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STATE OF HAWAII HIGHWAY SAFETY OFFICE <br /> GRANT AGREEMENT <br /> Grant No:E141 2-04(04-H-01) <br /> Page 1(To be completed by applicant agency) <br /> 1. Grant Title <br /> HCFD Pediatric Spinal Immobilization System <br /> 2. Name and Address of Applicant Agency 4. Duration <br /> Month-Day-Year <br /> Hawaii Fire Department <br /> 25 Aupuni St suite#2501 A. Grant Period <br /> Hilo,HI. 96720 From: October 1st,2011 <br /> To: September 30th, 2012 <br /> 3. Agency Unit to Handle Grant(Name and Address) <br /> B. Project Period <br /> Hawaii Fire Department From: October 1st,2011 <br /> 25 Aupuni St suite#2501 To: September 30th, 2012 <br /> Hilo,HI.96720 <br /> 5. Location of Project 6a. Type of Application <br /> Check Ap priate Item) <br /> Hawaii County Initial Revision ['Continuation <br /> 6b. Reimbursement Schedule Desired <br /> ®Monthly ['Quarterly <br /> 7. Grant Description(Summarize the grant plan covering activities that address the major goals and objectives in <br /> approximately 100 words. Limit to 6 lines.) <br /> To acquire specialized pediatric spinal immobilization equipment for the department's 15 Advanced Life Support ground <br /> ambulances.Upon receipt of device,initiate in service training to all affected operations personnel,establish protocols and <br /> guidelines,and distribute equipment.Utilization of the device shall be inputted and captured in the ePCR.Patient outcomes shall <br /> be monitored and recorded through the collaboration of the medical centers involved and the Hawaii's State Trauma Registry. <br /> 8. Federal funds allocated under this agreement shall not exceed $12,802.74 <br /> 9. Approval Signatures <br /> Acceptance of Conditions: It is understood and agreed by the undersigned that a reimbursement grant received as a result of this grant agreement is subject to <br /> Public Law 89-564(Highway Safety Act of 1966)and all administrative regulations governing grants established by the U.S.Department of Transportation <br /> and the State of Hawaii. It is expressly agreed that this project constitutes an official part of the Hawaii Highway Safety Program and that said applicant <br /> agency will meet the requirements as set forth herein,including accompanying schedules A,B,B-1,C&D,which are incorporated herein and made a part of <br /> this grant went. Authorization to proceed with this Highway Safety Project is requested. <br /> 9a. Grant Director 9b. Authorizing Official of Agency Unit <br /> Name: Lance Uchida Phone: (808)961-8319 Name: Darren Rosario Phone: (808)932-2903 <br /> Title: Battalion Chief Fax: (808)961-8048 Title: Fire Chief Fax: (808)932-2928 <br /> Address: 25 Aupuni St #2501 Address: 25 Aupuni St #2501 <br /> Hilo,HI. 96720 Hilo,HI 96720 <br /> E-Mail: luchida@co.hawaii.hi.us E-Mail: j'o a,co.hawaii.hius <br /> APR 9 201 /'"a' <br /> 2 APR ' 2012 <br /> (Signature) (Date) (Signature) (Date) <br /> To be prepared by applicant,use separate sheets as required. Form HS 3-71 Rev. 8/6/09 <br />