Form FEMA Form 080-0-2a FEMA Form 080-0-2a Activity Specific Questions for AFG Vehicle Appliants

2012 Assistance to Firefighters Grant Program Application - Fire

Operations and Firefighter Safety – Equipment

P lease 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 your organization purchase with this grant? (select one from Equipment List on pages 17-18)

*Please provide further description of the item selected.

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

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

* 4. Generally the equipment purchased under this grant program will: (select one)

○ Be bought for the first time

○ Replace or upgrade old, obsolete, tattered, torn, or substandard equipment currently owned by your organization

○ Replace contaminated equipment

○ Address a new risk

○ Expand the capabilities of your organization into a new mission area

○ Replace worn but usable equipment

○ Replace used equipment

○ Replace new equipment

○ Increase your organization'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 ○ N/A

○ 6 years ○ 7 years ○ 8 years ○ 9 years ○ 10 or more years

(continued on next page)

* 5. 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.
* 6. 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:
* 7. Will this equipment be used for wildland firefighting purposes?				○ Yes ○ No
* 8. Is your department trained in the proper use of the equipment being requested?				○ Yes ○ No
*9. Are you requesting funding for training? (Funding for requested training should be requested in the Equipment Additional Funding section).				Yes ○ No
10. If you are not requesting training funds through this application, will you obtain training for this equipment through other sources?				○ Yes ○ No

Equipment List (select one to answer Equipment Details Q1)

Basic Equipment
Adapters, Wyes & Siamese	Portable Deluge Sets
Basic Hand Tools	Electric/Gas Powered Saws/Tools
Foam Eductors and foam concentrate	Ropes, Harnesses, Carabiners, Pulleys, etc.
Hose- (3½ inches or less)	RIT Pack
Hose- Large Diameter (LDH 4 inches or larger)	Wildland
Hydrant and Spanner Wrenches	Complete air-fill system
Ladders	Generator - Mobile
Nozzles	Thermal Imaging Camera
Compressor/Cascade/Fill Station (Fixed)

(continued on next page)

Communications
Base Station	Mobile Date Terminal (MDT)
Computer Aided Dispatch (CAD)	Pagers
Computers	Equipment to support dispatch
Headsets	Portable Radios (must be P-25 Compliant)
Mobile Radios (must be P-25 Compliant)	Repeaters
EMS/Rescue
ALS Airway Equipment	ANSI Traffic Vest
BLS Airway Equipment	Vest Extrication Devices
Power lift cots/stretchers	EMS/Rescue Equipment
Automated External Defibrillators (AEDs)	Cutter
Pulse Oximeters	Spreader
Blood Pressure Cuffs	Combo-Tool
Stethoscopes	Power Unit
Rehab Equipment	Vehicle stabilization/air bags, RAMS, etc.
Stretchers, Backboards, Splint, etc.
Haz-Mat
Decon, Clean-Up, Containment and Packaging Equipment			Spark Proof Tools
Monitoring and Sampling Devices			Suppression
Reference Library			Haz-Mat
Investigation
Cameras	Lights, Portable
Hand Tools	Monitoring and Sampling Devices
Investigation Tools
Specialized
Compressors/Cascade/Fill Station (Mobile)		Skid Unit
Portable/Mobile Generator		Washer/Extractor
Portable Pump		Cascade/Oxygen
Class A Boats		Oxygen refill systems
Class One Boats (20 feet or less)		Specialized Equipment
CBRNE Equipment
Biological Detection		CBRNE-related Pharmaceuticals
Auto-injectors		CBRNE-related Equipment

Firefighting Equipment - Additional Funding (optional unless you’re applying for Training funds)

Enter any additional funding for your grant in the space provided below. You will need to explain the additional costs. The costs added in this section must show a direct relationship to the costs already included in your Request Details. Please note that this section is optional. Definitions can be found on page 6 of this application.

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

Firefighter Equipment Narrative Statement

The program narratives should provide all the information necessary for you to justify your needs and for the program office to make an award decision. In the program narrative sections, please explain your needs and how the grants funds will be utilized. A panel of your peers will review the narratives below and the financial need narrative in the Applicant Characteristics II section as part of their evaluation of your entire grant application.

Please ensure that your narrative clearly addresses each of the following areas to the best of your ability. Follow the sequence and specifically address each of the following topics:

• Section #1 Project Description: What are you requesting funding for, including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc?

• Section #2 Cost/Benefit: What benefits will your department or community realize if the project described is funded? Provide justification for the budget items relating to the cost of the requested items.

• Section #3 Statement of Effect: How would this award affect the daily operations of your department and how would this award affect your department’s ability to protect lives and property in your community?

• Section #4 Additional Information: In the space provided below, include details regarding your organization’s request not covered in any other section.

Your narrative should be detailed but concise. You may either type your project narrative in the space provided below; or create the text in your word processing system then copy it into the space provided below. Images are not allowed, attach additional pages if necessary.

Note: Fields marked with an * are required.

Project Description

* Section #1 Project Description: In the space provided below include clear and concise details regarding your organization’s project’s description and budget. This includes providing local statistics to justify the needs of your department and a detailed plan for how your department will implement the proposed project. Further, please describe what you are requesting funding for including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc.

* Section #2 Cost/Benefit: In the space provided below please explain, as clearly as possible, what will be the benefits your department or your community will realize if the project described is funded (i.e. anticipated savings and/or efficiencies)? Is there a high benefit for the cost incurred? Are the costs reasonable? Provide justification for the budget items relating to the cost of the requested items.

* Section #3 Statement of Effect: How would this award affect the daily operations of your department (i.e., describe how frequently the equipment will be used or what the benefits will provide the personnel in your department)? How would this award affect your department’s ability to protect lives and property in your community?

* Section #4 In the space provided below include details regarding your organization’s request not covered in any other section.

Operations and Firefighter Safety - Modify Facilities

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

Note: When requesting one or more multiple projects for one station (e.g. sprinklers & exhaust system) the total request cannot exceed $100,000 per station. For FY 2012, all projects must be entered as separate line-items regardless if the projects are in the same station. If you wish to enter an additional project, please fill out another set of Operations and Firefighter Safety – Modify Facilities questions.

Note: Fields marked with an * are required.

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.

Modify Facilities Details
* 1. On what type of modification will the funds be spent? (Add one line-item request per station being modified)	○ Source Capture Exhaust System(s) ○ Sprinkler System(s) ○ Smoke/Alarm System(s) ○ Emergency generator(s) ○ Air Quality System(s)
* Please provide further description of the item selected above.
2. If you are installing an exhaust system, how many vehicles do you plan on attaching to the system (only include currently owned vehicles or vehicles on order – do not include equipment for future capacity)?
* 3. Does the facility you wish to modify have a drive through bay?		○ Yes ○ No

(continued on next page)

(continued from previous page)

* 4. Number of units: (whole number only)
* 5. Cost per unit: (whole dollar amounts only)
* 6. What is the age of the facility (in years) that is being modified?	○ less than 5 ○ 5-10 ○ 11-15 ○ 16-20 ○ 21-25 ○ 26-30 ○ greater than 30
* 7. What type of facility will be modified?	○ Station(s) with sleeping quarters (to include marine fire facilities) ○ Station(s) w/o sleeping quarters ○ Training Facilities ○ Dispatch/Administrative Offices/Maintenance Facilities/Storage Buildings
* 8. 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 (24/7) ○ Part-Time (Daily, but not 24/7) ○ Occasional

Modify Facilities - Additional Funding (optional)

Enter any additional funding for your grant in the space provided below. You will need to explain the additional costs. The costs added in this section must show a direct relationship to the costs already included in your Request Details. Please note that this section is optional. Definitions can be found on page 6 of this application.

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

Firefighter Modify Facilities Narrative Statement

The program narratives should provide all the information necessary for you to justify your needs and for the program office to make an award decision. In the program narrative sections, please explain your needs and how the grants funds will be utilized. A panel of your peers will review the narratives below and the financial need narrative in the Applicant Characteristics II section as part of their evaluation of your entire grant application.

