your region served? Remember this is the combined population of all departments/agencies included in this application (whole number only) Primary/First Due Response Area is a geographical area proximate to a fire or rescue facility and normally served by the personnel and apparatus from that facility in the event of a fire or other emergency and does not include daily or seasonal population surges. Population shall be based upon the most recent official census and shall include only those individuals who permanently reside within the jurisdiction served.

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* What is the total membership in your region?   Remember this is the combined personnel of all departments/agencies included in this application. (whole number only)
* How many active members are trained to Firefighter I? (whole number only)
* How many active members are trained to Firefighter II? (whole number only)
* How many active BLS providers does your region have? (whole number only)
* How many active ALS providers does your region have? (whole number only)
* How many active Emergency Medical Responders does your region have? (whole number only)
* How many stations are in your region? (whole number only)
* If you (the host applicant) are a fire department, do you report to the National Fire Incident Reporting System (NFIRS)?		○ Yes ○ No
If yes, please enter your FDIN/FDID
* Do all departments in this request report to NFIRS?		○ Yes ○ No
* Do all agencies meet the regional minimum for NIMS compliancy?		○ Yes ○ No
* What services are provided by your organization and the organizations participating in the regional application?
○ Medical First Response ○ Haz-Mat Operational Level ○ Basic Life Support Transport ○ Haz-Mat Technical Level ○ Advanced Life Support Transport ○ Rescue Operational Level ○ Basic Life Support Non-Transport ○ Rescue Fire Suppression ○ BLS/ALS Schedule Transport ○ Advanced Life Support Non-Transport ○ Swift Water Rescue ○ Vehicle Extrication ○ Structural Fire Suppression ○ Wildland Fire Suppression ○ Rescue Technical Level ○ Airport Rescue Firefighting (ARFF) ○ Maritime Response
* Please describe your organization and/or community that you serve. Use additional sheet if necessary.

Regional Characteristics (Part II)

Please provide the following additional information regarding your organization.

Note: Fields marked with an * are required.

* What is the total number of line of duty member fatalities in your region over the last three years? (whole numbers only)		2011		2010	2009
* What is the total number of line of duty member injuries in your region over the last three years? (whole numbers only)		2011		2010	2009
* What is the cumulative total of the three-year average budgets of all participating organizations in this project? (number only)
* What percentage of this declared budget is dedicated to personnel costs (salary, fringe, and overtime)?			%
* What percentage of the declared operating budget is derived from: (Enter numbers only; percentages must sum up to 100%)
Taxes?			%
EMS Billing?
Grants?			%
Donations?			%
Fund drives?			%
Fee for Service?			%
Other?			%
If you entered a value into Other field (other than 0), please explain:
* Please describe your organization's need for Federal financial assistance. Use additional sheet if necessary.

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*How many vehicles are operational within the region in each of the types or classes of vehicle listed below? You must include vehicles that are leased or on long-term loan as well as any vehicles that have been ordered or otherwise currently under contract for purchase or lease by your organization but not yet in your possession. (Enter numbers only and enter 0 if you do not have any of the vehicles below)
Type or Class of Vehicle	Number of Front Line Apparatus	Number of Reserve Apparatus	Number of Seated Riding Positions
Engines or Pumpers (pumping capacity of 750 gpm or greater and water capacity of 300 gallons or more): Pumper, Pumper/Tanker, Rescue/Pumper, Foam Pumper, CAFS Pumper, Type I, Type II Engine Urban Interface
Ambulances that are used for transport
Tankers or Tenders (pumping capacity of less than 750 gallons per minute (gpm) and water capacity of 1,000 gallons or more):
Aerial Apparatus: Aerial Ladder Truck, Telescoping, Articulating, Ladder Towers, Platform, Tiller Ladder Truck, Quint (Aerial device of 76 feet or greater)
Brush/Quick Attack (pumping capacity of less than 750 gpm and water carrying capacity of at least 300 gallons): Brush Truck, Patrol Unit (Pick up w/ Skid Unit), Quick Attack Unit, Mini-Pumper, Type III Engine, Type IV Engine, Type V Engine, Type VI Engine, Type VII Engine
Rescue Vehicles: Rescue Squad, Rescue (Light, Medium, Heavy), Technical Rescue Vehicle, Hazardous Materials Unit
Additional Vehicles: EMS Chase Vehicle, Air/Light Unit, Rehab Units, Bomb Unit, Technical Support (Command, Operational Support/Supply), Salvage Truck, ARFF (Aircraft Rescue Firefighting), Command/Mobile Communications Vehicle

Regional Call Volume

Please provide the number of incidents your region responded to in each of the following categories last calendar year - do not include incidents in which more than one agency responded.

Note: Each incident must be counted only once regardless of the number of units that responded to that incident. (e.g. a vehicle fire with entrapment and injuries may be counted as a vehicle fire or a rescue call or an EMS call, but not all three.)

How many responses per year by category? (Enter whole numbers only: If you have no calls for any of the categories, enter 0)
Working Structural Fires - Includes cooking fires, chimney fires, smoke odor calls, unauthorized burning calls, and trash and rubbish fires that spread to a structure(s).	2011	2010	2009
False Alarms/Good Intent Calls Good Intent Calls - Includes canceled enroute, authorized burning calls, prescribed fire calls, smoke scares. False Alarm: Making a false report of a fire or other emergency via telephone to 911 or other emergency number, the false activation of a manual or automatic fire alarm system, and/or the transmission of a malicious false alarm via a dedicated public alarm system (telephone, telegraph, or radio call box).	2011	2010	2009
Vehicle Fires- Includes all vehicle fires except those that were inside a structure.	2011	2010	2009
Vegetation Fires - Includes wildland fires, brush fires, and grass fires.	2011	2010	2009
EMS-BLS Response Calls - Includes medical assists, EMS calls, vehicle accident EMS calls, sickness/injuries, vehicle/pedestrian EMS calls, etc.	2011	2010	2009
EMS-ALS Response Calls - Calls that require an advanced level of treatment typically provided by an Advanced Life Support Provider (EMT-I or EMT-P). Examples: cardiac/respiratory arrest/distress, traumatic injury, I.V. treatment, trouble breathing, chest pains, unconscious/unresponsive, cardiac monitoring, intubation.	2011	2010	2009
EMS-BLS Scheduled Transports - Non-critical patient transports, ALS/critical transports, transports from one medical facility to another, etc.	2011	2010	2009
EMS-ALS Scheduled Transports - Pre-scheduled transports of patients to or from a medical facility that requires monitoring or treatment typically administered by an Advanced Life Support Provider (EMT-P or EMT-I). Examples: cardiac/respiratory distress, traumatic injury, I.V. treatment, trouble breathing, chest pains, unconscious/unresponsive, cardiac monitoring, intubation.	2011	2010	2009
Vehicle Accidents w/o Extrication- Response to incidents involving any motorized vehicle (automobiles, motorcycles, trucks, etc…) with or without injury, where there is no entrapment of the occupants	2011	2010	2009
Vehicle Extrications - Vehicle extrication is the process of removing a person(s) from a vehicle that has been involved in an accident which has resulted in making ordinary means of exit impractical. Vehicle extrication is typically accomplished by utilizing hydraulic cutting, spreading, and stabilization tools.	2011	2010	2009

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Other Rescue- Includes lock-outs, lock-ins, searches, rescues, and extrications.	2011	2010	2009
Hazardous Condition/Materials Calls- Includes spills and leaks, chemical releases, electrical transmission and service lines down.	2011	2010	2009
Service Calls- Includes persons in distress calls, water problem calls, smoke odor calls, animal rescue calls, public service assist calls, and unauthorized burning calls.	2011	2010	2009
Other Calls and Incidents- Anything that doesn't fit in another category.	2011	2010	2009
Total	2011	2010	2009
What is the total acreage of all vegetation fires?

Regional Request Information

Program 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] [Personal Protective 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)
$
*From the requested activities, what is the total dollar amount requested for EMS equipment, supplies, training, etc in the Request Details of this application? If none of the items requested are for fire-based EMS, then enter $0.

Total Budget (All types of applicants)

Note: Fields marked with an * are required.

Budget Object Class
a. Personnel	$
b. Fringe Benefits	$
c. Travel	$
d. Equipment	$
e. Supplies	$
f. Contractual	$
g. Construction	$
h. Other (includes grant writer fee)	$
i. Indirect Charges	$
j. State Taxes	$
Federal and Applicant Share
Federal Share	$
Applicant Share	$
Federal Rate Sharing (%)
* Non-Federal Resources (The combined Non-Federal Resources must equal the Applicant Share)
a. Applicant: (whole dollar amounts only)	$
b. State: (whole dollar amounts only)	$
c. Local: (whole dollar amounts only)	$
d. Other Sources: (whole dollar amounts only)	$
If you entered a value in Other Sources other than zero (0), include your explanation below. You can use this space to provide information on the project, cost share match, or if you have an indirect cost agreement with a Federal agency.
Total Budget	$