HomeMy WebLinkAboutAgenda - 02-03-2004-9aORANGE COUNTY
BOARD OF COMMISSIONERS
ACTION AGENDA ITEM ABSTRACT
Meeting Date: February 3, 2004
Action Agenda
Item No. 9 _a
SUBJECT: Acceptance of Grant Allocation from the Department of Homeland Security
State Homeland Security Grant Program
DEPARTMENT: Emergency Management PUBLIC HEARING: (Y/N) No
ATTACHMENT(S):
Grant Transmittal Letter
Memorandum of Agreement
Annex B, Subgrant Forms
List of Allowable Equipment
(under separate cover)
INFORMATION CONTACT:
Nick Waters, ext 3030
TELEPHONE NUMBERS:
Hillsborough 732-8181
Chapel Hill 968-4501
Durham 688-7331
Mebane 336-227-2031
PURPOSE: To approve acceptance of a State pass-through grant allocation of federal
Homeland Security funds in the amount of $363,908 to reimburse Orange County for the
purchase of equipment associated with homeland security activities of the County, its
municipalities, and the University,
BACKGROUND: The United States Department of Homeland Security (DHS) awarded the
State of North Carolina funding for equipment, exercises, and training through the FY 2003
State Homeland Security Grant Program Part II, The program is designed to improve domestic
preparedness through the purchase of equipment for first responders. Federal funding is
allocated in accordance with a DHS formula of 80% for local government use and 20% for state
use,
Orange County's allocation from the State of North Carolina for this award is $363,908 and did
not require the County to submit a grant application. The accompanying Memorandum of
Agreement between the County and North Carolina Emergency Management expresses the
conditions for the grant funding.
Orange County staff facilitated a meeting on January 20, 2004 to begin determining the needs
of response agencies within the County. Invited to the meeting were representatives from
Chapel Hill fire and police, Carrboro fire and police, UNC Public Safety, Hillsborough Police,
Orange County Sheriff, Orange County Public Health, and Orange County Emergency
Management, These members have begun developing purchase requests choosing from a
selection of equipment from the Approved Equipment List provided by the U.S. Department of
Homeland Security. All equipment requests are chosen under the concept that whatever is
ultimately purchased may be used by any agency in the County. It should be noted that the
funding available under this grant cannot be used to purchase backup generators for buildings
or related infrastructure improvements, The County has submitted a request for generator
funding through a different grant. Preliminary indications are that Orange County will receive
favorable consideration of a portion of the grant funding it has requested for emergency power
enhancements. Formal notification and acceptance of those grant funds are expected later this
spring.
Two similar equipment and training grant projects were undertaken in FY 2002-03, using the
same approach as for this proposed grant acceptance. Through these two grants, the BOCC
accepted $172,235 in funding for the County distributed through the Department of Justice (now
Department of Homeland Security) for terrorism preparedness equipment, exercise costs, and
training expenses. The County used a similar consultative process during these past two grant
awards for determining emergency response agency needs. The decision was made to
purchase gas masks and accessories for use by community public safety and emergency
response personnel, other personal protective equipment, chemical detection devices, and
computer-based incident management programs. The gas masks have been received and
were distributed to users on August 19, 2003. Staff is currently in the process of ordering the
equipment from the most recently approved grant.
An exercise design team is developing a series of exercises to test the capabilities of the
County's contagious disease response plan and other County and municipal agencies' plans
associated with such an incident. These exercises are expected to occur this summer.
Training for emergency responders is being scheduled to provide all interested responders with
the necessary skills and information to increase the capability to act in a terrorism awareness
and response capacity.. Other more advanced training classes are expected to occur
throughout the year.
FINANCIAL IMPACT: There is no County match required for the receipt of the State-
administered reimbursable Federal grant, The County will seek reimbursement from the State
pursuant to the terms of the grant, There may be some incidental use of existing staff time;
however, no additional County costs should be expected.
RECOMMENDATION(S): The Manager recommends that the Board:
Accept the allocation award;
Authorize the Manager to sign the Memorandum of Agreement;
Authorize the Manager to sign the Assurances of Participation;
Authorize the Manager to identify Nick Waters, Director of Emergency Management, as
the Designated Agent under Annex B; and
Authorize the Manager to identify Eric Griffin, Emergency Management Specialist, as
the Point of Contact under Annex B.
