Cultivating peace

Escaped Brooklyn for a few days. *edit* the steak

Smoke some weed. Feel a little better. From the FD

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The report was how to get ventolin without prescription made possible with support from the United Hospital Fund and benefited from the advice advair ventolin and input from many of our national partners in the effort to ensure maximum participation of immigrants in the nation's healthcare system as well as experts from the New York State Department of Health and the Centers for Medicare and Medicaid Services. SEE more about "PRUCOL" immigrant eligibility for Medicaid in this article. "Undocumented" immigrants are, with some exceptions for pregnant women and Child Health Plus, only eligible for "emergency Medicaid."NYS announced the 2020 Income and Resource levels in GIS 19 MA/12 â 2020 Medicaid Levels and Other Updates ) and levels based on the Federal Poverty Level are in GIS 20 MA/02 â 2020 Federal Poverty Levels Here is the 2020 HRA Income and Resources Level Chart Non-MAGI - 2020 Disabled, 65+ or Blind ("DAB" or SSI-Related) and have Medicare MAGI (2020) (<. 65, Does not have Medicare)(OR how to get ventolin without prescription has Medicare and has dependent child <. 18 or <.

19 in school) 138% FPL*** Children <. 5 and pregnant women have HIGHER LIMITS than shown ESSENTIAL PLAN For MAGI-eligible people over MAGI income how to get ventolin without prescription limit up to 200% FPL No long term care. See info here 1 2 1 2 3 1 2 Income $875 (up from $859 in 201) $1284 (up from $1,267 in 2019) $1,468 $1,983 $2,498 $2,127 $2,873 Resources $15,750 (up from $15,450 in 2019) $23,100 (up from $22,800 in 2019) NO LIMIT** NO LIMIT SOURCE for 2019 figures is GIS 18 MA/015 - 2019 Medicaid Levels and Other Updates (PDF). All of the attachments with the various levels are posted here. NEED TO how to get ventolin without prescription KNOW PAST MEDICAID INCOME AND RESOURCE LEVELS?.

Which household size applies?. The rules are complicated. See rules how to get ventolin without prescription here. On the HRA Medicaid Levels chart - Boxes 1 and 2 are NON-MAGI Income and Resource levels -- Age 65+, Blind or Disabled and other adults who need to use "spend-down" because they are over the MAGI income levels. Box 10 on page 3 are the MAGI income levels -- The Affordable Care Act changed the rules for Medicaid income eligibility for many BUT NOT ALL New Yorkers.

People in the "MAGI" category - those NOT on Medicare -- have expanded eligibility up to 138% of the Federal Poverty Line, so may now qualify for Medicaid even if they were not eligible before, or may now be eligible for Medicaid without a "spend-down." They have how to get ventolin without prescription NO resource limit. Box 3 on page 1 is Spousal Impoverishment levels for Managed Long Term Care &. Nursing Homes and Box 8 has the Transfer Penalty rates for nursing home eligibility Box 4 has Medicaid Buy-In for Working People with Disabilities Under Age 65 (still 2017 levels til April 2018) Box 6 are Medicare Savings Program levels (will be updated in April 2018) MAGI INCOME LEVEL of 138% FPL applies to most adults who are not disabled and who do not have Medicare, AND can also apply to adults with Medicare if they have a dependent child/relative under age 18 or under 19 if in school. 42 how to get ventolin without prescription C.F.R. Â§ 435.4.

Certain populations have an even higher income limit - 224% FPL for pregnant women and babies <. Age 1, how to get ventolin without prescription 154% FPL for children age 1 - 19. CAUTION. What is counted as income may not be what you think. For the NON-MAGI Disabled/Aged 65+/Blind, income will still be determined how to get ventolin without prescription by the same rules as before, explained in this outline and these charts on income disregards.

However, for the MAGI population - which is virtually everyone under age 65 who is not on Medicare - their income will now be determined under new rules, based on federal income tax concepts - called "Modifed Adjusted Gross Income" (MAGI). There are good changes and bad changes. GOOD how to get ventolin without prescription. Veteran's benefits, Workers compensation, and gifts from family or others no longer count as income. BAD.

There is no more "spousal" or parental refusal for this population (but there still is for the Disabled/Aged/Blind.) and some other rules. For all how to get ventolin without prescription of the rules see. ALSO SEE 2018 Manual on Lump Sums and Impact on Public Benefits - with resource rules The income limits increase with the "household size." In other words, the income limit for a family of 5 may be higher than the income limit for a single person. HOWEVER, Medicaid rules about how to calculate the household size are not intuitive or even logical. There are different how to get ventolin without prescription rules depending on the "category" of the person seeking Medicaid.

Here are the 2 basic categories and the rules for calculating their household size. People who are Disabled, Aged 65+ or Blind - "DAB" or "SSI-Related" Category -- NON-MAGI - See this chart for their household size. These same rules apply to the Medicare Savings how to get ventolin without prescription Program, with some exceptions explained in this article. Everyone else -- MAGI - All children and adults under age 65, including people with disabilities who are not yet on Medicare -- this is the new "MAGI" population. Their household size will be determined using federal income tax rules, which are very complicated.

New rule is explained in State's directive 13 ADM-03 - Medicaid Eligibility how to get ventolin without prescription Changes under the Affordable Care Act (ACA) of 2010 (PDF) pp. 8-10 of the PDF, This PowerPoint by NYLAG on MAGI Budgeting attempts to explain the new MAGI budgeting, including how to determine the Household Size. See slides 28-49. Also seeLegal Aid Society and Empire Justice Center materials OLD RULE used until end of 2013 -- Count the person(s) applying for Medicaid who live together, plus any of their legally responsible relatives who do not receive SNA, ADC, or SSI how to get ventolin without prescription and reside with an applicant/recipient. Spouses or legally responsible for one another, and parents are legally responsible for their children under age 21 (though if the child is disabled, use the rule in the 1st "DAB" category.

Under this rule, a child may be excluded from the household if that child's income causes other family members to lose Medicaid eligibility. See 18 NYCRR how to get ventolin without prescription 360-4.2, MRG p. 573, NYS GIS 2000 MA-007 CAUTION. Different people in the same household may be in different "categories" and hence have different household sizes AND Medicaid income and resource limits. If a man is age 67 and has Medicare and his wife is age 62 and not disabled or blind, the husband's household size for Medicaid is determined under Category 1/ Non-MAGI above and his wife's is under Category 2/MAGI.

The following programs were available prior to 2014, but are now discontinued because they are folded into MAGI Medicaid. Prenatal Care Assistance Program (PCAP) was Medicaid for pregnant women and children under age 19, with higher income limits for pregnant woman and infants under one year (200% FPL for pregnant women receiving perinatal coverage only not full Medicaid) than for children ages 1-18 (133% FPL). Medicaid for adults between ages 21-65 who are not disabled and without children under 21 in the household. It was sometimes known as "S/CC" category for Singles and Childless Couples. This category had lower income limits than DAB/ADC-related, but had no asset limits.

It did not allow "spend down" of excess income. This category has now been subsumed under the new MAGI adult group whose limit is now raised to 138% FPL. Family Health Plus - this was an expansion of Medicaid to families with income up to 150% FPL and for childless adults up to 100% FPL. This has now been folded into the new MAGI adult group whose limit is 138% FPL.

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What are the key features of hospitals that consistently deliver Buy real cipro online safe care on labour and delivery? ventolin tablet for asthma. This is the primary question posed by Liberati and colleagues in this issue of ventolin tablet for asthma BMJ Quality &. Safety.1 The authors propose a framework distilled from observations on a group of high-performing units in the UK participating in a training activity to improve patient safety. This study combined ethnography with individual interviews and focus groups and involved over 400 hours of total observations at ventolin tablet for asthma six different maternity care sites. The seven features in their resulting For Us framework correspond well to existing theoretical as well as applied quality improvement strategies.

While we agree that their framework describes features that every labour and delivery unit should strive to include, this approach has some limitations in terms of ventolin tablet for asthma generalisability. Specifically, Liberati and colleagues studied maternity units that are high performing, but their sample included only large-volume hospitals in what appear to be well-resourced settings. What is potentially missing is observations on underperforming units, and how these findings may or may not apply to smaller, lower resourced settings ventolin tablet for asthma. Additionally, the structure of the UKâs National Health Service (NHS) also limits generalisability. For example, this is most analogous to employed physician models in the USA, with the potential advantage ventolin tablet for asthma of a more organisationally oriented provider workforce.

Given that most US hospitals do not have an employed provider model, we canât assume that these factors will have the same impact in other models of care.In the USA, the Agency for Healthcare Research and Quality (AHRQ) developed a Culture of Safety framework that delineates four key features. (1) organisations recognise that their primary activities are inherently high risk ventolin tablet for asthma and make it their goal to operate in a reliably safe manner. (2) organisations create a safe and ventolin tablet for asthma blame-free reporting environment. (3) interdisciplinary and interprofessional collaboration is encouraged to address safety problems. And (4) resources are deliberately allocated and made ventolin tablet for asthma available to address safety.2 This framework, as does For Us, focuses on a healthcare-oriented conceptualisation of safety and quality, and details medical outcomes as the primary metrics by which to measure success.

Although achievement of these medical quality outcomes is imperative, we propose that there are additional domains needed to provide safe intrapartum care. (A) prioritising patient experienceâincluding emotional safety, birthing with dignity ventolin tablet for asthma and an expectation of person-centred care. And (B) a unit culture that values low intervention births. Let us consider these domains in more depth.Patient experience and safety ventolin tablet for asthma are inextricable. While much work has been done to improve physicianâpatient communication,3 4 few have successfully targeted the perpetuation of dysfunctional behaviours grounded in healthcare professionalsâ implicit and explicit biases.5 This may be in part due to the tendency to observe and look for answers from the standpoint of the healthcare system rather than patients.

Women who had recently given birth were included in the study ventolin tablet for asthma of Liberati and colleagues, but represented only 8 of 65 individual stakeholder interviews, and were not included in focus groups. The framework ventolin tablet for asthma thus describes a high-functioning system from primarily the healthcare systemâs perspective. In general, the patientâs role in achieving safe care includes many aspects, including providing personal information to reach the correct diagnosis, providing their values and lived experience in shared decision-making discussions, choosing their provider such that their needs regarding provider experience and safe practice are met, making sure that they receive the recommended treatments in a timely manner, as well as identifying and reporting errors.6 The detriment to health outcomes among patients who have failed interactions with providers is well documented (eg, leaving against medical advice or experiencing disrespect during their care) while other harms, such as psychological trauma, often go unmeasured.7Emotional and psychological trauma are safety errors, whether or not a patient leaves the hospital physically intact.8 Research has shown that patients experience psychological trauma both as a result of an adverse outcome and as a result of how the incident was managed. In birth, patients conceptualise the meaning of safety very differently from that of the medical system, with physical and emotional safety being inextricably interwoven into a single concept.9 Psychological ventolin tablet for asthma trauma may manifest in postpartum depression, post-traumatic stress disorder10 and, some studies suggest, reduced childbearing in patients who experience traumatic birth.11 The experience of emotional safety on the part of the patient is only knowable to the patient, and only addressable when health systemsâand health services researchâask the appropriate questions. Therefore, patient-reported experience measures and critical examination of the process of patient-centred care should be at the centre of quality improvement.High-performing units prioritise patient voice and patient experience as a part of their culture.

In a recent ventolin tablet for asthma article, Morton and Simkin12 delineate steps to promote respectful maternity care in institutions, including obtaining unit commitment to respectful care, implementing training programmes to support respectful care as the norm and, finally, instituting respectful treatment of healthcare staff and clinicians by administrators and leadersâin other words, a unit culture of mutual respect and care among the entire team enables respectful care of the patient. Liberati and colleagues address the issue of hierarchies on labour and delivery, making the key observation that high-performing units create hierarchies around expertise rather than formal titles or disciplinary silos. However, this power differential applies to patients as well ventolin tablet for asthma. The existing hierarchy on most labour units places physicians at the top and patients at the bottom, which often acts to silence patientsâ voices.13 Implicit bias and interpersonal racism and sexism contribute to this cycle of silence and mistreatment on labour and delivery units.14 Disrespect and dismissal of patient concerns have been increasingly described, but still lack quantitative measurement in association with maternal and child health outcomes.15 Interventions aimed at harm reduction are emerging,16 but more work is desperately needed in this area.Valuing low intervention is an important dimension of safety. Safety culture, as it is conceptualised by AHRQ and the current study, is ideally created ventolin tablet for asthma to prevent or respond to harmful safety lapses.

This model is more difficult to apply to an environment where the goal is safe facilitation of a normal biological process. In this setting, interventions ventolin tablet for asthma (that often beget more interventions) can increase complications. High rates of primary and repeat caesarean deliveries, and other invasive obstetric interventions seen in many birthing units are now widely acknowledged to be overused and overuse constitutes a patient safety risk.17 In our work in California, we have been able to demonstrate that provider attitudes, beliefs and unit culture can drive caesarean delivery overuse in ways that do ventolin tablet for asthma not contribute to patient safety.18 19 Each intervention needs to be carefully and jointly considered for value and safety. This in no way diminishes the life-saving nature of caesarean delivery when it is medically indicated, but it sets up the expectation that safety measures, processes and procedures must be in place to actively work towards supporting vaginal birth rather than treating each labour as an emergency waiting to happen. The striking variation in obstetric intervention ventolin tablet for asthma rates among hospitals and providers can provide critical insights.

So, what is the right balance of intervention rates and mother/baby safety outcomes?. In many instances, this may be a false dichotomy ventolin tablet for asthma. In a study of California hospital labour practices, Lundsberg et al found that hospitals that prioritised low labour interventions and actively supported vaginal birth (eg, delaying admission until active labour onset, use of doulas, intermittent auscultation of fetal heart tones, non-pharmacological pain relief, and so on) had reduced caesarean delivery rates with well-preserved neonatal outcomes.20 It should be noted that in the USA, rates of intervention are starting at a high level so there is less danger of harm from achieving too low a rate. This may not be the case in the UK where there are now formal inquiries examining obstetric care in multiple NHS hospital trusts where poor ventolin tablet for asthma perinatal outcomes have been linked to a systematic aversion to medical interventions even when indicated.21 Getting this balance right has been referred to as the Goldilocks quandary. Doing too little, too much or just right?.

22In conclusion, physical safety is the bare minimum of what should be expected in childbirth ventolin tablet for asthma. Patients have a right, and healthcare providers and systems have an obligation to aim higher, to ensure patients emerge from childbirth as healthy or healthierâboth physically and psychologicallyâthan before entering the hospital. This can be best achieved by broadening the lens of what we consider essential to ventolin tablet for asthma safety on maternity units to include prioritising patient experience, birthing with dignity and valuing low intervention rates. All of these domains need to be in balance. Good mother or ventolin tablet for asthma baby medical outcomes at the cost of high rates of intervention and high maternal psychological trauma are not a success, nor is the opposite.

The true âsafeâ maternity unit is one that does well on all of these dimensions, which, of course, means that we need to be able to measure each of ventolin tablet for asthma them. Finally, all of these safety domains, including the âFor Usâ framework proposed by Liberati and colleagues, focus on unit culture, provider behaviours and processes of care, and thus are within the reach of all maternity units no matter their level of resources.Healthcare-associated s (HCAIs) are those s acquired by an individual who is seeking medical care in any healthcare facility, including acute care hospitals, long-term care facilities (including nursing homes), outpatient surgical centres, dialysis centres or ambulatory care clinics.1 They are further defined as occurring at least 48 hours after hospitalisation or within 30 days of receiving medical care.2 HCAIs have plagued hospitals, physicians and patients for centuries and likely played a role in the reputation that hospitals historically had as dangerous places.3 In the mid-19th century, Ignaz Semmelweis observed that labouring mothers in an obstetrics unit had a high incidence of Puerperal (Childbed) fever, which he thought was related to direct contact with medical students. After working ventolin tablet for asthma with cadavers, students often moved directly from the anatomy lab to the hospital, leading Semmelweis to postulate that students were contaminated and bringing a pathogen into the unit. He saw dramatic improvements in maternal mortality after introducing a chlorinated lime hand wash for healthcare providers.4 Though not quickly accepted at large, his observations would become part of the foundation of the germ theory that we intuitively accept today.Over a century after Semmelweis introduced the idea of hand hygiene, prevention in healthcare settings has been thrust into the spotlight worldwide. In the 1960s, the US Centers for Disease Control ventolin tablet for asthma and Prevention (CDC) conducted research within the Comprehensive Hospital s Project and introduced surveillance and control techniques still used today.

The creation of the National Healthcare Safety Network (NHSN) propelled control onto a national public health platform in the USA.3 Today, reduction of HCAIs has become a regulatory, financial and quality imperative across the world.Healthcare frequently involves the use of invasive devices and procedures that can increase the risk of HCAIs, including catheter-associated urinary tract s, central-line associated bloodstream s (CLABSIs), surgical site s and ventilator-associated events.5 The development of antimicrobial resistance related to antibiotic misuse or overuse6 has given rise to multidrug-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA), extended spectrum beta lactamase-producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae and diarrheal s with Clostridioides difficile. Today, most ventolin tablet for asthma states in the USA have passed legislation mandating that healthcare facilities publicly report HCAIs, most often using the CDC NHSN surveillance definition for event reporting.7 Globally, the WHOâs Clean Care is Safer Care Programme is working alongside many nations to introduce surveillance and reporting programmes to strengthen the international response.8The patient environment has become a major focus of control interventions. Although a large proportion of HCAIs are attributed to a patientâs endogenous microflora, up to 40% of nosocomial s are cross-s from the hands of healthcare providers, including transmission from high-touch patient-care surfaces.9 In order for pathogens to be transmitted, they generally must have characteristics that make them more robust in the environment, such as the ability to frequently colonise, survive and remain virulent on environmental surfaces and the ability to transiently colonise and pass from the hands of healthcare providers to patients or environmental surfaces.9 C. Difficile poses additional challenges for environmental control because of its ability to form spores ventolin tablet for asthma that resist dry heat and many disinfectants.9 Even with active surveillance and the introduction of new environmental dis technologies, such as uaviolet germicidal irradiation,10 studies have demonstrated that patients hospitalised in rooms with previous occupants who were MRSA colonised or infected with C. Difficile were more likely to become contaminated,7 supporting the notion that hospital environments play an important role in HCAI transmission.Both the duration of hospitalisation and frequency of transfer between and within healthcare facilities increase the likelihood of exposure to contaminated environments.

Intrahospital transfers refer to the movement of a patient within a healthcare facility, including transfers from the emergency room to an inpatient unit on admission, between two different units, to a different department for a procedure or diagnostic study or between rooms on the same unit.11 McHaney-Lindstrom and colleagues conducted a retrospective case-control study that found that with every additional intrahospital ventolin tablet for asthma transfer, the odds of acquiring an with C. Difficile increased by 7%.12 These transfers require a complex cascade of ventolin tablet for asthma events and are affected by environmental control and communication challenges, professional conflicts related to variation in culture between units, hospital census and provider workload.13 In a systematic review, Bristol and colleagues found that intrahospital transfers are frequently associated with adverse outcomes, such as delirium, increased risk of falls, increased length of stay and prolonged duration of mechanical ventilation and central venous catheterisation.13 This therefore further highlights the significance of intrahospital transfers on patient outcomes.In this issue, Boncea and colleagues report on a retrospective case-control study conducted to estimate the risk of developing a HCAI depending on the number of intrahospital transfers between inpatient units or the same unit.11 The study was conducted in three urban hospitals within one UK hospital organisation. The study focused on patients aged 65 or older, given their higher frequency of access to medical care. Data were collected from the electronic health record (EHR) over a 3-year period and included a total of 24 240 hospitalisations of which 2877 were cases ventolin tablet for asthma where the patient had a positive clinical culture obtained at least 48 hours after hospitalisation. Cases and controls were matched by potential confounding variables, including Elixhauser comorbidities, age, gender and total number of admissions.

Using multivariable logistic regression modelling, they found that for every additional intrahospital transfer, the odds of acquiring a HCAI increased ventolin tablet for asthma by 9%, with the most common HCAI being C. Difficile .This study is one of the first to quantify the risk associated with the number of intrahospital transfers and HCAIs. Cases and controls were well matched, and ventolin tablet for asthma the statistical modelling provides very compelling results. However, it is worth noting some features of the study that can affect the findings. The study does not provide specific details on the active ventolin tablet for asthma surveillance testing practices of the hospital network.

Without these data, theoretically (and by chance), cases selected for this study could have been colonised by MRSA more frequently than controls, which would introduce a level of bias. C. Difficile was measured from the EHR by positive toxin immunoassay results, but the clinical context of this testing is not clear, raising the possibility that some positive patients may have represented colonisation and not acute . The study also did not adjust for the indication for transfer (eg, transfer to or from the intensive care unit based on patient acuity, transfer for isolation precautions or transfer due to bed capacity or staffing issues) to determine if the patient care needs, isolation status or hospital strain modify the observed risk. As the authors acknowledge, prospective studies are needed to identify the clinical, administrative and systems factors that contribute to more frequent intrahospital transfers.Guidelines for prevention and control of HCAIs include evidence-based interventions that can be broadly categorised as either vertical or horizontal.

Vertical interventions focus on reducing colonisation, and transmission of specific pathogens,7 and include surveillance testing for asymptomatic carriers, contact isolation precautions and targeted decolonisation.7 Horizontal interventions aim to reduce the risk of by a larger group of pathogens, independent of patient-specific conditions, such as optimisation of hand hygiene, antimicrobial stewardship and environmental cleaning practices.7 control programmes are tasked with weighing the risks and benefits of interventions to reduce rates of HCAIs while also being cost effective. Vertical approaches to prevent MRSA transmission and remain controversial due to inconsistent findings.7 In a nationwide US Veteranâs Affairs study that assessed the impact of MRSA surveillance testing and contact isolation in MRSA carriers, researchers demonstrated that these interventions resulted in reduced rates of MRSA and colonisation as well as reductions in the incidence of healthcare-associated C. Difficile and vancomycin-resistant Enterococcus s.14 In contrast, other studies evaluating similar practices in intensive care units found little impact of vertical control measures on MRSA rates15 and describe unintended consequences, such as decreased provider-patient contact, increased patient anxiety and patient dissatisfaction with quality of care.16Under endemic conditions, horizontal interventions may be more cost effective and beneficial given the broader number of microorganisms that can be targeted.7 Hand hygiene remains a core horizontal intervention, but hand hygiene compliance varies widely, with some countriesâ hospitals compliance reported as low as 15%.17 Several studies focused on intensive care units have shown significant declines in MRSA colonisation rates when hand hygiene practices improve.7 In addition to hand hygiene, universal decolonisation strategies that typically use chlorhexidine gluconate bathing of high risk patients are more impactful than active surveillance testing for individual pathogens at reducing rates of HCAIs such as CLABSIs.7 A central pillar of control is antimicrobial stewardship. These programmes use coordinated interventions to promote appropriate antimicrobial use, improve patient outcomes, decrease antibiotic resistance and reduce the incidence of s secondary to multidrug-resistant organisms.18 Given variation in environmental dis practices and provider-to-provider communication, reducing the frequency of intrahospital transfers is another potential horizontal intervention to reduce the burden of HCAIs.Boncea and colleaguesâ study adds to the growing body of literature that intrahospital transfers may increase the risk of HCAIs. Prior studies have identified that patients experience an average of 2.4 transfers during a hospitalisation and approximately 96% of individuals experience a transfer during hospitalisation.13 Transfers within the hospital also affect patient care and safety in other ways, resulting in delays in diagnosis and treatment due, in part, to poor coordination of care and inadequate handoffs between units.19 Additionally, intrahospital transfers take an average of 1âhour to complete, adding significantly to nursing workload.19The field of control must continue to adapt to changing hospital environments in order to further reduce the risk of HCAIs.

In the most recent progress report from US CDC, one in every 31 US patients will experience a HCAI while hospitalised,20 contributing to preventable deaths and permanent harm and to a tremendous excess cost of care.21 While the impact of these s is readily recognised in the developed world, recent studies indicate that the impact of HCAIs in the developing world is staggering, with one study reporting that the pooled-prevalence of HCAIs in resource-limited settings is 15.5 per 100 patients, compared with 4.5 per 100 patients in the USA and 7.1 per 100 patients in Europe.22 control programmes must continue to survey their respective hospital populations and evolve to the demand of the time, weighing benefits, balancing measures and costs. Reducing the number of intrahospital transfers and improving care coordination across these transitions represent a future opportunity to further reduce the burden of HCAIs..

What are the key features of hospitals that consistently how to get ventolin without prescription deliver safe care on labour and delivery? http://ptandpilates.com/buy-real-cipro-online/. This is the primary question posed by Liberati and colleagues in this issue of BMJ how to get ventolin without prescription Quality &. Safety.1 The authors propose a framework distilled from observations on a group of high-performing units in the UK participating in a training activity to improve patient safety. This study combined ethnography with individual interviews and how to get ventolin without prescription focus groups and involved over 400 hours of total observations at six different maternity care sites. The seven features in their resulting For Us framework correspond well to existing theoretical as well as applied quality improvement strategies.

While we agree that their framework describes features that every labour and how to get ventolin without prescription delivery unit should strive to include, this approach has some limitations in terms of generalisability. Specifically, Liberati and colleagues studied maternity units that are high performing, but their sample included only large-volume hospitals in what appear to be well-resourced settings. What is potentially missing is how to get ventolin without prescription observations on underperforming units, and how these findings may or may not apply to smaller, lower resourced settings. Additionally, the structure of the UKâs National Health Service (NHS) also limits generalisability. For example, this is most analogous to employed physician models in the how to get ventolin without prescription USA, with the potential advantage of a more organisationally oriented provider workforce.

Given that most US hospitals do not have an employed provider model, we canât assume that these factors will have the same impact in other models of care.In the USA, the Agency for Healthcare Research and Quality (AHRQ) developed a Culture of Safety framework that delineates four key features. (1) organisations recognise that their primary activities how to get ventolin without prescription are inherently high risk and make it their goal to operate in a reliably safe manner. (2) organisations create a safe and blame-free reporting how to get ventolin without prescription environment. (3) interdisciplinary and interprofessional collaboration is encouraged to address safety problems. And (4) resources are deliberately allocated and made available to address safety.2 This framework, as does For Us, focuses on a healthcare-oriented conceptualisation of safety and quality, and details medical how to get ventolin without prescription outcomes as the primary metrics by which to measure success.

Although achievement of these medical quality outcomes is imperative, we propose that there are additional domains needed to provide safe intrapartum care. (A) prioritising patient experienceâincluding how to get ventolin without prescription emotional safety, birthing with dignity and an expectation of person-centred care. And (B) a unit culture that values low intervention births. Let us consider how to get ventolin without prescription these domains in more depth.Patient experience and safety are inextricable. While much work has been done to improve physicianâpatient communication,3 4 few have successfully targeted the perpetuation of dysfunctional behaviours grounded in healthcare professionalsâ implicit and explicit biases.5 This may be in part due to the tendency to observe and look for answers from the standpoint of the healthcare system rather than patients.

Women who had recently given birth were included in the study of Liberati and colleagues, but represented only 8 of 65 individual stakeholder interviews, and were not included in focus groups how to get ventolin without prescription. The framework thus describes a high-functioning system from primarily the healthcare systemâs perspective how to get ventolin without prescription. In general, the patientâs role in achieving safe care includes many aspects, including providing personal information to reach the correct diagnosis, providing their values and lived experience in shared decision-making discussions, choosing their provider such that their needs regarding provider experience and safe practice are met, making sure that they receive the recommended treatments in a timely manner, as well as identifying and reporting errors.6 The detriment to health outcomes among patients who have failed interactions with providers is well documented (eg, leaving against medical advice or experiencing disrespect during their care) while other harms, such as psychological trauma, often go unmeasured.7Emotional and psychological trauma are safety errors, whether or not a patient leaves the hospital physically intact.8 Research has shown that patients experience psychological trauma both as a result of an adverse outcome and as a result of how the incident was managed. In birth, how to get ventolin without prescription patients conceptualise the meaning of safety very differently from that of the medical system, with physical and emotional safety being inextricably interwoven into a single concept.9 Psychological trauma may manifest in postpartum depression, post-traumatic stress disorder10 and, some studies suggest, reduced childbearing in patients who experience traumatic birth.11 The experience of emotional safety on the part of the patient is only knowable to the patient, and only addressable when health systemsâand health services researchâask the appropriate questions. Therefore, patient-reported experience measures and critical examination of the process of patient-centred care should be at the centre of quality improvement.High-performing units prioritise patient voice and patient experience as a part of their culture.

In a recent article, Morton and Simkin12 delineate steps to promote respectful maternity care in institutions, including obtaining unit commitment to respectful care, implementing training programmes to support respectful care as the norm and, finally, instituting respectful treatment of healthcare staff and clinicians by administrators and leadersâin other words, a unit culture of mutual how to get ventolin without prescription respect and care among the entire team enables respectful care of the patient. Liberati and colleagues address the issue of hierarchies on labour and delivery, making the key observation that high-performing units create hierarchies around expertise rather than formal titles or disciplinary silos. However, this power how to get ventolin without prescription differential applies to patients as well. The existing hierarchy on most labour units places physicians at the top and patients at the bottom, which often acts to silence patientsâ voices.13 Implicit bias and interpersonal racism and sexism contribute to this cycle of silence and mistreatment on labour and delivery units.14 Disrespect and dismissal of patient concerns have been increasingly described, but still lack quantitative measurement in association with maternal and child health outcomes.15 Interventions aimed at harm reduction are emerging,16 but more work is desperately needed in this area.Valuing low intervention is an important dimension of safety. Safety culture, as it is conceptualised by AHRQ and the current study, is ideally created to prevent or respond to harmful how to get ventolin without prescription safety lapses.

This model is more difficult to apply to an environment where the goal is safe facilitation of a normal biological process. In this setting, how to get ventolin without prescription interventions (that often beget more interventions) can increase complications. High rates of primary and repeat caesarean deliveries, and other invasive obstetric interventions seen in many birthing units are now widely acknowledged to be overused and overuse constitutes a patient safety risk.17 In our work in California, we have been able to demonstrate that provider attitudes, beliefs and unit culture can drive caesarean delivery overuse in ways that do not contribute to patient safety.18 19 Each intervention needs to be carefully and jointly considered for value and how to get ventolin without prescription safety. This in no way diminishes the life-saving nature of caesarean delivery when it is medically indicated, but it sets up the expectation that safety measures, processes and procedures must be in place to actively work towards supporting vaginal birth rather than treating each labour as an emergency waiting to happen. The striking variation in how to get ventolin without prescription obstetric intervention rates among hospitals and providers can provide critical insights.

So, what is the right balance of intervention rates and mother/baby safety outcomes?. In many instances, this may be how to get ventolin without prescription a false dichotomy. In a study of California hospital labour practices, Lundsberg et al found that hospitals that prioritised low labour interventions and actively supported vaginal birth (eg, delaying admission until active labour onset, use of doulas, intermittent auscultation of fetal heart tones, non-pharmacological pain relief, and so on) had reduced caesarean delivery rates with well-preserved neonatal outcomes.20 It should be noted that in the USA, rates of intervention are starting at a high level so there is less danger of harm from achieving too low a rate. This may not be the case how to get ventolin without prescription in the UK where there are now formal inquiries examining obstetric care in multiple NHS hospital trusts where poor perinatal outcomes have been linked to a systematic aversion to medical interventions even when indicated.21 Getting this balance right has been referred to as the Goldilocks quandary. Doing too little, too much or just right?.

22In conclusion, physical safety is the bare minimum of what should be how to get ventolin without prescription expected in childbirth. Patients have a right, and healthcare providers and systems have an obligation to aim higher, to ensure patients emerge from childbirth as healthy or healthierâboth physically and psychologicallyâthan before entering the hospital. This can be best achieved by broadening the lens of what we consider essential to safety on maternity units to include prioritising patient experience, birthing with dignity and how to get ventolin without prescription valuing low intervention rates. All of these domains need to be in balance. Good mother or baby medical outcomes at the cost of high rates of intervention and high how to get ventolin without prescription maternal psychological trauma are not a success, nor is the opposite.

The true âsafeâ maternity unit is one that does well on all of these dimensions, which, of course, means that we need to be able to measure each of them how to get ventolin without prescription. Finally, all of these safety domains, including the âFor Usâ framework proposed by Liberati and colleagues, focus on unit culture, provider behaviours and processes of care, and thus are within the reach of all maternity units no matter their level of resources.Healthcare-associated s (HCAIs) are those s acquired by an individual who is seeking medical care in any healthcare facility, including acute care hospitals, long-term care facilities (including nursing homes), outpatient surgical centres, dialysis centres or ambulatory care clinics.1 They are further defined as occurring at least 48 hours after hospitalisation or within 30 days of receiving medical care.2 HCAIs have plagued hospitals, physicians and patients for centuries and likely played a role in the reputation that hospitals historically had as dangerous places.3 In the mid-19th century, Ignaz Semmelweis observed that labouring mothers in an obstetrics unit had a high incidence of Puerperal (Childbed) fever, which he thought was related to direct contact with medical students. After working with cadavers, students often how to get ventolin without prescription moved directly from the anatomy lab to the hospital, leading Semmelweis to postulate that students were contaminated and bringing a pathogen into the unit. He saw dramatic improvements in maternal mortality after introducing a chlorinated lime hand wash for healthcare providers.4 Though not quickly accepted at large, his observations would become part of the foundation of the germ theory that we intuitively accept today.Over a century after Semmelweis introduced the idea of hand hygiene, prevention in healthcare settings has been thrust into the spotlight worldwide. In the 1960s, the US Centers for Disease Control and Prevention (CDC) conducted research within the Comprehensive Hospital s Project and introduced surveillance and control how to get ventolin without prescription techniques still used today.

The creation of the National Healthcare Safety Network (NHSN) propelled control onto a national public health platform in the USA.3 Today, reduction of HCAIs has become a regulatory, financial and quality imperative across the world.Healthcare frequently involves the use of invasive devices and procedures that can increase the risk of HCAIs, including catheter-associated urinary tract s, central-line associated bloodstream s (CLABSIs), surgical site s and ventilator-associated events.5 The development of antimicrobial resistance related to antibiotic misuse or overuse6 has given rise to multidrug-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA), extended spectrum beta lactamase-producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae and diarrheal s with Clostridioides difficile. Today, most states in the USA have passed legislation mandating that healthcare facilities publicly report HCAIs, most often using the CDC NHSN surveillance definition for event reporting.7 Globally, the WHOâs Clean Care is Safer Care Programme is working alongside many nations to introduce surveillance and reporting programmes to strengthen the international response.8The patient how to get ventolin without prescription environment has become a major focus of control interventions. Although a large proportion of HCAIs are attributed to a patientâs endogenous microflora, up to 40% of nosocomial s are cross-s from the hands of healthcare providers, including transmission from high-touch patient-care surfaces.9 In order for pathogens to be transmitted, they generally must have characteristics that make them more robust in the environment, such as the ability to frequently colonise, survive and remain virulent on environmental surfaces and the ability to transiently colonise and pass from the hands of healthcare providers to patients or environmental surfaces.9 C. Difficile poses how to get ventolin without prescription additional challenges for environmental control because of its ability to form spores that resist dry heat and many disinfectants.9 Even with active surveillance and the introduction of new environmental dis technologies, such as uaviolet germicidal irradiation,10 studies have demonstrated that patients hospitalised in rooms with previous occupants who were MRSA colonised or infected with C. Difficile were more likely to become contaminated,7 supporting the notion that hospital environments play an important role in HCAI transmission.Both the duration of hospitalisation and frequency of transfer between and within healthcare facilities increase the likelihood of exposure to contaminated environments.

Intrahospital transfers refer to the movement of a patient within a healthcare facility, including transfers from the emergency room to an inpatient unit on admission, between two different units, to a different how to get ventolin without prescription department for a procedure or diagnostic study or between rooms on the same unit.11 McHaney-Lindstrom and colleagues conducted a retrospective case-control study that found that with every additional intrahospital transfer, the odds of acquiring an with C. Difficile increased by 7%.12 These transfers require a complex cascade of events and are affected by environmental control and communication challenges, professional conflicts related to variation in culture between units, hospital census and provider workload.13 In a systematic review, Bristol and colleagues found that intrahospital transfers are frequently associated with adverse outcomes, such as delirium, increased risk of falls, increased length of stay and prolonged duration of mechanical ventilation and central venous catheterisation.13 This therefore further how to get ventolin without prescription highlights the significance of intrahospital transfers on patient outcomes.In this issue, Boncea and colleagues report on a retrospective case-control study conducted to estimate the risk of developing a HCAI depending on the number of intrahospital transfers between inpatient units or the same unit.11 The study was conducted in three urban hospitals within one UK hospital organisation. The study focused on patients aged 65 or older, given their higher frequency of access to medical care. Data were collected from the electronic health record (EHR) over a 3-year period and included a total of 24 240 hospitalisations of which 2877 were cases how to get ventolin without prescription where the patient had a positive clinical culture obtained at least 48 hours after hospitalisation. Cases and controls were matched by potential confounding variables, including Elixhauser comorbidities, age, gender and total number of admissions.

Using multivariable how to get ventolin without prescription logistic regression modelling, they found that for every additional intrahospital transfer, the odds of acquiring a HCAI increased by 9%, with the most common HCAI being C. Difficile .This study is one of the first to quantify the risk associated with the number of intrahospital transfers and HCAIs. Cases and controls were well matched, and the statistical modelling provides very how to get ventolin without prescription compelling results. However, it is worth noting some features of the study that can affect the findings. The study does not provide specific details on how to get ventolin without prescription the active surveillance testing practices of the hospital network.

How should I use Ventolin?

Take Ventolin by mouth. If Ventolin upsets your stomach, take it with food or milk. Do not take more often than directed. Talk to your pediatrician regarding the use of Ventolin in children. Special care may be needed. Overdosage: If you think you have taken too much of Ventolin contact a poison control center or emergency room at once. Note: Ventolin is only for you. Do not share Ventolin with others.

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January is Cervical Health Awareness Month, and thereâs a lot that women can do to help ventolin street price prevent cervical cancer. Cervical cancer happens when normal cells in the cervix, the bottom part of the uterus, change into abnormal cells and grow out of control. Most women whose cervical cancer is found and treated early do well. In 2021, the ventolin street price American Cancer Society estimates 14,480 new cases of invasive cervical cancer will be diagnosed in the United States and 4,290 women will die from it.

One of the major causes of cervical cancer is Human papillomaventolin, or HPV. HPV causes 99 percent of cervical cancer. HPV can also cause vaginal, ventolin street price penile, anal, mouth and throat cancer. HPV is a very common that spreads through sexual activity.

About 79 million Americans currently have HPV, but many of them donât even know that theyâre infected. Thatâs because HPV ventolin street price generally doesnât have any symptoms. In fact, in many cases, the body can fight off HPV naturally, but in serious cases, the body is at risk for serious complications. Thankfully, the number of cervical cancer cases is declining, because of screening tests that are able to find cervical precancerous cells before they turn into cancer.

The HPV treatment also protects men and ventolin street price women from HPV. At MidMichigan Health, we encourage women to begin getting regular Pap tests at age 21. Talk to your gynecologist or health care provider to determine how often you should get these screenings. We also encourage ventolin street price pre-teens to get the HPV treatment.

It is most effect for boys and girls to get the treatment between the ages of nine to 12. Teens and young adults age 13 through 26 who have not been vaccinated or who havenât gotten all their doses should get the treatment as soon as possible. Vaccination of ventolin street price young adults will not prevent as many cancers as vaccination of children and teens. If you havenât received a Pap test or the HPV treatment, itâs important that you talk with your health care provider to determine a course of action that works best for you and your health.

Being proactive in your health care is key!. Brendan Conboy, M.D., is a board-certified obstetrician/gynecologist who sees patients at MidMichigan Medical ventolin street price Center â Alpena. He received his medical degree from Wayne State University School of Medicine, and completed his residency at William Beaumont Hospital in Royal Oak. Those who would like more information about becoming a patient may contact his office at (989) 356-5228..

January is Cervical how to get ventolin without prescription Health Awareness Month, and thereâs a lot that women can do to help prevent cervical cancer. Cervical cancer happens when normal cells in the cervix, the bottom part of the uterus, change into abnormal cells and grow out of control. Most women whose cervical cancer is found and treated early do well. In 2021, the American Cancer Society estimates 14,480 new cases of invasive cervical cancer will be diagnosed in the United States and 4,290 women will die how to get ventolin without prescription from it. One of the major causes of cervical cancer is Human papillomaventolin, or HPV.

HPV causes 99 percent of cervical cancer. HPV can also cause how to get ventolin without prescription vaginal, penile, anal, mouth and throat cancer. HPV is a very common that spreads through sexual activity. About 79 million Americans currently have HPV, but many of them donât even know that theyâre infected. Thatâs because HPV generally doesnât have any symptoms how to get ventolin without prescription.

In fact, in many cases, the body can fight off HPV naturally, but in serious cases, the body is at risk for serious complications. Thankfully, the number of cervical cancer cases is declining, because of screening tests that are able to find cervical precancerous cells before they turn into cancer. The HPV treatment also protects men and women from how to get ventolin without prescription HPV. At MidMichigan Health, we encourage women to begin getting regular Pap tests at age 21. Talk to your gynecologist or health care provider to determine how often you should get these screenings.

We also encourage pre-teens to get the HPV treatment how to get ventolin without prescription. It is most effect for boys and girls to get the treatment between the ages of nine to 12. Teens and young adults age 13 through 26 who have not been vaccinated or who havenât gotten all their doses should get the treatment as soon as possible. Vaccination of young adults will not prevent as many cancers as how to get ventolin without prescription vaccination of children and teens. If you havenât received a Pap test or the HPV treatment, itâs important that you talk with your health care provider to determine a course of action that works best for you and your health.

Being proactive in your health care is key!. Brendan how to get ventolin without prescription Conboy, M.D., is a board-certified obstetrician/gynecologist who sees patients at MidMichigan Medical Center â Alpena. He received his medical degree from Wayne State University School of Medicine, and completed his residency at William Beaumont Hospital in Royal Oak. Those who would like more information about becoming a patient may contact his office at (989) 356-5228..

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The asthma Outbreak 28m ago Amtrak chief pleads for billions in aid and warns of thousands of layoffs. 1h ago The C.D.C. Updates its definition of âclose contactâ in relation to risk. 3h ago A treatment trial volunteer in Brazil has died, but health authorities say the treatment was not to blame. See more updates More live coverage.

Markets A New York Times database has tracked clusters of at least 50 asthma cases in a dozen rural jails in Montana, Idaho, Utah and New Mexico during the ventolin. Among them. The Purgatory Correctional Center in Hurricane, Utah, with 166 s. The jail in Twin Falls, Idaho, with 279. And, in New Mexico, the Cibola County Correctional Center, which has reported 357 cases.In Cascade County, s at the jail make up about a quarter of all known ventolin cases in the county.

Health authorities say that the jailâs outbreak, which began in mid-August, was not believed to be the main cause of the communityâs recent surge, but that it had led to some cases. In the past two months, Mr. Krogue said, the jail released 29 people who were considered actively infected.s at the jail make up about a quarter of Cascade Countyâs known ventolin cases.Credit...Tailyr Irvine for The New York TimesGreat Falls, home to about 58,000 residents, is in the less mountainous part of Montana, with the Missouri River flowing through and a large oil refinery on its banks. The Cascade County Detention Center sits along a highway at the edge of town. Drive five miles in any direction and you are surrounded by wide-open plains.Montana requires that masks be worn inside businesses and indoor public spaces, and many people in Great Falls wear them when walking around downtownâs Central Avenue, where shops and cafes are still recovering from shutting down in the spring.

Others go without masks, citing the open space and lack of crowds.Bob Kelly, the mayor, said people had not been overly worried about how the jail outbreak might affect the rest of town when it started.âI think that by the very definition of a jail, hopefully, the disease will be incarcerated, as well as the patients,â he said. ÂIs there concern?. Sure, thereâs concern. But is there overreaction?. No.âThe mayor of Great Falls said that residents had considered the jailâs outbreak a distant concern at first.Credit...Tailyr Irvine for The New York TimesSome residentsâ nonchalance about the risks of the ventolin, said Mr.

Krogue, the jailâs medical director, can be traced to a spring and early summer when almost no one in Cascade County knew anyone who had been sickened.âWe benefited from that early on,â he said. ÂBut in some ways, I think it did us a disservice, too, because it also created a certain level of complacency.âThat has quickly shifted now, he said, as cases have spiked.The number of active cases known to county officials on any given day has risen sharply to about 600, according to Trisha Gardner, Cascade Countyâs health officer. The county has seen 1,261 cases and six deaths during the ventolin, a Times database shows. Some of the cases have been tied to the jail outbreak, she said, and others have been connected to bars and restaurants. Even figuring out what has led to some cases has been complex, she said, as residents have been reluctant to cooperate with contact tracers.âOur hospitals are at capacity, our public health system is at capacity,â she said.

ÂItâs not sustainable at this rate.âWhen the outbreak at the jail began, social distancing was impossible, the authorities said. Three inmates shared cells designed for two. At night, men slept on thin blue pads in every available space. On the floor in the day room, in shower stalls, in stairwells, in hallways outside of cells.Inmates did not receive masks until August, and jail officials said many have refused to wear them.In interviews with more than a dozen inmates and their family members, inmates described the jail during the outbreak as chaotic and unsanitary. They said their pleas for help often went unanswered by nurses and guards.Newly arriving inmates were not always quarantined from one another before their test results were known because of a lack of space, inmates and jail officials said.Owen Hawley, 30, said every inmate in his living area of 38 men had tested positive for the ventolin.

He said he had been unable to eat for three days, had intensive body aches and suffered from a headache so powerful it felt as if it was âbehind my eyes.ââAfter the fourth day of like, not eating and stuff, I just shut off, you know?. Â he said.A jail area set aside for quarantining new inmates.Credit...Tailyr Irvine for The New York TimesAt one point, Mr. Hawley said, he and other prisoners protested the way the ventolin was being handled by refusing to leave their living areas and by blocking new inmates from entering. Everyone was ultimately tested, Mr. Hawley said, and each prisoner was given a disposable mask.Sierra Jasmine Wells, 25, another inmate, said women in her dormitory had grown ill, one after the next.âEveryone around me was getting sick and it was tough on me,â she said.

