"Emergency Medical Services Training Grant Application Form" - Nevada

Emergency Medical Services Training Grant Application Form is a legal document that was released by the Nevada Department of Health and Human Services - a government authority operating within Nevada.

Form Details:

  • Released on November 1, 2017;
  • The latest edition currently provided by the Nevada Department of Health and Human Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.

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STATE OF NEVADA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Department of Public and Behavioral Health
EMS Program
4150 TECHNOLOGY WAY, SUITE 101
CARSON CITY, NEVADA 89706
(775) 687-7590
Emergency Medical Services Training Grant Application
Please complete the following application by typing or printing clearly.
Agency Name (Must be a Rural Agency)
: ________________________________________________________________________________________
Training to be conducted (CPR, BTLS, continuing education, ect)________________________________________________________________
Amount of funding requested: $_________________________
Local Government Agency to receive and administer the funds (If different from above)
:__________________________________________________
Address
: ______________________________________________________________________________________________
_______________________
(Street)
(City)
(State)
(Zip)
(Tax I.D. #)
Authorized Local Official
:______________________________________________________________
(Print Name)
Authorized Local Officia
l: _____________________________________________________________
Date: _______________________________
(Signature)
Training Program Coordinator
: _______________________________________________________________________________________________________
(Day time phone #)
Address
: ___________________________________________________________________________________________________________________________
(Street)
(City)
(State)
(Zip)
Email address:___________________________________________________________________________________________________
In addition to this application please submit (on agency letterhead) a brief explanation of the need for this training program and; the
following information:
Scope of Work: Needs to include a description or outline of the educational program to be conducted with a list of goals and objectives.
For equipment request, need to include a full detailed description of equipment, how the equipment will be used and the impact Nevada.
The number of EMS personnel expected to participate in the training (for training only)
A brief description of the geographic area to be served by the training or equipment.
A detailed budget that shows the total costs of the training program or equipment.
Return application and required documentation to:
Division of Public and Behavioral Health EMS
Program Attention: Jenna Burton
4150 Technology Way, Suite 101
Carson City NV 89706
Phone: (775) 687-7590 Fax: (775) 687-7595
EMS Office Use Only
Date Received: __________________
Reviewed By: _____________________
Approved: _______
Amount Recommended: ______________
Denied: _______
Reason for denial: ____________________________________________________________________________________
EMS Program Director: ______________________________________
Date:______________
Approved______
Denied_______
Amount authorized:__________________________
Budget/Category: __________
Training Grant Application 11-17
STATE OF NEVADA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Department of Public and Behavioral Health
EMS Program
4150 TECHNOLOGY WAY, SUITE 101
CARSON CITY, NEVADA 89706
(775) 687-7590
Emergency Medical Services Training Grant Application
Please complete the following application by typing or printing clearly.
Agency Name (Must be a Rural Agency)
: ________________________________________________________________________________________
Training to be conducted (CPR, BTLS, continuing education, ect)________________________________________________________________
Amount of funding requested: $_________________________
Local Government Agency to receive and administer the funds (If different from above)
:__________________________________________________
Address
: ______________________________________________________________________________________________
_______________________
(Street)
(City)
(State)
(Zip)
(Tax I.D. #)
Authorized Local Official
:______________________________________________________________
(Print Name)
Authorized Local Officia
l: _____________________________________________________________
Date: _______________________________
(Signature)
Training Program Coordinator
: _______________________________________________________________________________________________________
(Day time phone #)
Address
: ___________________________________________________________________________________________________________________________
(Street)
(City)
(State)
(Zip)
Email address:___________________________________________________________________________________________________
In addition to this application please submit (on agency letterhead) a brief explanation of the need for this training program and; the
following information:
Scope of Work: Needs to include a description or outline of the educational program to be conducted with a list of goals and objectives.
For equipment request, need to include a full detailed description of equipment, how the equipment will be used and the impact Nevada.
The number of EMS personnel expected to participate in the training (for training only)
A brief description of the geographic area to be served by the training or equipment.
A detailed budget that shows the total costs of the training program or equipment.
Return application and required documentation to:
Division of Public and Behavioral Health EMS
Program Attention: Jenna Burton
4150 Technology Way, Suite 101
Carson City NV 89706
Phone: (775) 687-7590 Fax: (775) 687-7595
EMS Office Use Only
Date Received: __________________
Reviewed By: _____________________
Approved: _______
Amount Recommended: ______________
Denied: _______
Reason for denial: ____________________________________________________________________________________
EMS Program Director: ______________________________________
Date:______________
Approved______
Denied_______
Amount authorized:__________________________
Budget/Category: __________
Training Grant Application 11-17