Form FEMA Form 080-0-4 FEMA Form 080-0-4 Staffing for Adequate Fire and Emergency Response (SAFER

OMB No.: 1660-NW78 Expiration Date:

BURDEN DISCLOSURE NOTICE

FEMA Form 080-0-4

Public reporting burden for this form is estimated to average 9 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting the form. This collection of information is required to obtain or retain benefits. You are not required to respond to this collection of information unless it displays a valid OMB control number.  Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (1660-NEW) NOTE: Do not send your completed form to this address.

Staffing for Adequate Fire and Emergency Response (SAFER) Grants Application

The electronic application period can be found on the Assistance to Firefighters Grants website (www.fema/firegrants. It does not matter how early you submit your application, as long as it within the current application period for the SAFER grant program. All paper applications must be postmarked by three days prior to the close of the current application period or otherwise received by the program office prior to the deadline.

FEMA has established a help desk to assist you during the application period. Technical assistance with completion of the application will be available by phone on our toll-free hotline at (866) 274-0960, Monday through Friday from 8:00 am to 4:30 pm EDT. On the final day of the application period the hotline will be open until 5:00 pm EDT.

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

The programs, and associated activities, eligible in this year's grant program are as follows:

1. Hiring of Firefighters Activity. For this SAFER grant solicitation, FEMA distinguishes between the hiring of new firefighters and the rehiring of laid-off firefighters. The goal of the hiring of firefighters activity, whether hiring new firefighters or rehiring laid-off firefighters, is to comply with staffing, response, and operational standards established by NFPA and OSHA. Compliance with these standards results in enhanced safety for the firefighters and more effective response for the community. Career fire departments may apply for funding only in the Hiring of Firefighters Activity. Volunteer and combination fire departments are eligible to apply for both the Hiring of Firefighters Activity and the Recruitment and Retention of Volunteer Firefighters Activity, however, eligible applicants seeking to do so must complete two separate applications.

2. Recruitment and Retention of Volunteer Firefighters Activity. The goal of this activity is to create a net increase in the number of trained, certified, and competent firefighters capable of responding safely to emergencies likely to occur within the fire department geographic response area. Organizations that support volunteerism or otherwise have an interest in volunteer firefighters may apply only for the Recruitment and Retention of Volunteer Firefighters Activity. Volunteer and combination fire departments are eligible to apply for both the Hiring of Firefighters Activity and the Recruitment and Retention of Volunteer Firefighters Activity, however, eligible applicants seeking to do so must complete two separate applications.

For more information about this program, visit www.firegrantsupport.com

SAFER Grant Program Office

(866) 274–0960

(866) 274–0942 Fax

Overview

The SAFER (Staffing for Adequate Fire and Emergency Response) program intends to improve or restore local fire departments’ staffing and deployment capabilities so they may more effectively respond to emergencies. With the enhanced or restored staffing, a SAFER grantee’s response time will be reduced sufficiently and an appropriate number of trained personnel will be assembled at the incident scene. Grant funds are available in two categories: Hiring Firefighters and Recruitment and Retention of Volunteer Firefighters. Please review the program guidance for information on available program areas and for more information on the evaluation process and conditions of award.

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

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

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

If you answered No, you must complete the information below. If you answered Yes, please skip the Preparer Information section.

Note: If you answered No to the above question, the fields marked with an * are required.

Preparer Information
* Preparer’s Name
* Address 1
Address 2
* City
* State
* Zip (with 4 digit extension)	-

In the space below please list the Primary Contact your organization has selected to be the point of contact for this grant. This should be a Chief Officer or long time member of the organization who will see this grant through completion. The Primary Contact, as listed below, is the person for which all exchanges of information will be made relative to the application. If you are not the person to be contacted, please provide the appropriate person’s contact information below.

In addition to the Primary Contact information, you will be asked to provide two (2) Alternate points of contact on the next page. The Alternate contacts should also be able to answer any questions relative to this application in the event that Primary Contact is unavailable.

Reminder: Please list only phone numbers where we can get in direct contact with the point of contact(s).

Primary Point of Contact
* Title
Prefix (check one)	○ N/A ○ Dr. ○ Mr. ○ Mrs. ○ Ms.
* First Name
Middle Initial
* Last Name
* Primary Phone (e.g. 123-456-7890)	Ext. (select one: home, cell, work)
* Secondary Phone (e.g. 123-456-7890)	Ext. (select one: home, cell, work)
Optional Phone (e.g. 123-456-7890)
Primary Fax (e.g. 123-456-7890)
* Email (e.g. [email protected])

Contact Information

In addition to Primary Point of Contact listed on the previous page, please provide two (2) additional points of contact for this application. These contacts should be long time members of the organization who will see this grant through completion, have the authority to make decisions on and to act upon this grant application.

Reminder: Please list only phone numbers where we can get in direct contact with the point of contact(s).

Note: Fields marked with an * are required.

Alternate Contact 1 Information
* Title
Prefix (check one)	○ Dr. ○ Mr. ○ Mrs. ○ Ms. ○ N/A
* First Name
Middle Initial
* Last Name
* Primary Phone (e.g. 123-456-7890)	Ext. (select one: home, cell, work)
* Secondary Phone (e.g. 123-456-7890)	Ext. (select one: home, cell, work)
Optional Phone (e.g. 123-456-7890)
Fax (e.g. 123-456-7890)
* Email (e.g. [email protected])

Alternate Contact 2 Information
* Title
Prefix (check one)	○ Dr. ○ Mr. ○ Mrs. ○ Ms. ○ N/A
* First Name
Middle Initial
* Last Name
* Primary Phone (e.g. 123-456-7890)	Ext. (select one: home, cell, work)
* Secondary Phone (e.g. 123-456-7890)	Ext. (select one: home, cell, work)
Optional Phone (e.g. 123-456-7890)
Fax (e.g. 123-456-7890)
* Email (e.g. [email protected])

Applicant Information

Please provide the following information about your organization.

Note: Fields marked with an * are required.

* Organization Name
* What kind of organization do you represent? All paid career department - An agency or organization in which all members receive financial compensation for their services on a full-time basis. All volunteer fire department - An agency or organization in which no member receives financial compensation (salary, wages) for their services other than life and health insurance and workers’ compensation insurance. Paid-on-call: Firefighters that are paid stipends or paid-on-call are considered to be volunteers for the purposes of this program Combination (mostly volunteer) - A fire department where more than 50 percent of its membership is made up of personnel who do not receive financial compensation for their services. Combination (mostly career) - A fire department where 50 percent or more of its membership is made up of personnel who are salaried staff. Local or State volunteer firefighter interest organization - Statewide and local firefighter interest groups are organizations that are in existence to support or represent the interests of firefighters in front of legislative bodies at the local, State, and Federal level. Such organizations include State or local firefighter and/or fire chiefs associations, volunteer firefighter relief organizations, and associations. DHS shall make the final determination as to whether an applicant is an appropriate firefighter interest group.			○ All Paid/Career ○ All Volunteer. ○ Combination (Majority Volunteer) ○ Combination (Majority Paid/Career) ○ National/State/Local volunteer interest organization
If you answered combination, above, what is the percentage of career members in your organization? (Numbers only)			%
* Type of Jurisdiction Served		○ City ○ County ○ Indian Tribe ○ Parish ○ Private/Not for profit Company ○ Town ○ Township ○ Unincorporated Community ○ Village ○ National, state or local organization serving the interest of volunteer firefighters ○ Other (Explain)
If Other, please enter the type of Jurisdiction
* In what county/parish is your organization physically located? If you have more than one station, in what county/parish is your main station located?
* Employer Identification Number (e.g. 12-3456789)
* Are you sharing an EIN with another organization?				○ Yes ○ No
If yes, please enter the name of the entity with whom you share an EIN
* Have you registered with the Central Contractor Registry (CCR)?				○ Yes ○ No