Please ensure that your narrative clearly addresses each of the following areas to the best of your ability. Follow the sequence and specifically address each of the following topics:

• Section #1 Project Description: What are you requesting funding for, including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc?

• Section #2 Cost/Benefit: What benefits will your department or community realize if the project described is funded? Provide justification for the budget items relating to the cost of the requested items.

• Section #3 Statement of Effect: How would this award affect the daily operations of your department and how would this award affect your department’s ability to protect lives and property in your community?

• Section #4 Additional Information: In the space provided below, include details regarding your organization’s request not covered in any other section.

Your narrative should be detailed but concise. You may either type your project narrative in the space provided below; or create the text in your word processing system then copy it into the space provided below. Images are not allowed, attach additional pages if necessary.

Note: Fields marked with an * are required.

Project Description

* Section #1 Project Description: In the space provided below include clear and concise details regarding your organization’s project’s description and budget. This includes providing local statistics to justify the needs of your department and a detailed plan for how your department will implement the proposed project. Further, please describe what you are requesting funding for including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc.

* Section #2 Cost/Benefit: In the space provided below please explain, as clearly as possible, what will be the benefits your department or your community will realize if the project described is funded (i.e. anticipated savings and/or efficiencies)? Is there a high benefit for the cost incurred? Are the costs reasonable? Provide justification for the budget items relating to the cost of the requested items.

* Section #3 Statement of Effect: How would this award affect the daily operations of your department (i.e., describe how frequently the equipment will be used or what the benefits will provide the personnel in your department)? How would this award affect your department’s ability to protect lives and property in your community?

* Section #4 In the space provided below include details regarding your organization’s request not covered in any other section.

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. Select the PPE that you propose to acquire (select one from PPE list on page 29)
* 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. Please provide your percentage for the appropriate question below: For turnout requests, what percentage of your on-duty active members will have PPE that meets 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 SCBA assigned to it if this grant is awarded? If you are asking for specialized PPE (e.g., Haz-Mat), what percentage of applicable members will have specialized PPE that meets established standards if this grant is awarded? For example, if your 100-member department has a 10-member Haz-Mat team and you are requesting 10 Haz-Mat suits, you are requesting 100% of the applicable members.			%
* 5. What is the purpose of this request? (select one)	○ to buy equipment for the first time (never owned before) ○ to replace or upgrade old/obsolete equipment (it must be a minimum of 10 years or older) ○ to replace torn/tattered/damaged equipment ○ to replace contaminated equipment ○ to meet new risk ○ 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

(continued on next page)

If you have indicated you are requesting PPE (any PPE other than SCBA) in the Question 1, 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 gear for ALL members declared in Department Characteristics - not just the gear you wish to replace.		○ N/A
		Age (in years)			Number of Items
		Less than 1
		1
		2
		3
		4
		5
		6
		7
		8
		9
		10
		11
		12
		13
		14
		15
		16 or more
		Number of members without gear _______
If you have indicated you are requesting SCBA in the Question 1, to which edition(s) of NFPA are your SCBA compliant? If not requesting SCBA, please select “N/A” and continue on to the next question. Please account for ALL SCBA currently in your department’s inventory - not just the equipment you wish to replace .	○ N/A
	Year			Number of NFPA Compliant SCBA
	2007 Standard
	2002 Standard
	Older Standards
* 6. Is this PPE:
○ For protection use against fire ○ For use in Haz-mat incidents	○ For use in Rescue incidents, vehicle extrication ○ For some other use
If you selected For some other use above, please specify_______________________________________________
* 7. Will this equipment be used for wildland firefighting purposes?			○ Yes ○ No
* 8. Is your department trained in the proper use of this equipment being requested?			○ Yes ○ No
*9. Are you requesting funding for training for this equipment? (Funding for requested training should be requested in the PPE Additional Funding section on page 30).			○ Yes ○ No
If you are not asking for training funds through this application, will you obtain training for this equipment through other sources?			○ Yes ○ No

Personal Protective Equipment List (select one to answer Q1)

Structural
Boots	Goggles
Coats	Helmets
Complete Set of Turnout Gear	Hoods
Flashlights	Pants
Gloves	PASS Devices
Respiratory
Accountability Systems	SCBA-45 minutes with face piece-With extra bottle
Air-Line Units	SCBA-60 minutes with face piece-With extra bottle
Face Pieces	Spare Cylinders-30 minutes
Respirators	Spare Cylinders-45 minutes
SCBA-30 minutes with face piece-With extra bottle	Spare Cylinders-60 minutes
Wildland
Jumpsuits/Coveralls	Shelters
Web Gear/Backpacks/Canteens
Other PPE
ANSI Traffic Vests	Infection Control
EMS Turnout	Proximity and Entry Suits
Encapsulated Suits	Splash Suits
Extrication Clothing/Rescue Clothing	Wet and Dry Suits
Chemical/Biological Suits (Must conform to NFPA 1994, 2001 edition)

PPE - Additional Funding (optional unless you’re applying for Training funds)

Enter any additional funding for your grant in the space provided below. You will need to explain the additional costs. The costs added in this section must show a direct relationship to the costs already included in your Request Details. Please note that this section is optional. Definitions can be found on page 6 of this application.

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

Firefighter PPE Narrative Statement

The program narratives should provide all the information necessary for you to justify your needs and for the program office to make an award decision. In the program narrative sections, please explain your needs and how the grants funds will be utilized. A panel of your peers will review the narratives below and the financial need narrative in the Applicant Characteristics II section as part of their evaluation of your entire grant application.

Please ensure that your narrative clearly addresses each of the following areas to the best of your ability. Follow the sequence and specifically address each of the following topics:

• Section #1 Project Description: What are you requesting funding for, including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc?

• Section #2 Cost/Benefit: What benefits will your department or community realize if the project described is funded? Provide justification for the budget items relating to the cost of the requested items.

• Section #3 Statement of Effect: How would this award affect the daily operations of your department and how would this award affect your department’s ability to protect lives and property in your community?

• Section #4 Additional Information: In the space provided below, include details regarding your organization’s request not covered in any other section.

Your narrative should be detailed but concise. You may either type your project narrative in the space provided below; or create the text in your word processing system then copy it into the space provided below. Images are not allowed, attach additional pages if necessary.

Note: Fields marked with an * are required.

Project Description

* Section #1 Project Description: In the space provided below include clear and concise details regarding your organization’s project’s description and budget. This includes providing local statistics to justify the needs of your department and a detailed plan for how your department will implement the proposed project. Further, please describe what you are requesting funding for including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc.

* Section #2 Cost/Benefit: In the space provided below please explain, as clearly as possible, what will be the benefits your department or your community will realize if the project described is funded (i.e. anticipated savings and/or efficiencies)? Is there a high benefit for the cost incurred? Are the costs reasonable? Provide justification for the budget items relating to the cost of the requested items.

* Section #3 Statement of Effect: How would this award affect the daily operations of your department (i.e., describe how frequently the equipment will be used or what the benefits will provide the personnel in your department)? How would this award affect your department’s ability to protect lives and property in your community?

* Section #4 In the space provided below include details regarding your organization’s request not covered in any other section.

Operations and Firefighter Safety - Training

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)

---General Training---

Operations (NFPA 472)

Firefighter I, Firefighter II (NFPA 1001)

Instructor Training (NFPA 1041)

Driver/Operator (NFPA 1002)

Officer Training (NFPA 1021)

Basic Wildland Firefighting (NFPA 1051/NWCG)

Wildland Firefighter Certification (NFPA 1051/NWCG)

Wildland Officer (NFPA 1051/1143/NWCG)

Airport Rescue Firefighting (ARFF) (NFPA 1003)

RIT Training (NPFA 1407/29 CFR 1910.134g(4))

Confined Space Rescue – Awareness level (NFPA 1670/29 CFR 1910.146)

Vehicle Rescue (NFPA 1670)

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)

Haz-Mat – Technician/Specialist level (NFPA 472)

Infection Control (NFPA 1581)

Medical First Responder Training (First Responder)

Emergency Medical Technician – Basic (EMT B)

Emergency Medical Technician – Intermediate (EMT I)

Emergency Scene Rehab (NFPA 1500/1584)

Paramedic Training (EMT-P)

Mass Casualty Incident Training (MCI)

NIMS (NFA/EMI/NWFCG)

Incident Management Course (NFA/EMI/NWFCG)

Integrated Emergency Management Course (NFPA 1561/IEMC)

Fire Inspector (NFPA 1031)

Fire Investigator (NFPA 1033)

Fire Educator (NFPA 1035)

Telecommunications/Dispatcher (NFPA 1601)

Safety Officer (NFPA 1521)

Physical Agility Program Training (NFPA 1583)

Firefighter Safety and Survival Training (NFPA 1407/29 CRF 1910.146

Fire Officer I,II, III, and/or IV (NFPA 1021)

Fire Prevention (NFPA 1)

Maritime (NFPA 1405/1005)

Environmental (EPA Train/Learning Center)

Exercises/Preparedness (NFA/EMI)

---CBRNE Training---

Operations-level Training (National Law Enforcement Training Agency)

Technician-level Training (National Law Enforcement Training Agency)

Other CBRNE Training (National Law Enforcement Training Agency)

Weapons of Mass Destruction – Awareness level (CBRNE)

Weapons of Mass Destruction – Operations level (NFPA 472)

Weapons of Mass Destruction – Technician Level for Rural (NFPA 472)

Weapons of Mass Destruction Training – Technician Level for Urban/Suburban (NFPA 472)

Other/Specialized Weapons of Mass Destruction Training (NFPA 472)

---Specialized CBRNE Training---

Specialist (National Law Enforcement Training Agency)

EMS for Incidents Involving CBRNE (National Law Enforcement Training Agency)

ICS for Terrorism (National Law Enforcement Training Agency)

Mass Decontamination (National Law Enforcement Training Agency)

Live Agent (National Domestic Preparedness Consortium)

Explosives and Secondary Device Awareness (National Domestic Preparedness Consortium)

(continued on next page)

(continued from previous page)

* Please provide further description of the Training Program you selected.
* 2. Generally, this program can best be categorized as: (select one)
○ Training that is evaluated/tested using a national or state standard ○ Non-certification training
* 3. What percentage of applicable personnel will be trained by this program?		%
* 4. Generally, the training program provided under this grant: (select one)
○ Will bring your department into compliance with recommended applicable NFPA or other standards, please specify:
○ Will bring your department into compliance with mandated training requirements, please specify:
○ Will address an identified risk for your department or community, please specify:
* 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 include members from other fire departments and/or non-affiliated EMS organizations?		○ Yes ○ No
* 7. Will this training be:		○ Instructor-led ○ Self/directed/test-validated ○ None of the above

Training Program

(continued from previous page)

Please provide the following information about the training you want funded. Only whole dollar amounts are acceptable. For each budget item, please fill out an additional page.

Training Program – Add Budget Item
* Item: (select one)	-- Equipment -- ○ Audio-Visual ○ Library ○ Classroom ○ Reference Texts ○ Rescue ○ Supplies ○ CPR Manikins -- Programs & Contract Instruction -- ○Firefighter I ○ Investigator ○Firefighter II ○ Public Educator ○Driver/Operator ○ Haz-Mat ○EVOC ○ Marine ○EMT ○ Aircraft ○Paramedic ○ Wildland ○Inspector ○ Officer I-IV ○Specialized -- Props: Non-Construction -- ○Simulators ○Manufacturer Burn Simulator ○Props: Non-Construction
* Please provide further description of the item selected above.
* Select Object Class:		○ Personnel ○ Contractual ○ Fringe Benefits ○ Construction ○ Travel ○ Indirect Charges ○ Equipment ○ Other ○ Supplies ○ State Taxes
If you selected Other above, please specify:
* Number of units: (whole number only)
* Cost per unit: (whole dollar amounts only)

Training - Additional Funding (optional)

Enter any additional funding for your grant in the space provided below. You will need to explain the additional costs. The costs added in this section must show a direct relationship to the costs already included in your Request Details. Please note that this section is optional. Definitions can be found on page 6 of this application.

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

Firefighter Training Narrative Statement

The program narratives should provide all the information necessary for you to justify your needs and for the program office to make an award decision. In the program narrative sections, please explain your needs and how the grants funds will be utilized. A panel of your peers will review the narratives below and the financial need narrative in the Applicant Characteristics II section as part of their evaluation of your entire grant application.

Please ensure that your narrative clearly addresses each of the following areas to the best of your ability. Follow the sequence and specifically address each of the following topics:

• Section #1 Project Description: What are you requesting funding for, including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc?

• Section #2 Cost/Benefit: What benefits will your department or community realize if the project described is funded? Provide justification for the budget items relating to the cost of the requested items.

• Section #3 Statement of Effect: How would this award affect the daily operations of your department and how would this award affect your department’s ability to protect lives and property in your community?

• Section #4 Additional Information: In the space provided below, include details regarding your organization’s request not covered in any other section.

Your narrative should be detailed but concise. You may either type your project narrative in the space provided below; or create the text in your word processing system then copy it into the space provided below. Images are not allowed, attach additional pages if necessary.

Note: Fields marked with an * are required.

Project Description

* Section #1 Project Description: In the space provided below include clear and concise details regarding your organization’s project’s description and budget. This includes providing local statistics to justify the needs of your department and a detailed plan for how your department will implement the proposed project. Further, please describe what you are requesting funding for including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc.

* Section #2 Cost/Benefit: In the space provided below please explain, as clearly as possible, what will be the benefits your department or your community will realize if the project described is funded (i.e. anticipated savings and/or efficiencies)? Is there a high benefit for the cost incurred? Are the costs reasonable? Provide justification for the budget items relating to the cost of the requested items.

* Section #3 Statement of Effect: How would this award affect the daily operations of your department (i.e., describe how frequently the equipment will be used or what the benefits will provide the personnel in your department)? How would this award affect your department’s ability to protect lives and property in your community?

* Section #4 In the space provided below include details regarding your organization’s request not covered in any other section.

Operations and Firefighter Safety – Wellness and Fitness

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?	Are you requesting funding for this activity in this application?	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 Medical Exam/Health Screening	○ Yes ○ No	○ Yes ○ No	○ Yes ○ No	○ Yes ○ No
* Behavioral Health NFPA 1500 or equivalent Behavioral health programs are described in NFPA 1500 chapter 11. If you have any questions call the AFG help desk at 866-274-0960.	○ Yes ○ No	○ Yes ○ No	○ Yes ○ No	○ Yes ○ No

Additional Wellness and Fitness (if you are requesting Wellness and Fitness activities outside of Initial Physical Exam, Job Related Immunization, Periodic Medical Exam/Health Screening and/or Behavorial Health):

* 1. What will your program offer during the grant year? (select one)	○ Formal fitness and injury prevention program ○ CISM Program ○ Employee assistance program ○ Injury/illness rehabilitation program
If you answered Other above, please specify.
* 2. Does your organization currently offer this activity?	○ Yes ○ No
* 3. Are you requesting funding with this application?	○ Yes ○ No
* 4. Will this program be mandatory?	○ Yes ○ No
* 5. Will this program be offered to all?	○ Yes ○ No

Add Budget Item (answer for each of the Wellness Activities you are requesting funding for, use additional sheets if necessary)

* Item	-- Physicals/Medical Examinations -- ○Job Related Immunization Program ○Initial Physical Exam ○Behavioral Health NFPA 1500 or equivalent ○Periodic Physical Exam/Health Screening ○Rehab and Therapy -- Wellness – ○Exercise Equipment ○ Aerobic Instructors ○Nutrition ○ Physical Trainers ○Smoking Cessation ○CISD Programs ○ Fitness Assessments and Counseling ○EAP Programs
* Please provide further description of the item selected above.
* Select Object Class:	○ Personnel ○ Fringe Benefits ○ Travel ○ Equipment ○ Supplies ○ Contractual ○ Construction ○ Indirect Charges ○ Other ○ State Taxes
If you selected Other above, please specify
* Number of units: (whole number only)
* Cost per unit: (whole dollar amounts only)

Wellness and Fitness - Additional Funding

Enter any additional funding for your grant in the space provided below. You will need to explain the additional costs. The costs added in this section must show a direct relationship to the costs already included in your Request Details. Please note that this section is optional. Definitions can be found on page 6 of this application.