0
North Carolina Department of Crime Control and Public Safety
Division of Emergency Management
4713 Mail Service Center • Raleigh, NC 27699-4713
Michael F, Easley Bryan E. Beatty
Governor Secretary
November 19, 2003
Mr.. John M. Link, Jr.
Orange County
P. O. Box 8181
Hillsborough, NC 27278
Re: US DHS FY2003 SHSGP Part II Grant Transmittal Letter
Dear Mr. Link
This letter provides the Memorandum of Agreement (MOA) between the Department of Crime Control and Public
Safety, Division of Emergency Management and the County of Orange for funding under the Department of
Homeland Security (DHS) FY2003 State Homeland Security Grant Part II (SHSGP II). This program is designed to
improve domestic terrorism preparedness through the purchase of equipment for first responders, as well as to
provide funding to train and exercise for chemical, biological, radiological, nuclear, and explosive (CBRNE)
incidents. Attached to the MOA are the following: 1) Annex A: NC Subgrant Instructions; 2) Annex B: Subgrant
Forms; and 3) Annex C: Federal Guidelines, The Agreement between the parties includes this transmittal letter,
MOA, Annex A, Annex B, and Annex C. The Agreement is complete only when you take these five elements as a
whole.
If the county chooses to participate, please sign the Memorandum of Agreement, Designation of Agent and
Designation of 'a Point of Contact Form, and give these forms to your NCEM Area Coordinators not later than
January 30, 2004. The NCEM Area Coordinator will then route them through the Branch Offices to the NCEM
Homeland Security Branch Manager. Failure to meet this date could result in the grant funds being unencumbered
and used for other counties. The Designation of Agent Form allows the County Manager to delegate grant signature
authority and a Point of Contact Form to designate a person who will be in day-to-day contact with NCEM.. These
forms are in Annex B, NC Subgrant Forms.
If the county chooses not to participate, please sign the Declination Form in Annex B and return it to the NCEM
Area Coordinator not later than January 30, 2004,
The CD-ROM included in this application package contains all three Annexes. Instructions on grant application
procedures are contained in Annex A. An internet web too] will be used for the first time to submit detailed
worksheets. This online web too] will streamline the grant application process. Counties may submit equipment,
exercise, training, and planning deliverables at any time before the deadlines. The schedule deadlines are found in
Appendix A to Annex A If you have any questions, or need further information, please contact your NCEM Area
Coordinator, Branch Manager, or the NCEM Homeland Security Branch Manager, Doug Boyd.
Dr Kenne[hB.laylor,
Director
Attachments (4):
Memorandum of Agreement and three Annexes (A-C), CD-ROM containing Annex A, B, and C
Location: 116 West Jones Street • Raleigh, NC 27603-1135 • (919) 733-3867
An Equal Opportunity/Affirmative Action Employer
Appendix .A
Sub-Grants for First Responder Preparedness
to NC Counties and Eastern Band of Cherokee Indians
Jurisdiction Population Grant Jurlsdidon Population Grant
Apt 2000 amount Apr2000 amount
ALAMANCE 130,800 $402,608 JACKSON 28,881 $91,075
ALEXANDER 33,603 103,431 JOHNSTON 121,985 375,413
ALLEGHANY 10,677 32,864 JONES 10,381 31,953
ANSON 25,275 77,798 LEE 49,040 160,947
ASHE 24.384 75,055 LENOIR 59,848 183,599
AVERY 17,167 62,841 LINCOLN 63,760 106,3i8
BEAUFORT 44,958 138,383 MACON 29,811 91,760
EERTIE 19,773 60,882 MADISON 19,635 60,437
BLADEN 32,278 99,353 MARTIN 25,593 78,778
BRUNSWICK 73,143 225,137 MCDOWELL 42,151 120,743
BUNCOMBE 206,330 635,093 MECKLENBURG 895,454 2,140,637
BURKE 89,148 274,401 MITCHELL 15,887 40,285
CABARRUS 131,063 403,418 MONTGOMERY 28,822 82,559
CALDWELL 77,415 238287 MOORE 74,789 230,142
CAMDEN 8,885 21,192 NASH 87,420 289,082
CARTERET 59,383 102,783 NEWHANOVER 160,307 493,432
CASWELL 23,601 72,337 NORTHAMPTON 22,086 67,082
CATAWBA 141,685 436,112 ONSLOW 160,355 462,709
CHATHAM 49,329 t61,837 ORANGE 118,227 363,008
CHEROKEE 2047 74,018 PAMLICO 12,934 39,811
CHOWAN 14,626 44,712 PABOUOTANK 34,897 107,414
CLAY 8,776 27,010 FENDER 41,002 126,462
CLEVELAND 96287 298,375 PEROUIMANS 11,388 34,901
COLUMBUS 64,749 188,620 PERSON 35,623 109,649
CRAVEN 91,438 281,444 PITT 133,798 411,638
CUMBERLAND 302,963 932,633 POLK 18,324 56,402
CURRITUCK 18,190 65,860 RANDOLPH 130,464 401,543
DARE 20,987 92240 RICHMOND 48,664 143,325
DAVIDSON 147,246 463,229 ROBESON 123,339 379,643
DAVIE 34,835 107,224 ROCKINGHAM 91,928 282,956
DUPLIN 49,063 151,018 ROWAN 130,340 401,192
DURHAM 223,314 687,370 RUTHERFORD 52,099 1113,608
ESCI 8,092 24,908 SAMPSON 60,161 105,178
EDGECOMBE 55.608 171,158 SCOTLAND 35,988 110,803
FORSYTH 306,087 942,087 STANLY 5a1
0
0 170,834
FRANKLIN
47,260
145,488
STOKES 71
1 1
37,622
GASTON 190,385 688,952 BURRY 71,219 216,215
GATES 10,616 32,360 SWAIN 8,845 27,226
GRAHAM 7,516 23,131 TRANSYLVANIA 29,334 90,291
GRANVILLE 48,498 149,270 TYRRELL
UNION 4,149
677
123 12,771
380,683
GREENE
GUILFORD 18,074
421,04B 68,403
1,298,004 VANCE ,
42,954 132,214
HALIFAX 57,370 176,067 WAKE 527,848 1,932,637
HARNETT 91,025 260,179 WARREN 19,972 81,476
HAYWOOD 54,033 168,318 WASHINGTON 13,723 42,240
HENDERSON 89,173 274,478 WATAUGA 42,605 131,417
HERTFORD 22,601 89,567 WAYNE 113,329
632
05 348,831
202
018
HOKE 33,646
6
626 103,564
933
17 WILKES
WILSON ,
73,814 ,
227,203
HYDE
IREDELL ,
122,660 ,
377,653 YADKIN 36.348 111,881
JACKSON 29,861 91,975 YANCEY 17.774 54,709
tonds 5,048,313 624,770,126
5
Department of Homeland Security
FY2003 State Homeland Security Grant Program
(SHSGP)
PART II
Memorandum of Agreement
between the
N.C. Department of Crime Control and Public Safety,
Division of Emergency Management
and
The County of Orange
(Return completed form to NCEM Area Coordinator)
FY2003 DHS SHSGP Part 11 Memorandum of Agreement 1 of 6
I. PURPOSE
The purpose of this Memorandum of Agreement (MOA) is to establish responsibilities and
procedures to implement the terms of the Department of Homeland Security (DHS), Office of
Domestic Preparedness (ODP), FY2003 State Homeland Security Grant Program (SHSGP) Part
II, A copy of the complete federal grant instructions is provided as Annex C, attached and
incorporated by reference herein.
II. PARTIES
The parties to this MOA are the North Carolina Department of Crime Control & Public Safety,
North Carolina Division of Emergency Management, and the County of Orange,
III. BACKGROUND
The Department of Homeland Security (DHS), through the Office of Domestic Preparedness
(ODP), in accordance with the authorities listed below, created the FY2003 State Homeland
Security Grant Program Part II, also known as the Supplemental Grant Program. This program
was established to provide federal reimbursement to state and local governments for the costs
associated with purchasing equipment, conducting exercises, training, and planning for chemical,
biological, radiological, nuclear, and explosive (CBRNE) terrorism events.
IV. AUTHORITY
The parties enter into this MOA under the authority of the following: 1) Public Law 108-11, the
Wartime Supplemental Appropriations Act of 2003; 2) Public Law 107-56, the USA Patriot Act
of 2001; 3) Public Law 107-296, the Homeland Security Act of 2002; 4) the implementing
regulations of each Act or Law, if any; 5) the U.S. Department of Homeland Security, Office of
Domestic Preparedness, FY2003 State Homeland Security Grant Program Part II Guidelines and
Application Kit available at http://www.oip.usdoi. og v/odp/does/fy03shsgt)2.ydf 6) applicable
ODP Information Bulletins; and 7) the N.C. Emergency Management Act, Chapter 166A of the
North Carolina General Statutes,.
