"Emergency Medical Services (EMS) Needs Assessment Grant" - Wyoming

Emergency Medical Services (EMS) Needs Assessment Grant is a legal document that was released by the Wyoming Department of Health - a government authority operating within Wyoming.

Form Details:

  • Released on September 1, 2014;
  • The latest edition currently provided by the Wyoming Department of Health;
  • 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 Wyoming Department of Health.

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Emergency Medical Services (EMS) Needs Assessment Grant
Wyoming Department of Health
Pubic Health Division
Office of Emergency Medical Services
This is a fillable form; handwritten forms will not be accepted.
Date
Section I: Contact Information
Primary Contact
Title
Phone Number
E-Mail
Please refer to Appendix A, Column C of the Grant Guidance document for RUCA information.
RUCA Number
List political
subdivisions
within the
RUCA
RUCA Number
List political
subdivisions
within the
RUCA
RUCA Number
List political
subdivisions
within the
RUCA
If additional space is needed, please attach a type-written document outlining political subdivisions.
Section II: EMS Agency/Agencies
If more than one EMS agency is within the RUCA(s), all additional EMS agencies will be required to complete
and submit EMS Agency Addendum.
Year Established
Ambulance License
Service Director
Physician Medical
Director
09/14
Page 1 of 9
Emergency Medical Services (EMS) Needs Assessment Grant
Wyoming Department of Health
Pubic Health Division
Office of Emergency Medical Services
This is a fillable form; handwritten forms will not be accepted.
Date
Section I: Contact Information
Primary Contact
Title
Phone Number
E-Mail
Please refer to Appendix A, Column C of the Grant Guidance document for RUCA information.
RUCA Number
List political
subdivisions
within the
RUCA
RUCA Number
List political
subdivisions
within the
RUCA
RUCA Number
List political
subdivisions
within the
RUCA
If additional space is needed, please attach a type-written document outlining political subdivisions.
Section II: EMS Agency/Agencies
If more than one EMS agency is within the RUCA(s), all additional EMS agencies will be required to complete
and submit EMS Agency Addendum.
Year Established
Ambulance License
Service Director
Physician Medical
Director
09/14
Page 1 of 9
Geographical Area
Served
Population Served
Trauma Region
Call Volume
Highest Skill
EMT
Per Year
Level
Intermediate
Provided
Paramedic
Total # of
Total # of Paid Staff
Volunteers
Total # of Stations
Total # of EMTs
Section III: Budget Information
Is the EMS Agency a
Yes
501 (c)(3)?
No
Does the EMS
Yes
Agency bill for
No
services ?
If not, why?
Previous FY
Expenditures
Previous FY
Operating Budget
09/14
Page 2 of 9
Current FY
Operating Budget
FY to Date
Expenditures
List Funding and/or Revenue Sources
Source 1
Amount
Source 2
Amount
Source 3
Amount
Source 4
Amount
Source 5
Amount
Source 6
Amount
Outline billing
practices.
Payor Mix Percentage:
Medicare
Medicaid
Uncompensated
Tribal
Private Insurance
Veterans Administration
Worker's Comp.
Self Pay
Other (list)
Percentage
Other (list)
Percentage
09/14
Page 3 of 9
Section IV: Needs Assessment
Provide reasons for
effectiveness of
services and identify
opportunities for
improvement.
State concerns with
maintaining staff
and/or volunteer
levels.
09/14
Page 4 of 9
Identify gaps in
emergency medical
services delivery
within service area.
Describe concerns
with maintaining
certification levels
of current staff.
09/14
Page 5 of 9
Page of 9