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

Firefighter Wellness and Fitness Narrative Statement

The program narratives should provide all the information necessary for you to justify your needs and for the program office to make an award decision. In the program narrative sections, please explain your needs and how the grants funds will be utilized. A panel of your peers will review the narratives below and the financial need narrative in the Applicant Characteristics II section as part of their evaluation of your entire grant application.

Please ensure that your narrative clearly addresses each of the following areas to the best of your ability. Follow the sequence and specifically address each of the following topics:

• Section #1 Project Description: What are you requesting funding for, including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc?

• Section #2 Cost/Benefit: What benefits will your department or community realize if the project described is funded? Provide justification for the budget items relating to the cost of the requested items.

• Section #3 Statement of Effect: How would this award affect the daily operations of your department and how would this award affect your department’s ability to protect lives and property in your community?

• Section #4 Additional Information: In the space provided below, include details regarding your organization’s request not covered in any other section.

Your narrative should be detailed but concise. You may either type your project narrative in the space provided below; or create the text in your word processing system then copy it into the space provided below. Images are not allowed, attach additional pages if necessary.

Note: Fields marked with an * are required.

Project Description

* Section #1 Project Description: In the space provided below include clear and concise details regarding your organization’s project’s description and budget. This includes providing local statistics to justify the needs of your department and a detailed plan for how your department will implement the proposed project. Further, please describe what you are requesting funding for including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc.

* Section #2 Cost/Benefit: In the space provided below please explain, as clearly as possible, what will be the benefits your department or your community will realize if the project described is funded (i.e. anticipated savings and/or efficiencies)? Is there a high benefit for the cost incurred? Are the costs reasonable? Provide justification for the budget items relating to the cost of the requested items.

* Section #3 Statement of Effect: How would this award affect the daily operations of your department (i.e., describe how frequently the equipment will be used or what the benefits will provide the personnel in your department)? How would this award affect your department’s ability to protect lives and property in your community?

* Section #4 In the space provided below include details regarding your organization’s request not covered in any other section.

Please go directly to page 112 and 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)	---Communications--- ○ Mobile Radios (Must be P-25 Compliant) ○ Portable Radios (Must be P-25 Compliant) ○ Pagers ○ Base stations ○ Computers/MDT ---EMS--- ○ Defibrillators ○ Pulse Oximeters ○ ALS/BLS equipment ○ Power lift cots/stretchers ○ ALS Airway Equipment ○ BLS Airway Equipment ○ Suction ○ Stretchers, Backboards, Splints, etc. ○ EMS/Rescue (explain) ---Basic Equipment--- ○ Powered/Mechanical Extrication Tools/Equipment ---Haz-Mat--- ○ Decon, Clean-Up, Containment and Packaging Equipment ○ Reference Library ○ Haz-Mat ---Technical Rescue--- ○ Technical Rescue Equipment ---CBRNE--- ○ Monitoring and Sampling Devices
* Please provide further description of the item selected above.
* 2. Number of units: (whole number only)
* 3. Cost per unit: (whole dollar amounts only)	$

(continued on next page)

(continued from previous page)

* 4. Generally the equipment purchased under this grant program will: (select one)
○ Be bought for the first time (has never been owned before) ○ Replace or upgrade old, obsolete, tattered, torn, or substandard equipment currently owned by your organization ○ Replace contaminated equipment ○ Address a new risk ○ Replace used or obsolete equipment ○ Expand the capabilities of your organization into a new mission area ○ Replace worn but usable equipment ○ Replace used equipment ○ Replace new equipment ○ Increase your organization’s available supply of this equipment to meet basic mission
* 5. Will this equipment bring you into compliance with state or federal or local protocols, standards/regulations?	○ Yes ○ No ○ N/A
*6. At what level of service will this equipment be used if awarded this grant?	○ ALS (EMT-I and EMT-P) ○ BLS (EMT-B) ○ ALS/EMR (First Responder) ○ Haz-Mat Ops/Tech ○ Rescue Ops/Tech
*7. Is your department trained in the proper use of the equipment being purchased with grant funds?	○ Yes ○ No
*8. Is your department trained in the proper use of this equipment being requested?	○ Yes ○ No
*9. Are you requesting funding for training? (Funding for requested training should be requested in the Equipment Additional Funding section on page 59).	○ Yes ○ No
10. If you are not requesting training funds through this application, will you obtain training for this equipment through other sources?	○ Yes ○ No

EMS Equipment - Additional Funding (optional unless you’re applying for Training funds)

Enter any additional funding for your grant in the space provided below. You will need to explain the additional costs. The costs added in this section must show a direct relationship to the costs already included in your Request Details. Please note that this section is optional. Definitions can be found on page 6 of this application.

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

EMS Equipment Narrative Statement

The program narratives should provide all the information necessary for you to justify your needs and for the program office to make an award decision. In the program narrative sections, please explain your needs and how the grants funds will be utilized. A panel of your peers will review the narratives below and the financial need narrative in the Applicant Characteristics II section as part of their evaluation of your entire grant application.

Please ensure that your narrative clearly addresses each of the following areas to the best of your ability. Follow the sequence and specifically address each of the following topics:

• Section #1 Project Description: What are you requesting funding for, including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc?

• Section #2 Cost/Benefit: What benefits will your department or community realize if the project described is funded? Provide justification for the budget items relating to the cost of the requested items.

• Section #3 Statement of Effect: How would this award affect the daily operations of your department and how would this award affect your department’s ability to protect lives and property in your community?

• Section #4 Additional Information: In the space provided below, include details regarding your organization’s request not covered in any other section.

Your narrative should be detailed but concise. You may either type your project narrative in the space provided below; or create the text in your word processing system then copy it into the space provided below. Images are not allowed, attach additional pages if necessary.

Note: Fields marked with an * are required.

Project Description

* Section #1 Project Description: In the space provided below include clear and concise details regarding your organization’s project’s description and budget. This includes providing local statistics to justify the needs of your department and a detailed plan for how your department will implement the proposed project. Further, please describe what you are requesting funding for including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc.

* Section #2 Cost/Benefit: In the space provided below please explain, as clearly as possible, what will be the benefits your department or your community will realize if the project described is funded (i.e. anticipated savings and/or efficiencies)? Is there a high benefit for the cost incurred? Are the costs reasonable? Provide justification for the budget items relating to the cost of the requested items.

* Section #3 Statement of Effect: How would this award affect the daily operations of your department (i.e., describe how frequently the equipment will be used or what the benefits will provide the personnel in your department)? How would this award affect your department’s ability to protect lives and property in your community?

* Section #4 In the space provided below include details regarding your organization’s request not covered in any other section.

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:  When requesting one or more multiple projects for one station (e.g. sprinklers & exhaust system) the total request cannot exceed $100,000 per station. For FY 2012, all projects must be entered as separate line-items regardless if the projects are in the same station. If you wish to enter an additional project, please fill out another set of EMS Operations and Safety – Modify Facilities questions.