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* What is your organization’s DUNS number? (call 1-866-705-5711 to get a DUNS number)
* Is your DUNS Number registered in SAM.gov (System for Award Management, previously CCR.gov)?				○ Yes ○ No
* I acknowledge that before receiving a Federal Award from the Assistance to Firefighters Grant Program, my organization (Entity) must register in SAM.gov prior to being awarded. Note: Please be advised that you must renew your registration in SAM.gov annually. If you have previously registered in SAM.gov, go to www.sam.gov/portal/public/SAM to check the expiration date on your current registration. If your organization is currently not registered in SAM.gov, please complete the registration shortly after submitting this application. If you need assistance please go to https://www.fsd.gov/app/answers/detail/a_id/148 or your financial office if your organization is a part of the local government.				○ Yes
Headquarters Physical Address
* Physical Address 1
Physical Address 2
* City
* State
* Zip (with 4 digit extension)	-
○ Mailing Address is the same as the Physical Address
* Mailing Address 1
Mailing Address 2
* City
* State
* Zip (with 4 digit extension)	-
Account Information
* Type of bank account	○ Checking ○ Savings
* Bank routing number - 9 digit number on the bottom left hand corner of your check	(numbers only, no dashes)
* Your account number	(numbers only, no dashes)
Additional Information
* For this fiscal year (Federal) is your jurisdiction receiving Federal funding from any other grant program that may duplicate the purpose and/or scope of this grant request?			○ Yes ○ No
* If awarded this grant, will your jurisdiction expend greater than $500,000 in Federal share funds during the Federal fiscal year in which the grant was awarded?			○ Yes ○ No
* Is the applicant delinquent on any federal debt? (This question applies to the applicant's organization, not the person who signs as the authorized representative. Categories of debt include delinquent audit disallowances, loans, and taxes.)			○ Yes ○ No
If you answered yes to any of the additional questions above, please provide an explanation in the space provided below (attach additional sheet if necessary):

If you selected “National/State/Local Volunteer Firefighter Interest Organization” as your organization, Applicant Characteristics I & II and Department Call Volume sections are not applicable. Please skip ahead to page 14.

Applicant Characteristics (Part I)

Please provide the following information regarding your Fire Department.

Note: Fields marked with an * are required.

* Are you a member of a Fire Department or authorized representative of a Fire Department? Fire Department – An agency or organization that has a formally recognized arrangement with a territory, tribe, or local authority (city, county, parish, fire district, township, town, or other governing body) to provide fire suppression on a first-due basis to a fixed geographical area. Fire departments may be comprised of members who are all volunteer, all career, or combination of volunteer and career.	○Yes ○ No
* Are you a member of a Federal Fire Department or contracted by the Federal government and solely responsible for suppression of fires on Federal property?	○Yes ○ No
* Please indicate the type of community your organization serves.	○ Rural ○ Suburban ○ Urban
* What is the square mileage of your first-due response area? (Numbers only)
* What percentage of your response area is protected by hydrants? (Numbers only)	%
* Does your organization protect critical infrastructure of the state? (see definitions on page 8)	○ Yes ○ No
Percentages in three answers below must sum up to 100%:
* How much of your jurisdiction’s land use is for agriculture, wild land, open space, or undeveloped properties?		%
* What percentage of your jurisdiction’s land use is for commercial, industrial, or institutional purposes?		%
* What percentage of your jurisdiction’s land is used for residential purposes?		%
* How many occupied structures (commercial, industrial, residential, or institutional) in your jurisdiction are more than four stories tall? Do not include structures which are not regularly occupied such as silos, towers, steeples, etc. (Whole Numbers only)
* What is the permanent resident population of your Primary/First Due Response Area or jurisdiction served? (Whole Numbers only) Primary/First Due Response Area is a geographical area proximate to a fire or rescue facility and normally served by the personnel and apparatus from that facility in the event of a fire or other emergency and does not include daily or seasonal population surges. Population shall be based upon the most recent official census and shall include only those individuals who permanently reside within the jurisdiction served.
* How many stations are operated by your organization? (Whole Numbers only)