V. DUTIES & RESPONSIBILITIES OF THE DIVISION OF EMERGENCY
MANAGEMENT AND THE COUNTY OF ORANGE
The Division of Emergency Management and the County of Orange agree to comply with the
duties and responsibilities assigned by DHS as outlined in Annex A, Appendices A through J
(North Carolina Subgrant Instructions), Annex B and Annex C (U.S, Department of Homeland
Security, Office for Domestic Preparedness Guidelines), attached and incorporated by reference
herein.
FY2003 DHS SHSGP Part 11 Memorandum of'Agreement 2 of'6
VI. FUNDING AND COMPENSATION
All terms and conditions of this Agreement are dependent upon and subject to the allocation of
funds from DHS, ODP and the Department of Crime Control and Public Safety, Division of
Emergency Management for the purposes set forth and the MOA shall automatically terminate if
funds cease to be available. Allowable costs shall be determined in accordance with the U.S.
Department of Homeland Security, Office of Domestic Preparedness, FY 2003 State Homeland
Security Grant Program Part II Guidelines and Application Kit (Annex C).
The Federal Department of Homeland Security will reimburse the State of North Carolina for
expenses that were approved on Detailed Budget Worksheets as explained in the FY2003
SHSGP Part II. The State of North Carolina, Department of Crime Control and Public Safety,
Division of Emergency Management will reimburse local governments for eligible expenses that
were approved on the Detailed Budget Worksheets. The NC Subgrant Instructions in Annex A,
attached and incorporated by reference herein, describe the Detailed Budget Worksheets and
how they are prepared and approved.
The Department of Crime Control and Public Safety, Division of Emergency Management will
reimburse the County of Orange for the actual eligible costs incurred, not to exceed the amount
of $363,908, Three hundred sixty-three thousand, nine hundred eight dollars. Funds will be
provided by the Department of Crime Control and Public Safety. Annex B also contains a form
to decline all of the funds.
VII. MODIFICATION OF THE AGREEMENT
Modification of this Agreement must be in writing and upon approval of both parties.
VIII. PROPERTY
The County of Orange shall be responsible for the custody and care of any property furnished for
use in connection with the performance of this agreement and shall reimburse the Division of
Emergency Management for any loss or damage to said property until the property is transferred
to another agency. The Department of Crime Control and Public Safety, Division of Emergency
Management will not be held responsible for any equipment bought by the Subgrantees.
IX. COMMUNICATIONS
To provide consistent and effective communication between the County of Orange and the
Department of Crime Control and Public Safety, Division of Emergency Management, each
party shall appoint a Principal Representative(s) to serve as its central point of contact
responsible for coordinating and implementing this MOA. The Department of Crime Control
and Public Safety, Division of Emergency Management contacts shall be Dr. Kenneth B. Taylor,
Director, and Mr. Don Needham, Information and Planning Chief. The County of Orange
contacts shall be John M. Link, Jr., County Manager, and the Designated Agent. The County
Manager will identify a Designated Agent who is authorized to sign and submit required grant
documentation, and will identify a Point of Contact for routine grant coordination using the
FY2003 DHS SHSGP Part If Memorandum of Agreement 3 of '6
attached Designated Agent and Point of Contact forms located in Annex B, attached and
incorporated by reference herein.
All confidential information of either party disclosed to the other party in connection with the
services provided hereunder will be treated by the receiving party as confidential and restricted
in its use to only those uses contemplated by the terms of this Agreement. Any information to be
treated as confidential must be clearly marked as confidential prior to transmittal to the other
party, Neither party shall disclose to third parties, the other party's confidential information
without written authorization to do so from the other party. Specifically excluded fiom such
confidential treatment shall be information that: (i) as of the date of disclosure and/or delivery,
is already known to the party receiving such information; (ii) is or becomes part of the public
domain, through no fault of the receiving party; (iii) is lawfully disclosed to the receiving party
by a third party who is not obligated to retain such information in confidence; or (iv) is
independently developed at the receiving party by someone not privy to the confidential
information.