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. On what type of modification will the funds be spent?		○ Source Capture Exhaust System(s) ○ Sprinkler System(s) ○ Smoke/Alarm System(s) ○ Emergency Generator(s) ○ Air Quality System(s)
*Please provide further description of the item selected above.
* 2. What is the age of the facility that is being modified (in years)?		○ less than 5 ○ 16-20 ○ 5-10 ○ 26-30 ○ 11-15 ○ greater than 30 ○ 21-25
* 3. What type of facility will be modified?	○ Station(s) with sleeping quarters (to include marine fire facilities) ○ Station(s) w/o sleeping quarters ○ Training Facilities ○ Dispatch/Administrative Offices/Maintenance Facilities/Storage Buildings
4. If you are installing an exhaust extraction system, how many vehicles do you plan on attaching to the system (only include currently owned vehicles or vehicles on order – do not include equipment for future capacity)?
* 5. Number of units: (whole number only)
* 6. Cost per unit: (whole dollar amounts only)
* 7. 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 (24/7) ○ Part-Time (Daily, but not 24/7) ○ Occasional
* Does the facility you wish to modify have a drive through bay?		○ Yes ○ No

EMS Modification to Facilities - Additional Funding (optional)

Enter any additional funding for your grant in the space provided below. You will need to explain the additional costs. The costs added in this section must show a direct relationship to the costs already included in your Request Details. Please note that this section is optional. Definitions can be found on page 6 of this application.

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

EMS Modify Facilities Narrative Statement

The program narratives should provide all the information necessary for you to justify your needs and for the program office to make an award decision. In the program narrative sections, please explain your needs and how the grants funds will be utilized. A panel of your peers will review the narratives below and the financial need narrative in the Applicant Characteristics II section as part of their evaluation of your entire grant application.

Please ensure that your narrative clearly addresses each of the following areas to the best of your ability. Follow the sequence and specifically address each of the following topics:

• Section #1 Project Description: What are you requesting funding for, including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc?

• Section #2 Cost/Benefit: What benefits will your department or community realize if the project described is funded? Provide justification for the budget items relating to the cost of the requested items.

• Section #3 Statement of Effect: How would this award affect the daily operations of your department and how would this award affect your department’s ability to protect lives and property in your community?

• Section #4 Additional Information: In the space provided below, include details regarding your organization’s request not covered in any other section.

Your narrative should be detailed but concise. You may either type your project narrative in the space provided below; or create the text in your word processing system then copy it into the space provided below. Images are not allowed, attach additional pages if necessary.

Note: Fields marked with an * are required.

Project Description

* Section #1 Project Description: In the space provided below include clear and concise details regarding your organization’s project’s description and budget. This includes providing local statistics to justify the needs of your department and a detailed plan for how your department will implement the proposed project. Further, please describe what you are requesting funding for including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc.

* Section #2 Cost/Benefit: In the space provided below please explain, as clearly as possible, what will be the benefits your department or your community will realize if the project described is funded (i.e. anticipated savings and/or efficiencies)? Is there a high benefit for the cost incurred? Are the costs reasonable? Provide justification for the budget items relating to the cost of the requested items.

* Section #3 Statement of Effect: How would this award affect the daily operations of your department (i.e., describe how frequently the equipment will be used or what the benefits will provide the personnel in your department)? How would this award affect your department’s ability to protect lives and property in your community?

* Section #4 In the space provided below include details regarding your organization’s request not covered in any other section.

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:	---PPE--- ○ ANSI Traffic Vests ○ Respirators ○ Helmets ○ Boots ○ Goggles ○ Gloves ○ Face Pieces ○ Hearing Protection ○ EMS Turnout Coats ○ EMS Turnout Pants ---SCBA--- ○ SCBA-30 minutes with face piece-With extra bottle ○ SCBA-45 minutes with face piece-With extra bottle ○ SCBA-60 minutes with face piece-With extra bottle ○ Spare Cylinders-30 minutes ○ Spare Cylinders-45 minutes ○ Spare Cylinders-60 minutes ○ Air-Line Units ---Specialized--- ○ Respirators ○ Extrication Jumpsuits ○ Level-B De-con Suits
* Please provide further description of the item selected above.
* 2. Number of units: (whole number only)
* 3. Cost per unit: (whole dollar amounts only)		$
* 4. Please provide your percentage for the appropriate question below: For turnout requests, what percentage of your on-duty active members will have PPE that meets 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., Haz-Mat), what percentage of applicable members will have specialized PPE that meets applicable NFPA and OSHA standards if this grant is awarded?			%

* 5. What is the purpose of this request? (select one)	○ to buy equipment for the first time (never owned before) ○ to replace or upgrade old/obsolete equipment (it must be a minimum of 10 years or older) ○ to replace torn/tattered/damaged equipment ○ to replace contaminated equipment ○ to meet new risk ○ 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 requesting PPE (any PPE other than SCBA) in the Question 1, 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 gear for ALL members declared in Department Characteristics – not just the gear you wish to replace.		○ N/A
		Age (in years)	Number of Items
		Less than 1 year
		1
		2
		3
		4
		5
		6
		7
		8
		9
		10
		11
		12
		13
		14
		15
		16 or more
		Number of members without gear __________

(continued on next page)

(continued from previous page)

If you have indicated you are requesting SCBA in the Question 1, to which edition(s) of NFPA are your SCBA compliant? If not requesting SCBA, please select “N/A” and continue to next question. Please account for ALL SCBA currently in your department’s inventory – not just the equipment you wish to replace.		Year	Number of NFPA Compliant SCBA
		○ N/A
		2007 Standard
		2002 Standard
		Older Standards
* 6. Is this PPE:	○ For daily use (station wear) ○ Against Blood borne pathogens or other contaminants ○ For use in Rescue incidents ○ For use in Haz-Mat incidents ○ For some other use
If you selected For some other use above, please specify:
* 7. Is your department trained in the proper use of the equipment being requested?				○ Yes ○ No
* 8. Are you requesting funding for training for this equipment? (Funding for requested training should be requested in the EMS PPE Additional Funding section on page 69).				○ Yes ○ No
If you are not requesting training funds through this application, will you obtain training for this equipment through other sources?				○ Yes ○ No

EMS PPE - Additional Funding (optional unless you’re applying for Training funds)

Enter any additional funding for your grant in the space provided below. You will need to explain the additional costs. The costs added in this section must show a direct relationship to the costs already included in your Request Details. Please note that this section is optional. Definitions can be found on page 6 of this application.

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

EMS PPE Narrative Statement

The program narratives should provide all the information necessary for you to justify your needs and for the program office to make an award decision. In the program narrative sections, please explain your needs and how the grants funds will be utilized. A panel of your peers will review the narratives below and the financial need narrative in the Applicant Characteristics II section as part of their evaluation of your entire grant application.

Please ensure that your narrative clearly addresses each of the following areas to the best of your ability. Follow the sequence and specifically address each of the following topics:

• Section #1 Project Description: What are you requesting funding for, including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc?

• Section #2 Cost/Benefit: What benefits will your department or community realize if the project described is funded? Provide justification for the budget items relating to the cost of the requested items.

• Section #3 Statement of Effect: How would this award affect the daily operations of your department and how would this award affect your department’s ability to protect lives and property in your community?

• Section #4 Additional Information: In the space provided below, include details regarding your organization’s request not covered in any other section.

Your narrative should be detailed but concise. You may either type your project narrative in the space provided below; or create the text in your word processing system then copy it into the space provided below. Images are not allowed, attach additional pages if necessary.

Note: Fields marked with an * are required.

Project Description

* Section #1 Project Description: In the space provided below include clear and concise details regarding your organization’s project’s description and budget. This includes providing local statistics to justify the needs of your department and a detailed plan for how your department will implement the proposed project. Further, please describe what you are requesting funding for including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc.

* Section #2 Cost/Benefit: In the space provided below please explain, as clearly as possible, what will be the benefits your department or your community will realize if the project described is funded (i.e. anticipated savings and/or efficiencies)? Is there a high benefit for the cost incurred? Are the costs reasonable? Provide justification for the budget items relating to the cost of the requested items.

* Section #3 Statement of Effect: How would this award affect the daily operations of your department (i.e., describe how frequently the equipment will be used or what the benefits will provide the personnel in your department)? How would this award affect your department’s ability to protect lives and property in your community?

* Section #4 In the space provided below include details regarding your organization’s request not covered in any other section.

EMS Training Program

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?	○ ALS ○ BLS
* 2. If awarded these funds, to what level will you be training your personnel?	○ EMT-I or EMT-P ○ EMT-B ○ First Responder/EMR ○ Haz-Mat Ops/Tech ○ Rescue Ops/Tech
* 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.

Training Program – Add Budget Item
* Item: (select one)	--- Equipment --- ○ Audio-Visual ○ Library ○ Classroom ○ Reference Texts ○ Media ○ Supplies --- Programs & Contract Instruction --- ○ Driver/Operator ○ ALS ○ BLS ○ Haz-Mat --- Props: Non-Construction --- ○ Simulators ○ CPR Manikins
* Please provide further description of the item selected above.
* 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)	$

EMS Training - Additional Funding (optional)

Enter any additional funding for your grant in the space provided below. You will need to explain the additional costs. The costs added in this section must show a direct relationship to the costs already included in your Request Details. Please note that this section is optional. Definitions can be found on page 6 of this application.

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

EMS Training Narrative Statement

The program narratives should provide all the information necessary for you to justify your needs and for the program office to make an award decision. In the program narrative sections, please explain your needs and how the grants funds will be utilized. A panel of your peers will review the narratives below and the financial need narrative in the Applicant Characteristics II section as part of their evaluation of your entire grant application.

Please ensure that your narrative clearly addresses each of the following areas to the best of your ability. Follow the sequence and specifically address each of the following topics:

• Section #1 Project Description: What are you requesting funding for, including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc?

• Section #2 Cost/Benefit: What benefits will your department or community realize if the project described is funded? Provide justification for the budget items relating to the cost of the requested items.

• Section #3 Statement of Effect: How would this award affect the daily operations of your department and how would this award affect your department’s ability to protect lives and property in your community?

• Section #4 Additional Information: In the space provided below, include details regarding your organization’s request not covered in any other section.

Your narrative should be detailed but concise. You may either type your project narrative in the space provided below; or create the text in your word processing system then copy it into the space provided below. Images are not allowed, attach additional pages if necessary.

Note: Fields marked with an * are required.

Project Description

* Section #1 Project Description: In the space provided below include clear and concise details regarding your organization’s project’s description and budget. This includes providing local statistics to justify the needs of your department and a detailed plan for how your department will implement the proposed project. Further, please describe what you are requesting funding for including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc.

* Section #2 Cost/Benefit: In the space provided below please explain, as clearly as possible, what will be the benefits your department or your community will realize if the project described is funded (i.e. anticipated savings and/or efficiencies)? Is there a high benefit for the cost incurred? Are the costs reasonable? Provide justification for the budget items relating to the cost of the requested items.

* Section #3 Statement of Effect: How would this award affect the daily operations of your department (i.e., describe how frequently the equipment will be used or what the benefits will provide the personnel in your department)? How would this award affect your department’s ability to protect lives and property in your community?

* Section #4 In the space provided below include details regarding your organization’s request not covered in any other section.

EMS Wellness and Fitness

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?	Are you requesting funding for this activity in this application?	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 Medical Exam/Health Screening	○ Yes ○ No	○ Yes ○ No	○ Yes ○ No	○ Yes ○ No
* Behavioral Health NFPA 1500 or equivalent Behavioral health programs are described in NFPA 1500 chapter 11. If you have any questions call the AFG help desk at 866-274-0960.	○ Yes ○ No	○ Yes ○ No	○ Yes ○ No	○ Yes ○ No

Additional Wellness and Fitness (if you are requesting Wellness and Fitness activities outside of Initial Physical Exam, Job Related Immunization, Periodic Medical Exam/Health Screening and/or Behavioral Health):

* 1. What will your program offer during the grant year? (select one)	○ Formal fitness and injury prevention program ○ CISM program ○ Employee assistance program ○ Injury/illness rehabilitation program
* 2. Does your organization currently offer this activity?	○ Yes ○ No
* 3. Are you requesting funding with this application?	○ Yes ○ No
* 4. Will this activity be mandatory?	○ Yes ○ No
* 5. Will this activity be offered to all?	○ Yes ○ No

(continued on next page)

(continued from previous page)

Add Budget Item (answer for each of the Wellness Activities you are requesting funding for, use additional sheets if necessary)

* Item	-- Physicals/Medical Examinations -- ○Job Related Immunization Program ○Initial Physical Exam ○Behavioral Health NFPA 1500 or equivalent ○Periodic Physical Exam/Health Screening ○Rehab and Therapy -- Wellness – ○Exercise Equipment ○ Aerobic Instructors ○Nutrition ○ Physical Trainers ○Smoking Cessation ○CISD Programs ○ Fitness Assessments and Counseling ○EAP Programs
* Please provide further description of the item selected above.
* Select Object Class:	○ Personnel ○ Fringe Benefits ○ Travel ○ Equipment ○ Supplies ○ Contractual ○ Construction ○ Indirect Charges ○ Other ○ State Taxes
If you selected Other above, please specify
* Number of units: (whole number only)
* Cost per unit: (whole dollar amounts only)

EMS Wellness and Fitness - Additional Funding (optional)

Enter any additional funding for your grant in the space provided below. You will need to explain the additional costs. The costs added in this section must show a direct relationship to the costs already included in your Request Details. Please note that this section is optional. Definitions can be found on page 6 of this application.

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

EMS Wellness and Fitness Narrative Statement

The program narratives should provide all the information necessary for you to justify your needs and for the program office to make an award decision. In the program narrative sections, please explain your needs and how the grants funds will be utilized. A panel of your peers will review the narratives below and the financial need narrative in the Applicant Characteristics II section as part of their evaluation of your entire grant application.

Please ensure that your narrative clearly addresses each of the following areas to the best of your ability. Follow the sequence and specifically address each of the following topics:

• Section #1 Project Description: What are you requesting funding for, including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc?

• Section #2 Cost/Benefit: What benefits will your department or community realize if the project described is funded? Provide justification for the budget items relating to the cost of the requested items.

• Section #3 Statement of Effect: How would this award affect the daily operations of your department and how would this award affect your department’s ability to protect lives and property in your community?

• Section #4 Additional Information: In the space provided below, include details regarding your organization’s request not covered in any other section.

Your narrative should be detailed but concise. You may either type your project narrative in the space provided below; or create the text in your word processing system then copy it into the space provided below. Images are not allowed, attach additional pages if necessary.

Note: Fields marked with an * are required.

Project Description

* Section #1 Project Description: In the space provided below include clear and concise details regarding your organization’s project’s description and budget. This includes providing local statistics to justify the needs of your department and a detailed plan for how your department will implement the proposed project. Further, please describe what you are requesting funding for including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc.

* Section #2 Cost/Benefit: In the space provided below please explain, as clearly as possible, what will be the benefits your department or your community will realize if the project described is funded (i.e. anticipated savings and/or efficiencies)? Is there a high benefit for the cost incurred? Are the costs reasonable? Provide justification for the budget items relating to the cost of the requested items.

* Section #3 Statement of Effect: How would this award affect the daily operations of your department (i.e., describe how frequently the equipment will be used or what the benefits will provide the personnel in your department)? How would this award affect your department’s ability to protect lives and property in your community?

* Section #4 In the space provided below include details regarding your organization’s request not covered in any other section.

Please continue to Budget on page 112.

