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STATE OF HAWAII PURCHASE 00 210212 r <br /> * '' 'iORDER NO. i <br /> REQUISITION & PURCHASE ORDER DOC 00136678 <br /> E m etwagy Med Svc&lnj Prey Stm Br HTH 730 MO iDate 11/19/2014 <br /> ORGANIZATION FUNCTION AND ACTIVITY <br /> Deliver Before <br /> NOTICE TO VENDORS DELIVERY ADDRESS • <br /> Conditions of purchase are listed at the bottom of this purchase order. Please read carefully, EMSIPSB <br /> Payments may be delayed if all steps are not followed. <br /> Leahi Hospital,Trotter Basement <br /> COUNTY OF HAWAII 3675 Kilauea Avenue <br /> HAWAII FIRE DEPARTMENT Honolulu HI 96816 • <br /> • <br /> 25 AUPUNI ST STE 2501 BILLING ADDRESS <br /> HILO, HI 96720- EMSIPSB <br /> Leahi Hospital,Trotter Basement <br /> The State of Hawaii is an EQUAL EMPLOYMENT OPPORTUNITY and AFFIRMATIVE ACTION 3675 Kilauea Avenue <br /> employer. We encourage the participation of women and minorities in all phases of employment. Honolulu HI 96816 <br /> QUANTITY UNIT (1.. DESCRIPTION OBJECT UNIT PRICE AMOUNT <br /> For services related to developing a fall prevention/home safety 2990 3,360.00 <br /> assessment program for seniors and their families In Hawaii <br /> County in partnership with the County of Hawaii Office of Aging <br /> Iand the Department of Health,EMS and Injury Prevention System <br /> Branch. Services,which run from December 1,2014 through <br /> November 30,2015 include:conducting home safety <br /> assessments with individuals identified as at risk for falls; <br /> referring individuals to prevention services that include <br /> medication review,exercise programs,and home modification <br /> services;installation of safety devices such as grab bars,ramps, <br /> or smoke/CO detectors to eliminate fall hazards in the home. <br /> Note:Operational funds are needed up front to cover fall <br /> prevention activities for this period. <br /> HRS§103D-102(b)(5)(A); HRS§321-22.5(a)Expenditures from <br /> the trauma system special fund shall be exempt from chapters <br /> 103D and 103F. <br /> Non Bid. Vendor does not accept p-card. <br /> _/ /,' i ' <br /> I,iue�, TOTAL: $3,360.00 <br /> Therese Ar•oud 8'j'33-9320 VOUCHER AUTHENTICATED BY: <br /> REQUISITIONER T PHONE NUMBER 1/1.1.4,..'-tf <br /> / <br /> GOODS/SERVICES RECEIVED IN GOOD ORDER AND CONDITION BY: DATEAUTHOR D BY <br /> —.__Conditions:READ CAREFULLY.�. <br /> REQUISITION NO. 1.A valid Purchase Order must have a P.D.Number and be authenticated by an authorized signature or n e. <br /> 2.Prices include delivery charges unless otherwise stated. <br /> 3.The State reserves the right to reject any items supplied that are not in accordance with spedbrations even though payment has been made in order to <br /> obtain discounts. <br /> VENDOR FOR DEPARTMENT USE ONLY <br /> NUMBER SFX <br /> '00002 29436 06 <br /> SFX TC F YR APP vD OBJECT CC PROJ NO. PH ACT ESTIMATED COST ACTUAL COST M R OPT DATA <br /> 01 621 S ' 15 311 H , 2990 467 3,360.00 <br /> State Accounting Form C-03 <br /> COPY#1 -VENDOR (WHITE) July 1. 1983(Revised) <br />