X. SUBCONTRACTING AND SUBGRANTING
If the County of Orange subcontracts or subgrants any or all of the work required under this
Agreement, the County of Orange agrees to include in the subcontract or subgrant that the
subcontractor/subgrantee is bound by the terms and conditions of this MOA. The County of
Orange agrees to include in the subcontract/subgrant that the subcontractor/subgrantee shall hold
the Department of Crime Control and Public Safety, Division of Emergency Management
harmless against all claims of whatever nature arising out of the subcontractor's performance of
work under this MOA, to the extent allowed and required by law. If the County of Orange
subcontracts/subgrants, a copy of the executed subcontract/subgrant agreement must be
forwarded to the Division of Emergency Management within ten (10) days of execution of said
subcontract/subgrant. Contractual arrangement shall in no way relieve the County of Orange of
its responsibilities to ensure that all funds issued pursuant to this grant be administered in
accordance with all state and federal requirements, The County of Orange is bound by the terms,
conditions and restrictions of the U.S, Department of Homeland Security, Office of Domestic
Preparedness, FY 2003 State Homeland Security Grant Program Part II Guidelines and
Application Kit (Annex Q.
XI. COMPLIANCE WITH LAW
The County of Orange shall be wholly responsible for the work to be performed under this MOA
and for the supervision of its employees and assistants. The County of Orange shall be
responsible for compliance with all laws, ordinances, codes, rules, regulations, licensing
requirements and other regulatory matters that are applicable to the conduct of its business and
work performance under this MOA, including those of federal, State, and local agencies having
appropriate jurisdiction,
FY2003 DHS SHSGP Part It Memorandum of Agreement 4 of6
XII. WARRANTY
The County of Orange shall hold the Department of Crime Control and Public Safety, Division
of Emergency Management harmless for any liability and personal injury that may occur from or
in connection with the performance of this MOA to the extent permitted by the North Carolina
Tort Claims Act.
XIII. ANTITRUST LAWS
This Agreement is entered into in compliance with all State and Federal antitrust laws,
XIV. TERMINATION
This MOA shall be in effect from the date of execution to April 30, 2005.
This MOA may be terminated upon submission of a 30-day advance written notice of
termination,
If DHS suspends or terminates funding in accordance with Section VI, paragraph B5 of the U.S.
Department of Homeland Security, Office of Domestic Preparedness, FY 2003 State Homeland
Security Grant Program Part II Guidelines and Application Kit (Annex C), attached and
incorporated by reference herein, the County of Orange shall reimburse the Division of
Emergency Management for said property,
XV. ENTIRE AGREEMENT
This Agreement and any annexes, exhibits and amendments annexed hereto and any documents
incorporated specifically by reference represent the entire agreement between the parties and
supersede all prior oral and written statements or agreements.
XVI. EXECUTION
This MOA will become effective upon execution of all parties to the MOA, The date of
execution shall be the date of the last signature,
FY2003 DHS SHSGP Part 11 Memorandum of Agreement 5 of 6
10
EXECUTED THIS THE DAY OF 200
CONTRACTING AGENCY
DIVISION OF EMERGENCY MANAGEMENT
DEPARTMENT OF CRIME CONTROL AND PUBLIC SAFETY
WI INESS:
WITNESS:
WI INESS:
BY:
DR. KENNETH IT, TAYLOR, DIRECTOR
DIVISION OF EMERGENCY MANAGEMENT
DATE:
BY:
GERALD A. RUDISILL, .JR:,
DEPUTY SECRETARY
DEPARTMENT OF CRIME CONTROL & PUBLIC SAFETY
DATE:
BY:
JOHN M. LINK, JR.
COUNTY MANAGER
THE COUNTY OF ORANGE
COUNTY TAX FD O 5R-Rnnn977
DATE:
APPROVED AS TO PROCEDURES:
BY:
FRED J. TUCKER, CONTROLLER
DEPARTMENT OF CRIME CONTROL & PUBLIC SAFETY
DATE:
APPROVED AS TO FORM SUBJECT TO EXECUTION BY GERALD A. RUDISILL, JR-, DEPUTY
SECRETARY OF THE DEPARTMENT OF CRIME CONTROL AND PUBLIC SAFETY.