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* Please indicate if your department has a formal automatic/mutual aid agreement with another community or fire department and the type of agreement that exists.		○Automatic aid ○Mutual aid ○Both automatic and mutal aid ○No aid
* What services does your organization provide?
○ Structural Fire Suppression ○ Basic Life Support ○ Hazmat Technical Level ○ Wildland Fire Suppression ○ Advanced Life Support ○ Rescue Operational Level ○ Medical First Response ○ Hazmat Operational Level ○ Rescue Technical Level
Active Firefighting Staff, use these definitions to answer the following questions about “firefighter” positions.
Active Firefighter Position	An individual having the legal authority and responsibility to engage in fire suppression; being employed by a fire department of a municipality, county, or fire district; being engaged in the prevention, control, and extinguishing of fires; and/or responding to emergency situations in which life, property, or the environment is at risk. This individual must be trained in fire suppression, but may also be trained in emergency medical care, hazardous materials awareness, rescue techniques, and any other related duties provided by the fire department.
Full-time Paid Firefighter Position	Full-time positions are those that are funded for at least 2,080 hours per year (i.e., 40 hours per week, 52 weeks per year.)  The program office will also consider funding the sharing of a full-time position with sufficient justification.  A job-share position is a full-time position that is occupied by more than one person.
Part-time Paid Firefighter Position	Part-time paid firefighters receive pay for being on duty at the fire station, whether or not they respond to any alarms. They may or may not receive benefits.
Volunteer Firefighter Position	Volunteer firefighters receive no financial compensation for their services other than life/health insurance, workers compensation insurance, and/or stipend per call.
SAFER intends to improve or restore local fire departments' staffing and deployment capabilities so they may more effectively respond to emergencies. With the enhanced or restored staffing, a SAFER grantee's response time will be reduced sufficiently and an appropriate number of trained personnel will be assembled at the incident scene. The following questions are designed to help us understand the changes that will occur in departments receiving grants. Use the following definitions when completing the table on page 7. Total # of Operational Career Personnel – this number represents the total number of authorized and funded active, full-time uniformed/operational career positions employed by your department on the dates indicated. (Note: only operational positions — including operational officers - should be included) # Operational Officers – of the operational career positions indicated in the "Total # of Operational Career Personnel" field above, how many of those serve in operational officer-level (both command and company) positions? # NFPA Support – of the "Total # of Operational Career Personnel" indicated, how many are assigned to field or response apparatus positions that directly comply with NFPA 1710 (Section 5.2.4.2 — Initial Full Alarm Assignment Capability) or NFPA 1720 (Section 4.3 — Staffing and Deployment)? (Note: Officers should also be included in this number but only if they directly support NFPA 1710 or NFPA 1720 compliance) Note: The number of career positions in any of these fields should include positions which are job-shared. Job-shared positions will be counted as one (1) regardless of how many personnel fill those positions. For more information regarding these standards please see the Program Guidance or go to www.nfpa.org/saferactgrant.

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	Total # of Operational Career Personnel	# Operational Officers		# NFPA Support
* Staffing levels as of January 1, 2008
* Staffing levels as of June 30, 2012
* Staffing levels at the time of application
* If awarded this grant, how many authorized and funded active, full-time uniformed career positions will be in your department? (Whole Numbers only)
* If awarded the number of positions requested in this application, will this restore your department’s staffing level to the level that existed before the department lost positions to layoffs or attrition?			○ Yes ○ No ○N/A
* At the time of application, how many positions in your department are filled with part-time paid firefighters? (Whole Numbers only) Note: If you utilize part-time firefighters, please explain, in your narrative, the number of part-time firefighters, the number of NFPA support positions that these part-time firefighters occupy, and how they are scheduled to meet your staffing needs.
* At the time of application, how many active volunteer firefighters are in your department? (Whole Numbers only)
* If awarded this grant, how many active volunteer firefighters will be in your department? (Whole Numbers only)
* Do you currently report to the National Fire Incident Reporting System (NFIRS)?			○ Yes ○ No

Critical Infrastructure

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

• Public water systems serving large population centers.