Regional Operations and Safety – Equipment

P lease 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 Data Terminal (MDT)

○ Mobile Radios (Must be P-25 compliant)

○ Portable Radios (Must be P-25 compliant)

○ Repeaters

○ Communications Systems

-- EMS --

○ Defibrillators

○ EMS

-- EMS/Rescue --

○ Haz-Mat

○ Investigation

-- Specialized --

○ Specialized

* Please provide further description of the item selected above.

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

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

* 4. Generally the equipment purchased under this grant program will: (select one)

○ Be bought for the first time (has never been owned before)

○ Replace or upgrade old, obsolete, tattered, torn, or substandard equipment currently owned by your organization

○ Replace contaminated equipment

○ Address a new risk

○ Expand the capabilities of your organization into a new mission area

○ Replace worn but usable equipment

○ Replace used equipment

○ Replace new equipment

○ Increase your organization’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

○ 6 years ○ 7 years ○ 8 years ○ 9 years ○ Over 10 years

(continued from previous page)

* 5. Generally the equipment purchased under this grant program is: (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.
* 6. 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:
* 7. Will this equipment be used for wildland firefighting purposes?				○ Yes ○ No
* 8. Is your department trained in the proper use of this equipment being requested?				○ Yes ○ No
* 9. Are you requesting funding for training? (Funding for requested training should be requested in the Regional Equipment - Additional Funding section on page 96).				○ Yes ○ No
10. If you are not requesting training funds through this application, will you obtain the appropriate training for this equipment through other sources?				○ Yes ○ No

Regional Equipment - Additional Funding (optional unless you’re applying for Training funds)

Enter any additional funding for your grant in the space provided below. You will need to explain the additional costs. The costs added in this section must show a direct relationship to the costs already included in your Request Details. Please note that this section is optional. Definitions can be found on page 6 of this application.

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

Regional Equipment Narrative Statement

The program narratives should provide all the information necessary for you to justify your needs and for the program office to make an award decision. In the program narrative sections, please explain your needs and how the grants funds will be utilized. A panel of your peers will review the narratives below and the financial need narrative in the Applicant Characteristics II section as part of their evaluation of your entire grant application.

Please ensure that your narrative clearly addresses each of the following areas to the best of your ability. Follow the sequence and specifically address each of the following topics:

• Section #1 Project Description: What are you requesting funding for, including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc?

• Section #2 Cost/Benefit: What benefits will your department or community realize if the project described is funded? Provide justification for the budget items relating to the cost of the requested items.

• Section #3 Statement of Effect: How would this award affect the daily operations of your department and how would this award affect your department’s ability to protect lives and property in your community?

• Section #4 Additional Information: In the space provided below, include details regarding your organization’s request not covered in any other section.

Your narrative should be detailed but concise. You may either type your project narrative in the space provided below; or create the text in your word processing system then copy it into the space provided below. Images are not allowed, attach additional pages if necessary.

Note: Fields marked with an * are required.

Project Description

* Section #1 Project Description: In the space provided below include clear and concise details regarding your organization’s project’s description and budget. This includes providing local statistics to justify the needs of your department and a detailed plan for how your department will implement the proposed project. Further, please describe what you are requesting funding for including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc.

* Section #2 Cost/Benefit: In the space provided below please explain, as clearly as possible, what will be the benefits your department or your community will realize if the project described is funded (i.e. anticipated savings and/or efficiencies)? Is there a high benefit for the cost incurred? Are the costs reasonable? Provide justification for the budget items relating to the cost of the requested items.

* Section #3 Statement of Effect: How would this award affect the daily operations of your department (i.e., describe how frequently the equipment will be used or what the benefits will provide the personnel in your department)? How would this award affect your department’s ability to protect lives and property in your community?

* Section #4 In the space provided below, include details regarding your organization’s request not covered in any other section.

Regional - 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 (from the list on page 101)
* Please provide further description of the item selected above.
* 2. Number of units: (whole number only)
* 3. Cost per unit: (whole dollar amounts only)		$
* 4. Please provide your percentage for the appropriate question below: For turnout requests, what percentage of your on-duty active members will have PPE that meets 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 SCBA assigned to it if this grant is awarded? If you are asking for specialized PPE (e.g., Haz-Mat), what percentage of applicable members will have specialized PPE that meets applicable NFPA and OSHA standards if this grant is awarded?			%
* 5. What is the purpose of this request? (select one)	○ to buy equipment for the first time (never owned before) ○ to replace or upgrade old/obsolete equipment (it must be a minimum of 10 years or older) ○ to replace torn/tattered/damaged equipment ○ to replace contaminated equipment ○ to meet new risk ○ 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

(continued from previous page)

If you have indicated you are replacing PPE (any PPE other than SCBA) in Question 5, 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 gear for ALL members declared in Department Characteristics - not just the gear you wish to replace.		○ N/A
		Age (in years)			Number of Items
		Less than 1
		1
		2
		3
		4
		5
		6
		7
		8
		9
		10
		11
		12
		13
		14
		15
		16 or more
		Number of members without gear _______
If you have indicated you are requesting SCBA in the Question 1, to which edition(s) of NFPA are your SCBA compliant? If not requesting SCBA, please select “N/A” and continue on to the next question. Please account for ALL SCBA currently in your department’s inventory - not just the equipment you wish to replace .	○ N/A
	Year		Number of NFPA Compliant SCBA
	2007 Standard
	2002 Standard
	Older Standards
* 6. Is this PPE:
○ For protection use against fire ○ For use in Haz-mat incidents	○ For use in Rescue incidents, vehicle extrication ○ For some other use
If you selected For some other use above, please specify_______________________________________________
* 7. Will this equipment be used for wildland firefighting purposes?				○ Yes ○ No
* 8. Is your department trained in the proper use of this equipment being requested?				○ Yes ○ No
* 9. Are you requesting funding for training for this equipment?				○ Yes ○ No
If you are not requesting training funds through this application, will you obtain training for this equipment through other sources?				○ Yes ○ No

Regional Personal Protective Equipment List (select one to answer Q1)

Structural
Boots	Goggles
Coats	Helmets
Complete Set of Turnout Gear	Hoods
Flashlights	Pants
Gloves	PASS Devices
Respiratory
Accountability Systems	SCBA-45 minutes with face piece-With extra bottle
Air-Line Units	SCBA-60 minutes with face piece-With extra bottle
Face Pieces	Spare Cylinders-30 minutes
Respirators	Spare Cylinders-45 minutes
SCBA-30 minutes with face piece-With extra bottle	Spare Cylinders-60 minutes
Wildland
Jumpsuits/Coveralls	Shelters
Web Gear/Backpacks/Canteens
Specialized PPE
ANSI Traffic Vests	Infection Control
Chemical/Biological Suits (Must conform to NFPA 1994, 2001 edition)	Proximity and Entry Suits
EMS Turnout	Splash Suits
Encapsulated Suits	Wet and Dry Suits
Extrication Clothing/Rescue Clothing

Regional PPE - Additional Funding (optional unless you’re applying for Training funds)

Enter any additional funding for your grant in the space provided below. You will need to explain the additional costs. The costs added in this section must show a direct relationship to the costs already included in your Request Details. Please note that this section is optional. Definitions can be found on page 6 of this application.

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

Regional PPE Narrative Statement

The program narratives should provide all the information necessary for you to justify your needs and for the program office to make an award decision. In the program narrative sections, please explain your needs and how the grants funds will be utilized. A panel of your peers will review the narratives below and the financial need narrative in the Applicant Characteristics II section as part of their evaluation of your entire grant application.

Please ensure that your narrative clearly addresses each of the following areas to the best of your ability. Follow the sequence and specifically address each of the following topics:

• Section #1 Project Description: What are you requesting funding for, including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc?

• Section #2 Cost/Benefit: What benefits will your department or community realize if the project described is funded? Provide justification for the budget items relating to the cost of the requested items.

• Section #3 Statement of Effect: How would this award affect the daily operations of your department and how would this award affect your department’s ability to protect lives and property in your community?

• Section #4 Additional Information: In the space provided below, include details regarding your organization’s request not covered in any other section.