ÂBy then, I had already accepted the fact that I was going to get sick.âWhen she became infected, she said, she was given cough syrup and Tylenol.âI kind of was just left alone to deal with it,â she said.Jesse Slaughter, the county sheriff who oversees the jail, said that the jailâs medical staff was doing everything it could, and that he had been seeking health care assistance from other counties. Officials defended their handling of the outbreak, noting that all inmates received standard medications including Tylenol twice a day and were taken to area hospitals when they needed added care. Seven inmates, as well as some staff members, were hospitalized. No one from the jail has died from the ventolin, officials said.Sheriff Jesse Slaughter, who oversees the jail, said he had been seeking health care assistance from other counties.Credit...Tailyr Irvine for The New York TimesMr. Krogue said that since the start of the outbreak he had been working up to 16 hours each day and sleeping in his basement, away from his wife and children.

He remains healthy but says he fears bringing the ventolin home. The ventolin has slowed some in the jail, and officials have moved some inmates to other facilities, but other prisons and jails in the state are now seeing outbreaks.âYou can start to see what some of these other places experienced much earlier on, and we just didnât have that experience, but itâs certainly happening now,â Mr. Krogue said. ÂItâs just real in a way that it wasnât.âLucy Tompkins reported from Great Falls, Maura Turcotte from Chicago and Libby Seline from Lincoln, Neb. Reporting was contributed by Izzy ColÃ³n from Columbia, Mo., Brendon Derr from Phoenix, Rebecca Griesbach from Tuscaloosa, Ala., Danya Issawi and Timothy Williams from New York, Ann Hinga Klein from Des Moines, K.B.

Mensah from Silver Spring, Md., and Mitch Smith from Chicago.Start Preamble Federal Transit Administration (FTA), DOT. Notice of funding opportunity. The asthma Disease 2019 (asthma treatment) public health emergency Start Printed Page 63654has had a significant impact on transit operations. During a series of FTA listening sessions held over the last three months, transit agencies asked FTA to support research to identify solutions to address the operational challenges that they are facing as a result of asthma treatment. In response, FTA makes available through this Notice of Funding Opportunity (NOFO) funding to support research demonstration grants to public transit agencies to develop, deploy, and demonstrate innovative solutions that improve the operational efficiency of transit agencies, as well as enhance the mobility of transit users affected by the asthma treatment public health emergency.

Demonstration grants under this NOFO are authorized under FTA's Public Transportation Innovation Program (49 U.S.C. 5312). Eligible projects will demonstrate innovative solutions to improve the operational efficiencies of transit systems and enhance mobility for their communities in four major areas. (1) Vehicle, facility, equipment and infrastructure cleaning and dis. (2) exposure mitigation measures.

(3) innovative mobility such as contactless payments. And (4) measures that strengthen public confidence in transit services. The total funding available for awards under this NOFO is $10,000,000. FTA may supplement this amount if additional funding becomes available. Applicants must submit completed proposals for funding opportunity FTA-2020-015-TRI through the GRANTS.GOV âAPPLYâ function by 11:59 p.m.

Eastern Time on November 2, 2020. Prospective applicants should register as soon as possible on the GRANTS.GOV website to ensure they can complete the application process before the submission deadline. Application instructions are available on FTA's website at http://transit.dot.gov/âhowtoapply and in the âFINDâ module of GRANTS.GOV. FTA will not accept mail and fax submissions. Start Further Info Please send any questions on this notice to Jamel El-Hamri email.

Jamel.El-Hamri@dot.gov phone. 2020-366-8985. A Telecommunication Device for the Deaf (TDD) is available for individuals who are deaf or hard of hearing at 1-800-877-8339. End Further Info End Preamble Start Supplemental Information Table of Contents A. Program Description B.

Federal Award Information C. Eligibility Information D. Application and Submission Information E. Application Review Information F. Federal Award Administration Information G.

Federal Awarding Agency Contact Information A. Program Description The Public Transportation asthma treatment Research Demonstration Grant Program is funded through the Public Transportation Innovation Program (49 U.S.C. 5312), with the goal to develop, deploy, and demonstrate innovative solutions that improve the operational efficiency of transit agencies, as well as enhance the mobility of transit users affected by the asthma treatment public health emergency. Eligible projects will propose to develop and deploy innovative solutions in four major areas. (1) Vehicle, facility, equipment and infrastructure cleaning and dis.

(2) exposure mitigation measures. (3) innovative mobility such as contactless payments. And (4) measures that strengthen public confidence in transit. As required by 49 U.S.C. 5312(e)(4), projects funded under this NOFO must participate in an evaluation by an independent outside entity that will conduct a comprehensive evaluation of the success or failure of the projects funded under this subsection and any plan for broad-based implementation of the innovation promoted by successful projects.

B. Federal Award Information FTA makes available $10,000,000 in fiscal year (FY) 2020 funds under the Public Transportation Innovation Program (49 U.S.C. 5312) to finance the Public Transportation asthma treatment Research Demonstration Grant Program. FTA may supplement the total funds available if additional funding becomes available at the time project selections are made. FTA will grant pre-award authority starting on the date of the project award announcement for selected projects and should be completed within 24 months from the date of award.

Funds are available only for eligible expenses incurred after the announcement of project selections. C. Eligibility Information (1) Eligible Applicants Eligible applicants include State and local governmental authorities, direct recipients of Urbanized Area (49 U.S.C. 5307) and Rural Area (49 U.S.C. 5311) formula funds, and Indian tribes.

Eligible applicants are limited to FTA grantees or subrecipients who would be the primary beneficiaries of the innovative products and services that are developedâtypically public transit agencies. Except for projects proposed by Indian tribes, proposals for projects in rural (non-urbanized) areas must be submitted as part of a consolidated State proposal. States and other eligible applicants also may submit consolidated proposals for projects in urbanized areas. The submission of the Statewide application will not preclude the submission and consideration of any application from other eligible recipients in an urbanized area in a State. Proposals may contain projects to be implemented by the recipient or its subrecipients.

Eligible subrecipients include public agencies, private nonprofit organizations, and private providers engaged in public transportation. Eligible applicants may submit consolidated proposals for projects. (2) Cost Sharing or Matching The maximum Federal share of project costs is 100 percent. FTA may give additional consideration to applicants that propose a local share and may view these applicants as more competitive. The applicant must document the source(s) of the local match, if any, in the grant application.

For any applicants proposing match, eligible local match sources include the following. Cash from non-Government sources other than revenues from providing public transportation services. Revenues derived from the sale of advertising and concessions. Revenues generated from value capture financing mechanisms. Funds from an undistributed cash surplus.

Replacement or depreciation cash fund or reserve. New capital. Or in-kind contributions. (3) Eligible Projects Eligible projects will propose innovative solutions to improve operational efficiencies of transit agencies and enhance the mobility of transit users, through projects that demonstrate innovative solutions for. Vehicle, facility, equipment and infrastructure cleaning and dis.

Exposure mitigation measures such a real-time notification of rail and bus passenger loads. New multi-modal payment innovative mobility systems such as contactless payments. And measures that strengthen public confidence in transit. Each applicant may only submit one proposal.Start Printed Page 63655 D. Application and Submission Information (1) Address and Form of Application Submission Applications must be submitted through GRANTS.GOV.

Applicants can find general information for submitting applications through GRANTS.GOV at www.fta.dot.gov/âhowtoapply, along with specific instructions for the forms and attachments required for submission. Mail and fax submissions will not be accepted. (2) Content and Form of Application Submission a. Proposal Submission A complete proposal submission consists of at least two forms. 1.

The SF-424 Mandatory Form (downloadable from GRANTS.GOV) and 2. The supplemental form for the FY 2020 asthma treatment Demonstration Program (downloadable from GRANTS.GOV), which is available on FTA's website at (placeholder for FTA asthma treatment Demonstration Program). The application must include responses to all sections of the SF-424 mandatory form and the supplemental form unless a section is indicated as optional. FTA will use the information on the supplemental form to determine applicant and project eligibility for the program and to evaluate the proposal against the selection criteria described in part E of this notice. FTA will accept only one supplemental form per SF-424 submission.

FTA encourages applicants to consider submitting a single supplemental form that includes multiple activities to be evaluated as a consolidated proposal. Applicants may attach additional supporting information to the SF-424 submission, including but not limited to letters of support, project budgets, or excerpts from relevant planning documents. Supporting documentation must be described and referenced by file name in the appropriate response section of the supplemental form, or it may not be reviewed. Information such as applicant name, Federal amount requested, local match amount, description of areas served, etc., may be requested in varying degrees of detail on both the SF-424 form and supplemental form. Applicants must fill in all fields unless stated otherwise on the forms.

If applicants copy information into the supplemental form from another source, they should verify that the supplemental form has fully captured pasted text and that it has not truncated the text due to character limits built into the form. Applicants should use both the âCheck Package for Errorsâ and the âValidate Formâ validation buttons on both forms to check all required fields. Applicants should also ensure that the Federal and local amounts specified are consistent. Addressing the deteriorating conditions and disproportionately high fatality rates on our rural transportation infrastructure is of critical interest to the Department, as rural transportation networks face unique challenges in safety, infrastructure condition, and passenger and freight usage. Consistent with the R.O.U.T.E.S.

Initiative, the Department encourages applicants to consider how the project will address the challenges faced by rural areas. B. Application Content The SF-424 Mandatory Form and the supplemental form will prompt applicants for the required information, including. I. Applicant Name ii.

Dun and Bradstreet (D&B) Data Universal Numbering System (DUNS) number iii. Key contact information (contact name, address, email address, and phone number) iv. Congressional district(s) where project will take place v. Project Information (title, executive summary, and type) vi. A detailed description of the need for the project vii.

A detailed description of how the project will support the Program objectives viii. Evidence that the applicant can provide the local cost shares ix. A description of the technical, legal, and financial capacity of the applicant x. A detailed project budget xi. Details on the local matching funds xii.

A detailed project timeline xiii. Whether the project impacts an Opportunity Zone (3) Unique Entity Identifier and System for Award Management (SAM) Each applicant is required to. (1) Be registered in SAM before submitting an application. (2) provide a valid unique entity identifier in its application. And (3) continue to maintain an active SAM registration with current information at all times during which the applicant has an active Federal award or an application or plan under consideration by FTA.

These requirements do not apply if the applicant. (1) Is excepted from the requirements under 2 CFR 25.110(b) or (c). Or (2) has an exception approved by FTA under 2 CFR 25.110(d). FTA may not make an award until the applicant has complied with all applicable unique entity identifier and SAM requirements. If an applicant has not fully complied with the requirements by the time FTA is ready to make an award, FTA may determine that the applicant is not qualified to receive an award and use that determination as a basis for making a Federal award to another applicant.

All applicants must provide a unique entity identifier provided by SAM. Registration in SAM may take as little as 3-5 business days, but there can be unexpected steps or delays. For example, the applicant may need to obtain an Employer Identification Number. FTA recommends allowing ample time, up to several weeks, to complete all steps. For additional information on obtaining a unique entity identifier, please visit www.sam.gov.

(4) Submission Dates and Times Project proposals must be submitted electronically through GRANTS.GOV by 11:59 p.m. Eastern on November 2, 2020. Mail and fax submissions will not be accepted. FTA urges applicants to submit applications at least 72 hours prior to the due date to allow time to correct any problems that may have caused either GRANTS.GOV or FTA systems to reject the submission. Proposals submitted after the deadline will only be considered under extraordinary circumstances not within the applicant's control.

Deadlines will not be extended due to scheduled website maintenance. GRANTS.GOV scheduled maintenance and outage times are announced on the GRANTS.GOV website. Within 48 hours after submitting an electronic application, the applicant should receive two email messages from GRANTS.GOV. (1) Confirmation of successful transmission to GRANTS.GOV. And (2) confirmation of successful validation by GRANTS.GOV.

If the applicant does not receive confirmation of successful validation or receives a notice of failed validation or incomplete materials, the applicant must address the reason for the failed validation, as described in the email notice, and resubmit before the submission deadline. If making a resubmission for any reason, applicants must include all original attachments regardless of which attachments were updated and check the box on the supplemental form indicating this is a resubmission. Applicants are encouraged to begin the process of registration on the GRANTS.GOV site well in advance of the submission deadline. Registration is Start Printed Page 63656a multi-step process, which may take several weeks to complete before an application can be submitted. Registered applicants may still be required to update their registration before submitting an application.

Registration in SAM is renewed annually and persons making submissions on behalf of the Authorized Organization Representative (AOR) must be authorized in GRANTS.GOV by the AOR to make submissions. (5) Funding Restrictions Funds may be used for post-award expenditures only. Funds under this NOFO cannot be used to reimburse projects for otherwise eligible expenses incurred prior to the date of project award announcements. (6) Other Submission Requirements FTA encourages applicants to identify scaled funding options in case insufficient funding is available to fund a project at the full requested amount. If an applicant indicates that a project is scalable, the applicant must provide an appropriate minimum funding amount that will fund an eligible project that achieves the objectives of the program and meets all relevant program requirements.

The applicant must provide a clear explanation of how a reduced award would affect the project budget and scope. FTA may award a lesser amount whether or not the applicant provides a scalable option. E. Application Review Information (1) Project Evaluation Criteria Addressing the deteriorating conditions and disproportionately high fatality rates on our rural transportation infrastructure is of critical interest to the Department, as rural transportation networks face unique challenges in safety, infrastructure condition, and passenger and freight usage. Consistent with the R.O.U.T.E.S.

Initiative, the Department will consider how the project will address the challenges faced by rural areas. In addition, the Department will review and consider applications for funding pursuant to this Notice in accordance with the President's September 2, 2020 memorandum, entitled Memorandum on Reviewing Funding to State and Local Government Recipients of Federal Funds that Are Permitting Anarchy, Violence, and Destruction in American Cities, consistent with guidance from the Office of Management and Budget and the Attorney General and with all applicable laws. FTA will evaluate proposals submitted according to the following criteria. (a) Project Innovation and Impact. (b) Project Approach.

(c) National Applicability. (d) Commercialization and/or Knowledge Transfer. And (e) Technical, Legal and Financial Capacity. FTA encourages each applicant to demonstrate how a project supports all criteria with the most relevant information the applicant can provide, regardless of whether such information has been specifically requested or identified in this notice. A.

Project Innovation and Impact i. Effectiveness of the project in achieving and demonstrating the specific objectives of this program. Ii. Demonstration of benefits in addressing the needs of the transit agency and industry and impacts to infrastructure, equipment, transit workforce, and riders. Iii.

Degree of improvement over current and existing technologies, designs, and/or practices applicable to the transit industry. B. Project Approach i. Quality of the project approach such as existing partnerships, collaboration strategies and level of commitment of the project partners. Ii.

Proposal is realistic in its approach to fulfill the milestones/deliverables, schedule and goals. C. National Applicability i. Degree to which the project could be replicated by other transit agencies regionally or nationally. Ii.

Ability to evaluate technologies, designs and/or practices in a wide variety of conditions and locales. Iii. Degree to which the technology, designs and/or practices can be replicated by other transportation modes. D. Commercialization and/or Knowledge Transfer i.

Demonstrates a realistic plan for moving the results of the project into the transit marketplace (patents, conferences, articles in trade magazines, webinar, site visits, etc.). Ii. How the project team plans to work with the industry on improving best practices, guidance and/or standards, if applicable. Iii. Demonstrate a clear understanding and robust approach to data collection, access and management.

E. Technical, Legal and Financial Capacity Capacity of the applicant and any partners to successfully execute the project effort. There should be no outstanding legal, technical, or financial issues with the applicant that would make this a high-risk project. (2) Review and Selection Process An FTA technical evaluation committee will evaluate proposals based on the published project evaluation criteria. Members of the technical evaluation committee will rate the applications and may seek clarification about any statement in an application.

The FTA Administrator will determine the final selection and amount of funding for each project after consideration of the findings of the technical evaluation committee. Geographic diversity, diversity of the project type, the amount of local match to be provided, and the applicant's receipt and management of other Federal transit funds may be considered in FTA's award decisions. Prior fare payment innovation efforts may receive priority consideration. The FTA Administrator will consider the following key DOT objectives. A.

Utilizing alternative funding sources and innovative financing models to attract non-Federal sources of investment. B. Whether the project is located in or supports public transportation service in a qualified opportunity zone designated pursuant to 26.U.S.C. 1400Z-1. And c.

The extent to which the project addresses challenges specific to the provision of rural public transportation. (3) FAPIIS Review Prior to making a grant award, FTA is required to review and consider any information about the applicant that is in the Federal Awardee Performance and Integrity Information System (FAPIIS) accessible through SAM. An applicant may review and comment on information about itself that a Federal awarding agency previously entered. FTA will consider any comments by the applicant, in addition to the other information in FAPIIS, in making a judgment about the applicant's integrity, business ethics, and record of performance under Federal awards when completing the review of risk posed by applicants as described in 2 CFR 200.205 Federal Awarding Agency Review of Risk Posed by Applicants. F.

Federal Award Administration Information (1) Federal Award Notices FTA will announce the final project selections on the FTA website. Project recipients should contact their FTA Regional Office for additional information regarding allocations for Start Printed Page 63657projects. At the time project selections are announced, FTA will extend pre-award authority for the selected projects. There is no blanket pre-award authority for these projects before announcement. There is no minimum or maximum grant award amount, but FTA intends to fund as many meritorious projects as possible.

FTA only will consider proposals from eligible recipients for eligible activities. Due to funding limitations, projects selected for funding may receive less than the amount originally requested. In those cases, applicants must be able to demonstrate that the proposed projects are still viable and can be completed with the amount awarded. (2) Administrative and National Policy Requirements a. Pre-Award Authority FTA will issue specific guidance to recipients regarding pre-award authority at the time of selection.

FTA does not provide pre-award authority for competitive funds until projects are selected, and there are Federal requirements that must be met before costs are incurred. For more information about FTA's policy on pre-award authority, see the FY 2020 Apportionments Notice published on June 3, 2020, at https://www.govinfo.gov/âcontent/âpkg/âFR-2020-06-03/âpdf/â2020-11946.pdf. b. Grant Requirements Selected applicants will submit a grant application through FTA's electronic grant management system and adhere to the customary FTA grant requirements for research project (insert Circular name). All competitive grants, regardless of award amount, will be subject to the Congressional notification and release process.

FTA emphasizes that third-party procurement applies to all funding awards, as described in FTA Circular 4220.1F, âThird Party Contracting Guidance.â However, FTA may approve applications that include a specifically identified partnering organization(s) (2 CFR 200.302(f)). When included, the application, budget, and budget narrative should provide a clear understanding of how the selection of these organizations is critical for the project and give sufficient detail about the costs involved. C. Planning FTA encourages applicants to engage the appropriate State Departments of Transportation, Regional Transportation Planning Organizations, or Metropolitan Planning Organizations in areas to be served by the project funds available under this program. D.

Standard Assurances The applicant assures that it will comply with all applicable Federal statutes, regulations, executive orders, FTA circulars, and other Federal administrative requirements in carrying out any project supported by the FTA grant. The applicant acknowledges that it is under a continuing obligation to comply with the terms and conditions of the grant agreement issued for its project with FTA. The applicant understands that Federal laws, regulations, policies, and administrative practices might be modified from time to time and may affect the implementation of the project. The applicant agrees that the most recent Federal requirements will apply to the project unless FTA issues a written determination otherwise. The applicant must submit the Certifications and Assurances before receiving a grant if it does not have current certifications on file.

E. Free Speech and Religious Liberty In connection with any program or activity conducted with or benefiting from funds awarded under this notice, recipients of funds must comply with all applicable requirements of Federal law, including, without limitation, the Constitution of the United States. Statutory, regulatory, and public policy requirements, including without limitation, those protecting free speech, religious liberty, public welfare, the environment, and prohibiting discrimination. The conditions of performance, non-discrimination requirements, and other assurances made applicable to the award of funds in accordance with regulations of the Department of Transportation. And applicable Federal financial assistance and contracting principles promulgated by the Office of Management and Budget.

In complying with these requirements, recipients must ensure that no concession agreements are denied or other contracting decisions made on the basis of speech or other activities protected by the First Amendment. If the Department determines that a recipient has failed to comply with applicable Federal requirements, the Department may terminate the award of funds and disallow previously incurred costs, requiring the recipient to reimburse any expended award funds. (3) Reporting The post-award reporting requirements include submission of the Federal Financial Report (FFR) and Milestone Progress Report in TrAMS. An evaluation of the grant will occur at various points in the demonstration process and at the end of the project. In addition, FTA is responsible for producing an Annual Report to Congress that compiles evaluation of selected projects, including an evaluation of the performance measures identified by the applicants.

All applicants must develop an evaluation plan to measure the success or failure of their projects and describe any plans for broad-based implementation of successful projects. FTA may request data and reports to support the evaluation and Annual Report. A. Independent Evaluation To achieve a comprehensive understanding of the impacts and implications of each proposed asthma treatment Research Demonstration Program, projects funded under this announcement will require the recipient to conduct a third party independent evaluation of their project. Recipients will be required to contract with a third party independent evaluator to assist in developing an evaluation plan, and collecting, storing and managing data required to fulfill the evaluation requirement.

No more than 10 percent of the Federal share of the project may be used to hire the third-party independent evaluator and the inclusion of a third-party independent evaluation should be described in the grant application. If the project duration is more than two years, an interim evaluation report would need to be submitted to FTA, otherwise the evaluation report should be included as part of the final project report. B. asthma treatment Research Demonstration Grant Program Evaluation Projects funded under this announcement will be required to establish a set of performance metrics set by the third-party independent evaluator and shared with FTA. G.

Federal Awarding Agency Contacts Information For questions about applying, please contact Jamel El-Hamri email. Jamel.El-Hamri@dot.gov phone. 202-366-8985. A TDD is available at 1-800-877-8339 (TDDFIRS). To ensure that applicants receive accurate information about eligibility or the program, applicants are encouraged to contact FTA directly with questions, rather than through intermediaries or third parties.Start Printed Page 63658 FTA staff also may conduct briefings on the competitive grants selection and award process upon request.

Start Signature K. Jane Williams, Deputy Administrator. End Signature End Supplemental Information [FR Doc. 2020-22316 Filed 10-7-20.

And the spread through sparsely populated areas of rural America has created how to get ventolin without prescription problems in small towns that lack critical resources http://spinslotsdeals.com/where-can-i-buy-zithromax-uk/ â including doctors â even in ordinary times.Wyoming, which did not have 1,000 total cases until June, recently added more than 1,000 in a single week. Reports of new s have recently reached record levels in Alaska, Colorado and Idaho. And Montana, where more than half of the stateâs cases have been announced since August, is averaging more than 500 cases per day.In Cascade County, more than 300 inmates and staff members have been infected in a facility meant to hold 365 people, the countyâs first major outbreak in a region where the ventolin is suddenly surging.The county seat, Great Falls, is seeing its worst case numbers yet. The local hospital and how to get ventolin without prescription its 27-bed asthma treatment unit is at capacity. The county health department is racing to hire new contact tracers.

And Mr. Krogue, who also teaches nursing at Montana State Universityâs Great how to get ventolin without prescription Falls campus, has seen attendance in his classes dwindle as students fall ill or quarantine.âI was just scared that Iâm not going to be able to see it through, that Iâm going to get sick,â said Paul Krogue, the jailâs medical director.Credit...Tailyr Irvine for The New York TimesOne place where the s have spread has been local jails, which are confined, often crowded spaces. Jails are staples of local communities and tend to have people coming and going more quickly than prisons. Jails can hold everyone from people awaiting criminal trials for months to those picked up for a suspended driverâs license for a few hours. With so many people filtering in and out, jails pose extra risks for the ventolinâs spread â not only inside facilities but in potentially feeding outbreaks in the rest of the community.Nationally, jails and prisons have seen how to get ventolin without prescription disproportionate rates of and death, with a mortality rate twice as high as in the general population and an rate more than four times as high, according to recent data.

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1024px) { #styln-briefing-block { width. 100%. } } Latest Updates. The asthma Outbreak 28m ago Amtrak chief pleads for billions in aid and warns of thousands of layoffs. 1h ago The C.D.C.

Updates its definition of âclose contactâ in relation to risk. 3h ago A treatment trial volunteer in Brazil has died, but health authorities say the treatment was not to blame. See more updates More live coverage. Markets A New York Times database has tracked clusters of at least 50 asthma cases in a dozen rural jails in Montana, Idaho, Utah and New Mexico during the ventolin. Among them.

The Purgatory Correctional Center in Hurricane, Utah, with 166 s. The jail in Twin Falls, Idaho, with 279. And, in New Mexico, the Cibola County Correctional Center, which has reported 357 cases.In Cascade County, s at the jail make up about a quarter of all known ventolin cases in the county. Health authorities say that the jailâs outbreak, which began in mid-August, was not believed to be the main cause of the communityâs recent surge, but that it had led to some cases. In the past two months, Mr.

Krogue said, the jail released 29 people who were considered actively infected.s at the jail make up about a quarter of Cascade Countyâs known ventolin cases.Credit...Tailyr Irvine for The New York TimesGreat Falls, home to about 58,000 residents, is in the less mountainous part of Montana, with the Missouri River flowing through and a large oil refinery on its banks. The Cascade County Detention Center sits along a highway at the edge of town. Drive five miles in any direction and you are surrounded by wide-open plains.Montana requires that masks be worn inside businesses and indoor public spaces, and many people in Great Falls wear them when walking around downtownâs Central Avenue, where shops and cafes are still recovering from shutting down in the spring. Others go without masks, citing the open space and lack of crowds.Bob Kelly, the mayor, said people had not been overly worried about how the jail outbreak might affect the rest of town when it started.âI think that by the very definition of a jail, hopefully, the disease will be incarcerated, as well as the patients,â he said. ÂIs there concern?.

Sure, thereâs concern. But is there overreaction?. No.âThe mayor of Great Falls said that residents had considered the jailâs outbreak a distant concern at first.Credit...Tailyr Irvine for The New York TimesSome residentsâ nonchalance about the risks of the ventolin, said Mr. Krogue, the jailâs medical director, can be traced to a spring and early summer when almost no one in Cascade County knew anyone who had been sickened.âWe benefited from that early on,â he said. ÂBut in some ways, I think it did us a disservice, too, because it also created a certain level of complacency.âThat has quickly shifted now, he said, as cases have spiked.The number of active cases known to county officials on any given day has risen sharply to about 600, according to Trisha Gardner, Cascade Countyâs health officer.

The county has seen 1,261 cases and six deaths during the ventolin, a Times database shows. Some of the cases have been tied to the jail outbreak, she said, and others have been connected to bars and restaurants. Even figuring out what has led to some cases has been complex, she said, as residents have been reluctant to cooperate with contact tracers.âOur hospitals are at capacity, our public health system is at capacity,â she said. ÂItâs not sustainable at this rate.âWhen the outbreak at the jail began, social distancing was impossible, the authorities said. Three inmates shared cells designed for two.

At night, men slept on thin blue pads in every available space. On the floor in the day room, in shower stalls, in stairwells, in hallways outside of cells.Inmates did not receive masks until August, and jail officials said many have refused to wear them.In interviews with more than a dozen inmates and their family members, inmates described the jail during the outbreak as chaotic and unsanitary. They said their pleas for help often went unanswered by nurses and guards.Newly arriving inmates were not always quarantined from one another before their test results were known because of a lack of space, inmates and jail officials said.Owen Hawley, 30, said every inmate in his living area of 38 men had tested positive for the ventolin. He said he had been unable to eat for three days, had intensive body aches and suffered from a headache so powerful it felt as if it was âbehind my eyes.ââAfter the fourth day of like, not eating and stuff, I just shut off, you know?. Â he said.A jail area set aside for quarantining new inmates.Credit...Tailyr Irvine for The New York TimesAt one point, Mr.

Hawley said, he and other prisoners protested the way the ventolin was being handled by refusing to leave their living areas and by blocking new inmates from entering. Everyone was ultimately tested, Mr. Hawley said, and each prisoner was given a disposable mask.Sierra Jasmine Wells, 25, another inmate, said women in her dormitory had grown ill, one after the next.âEveryone around me was getting sick and it was tough on me,â she said. ÂBy then, I had already accepted the fact that I was going to get sick.âWhen she became infected, she said, she was given cough syrup and Tylenol.âI kind of was just left alone to deal with it,â she said.Jesse Slaughter, the county sheriff who oversees the jail, said that the jailâs medical staff was doing everything it could, and that he had been seeking health care assistance from other counties. Officials defended their handling of the outbreak, noting that all inmates received standard medications including Tylenol twice a day and were taken to area hospitals when they needed added care.

Seven inmates, as well as some staff members, were hospitalized. No one from the jail has died from the ventolin, officials said.Sheriff Jesse Slaughter, who oversees the jail, said he had been seeking health care assistance from other counties.Credit...Tailyr Irvine for The New York TimesMr. Krogue said that since the start of the outbreak he had been working up to 16 hours each day and sleeping in his basement, away from his wife and children. He remains healthy but says he fears bringing the ventolin home. The ventolin has slowed some in the jail, and officials have moved some inmates to other facilities, but other prisons and jails in the state are now seeing outbreaks.âYou can start to see what some of these other places experienced much earlier on, and we just didnât have that experience, but itâs certainly happening now,â Mr.

Krogue said. ÂItâs just real in a way that it wasnât.âLucy Tompkins reported from Great Falls, Maura Turcotte from Chicago and Libby Seline from Lincoln, Neb. Reporting was contributed by Izzy ColÃ³n from Columbia, Mo., Brendon Derr from Phoenix, Rebecca Griesbach from Tuscaloosa, Ala., Danya Issawi and Timothy Williams from New York, Ann Hinga Klein from Des Moines, K.B. Mensah from Silver Spring, Md., and Mitch Smith from Chicago.Start Preamble Federal Transit Administration (FTA), DOT. Notice of funding opportunity.

The asthma Disease 2019 (asthma treatment) public health emergency Start Printed Page 63654has had a significant impact on transit operations. During a series of FTA listening sessions held over the last three months, transit agencies asked FTA to support research to identify solutions to address the operational challenges that they are facing as a result of asthma treatment. In response, FTA makes available through this Notice of Funding Opportunity (NOFO) funding to support research demonstration grants to public transit agencies to develop, deploy, and demonstrate innovative solutions that improve the operational efficiency of transit agencies, as well as enhance the mobility of transit users affected by the asthma treatment public health emergency. Demonstration grants under this NOFO are authorized under FTA's Public Transportation Innovation Program (49 U.S.C. 5312).

Eligible projects will demonstrate innovative solutions to improve the operational efficiencies of transit systems and enhance mobility for their communities in four major areas. (1) Vehicle, facility, equipment and infrastructure cleaning and dis. (2) exposure mitigation measures. (3) innovative mobility such as contactless payments. And (4) measures that strengthen public confidence in transit services.

The total funding available for awards under this NOFO is $10,000,000. FTA may supplement this amount if additional funding becomes available. Applicants must submit completed proposals for funding opportunity FTA-2020-015-TRI through the GRANTS.GOV âAPPLYâ function by 11:59 p.m. Eastern Time on November 2, 2020. Prospective applicants should register as soon as possible on the GRANTS.GOV website to ensure they can complete the application process before the submission deadline.

Application instructions are available on FTA's website at http://transit.dot.gov/âhowtoapply and in the âFINDâ module of GRANTS.GOV. FTA will not accept mail and fax submissions. Start Further Info Please send any questions on this notice to Jamel El-Hamri email. Jamel.El-Hamri@dot.gov phone. 2020-366-8985.

A Telecommunication Device for the Deaf (TDD) is available for individuals who are deaf or hard of hearing at 1-800-877-8339. End Further Info End Preamble Start Supplemental Information Table of Contents A. Program Description B. Federal Award Information C. Eligibility Information D.

Application and Submission Information E. Application Review Information F. Federal Award Administration Information G. Federal Awarding Agency Contact Information A. Program Description The Public Transportation asthma treatment Research Demonstration Grant Program is funded through the Public Transportation Innovation Program (49 U.S.C.

5312), with the goal to develop, deploy, and demonstrate innovative solutions that improve the operational efficiency of transit agencies, as well as enhance the mobility of transit users affected by the asthma treatment public health emergency. Eligible projects will propose to develop and deploy innovative solutions in four major areas. (1) Vehicle, facility, equipment and infrastructure cleaning and dis. (2) exposure mitigation measures. (3) innovative mobility such as contactless payments.

And (4) measures that strengthen public confidence in transit. As required by 49 U.S.C. 5312(e)(4), projects funded under this NOFO must participate in an evaluation by an independent outside entity that will conduct a comprehensive evaluation of the success or failure of the projects funded under this subsection and any plan for broad-based implementation of the innovation promoted by successful projects. B. Federal Award Information FTA makes available $10,000,000 in fiscal year (FY) 2020 funds under the Public Transportation Innovation Program (49 U.S.C.

5312) to finance the Public Transportation asthma treatment Research Demonstration Grant Program. FTA may supplement the total funds available if additional funding becomes available at the time project selections are made. FTA will grant pre-award authority starting on the date of the project award announcement for selected projects and should be completed within 24 months from the date of award. Funds are available only for eligible expenses incurred after the announcement of project selections. C.

Eligibility Information (1) Eligible Applicants Eligible applicants include State and local governmental authorities, direct recipients of Urbanized Area (49 U.S.C. 5307) and Rural Area (49 U.S.C. 5311) formula funds, and Indian tribes. Eligible applicants are limited to FTA grantees or subrecipients who would be the primary beneficiaries of the innovative products and services that are developedâtypically public transit agencies. Except for projects proposed by Indian tribes, proposals for projects in rural (non-urbanized) areas must be submitted as part of a consolidated State proposal.

States and other eligible applicants also may submit consolidated proposals for projects in urbanized areas. The submission of the Statewide application will not preclude the submission and consideration of any application from other eligible recipients in an urbanized area in a State. Proposals may contain projects to be implemented by the recipient or its subrecipients. Eligible subrecipients include public agencies, private nonprofit organizations, and private providers engaged in public transportation. Eligible applicants may submit consolidated proposals for projects.

(2) Cost Sharing or Matching The maximum Federal share of project costs is 100 percent. FTA may give additional consideration to applicants that propose a local share and may view these applicants as more competitive. The applicant must document the source(s) of the local match, if any, in the grant application. For any applicants proposing match, eligible local match sources include the following. Cash from non-Government sources other than revenues from providing public transportation services.

Revenues derived from the sale of advertising and concessions. Revenues generated from value capture financing mechanisms. Funds from an undistributed cash surplus. Replacement or depreciation cash fund or reserve. New capital.

Or in-kind contributions. (3) Eligible Projects Eligible projects will propose innovative solutions to improve operational efficiencies of transit agencies and enhance the mobility of transit users, through projects that demonstrate innovative solutions for. Vehicle, facility, equipment and infrastructure cleaning and dis. Exposure mitigation measures such a real-time notification of rail and bus passenger loads. New multi-modal payment innovative mobility systems such as contactless payments.

And measures that strengthen public confidence in transit. Each applicant may only submit one proposal.Start Printed Page 63655 D. Application and Submission Information (1) Address and Form of Application Submission Applications must be submitted through GRANTS.GOV. Applicants can find general information for submitting applications through GRANTS.GOV at www.fta.dot.gov/âhowtoapply, along with specific instructions for the forms and attachments required for submission. Mail and fax submissions will not be accepted.

