Rural / Frontier EMS Education Grant Request for Funding

NOTE: Classes are not eligible for reimbursement until this application has been submitted and approved by TEEX-ESTI staff. All classes approved through this grant must be completed by ***AUGUST 15th***. This application is not considered complete until all blanks are answered / completed by applicant.

Position in Organization:

Hosting Organization:

Mailing Address:

Physical Address:

Mailing City, State, Zip:

Physical City, State, Zip:

Organization Type: Vol. EMS

Other (specify) Paid FD

Paid EMS

Vol. FD

Primary Contact

E -mail:Name:

Fax Number:

E -mail:

Home Phone:

Work Phone:

Name:

Secondary Contact

Web Contact (All funded classes will be posted on the TEEX website. Please enter contact information below):

Contact E -mail:

Contact Phone:

Contact Name:

Board Member

Chief Training Officer

Other (specify)

Fax Number:

Home Phone:

Work Phone:

Section 2: Course Information (submit one application per checked box)

TxDSHS Courses Continuing Education (cont.)Continuing Education EMR (formerly ECA)

EMS Instructor

Advanced EMT (formerly EMT Inter.)

EMT Basic

ITLS Provider ITLS Instructor Pediatric ITLS ITLS Access

EVOC / CEVO EVOC / CEVO Instructor

PHTLS PHTLS Instructor

Yes NoHas your agency requested funding for this class from any other funding entity?

If yes, from whom?

How much?

Section 1: Organizational Information (to be completed by or on behalf of the organization requesting training).

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Org. is in County:

EMT Paramedic GEMS

PALS Provider PEPP Provider PEPP Course Coordinator

Emergency Pediatric Care (EPC) EPC Instructor

GEMS Course Coordinator

ACLS Provider AMLS Provider Adv. Trauma Life Support

Initial RecertRem

Initial RecertRem

Initial RecertRem

Initial RecertRem

Instructor Time Quantity (hours) Number of Instructors TotalRate

Instruction hours (lecture only):

Instruction hours (skills only): cannot exceed 45% of total class hours

Coordinator Fee (select course type):

Class Location (facility):

Class Location Address:

Class Location City, State, Zip:

Complete the next section for all courses:

E -mail:Coordinator Name:

Section 4: Proposed Course Budget - Complete a course budget for each class requested. - Rates are for budgeting purposes only.

Total Class Size (must have at least 10 students):

Cell / Pager

Number:

Fax Number:Phone:

Section 3: Class Information (must be completed)

Number of rural responders (must be at least 80% rural responders):

Additional participating agencies

(please list each):

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Proposed Start Date:

Hours of Lecture:

Hours of Skills (not to exceed 45% of total):

Clinical Hours (not

reimbursable):

Total Course Hours:

Address: City: Zip:

TotalNumber of InstructorsQuantity (days / miles)Rate

Overnight lodging (not to exceed GSA allowance)

Per diem - must submit all meal receipts for reimbursement.of actual amount spent not to exceed GSA allowance.

Mileage - trip must be over 150 miles round trip (carpooling is strongly recommended).

Total:

Travel (must be pre-approved)

Class in County:

Proposed End Date:

Proposed Clinical End Date:

Page 3 of 4

Authorized Signature

Signer's Name:

City, State, Zip:

Mailing Address:

Hosting Organization

Name:

Signer's Title:

Phone Number:

Return completed applications to: TEEX - ESTI Attention: Jennifer Harding, Project Coordinator TxDOT EMS Educaton Grant Program PO Box 40006 College Station, TX 77842-4006 (979) 862-6650 office (979) 979-458-3533 fax Jennifer.Harding@teex.tamu.edu Forms can also be submitted electronically using the "Submit by Email" button on the next page.

Page 4 of 4

FEE DISCLOSURE FORM

Please disclose what your customary student enrollment / class fee is for the class for which you are requesting funding. Additionally, we are asking for you to disclose the fee which will be charged to students who will be attending the grant subsidized program.

Customary Student fee for a class without grant funding (per student):

Subsidized Student Fee (per student):

Eligible Expenses: Fees listed below are all eligible for reimbursement through the use of this grant. • Instructional Fees at $23 / hour • Coordination Time at $23 / hour • Lodging and per diem for overnight stays at state rates (only with pre-approval) • Mileage in excess of 150 miles round trip at state rates (only with pre-approval)

Ineligible Expenses: Expenses listed below are not eligible for reimbursement under the grant and may, at the Coordinator's discretion, become part of the fee structure students pay as a requirement for admission into the class. Please indicate distribution of the fees below on a price per student basis::

Insurance:

Certificates:

Printing:

Books:

Building Use:

Refreshments:

Course Applications:

Medical Director Fees:

Workbooks:

Other:

By signing this document, you acknowledge that you will not include eligible expenses as a component of student fees. You further understand and acknowledge that violation of the fee structure stated above may be grounds for sanctions to include, but not limited to, revocation of the grant and reimbursement of overcharged fees back to TEEX.

Name:

Signature

Date:

Please use this box explain any "Other" charges and any other comments you wish to make in regards to course cost and how much students will be charged.