Your narrative should be detailed but concise. You may either type your project narrative in the space provided below; or create the text in your word processing system then copy it into the space provided below. Images are not allowed, attach additional pages if necessary.

Note: Fields marked with an * are required.

Project Description

* Section #1 Project Description: In the space provided below include clear and concise details regarding your organization’s project’s description and budget. This includes providing local statistics to justify the needs of your department and a detailed plan for how your department will implement the proposed project. Further, please describe what you are requesting funding for including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc.

* Section #2 Cost/Benefit: In the space provided below please explain, as clearly as possible, what will be the benefits your department or your community will realize if the project described is funded (i.e. anticipated savings and/or efficiencies)? Is there a high benefit for the cost incurred? Are the costs reasonable? Provide justification for the budget items relating to the cost of the requested items.

* Section #3 Statement of Effect: How would this award affect the daily operations of your department (i.e., describe how frequently the equipment will be used or what the benefits will provide the personnel in your department)? How would this award affect your department’s ability to protect lives and property in your community?

* Section #4 In the space provided below, include details regarding your organization’s request not covered in any other section.

Regional Training Program

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 from list on pages 107-108)
Please provide further description of the Training Program you selected.
* 2. Generally, this program can best be categorized as (select one):
○ Training that is evaluated/tested using a national or state standard ○ Non-certification training
* 3. What percentage of applicable personnel will be trained by this program?			%
* 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 into compliance with federal or state mandated training requirements, please specify:
○ Will address an identified risk for your region or community, please specify:
* 5. Will this training enhance your ability to perform mutual aid?			○ Yes ○ No
If you answered Yes to the question above, please explain
* 8. Will this training be:			○ Instructor Led ○ Self-directed/test-validated ○ None of the above

(continued on next page)

Training Program – Add Budget Item
* Item: (select one)	-- Equipment -- ○ Audio-Visual ○ Library ○ Classroom ○ Reference Texts ○ Rescue ○ Supplies ○ CPR Manikins -- Programs & Contract Instruction -- ○Firefighter I ○ Investigator ○Firefighter II ○ Public Educator ○Driver/Operator ○ Haz-Mat ○EVOC ○ Marine ○EMT ○ Aircraft ○Paramedic ○ Wildland ○Inspector ○ Officer I-IV ○Specialized -- Props: Non-Construction -- ○Simulators ○Manufacturer Burn Simulator ○ Props: Non-Construction
*Please provide further description of the item selected above.
* Select Object Class:		○ Personnel ○ Fringe Benefits ○ Travel ○ Equipment ○ Supplies ○ Contractual ○ Construction ○ Indirect Charges ○ Other ○ State Taxes
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 to answer Q1)

---General Training---

Operations (NFPA 472)

Firefighter I, Firefighter II (NFPA 1001)

Instructor Training (NFPA 1041)

Driver/Operator (NFPA 1002)

Officer Training (NFPA 1021)

Basic Wildland Firefighting (NFPA 1051/NWCG)

Wildland Firefighter Certification (NFPA 1051/NWCG)

Wildland Officer (NFPA 1051/1143/NWCG)

Airport Rescue Firefighting (ARFF) (NFPA 1003)

RIT Training (NPFA 1407/29 CFR 1910.134g(4))

Confined Space Rescue – Awareness level (NFPA 1670/29 CFR 1910.146)

Vehicle Rescue (NFPA 1670)

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)

Haz-Mat – Technician/Specialist level (NFPA 472)

Infection Control (NFPA 1581)

Medical First Responder Training (First Responder)

Emergency Medical Technician – Basic (EMT B)

Emergency Medical Technician – Intermediate (EMT I)

Emergency Scene Rehab (NFPA 1500/1584)

Paramedic Training (EMT-P)

Mass Casualty Incident Training (MCI)

NIMS (NFA/EMI/NWFCG)

Incident Management Course (NFA/EMI/NWFCG)

Integrated Emergency Management Course (NFPA 1561/IEMC)

Fire Inspector (NFPA 1031)

Fire Investigator (NFPA 1033)

Fire Educator (NFPA 1035)

Telecommunications/Dispatcher (NFPA 1601)

Safety Officer (NFPA 1521)

Physical Agility Program Training (NFPA 1583)

Firefighter Safety and Survival Training (NFPA 1407/29 CRF 1910.146

(continued on next page)

(continued from previous page)

Fire Officer I,II, III, and/or IV (NFPA 1021)

Fire Prevention (NFPA 1)

Maritime (NFPA 1405/1005)

Environmental (EPA Train/Learning Center)

Exercises/Preparedness (NFA/EMI)

---CBRNE Training---

Operations-level Training (National Law Enforcement Training Agency)

Technician-level Training (National Law Enforcement Training Agency)

Other CBRNE Training (National Law Enforcement Training Agency)

Weapons of Mass Destruction – Awareness level (CBRNE)

Weapons of Mass Destruction – Operations level (NFPA 472)

Weapons of Mass Destruction – Technician Level for Rural (NFPA 472)

Weapons of Mass Destruction Training – Technician Level for Urban/Suburban (NFPA 472)

Other/Specialized Weapons of Mass Destruction Training (NFPA 472)

---Specialized CBRNE Training---

Specialist (National Law Enforcement Training Agency)

EMS for Incidents Involving CBRNE (National Law Enforcement Training Agency)

ICS for Terrorism (National Law Enforcement Training Agency)

Mass Decontamination (National Law Enforcement Training Agency)

Live Agent (National Domestic Preparedness Consortium)

Explosives and Secondary Device Awareness (National Domestic Preparedness Consortium)

Regional Training Narrative Statement

The program narratives should provide all the information necessary for you to justify your needs and for the program office to make an award decision. In the program narrative sections, please explain your needs and how the grants funds will be utilized. A panel of your peers will review the narratives below and the financial need narrative in the Applicant Characteristics II section as part of their evaluation of your entire grant application.

Please ensure that your narrative clearly addresses each of the following areas to the best of your ability. Follow the sequence and specifically address each of the following topics:

• Section #1 Project Description: What are you requesting funding for, including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc?

• Section #2 Cost/Benefit: What benefits will your department or community realize if the project described is funded? Provide justification for the budget items relating to the cost of the requested items.

• Section #3 Statement of Effect: How would this award affect the daily operations of your department and how would this award affect your department’s ability to protect lives and property in your community?

• Section #4 Additional Information: In the space provided below, include details regarding your organization’s request not covered in any other section.

Your narrative should be detailed but concise. You may either type your project narrative in the space provided below; or create the text in your word processing system then copy it into the space provided below. Images are not allowed, attach additional pages if necessary.

Note: Fields marked with an * are required.

Project Description

* Section #1 Project Description: In the space provided below include clear and concise details regarding your organization’s project’s description and budget. This includes providing local statistics to justify the needs of your department and a detailed plan for how your department will implement the proposed project. Further, please describe what you are requesting funding for including budget descriptions of the major budget items, i.e., personnel, equipment, contracts, etc.

* Section #2 Cost/Benefit: In the space provided below please explain, as clearly as possible, what will be the benefits your department or your community will realize if the project described is funded (i.e. anticipated savings and/or efficiencies)? Is there a high benefit for the cost incurred? Are the costs reasonable? Provide justification for the budget items relating to the cost of the requested items.

* Section #3 Statement of Effect: How would this award affect the daily operations of your department (i.e., describe how frequently the equipment will be used or what the benefits will provide the personnel in your department)? How would this award affect your department’s ability to protect lives and property in your community?

* Section #4 In the space provided below include details regarding your organization’s request not covered in any other section.

Regional Training - Additional Funding (optional)

Enter any additional funding for your grant in the space provided below. You will need to explain the additional costs. The costs added in this section must show a direct relationship to the costs already included in your Request Details. Please note that this section is optional. Definitions can be found on page 6 of this application.

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

FEMA FORM 080-0-2a