(2) Content and Form of Application Submission a. Proposal Submission A complete proposal submission consists of at least two forms. 1. The SF-424 Mandatory Form (downloadable from GRANTS.GOV) and 2. The supplemental form for the FY 2020 asthma treatment Demonstration Program (downloadable from GRANTS.GOV), which is available on FTA's website at (placeholder for FTA asthma treatment Demonstration Program).

The application must include responses to all sections of the SF-424 mandatory form and the supplemental form unless a section is indicated as optional. FTA will use the information on the supplemental form to determine applicant and project eligibility for the program and to evaluate the proposal against the selection criteria described in part E of this notice. FTA will accept only one supplemental form per SF-424 submission. FTA encourages applicants to consider submitting a single supplemental form that includes multiple activities to be evaluated as a consolidated proposal. Applicants may attach additional supporting information to the SF-424 submission, including but not limited to letters of support, project budgets, or excerpts from relevant planning documents.

Supporting documentation must be described and referenced by file name in the appropriate response section of the supplemental form, or it may not be reviewed. Information such as applicant name, Federal amount requested, local match amount, description of areas served, etc., may be requested in varying degrees of detail on both the SF-424 form and supplemental form. Applicants must fill in all fields unless stated otherwise on the forms. If applicants copy information into the supplemental form from another source, they should verify that the supplemental form has fully captured pasted text and that it has not truncated the text due to character limits built into the form. Applicants should use both the âCheck Package for Errorsâ and the âValidate Formâ validation buttons on both forms to check all required fields.

Applicants should also ensure that the Federal and local amounts specified are consistent. Addressing the deteriorating conditions and disproportionately high fatality rates on our rural transportation infrastructure is of critical interest to the Department, as rural transportation networks face unique challenges in safety, infrastructure condition, and passenger and freight usage. Consistent with the R.O.U.T.E.S. Initiative, the Department encourages applicants to consider how the project will address the challenges faced by rural areas. B.

Application Content The SF-424 Mandatory Form and the supplemental form will prompt applicants for the required information, including. I. Applicant Name ii. Dun and Bradstreet (D&B) Data Universal Numbering System (DUNS) number iii. Key contact information (contact name, address, email address, and phone number) iv.

Congressional district(s) where project will take place v. Project Information (title, executive summary, and type) vi. A detailed description of the need for the project vii. A detailed description of how the project will support the Program objectives viii. Evidence that the applicant can provide the local cost shares ix.

A description of the technical, legal, and financial capacity of the applicant x. A detailed project budget xi. Details on the local matching funds xii. A detailed project timeline xiii. Whether the project impacts an Opportunity Zone (3) Unique Entity Identifier and System for Award Management (SAM) Each applicant is required to.

(1) Be registered in SAM before submitting an application. (2) provide a valid unique entity identifier in its application. And (3) continue to maintain an active SAM registration with current information at all times during which the applicant has an active Federal award or an application or plan under consideration by FTA. These requirements do not apply if the applicant. (1) Is excepted from the requirements under 2 CFR 25.110(b) or (c).

Or (2) has an exception approved by FTA under 2 CFR 25.110(d). FTA may not make an award until the applicant has complied with all applicable unique entity identifier and SAM requirements. If an applicant has not fully complied with the requirements by the time FTA is ready to make an award, FTA may determine that the applicant is not qualified to receive an award and use that determination as a basis for making a Federal award to another applicant. All applicants must provide a unique entity identifier provided by SAM. Registration in SAM may take as little as 3-5 business days, but there can be unexpected steps or delays.

For example, the applicant may need to obtain an Employer Identification Number. FTA recommends allowing ample time, up to several weeks, to complete all steps. For additional information on obtaining a unique entity identifier, please visit www.sam.gov. (4) Submission Dates and Times Project proposals must be submitted electronically through GRANTS.GOV by 11:59 p.m. Eastern on November 2, 2020.

Mail and fax submissions will not be accepted. FTA urges applicants to submit applications at least 72 hours prior to the due date to allow time to correct any problems that may have caused either GRANTS.GOV or FTA systems to reject the submission. Proposals submitted after the deadline will only be considered under extraordinary circumstances not within the applicant's control. Deadlines will not be extended due to scheduled website maintenance. GRANTS.GOV scheduled maintenance and outage times are announced on the GRANTS.GOV website.

Within 48 hours after submitting an electronic application, the applicant should receive two email messages from GRANTS.GOV. (1) Confirmation of successful transmission to GRANTS.GOV. And (2) confirmation of successful validation by GRANTS.GOV. If the applicant does not receive confirmation of successful validation or receives a notice of failed validation or incomplete materials, the applicant must address the reason for the failed validation, as described in the email notice, and resubmit before the submission deadline. If making a resubmission for any reason, applicants must include all original attachments regardless of which attachments were updated and check the box on the supplemental form indicating this is a resubmission.

Applicants are encouraged to begin the process of registration on the GRANTS.GOV site well in advance of the submission deadline. Registration is Start Printed Page 63656a multi-step process, which may take several weeks to complete before an application can be submitted. Registered applicants may still be required to update their registration before submitting an application. Registration in SAM is renewed annually and persons making submissions on behalf of the Authorized Organization Representative (AOR) must be authorized in GRANTS.GOV by the AOR to make submissions. (5) Funding Restrictions Funds may be used for post-award expenditures only.

Funds under this NOFO cannot be used to reimburse projects for otherwise eligible expenses incurred prior to the date of project award announcements. (6) Other Submission Requirements FTA encourages applicants to identify scaled funding options in case insufficient funding is available to fund a project at the full requested amount. If an applicant indicates that a project is scalable, the applicant must provide an appropriate minimum funding amount that will fund an eligible project that achieves the objectives of the program and meets all relevant program requirements. The applicant must provide a clear explanation of how a reduced award would affect the project budget and scope. FTA may award a lesser amount whether or not the applicant provides a scalable option.

E. Application Review Information (1) Project Evaluation Criteria Addressing the deteriorating conditions and disproportionately high fatality rates on our rural transportation infrastructure is of critical interest to the Department, as rural transportation networks face unique challenges in safety, infrastructure condition, and passenger and freight usage. Consistent with the R.O.U.T.E.S. Initiative, the Department will consider how the project will address the challenges faced by rural areas. In addition, the Department will review and consider applications for funding pursuant to this Notice in accordance with the President's September 2, 2020 memorandum, entitled Memorandum on Reviewing Funding to State and Local Government Recipients of Federal Funds that Are Permitting Anarchy, Violence, and Destruction in American Cities, consistent with guidance from the Office of Management and Budget and the Attorney General and with all applicable laws.

FTA will evaluate proposals submitted according to the following criteria. (a) Project Innovation and Impact. (b) Project Approach. (c) National Applicability. (d) Commercialization and/or Knowledge Transfer.

And (e) Technical, Legal and Financial Capacity. FTA encourages each applicant to demonstrate how a project supports all criteria with the most relevant information the applicant can provide, regardless of whether such information has been specifically requested or identified in this notice. A. Project Innovation and Impact i. Effectiveness of the project in achieving and demonstrating the specific objectives of this program.

Ii. Demonstration of benefits in addressing the needs of the transit agency and industry and impacts to infrastructure, equipment, transit workforce, and riders. Iii. Degree of improvement over current and existing technologies, designs, and/or practices applicable to the transit industry. B.

Project Approach i. Quality of the project approach such as existing partnerships, collaboration strategies and level of commitment of the project partners. Ii. Proposal is realistic in its approach to fulfill the milestones/deliverables, schedule and goals. C.

National Applicability i. Degree to which the project could be replicated by other transit agencies regionally or nationally. Ii. Ability to evaluate technologies, designs and/or practices in a wide variety of conditions and locales. Iii.

Degree to which the technology, designs and/or practices can be replicated by other transportation modes. D. Commercialization and/or Knowledge Transfer i. Demonstrates a realistic plan for moving the results of the project into the transit marketplace (patents, conferences, articles in trade magazines, webinar, site visits, etc.). Ii.

How the project team plans to work with the industry on improving best practices, guidance and/or standards, if applicable. Iii. Demonstrate a clear understanding and robust approach to data collection, access and management. E. Technical, Legal and Financial Capacity Capacity of the applicant and any partners to successfully execute the project effort.

There should be no outstanding legal, technical, or financial issues with the applicant that would make this a high-risk project. (2) Review and Selection Process An FTA technical evaluation committee will evaluate proposals based on the published project evaluation criteria. Members of the technical evaluation committee will rate the applications and may seek clarification about any statement in an application. The FTA Administrator will determine the final selection and amount of funding for each project after consideration of the findings of the technical evaluation committee. Geographic diversity, diversity of the project type, the amount of local match to be provided, and the applicant's receipt and management of other Federal transit funds may be considered in FTA's award decisions.

Prior fare payment innovation efforts may receive priority consideration. The FTA Administrator will consider the following key DOT objectives. A. Utilizing alternative funding sources and innovative financing models to attract non-Federal sources of investment. B.

Whether the project is located in or supports public transportation service in a qualified opportunity zone designated pursuant to 26.U.S.C. 1400Z-1. And c. The extent to which the project addresses challenges specific to the provision of rural public transportation. (3) FAPIIS Review Prior to making a grant award, FTA is required to review and consider any information about the applicant that is in the Federal Awardee Performance and Integrity Information System (FAPIIS) accessible through SAM.

An applicant may review and comment on information about itself that a Federal awarding agency previously entered. FTA will consider any comments by the applicant, in addition to the other information in FAPIIS, in making a judgment about the applicant's integrity, business ethics, and record of performance under Federal awards when completing the review of risk posed by applicants as described in 2 CFR 200.205 Federal Awarding Agency Review of Risk Posed by Applicants. F. Federal Award Administration Information (1) Federal Award Notices FTA will announce the final project selections on the FTA website. Project recipients should contact their FTA Regional Office for additional information regarding allocations for Start Printed Page 63657projects.

At the time project selections are announced, FTA will extend pre-award authority for the selected projects. There is no blanket pre-award authority for these projects before announcement. There is no minimum or maximum grant award amount, but FTA intends to fund as many meritorious projects as possible. FTA only will consider proposals from eligible recipients for eligible activities. Due to funding limitations, projects selected for funding may receive less than the amount originally requested.

In those cases, applicants must be able to demonstrate that the proposed projects are still viable and can be completed with the amount awarded. (2) Administrative and National Policy Requirements a. Pre-Award Authority FTA will issue specific guidance to recipients regarding pre-award authority at the time of selection. FTA does not provide pre-award authority for competitive funds until projects are selected, and there are Federal requirements that must be met before costs are incurred. For more information about FTA's policy on pre-award authority, see the FY 2020 Apportionments Notice published on June 3, 2020, at https://www.govinfo.gov/âcontent/âpkg/âFR-2020-06-03/âpdf/â2020-11946.pdf.

b. Grant Requirements Selected applicants will submit a grant application through FTA's electronic grant management system and adhere to the customary FTA grant requirements for research project (insert Circular name). All competitive grants, regardless of award amount, will be subject to the Congressional notification and release process. FTA emphasizes that third-party procurement applies to all funding awards, as described in FTA Circular 4220.1F, âThird Party Contracting Guidance.â However, FTA may approve applications that include a specifically identified partnering organization(s) (2 CFR 200.302(f)). When included, the application, budget, and budget narrative should provide a clear understanding of how the selection of these organizations is critical for the project and give sufficient detail about the costs involved.

C. Planning FTA encourages applicants to engage the appropriate State Departments of Transportation, Regional Transportation Planning Organizations, or Metropolitan Planning Organizations in areas to be served by the project funds available under this program. D. Standard Assurances The applicant assures that it will comply with all applicable Federal statutes, regulations, executive orders, FTA circulars, and other Federal administrative requirements in carrying out any project supported by the FTA grant.

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