DOT&PF Safe Systems Approach
The Alaska Department of Transportation & Public Facilities (DOT&PF) is pleased to announce a safety funding program aimed at supporting agencies that provide Emergency Medical Services (EMS) and other safety-related services in their communities. This funding will provide essential tools and resources to enhance safety on Alaska’s roadways. To ensure a fair and effective allocation of funds, applications will be evaluated based on specific criteria outlined in this guide.
Organization Name
*
Address Location
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Contact Person Name
*
First Name
Last Name
Contact Person Phone
*
Please enter a valid phone number.
Type of Organization
*
Amount Requested ($)
*
Alaska Business License Number
*
Attach your business license here
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Is your agency a non-profit (401.C3 or 501.C3)?
*
Yes
No
If your agency is a non-profit, attach your certificate here.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
What is the mission if your organization?
*
Items included in your agencies request
*
Quantity
Total Cost
Vendor
Priority
Item 1
Item 2
Item 3
Item 4
Provide a summary for item requested, provide details on how receiving the items listed above will be utilized and the impact for your agency.
*
Total miles of road your agency supports
*
200+ miles of road
100-199 miles of road
50-99 miles of road
less than 50 miles of road
Please provide a summary of road miles your agency supports.
*
Fatalities and serious injuries: based on the number of fatalities and serious injuries on the roadways supported by the agency in the past three years.
*
More than 10 fatalities and serious injuries.
5-10 fatalities and serious injuries.
1-4 fatalities and serious injuries.
No fatalities or serious injuries.
Briefly summarize events your agency has responded to over the past three years.
*
Preventive measures and safety programs: evaluation of existing safety measures and programs implemented by the agency.
*
Multiple proactive safety programs in place.
At least one safety program in place.
No safety programs in place.
Briefly summarize safety measures and programs implemented by your agency.
*
Resource availability: focus on the availability of existing EMS resources and funding in the community.
*
Limited EMS resources (e.g., outdated equipment, minimal funding, or reliance on volunteers with limited training).
Moderate EMS resources (e.g., some updated equipment or partial funding, occasional professional training).
Well-resourced EMS (e.g., new equipment, consistent funding, and access to professional training).
Briefly summarize your agencies resources.
*
Geographic isolation and accessibility: evaluate the challenges related to the community’s geographic location and access to medical and safety services.
*
High isolation with difficult access to hospitals or EMS services, requiring longer response times.
Moderate isolation with some barriers to access but manageable response times.
Easily accessible with minimal barriers to emergency response.
Briefly summarize your agencies challenged due to geographic location and accessibility.
*
Sustainability plan: evaluation of the agency's plan for sustaining safety improvements beyond the funding period.
*
Comprehensive sustainability plan with diverse funding sources.
Basic sustainability plan with limited funding sources.
No sustainability plan.
Briefly summarize your agencies sustainability plan.
*
Long-term impact: potential for the proposed project to have a lasting impact on roadway safety.
*
High potential for long-term impact.
Moderate potential for long-term impact.
Low potential for long-term impact.
Briefly summarize your agencies long-term impacts.
*
Contact person signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: