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ILLINOIS DEPARTMENT OF PUBLIC HEALTH EMERGENCY MEDICAL SERVICES ASSISTANCE FUND GRANT GUIDANCE GENERAL REQUIREMENTS Any Illinois licensed/designated EMS participant that provides EMS service within the State of Illinois may apply for funds through their Regional EMS Advisory Committee. 1. Applications must be submitted on the EMS Grant Application form supplied by the Department. 2. Programs, services, and equipment funded by the EMS Assistance Fund must comply with the Emergency Medical Services (EMS) Systems Act and the Regional EMS Plan in which the applicant participates. 3. All applications from providers must be submitted to their respective Regional EMS Advisory Committee by the deadline required by each Regional Committee. No applications will be accepted by the Department directly from an applicant. 4. A financial statement must be completed to be eligible to receive a grant. 5. Deadline for submission of applications with a recommendation and prioritization ranking from each Regional EMS Advisory Committee to the Department is June 30, 2011. 6. All award recipients are required to enter into a grant agreement as prescribed by the Department. 7. Funds might not be equally divided among the eleven regions; consequently, award decisions will not be made based on financial parity among regions. Emergency Medical Services Assistance Grant Application (February 2011) P a g e | 1 of 3 INSTRUCTION FOR COMPLETING APPLICATION 1. TYPE or PRINT with black ink (blue, red, or other colors of ink do not duplicate well). 2. If requesting more than one item, prioritize items in the Description of the Project section in the event a portion of the request may be granted. 3. List each item requested with projected cost. 4. Applications that include requests for more than one agency (i.e., regional, local, association or jurisdictional requests) must list each agency separately, the item(s) being requested for each agency, and include a completed data sheet and financial statement for each agency. 5. Applications must be submitted to the respective Regional EMS Advisory Committee by the deadline established by your region. 6. Applications shall contain these required components. Applications lacking any of these components may be precluded from consideration: - Fully completed Grant Application Cover Page. - Description of project consistent with Description of Project Criteria. - Description of the applicability of the Evaluation Criteria for the particular requests. - Self-assessment according to Grading Scale. - Any additional information regarding the request and information that would support this need. This should include a detailed list of how the grant funds will be spent. 7. Due to limited amount of grant funds available, the Department will not consider applications for new vehicles, vehicle re-chassis, building projects or grant requests over $5000.00. 8. If you require assistance in the preparation of your grant application, contact the Department’s Regional EMS Coordinator for your Region. Emergency Medical Services Assistance Grant Application (February 2011) P a g e | 2 of 3 GRADING SCALE Grade 1 Immediate Funding Need—Alternate funding sources exhausted or unavailable. System will suffer if program postponed. Program request is of greatest impact to citizens served. Grade 2 Definite Funding Need—Alternative funding limited or delayed availability. Program of high priority. Need is present. Program of high impact to citizens served. Grade 3 Project Needed Eventually—Local funding available in future. System will benefit from improved time table. Limited available funding. Grade 4 Project Can Be Delayed—Local funds available. Program of low impact to citizens served. Consideration will be given as need increases. Grade 5 Project Not Needed—Local funds available. Limited or impact to service area. Duplication of resources. Consideration will be given as needed is evident. EMS Assistance Fund Grant Guidance (February 2011) P a g e | 3 of 3 Division of Emergency Medial Services and Highway Safety Emergency Medical Services Assistance Fund Grant Application and Cover Page Name of Organization EMS Region Number EMS System Name Employer Identification Number (EIN) Address City State IL ZIP Code Primary Contact Person Telephone Number Email Secondary Contact Person Telephone Number Email Current funding source for your organization If your organization is an ambulance provider, please answer the following: Level of service Population of Service Area Total Yearly EMS Calls BLS ILS ALS Number of Licensed Personnel BLS ILS ALS Paid Paid on call Status of Personnel Volunteer Individual Who Prepared Application Signature of Individual Who Prepared Application Date Emergency Medical Services Assistance Grant Application (February 2011) P a g e | 1 of 4 Description of Project Criteria 1. Completely describe your agency/organization’s request for financial assistance. Describe the purpose and scope of the request. Please state clearly justification for the requested item(s). 2. Will Funding of this request maintain present services? If requested item(s) is for replacement purposes, describe current condition of item(s) to be replaced. 3. How does the requested item(s) impact the citizens served and on patient care? Emergency Medical Services Assistance Grant Application (February 2011) P a g e | 2 of 4 4. Is the requested item(s) required for licensure and/or certification Pursuant to the EMS Systems Act and /or the EMS and Trauma Center Code? 5. Is the item(s) requested necessary for an upgrade in services, i.e., BLS to ALS 6. Is the requested item(s) to be shared with other EMS agencies? Is the request identified in local, regional, and / or state plans/documents as a priority? Is the request compatible with goals and objectives of the applying agency/organization, jurisdiction, and region and /or state? 7. Provide any additional information that will help the reviewers to understand your need for the requested item(s), e.g., what are the unique characteristics of your service area relating to geography, demography, economic conditions, etc. Emergency Medical Services Assistance Grant Application (February 2011) P a g e | 3 of 4 Evaluation Criteria 1. Requested item/project is required for licensure and /or certification by the EMS Systems Act and /or EMS and Trauma Center Code. YES NO 2. Equipment requested is required for upgrade, i.e., BLS to ALS. A statement of endorsement from local EMS System supporting upgrade must be included. Yes NO 3. Current personnel are trained to operate requested items. Yes NO 4. Requesting Agency serves more than its own area, and an increasing number of calls are out of its own district. YES NO 5. Equipment requested is to be shared with the EMS agencies. YES NO 6. The request is identified in local, regional and/or state EMS plan(s) as priority. Include impact on citizens served. The program/equipment request is compatible with goals/objectives of the agency and the EMS Region. YES NO Provide any additional information that will help the reviewers understand your need for the requested Item(s). Emergency Medical Services Assistance Grant Application (February 2011) P a g e | 4 of 4