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

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

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

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

• Nuclear power plants.

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

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

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

• Natural gas and liquid natural gas storage facilities.

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

• Telecommunications, Internet and cyber facilities.

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

Applicant Characteristics (Part II)

Please provide the following additional information regarding your Fire Department. If you are applying on behalf of a State or Local Volunteer Firefighter Interest Organization please go directly to page 14.

Note: Fields marked with an * are required.

* What is the total number of fire-related civilian fatalities in your jurisdiction over the last three calendar years? (Whole Numbers only)	2012		2011		2010
* What is the total number of fire-related civilian injuries in your jurisdiction over the last three calendar years? (Whole Numbers only)	2012		2011		2010
* What is the total number of line of duty member fatalities in your jurisdiction over the last three calendar years? (Whole Numbers only)	2012		2011		2010
* What is the total number of line of duty member injuries in your jurisdiction over the last three calendar years? (Whole Numbers only) Injury means any physical damage to the body caused by violence or accident during the conduct of firefighting activities or training that requires treatment at a medical facility and/ loss or curtailment of the ability to provide normal active firefighting or EMS duties. Exposures would only count as an "injury" if the exposure eventually resulted in loss or curtailment of duties.	2012		2011		2010
* What is your department’s operating budget (including personnel costs) for your current fiscal year and what was your budget for the last three fiscal years? (all whole numbers only)	Current Fiscal Year (at time of application)
	Budget			Fiscal Year
	Budget			Fiscal Year
	Budget			Fiscal Year
* What percentage of your annual operating budget is derived from: (Enter numbers only; percentages must sum up to 100%)
Taxes?		%
Grants?		%
Donations?		%
Fund drives?		%
Fee for Service?		%
Other?		%
If you entered a value into Other field (other than 0), please explain:

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* How many frontline vehicles does your organization have in each of the types or classes of vehicle listed below that respond to first alarm assignments in support of NFPA 1710/1720? You must include vehicles that are leased or on long-term loan as well as any vehicles that have been ordered or otherwise currently under contract for purchase or lease by your organization but not yet in your possession. If you have multiple vehicles of the same type which have a different number of riding positions, please use the "average" number and provide additional information in the text box provided. Enter numbers only and enter 0 if you do not have any of the vehicles below.
Type or Class of Vehicle		Total Number of Frontline Vehicles	Total Number  of Available  Riding Positions  per Frontline Vehicle	Total Number of  Filled Riding Positions  per Frontline Vehicle  per first alarm assignment
Engines (or Pumpers): (pumping capacity of 750 gpm or greater and water capacity of 300 gallons or more): Pumper, Pumper/Tanker, Rescue/Pumper, Foam Pumper, CAFS Pumper, Quint (Aerial device of less than 76 feet), Type I engine, Type II engine
Tankers: (pumping capacity of less than 750 gpm and water capacity of 1,000 gallons or more): Tanker, Tender, Foam Tanker/Tender (greater than 1,250 gallon tank capacity)
Aerial Apparatus: Aerial Ladder Truck, Telescoping, Articulating, Ladder Towers, Platform, Tiller Ladder Truck, Quint (Aerial device of 76 feet or greater)
Brush/Quick Attack: (pumping capacity of less than 750 gpm and water capacity of at least 300 gallons): Brush Truck, Patrol Unit (Pick up w/ Skid Unit), Quick Attack Unit, Mini-Pumper, Type III Wildland/Urban Interface Engine, Type IV Engine, Type V Engine, Type VI Engine, Type VII Engine
Rescue Vehicles: Rescue Squad, Rescue (Light, Medium, Heavy), Technical Rescue Vehicle, Hazardous Materials Unit
Other: EMS Chase Vehicle, Air/Light Unit, Rehab Units, Bomb Unit, Technical Support (Command, Operational Support/Supply), Hose Tender, Salvage Truck, ARFF (Aircraft Rescue Firefighting), Command/Mobile Communications Vehicle, Other Vehicle
Please use this comments section if you wish to provide any additional information with regards to the Type or Class of Vehicle section above.