ROY COOPER
ATTORNEY GENERAL OF NORTH CAROLINA
BY:
ASSISTANT ATTORNEY GENERAL
FY2003 DHS SHSGP Pan 11 Memorandum of Agreement 6 of6
11
US Department of Homeland Security
FY2003
State Homeland Security Grant Program
(SHSGP)
Part II
ANNEX B
to the
Memorandum of Agreement
North Carolina Subgrant Forms
(Return completed forms to NCEM Part II Program Manager)
Attn: NCEM FY2003 SHSGP II Program Manager
4713 Mail Service Center
Raleigh, NC 27699-4713
DHS FY2003 SHSGP Part II Annex B: Subgrant Forms I of 7
12
Designation of Agent Form
As County Manager of Orange County I designate the following
person:
Name:
Title:
Address:
City & Zip:
Telephone:
Fax:
Nick Waters
Emergency Management Director
P.O. Box 8181
Hillsborough 27278
919-968-4066
Email: nwatersCco.oranae.nc.us
to be my Designated Agent for the DHS FY2003 SHSCP Part 11. The above-listed person may
sign and submit documents related to this grant.
Restrictions (If none, write none):
None
NCEM recommends that the County Emergency Manager be identified as the Designated
Agent.
DHS FY2003 SHSGP Part H Annex B: Subgrant Forms 2 of 7
13
I designate the following person:
Name:
Title:
Address:
City & Zip:
Telephone:
Fax:
Email:
Designation of a Point of Contact Form
Eric Griffin
Emergency Management Specialist
P.O. Box 8181
Hillsborough 27278
919-968-2050
919-968-4066
egriffin@co.orange.nc.us
to be the point of contact for all day-to-day communications for this grant program. The Point of
Contact will handle all routine communications with NCEM regarding the status of the grant
program.
County Manager's Signature
Date
NCEM recommends that the County Emergency Manager or other staff person be
identified as the Point of Contact.
DHS FY2003 SHSGP Pan II Annex B: Subgrant Forms 3 of 7
14
Assurance of Participation Form
This form provides written assurance that all First Responder disciplines within the county and
within all municipalities in the county were provided an opportunity to participate in this grant
program,
County Manager (or Principal Chief for the Eastern Band of the Cherokee Indians) (signing on behalf of
county first responder agencies within the county and largest municipality within the county which provides first
responder agencies in that municipality and any additional municipality with a population of 25,000 people or
greater))
I certify that all eligible county agencies and first responder agencies in the other municipalities were provided an
opportunity to participate in this grant program,
Manager Signature
Orange County
Jurisdiction Date
City Manager (of the largest incorporated municipality within the county who provides first responder services)
I certify that my first responder agencies were provided an opportunity to participate in this grant program.
City Manager Signature
Town of Chapel Hill
Jurisdiction Date
City Manager (if applicable, of any additional incorporated municipality with a population of 25,000 people or
greater that provides first responder services)
I certify that my first responder agencies were provided an opportunity to participate in this grant program.
City Manager Signature
City Manager Signature
Town of Carrboro
Jurisdiction
Town of Hillsborough
Jurisdiction
Date
Date
DHS FY2003 SHSGP Part II Annex B: Subgrant Forms 5 of 7
15
Discipline Points of Contact Form
To assist the State in preparing reports to DHS on the allocation of equipment, training, exercise,
and planning funds, please identify the Point-of-Contact for each discipline to ensure that all first
responder disciplines have been provided an opportunity to participate.
Signatures are not required.
Law Enforcement (LE)
(name of contact person) (phone number)
-------------- (agency / organization)
--------------------
------------
Emergency Medical
Services (EMS) (name of contact person) (phone number)
-------------- (agency / organization)
--------------------
------------
Emergency Medical
Agencies (EMA) (name of contact person) (phone number)
-------------- (agency / organization)
--------------------
------------
Fire Services (FS)
(name of contact person) (phone number)
-------------- (agency / organization)
--------------------
------------
DHS FY2003 SHSGP Part 11 Annex B: Subgrant Forms 6 of 7
16
Discipline Points of Contact (continued)
Signatures are not required.
Hazardous Materials (HZ)
(name of contact person) (phone number)
(agency / organization)
----------------------------------------------
Public Works (PW)
(name of contact person) (phone number)
(agency / organization)
----------------------------------------------
Public Safety
Communications (PSC) (name of contact person) (phone number)
(agency / organization)
----------------------------------------------
Health Care (HC)
(name of contact person) (phone number)
(agency / organization)
----------------------------------------------
Public Health (PH)
(name of contact person) (phone number)
(agency / organization)
----------------------------------------------
I verified the above data is correct, Please SIGN below.
(signature of the local emergency management coordinator) (date)
DHS FY2003 SHSGP Part II Annex B: Subgrant Forms 7 of 7