Department Call Volume

Please provide the number of incidents your department responded to in each of the following categories on an annual basis.

Note: Fields marked with an * are required.

*How many responses per year by category? Do not include responses/calls where your department was dispatched to provide mutual/automatic aid . (Enter whole numbers only; if you have no calls for any of the categories, enter 0.)
Structural Fires includes cooking fires, chimney fires, smoke odor calls, unauthorized burning calls, and trash and rubbish fires that spread to a structure(s).	2012	2011		2010
Vehicle Fires includes all vehicle fires except those that were inside a structure.	2012	2011		2010
Vegetation Fires includes wildland fires, brush fires, and grass fires.	2012	2011		2010
EMS includes medical assists, EMS calls, vehicle accident EMS calls, sickness/injuries, vehicle/pedestrian EMS calls, etc.	2012	2011		2010
Rescue includes searches, water and ice rescues, and extrications of trapped victims.	2012	2011		2010
Hazardous Condition/Materials Calls includes spills and leaks, chemical releases, electrical transmission and service lines down.	2012	2011		2010
Service Calls includes persons in distress calls, water problem calls, smoke odor calls, animal rescue calls, public service assist calls, and unauthorized burning calls.	2012	2011		2010
Good Intent Calls includes canceled enroute, authorized burning calls, prescribed fire calls, smoke scares.	2012	2011		2010
False Alarms making a false report of a fire or other emergency via telephone to 911 or other emergency number, the false activation of a manual or automatic fire alarm system, and/or the transmission of a malicious false alarm via a dedicated public alarm system (telephone, telegraph, or radio call box).	2012	2011		2010
Other Calls and Incidents anything that doesn't fit in another category.	2012	2011		2010
Totals:
In an average year, how many times does your organization receive mutual/automatic aid? (Whole Numbers only)
In an average year, how many times does your organization provide mutual/automatic aid? (Do not include first-due responses claimed above.) (Whole Numbers only)

Request Details (all applicants)

Activity Selection

Please use this section to select the category for which you want to apply and provide the additional information requested.

If you are a Volunteer Department or a Combination Department and are interested in applying under both the Hiring of Firefighters Category and the Recruitment and Retention of Volunteer Firefighters Category you will need to submit separate applications - one for each category.

Career departments are only eligible for the Hiring of New Firefighters or Rehiring of Laid-off Firefighters activities, and National, State or Local Volunteer Firefighter Interest Organizations are only eligible for the Recruitment and Retention of Volunteer Firefighters category.

If you intend to request funds for a category, you must answer all of the category specific questions and specify at least one budget item. Only whole dollar amounts should be provided (no cents please).

* 1. Select a category for which you are applying.
Category Name	Eligible Organizations:
○ Hiring of New Firefighters or Rehiring of Laid-off Firefighters	[Volunteer Fire Departments] [Combination Fire Departments] [Career Fire Departments]
○ Recruitment and Retention of Volunteer Firefighters	[Volunteer Fire Departments] [Combination Fire Departments] [National/State/Local Volunteer Firefighter Interest Organizations]

If you are only applying for the Recruitment and Retention of Volunteer Firefighters activity, you must also complete and submit form FF 080-0-4b along with this form.

If you are applying for both activities, you must complete and submit both the FF 080-0-4a and FF 080-0-4b along with this form.

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