04/20/2011 AgreementDANNY L. KOLHA GE
CLERK OF THE CIRCUIT COURT
DATE: April25, 2011
TO: Teresa Aguilar
Employee Services
ATTN: Christine Diaz
FROM: Isabel C. DeSantis, D.C.
At the April 20, 2011, Board of County Commissioner's meeting the Board approved the
following:
Item C22 Contract with Key West Urgent Care to provide employment physicals and
authorization for the Employee ServicesDirector to execute an agreement with Key West
Diagnostics to perform chest x-rays as needed.
Enclosed is a fully executed copy of the above -mentioned for your handling. Should you
have any questions please do not hesitate to contact this office.
cc: County Attorney
Finance
File
MONROE COUNTY
CONTRACTFOR
EMPLOYMENT PHYSICAL SERVICES
THIS AGREEMENT ("Agreement") is made and entered into this 20th day of April, 2011, by
MONROE COUNTY ("COUNTY"), a political subdivision of the State of Florida, whose address
is 1100 Simonton Street, Key West, Florida 33040 and KEY WEST URGENT CARE, INC.
("CONTRACTOR"), whose address is 1501 Government Road, Key West, FL 33040
Section 1. SCOPE OF SERVICES
CONTRACTOR shall do, perform and carry out in a professional and proper manner certain
duties as described in the Scope of Services — Section One — which is attached hereto and
made a part of this agreement.
CONTRACTOR shall provide the scope of services in Section One for COUNTY.
CONTRACTOR warrants that it is authorized by law to engage in the performance of the
activities herein described, subject to the terms and conditions set forth in these Agreement
documents. The CONTRACTOR shall at all times exercise independent, professional judgment
and shall assume professional responsibility for the services to be provided. Contractor shall
provide services using the following standards, as a minimum requirement:
A. The CONTRACTOR shall maintain adequate staffing levels to provide the
services required under the Agreement.
B. The contractor is responsible for obtaining proper releases from the
employee or prospective employee in order to discuss the results with
Monroe County BOCC.
C. The contractor will provide the required services at the location of:
Key West Urgent Care, Inc.
1501 Government Road
Key West, FL 33040
Phone: 305-295-7550
Fax: 305-296-3010
D. The Contractor will have an employee designated as coordinator or
facilitator to assist in the communications with the Monroe County BOCC's
primary contact personnel.
E. Appointments will be available throughout the business hours of the facility:
Monday — Friday 8:00 a.m. — 3:30 p.m. Walk-ins will also be accepted
if an appointment cannot be reasonably scheduled.
F. Appointments will be seen by the contractor in a reasonable and timely
fashion.
G. The Contractor will provide the County with at least a 24 — 48 hour
turnaround time for the receipt of any results.
H. The Medical Review Officer will be available for contact by the Monroe
County BOCC or its employees to answer questions about the effect of
prescribed drugs. Part of the requirements set forth by the State of Florida
drug free workplace policy, which Monroe County has adopted, and the
Depart vent of Transportation, the County must have a qualified Medical
Review Officer "MRO" perform drug screening services. The MRO receives
lab reports from the laboratory (as governed by regulations); Reviews lab
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reports for integrity, authenticity, false negatives, and false positives; interprets
lab results, including verification of lab positives; reports lab reports to the
employer (as defined by rules and regulations).
The personnel shall not be employees of or have any contractual relationship
with the County. To the extent that Contractor uses subcontractors or
independent contractors, this Agreement specifically requires that
subcontractors and independent contractors shall not be an employee of or
have any contractual relationship with County.
All personnel engaged in performing services under this Agreement shall be fully
qualified, and, if required, to be authorized or permitted under State and local law
to perform such services.
Section 2. QUALIFICATIONS NECESSARY OF CONTRACTOR
The CONTRACTOR must certify at least annually that all staff members, independent
contractors, subcontracted work, if any, all service providers it uses, engages or manages,
comply with Health Insurance Portability and Accountability Act (HIPAA) privacy and
security rules.
Physical examinations will be conducted by, or under the direct supervision, of a
physician or medical doctor currently licensed and practicing general medicine in the
State of Florida. The examining physician may employ assistants properly licensed and
trained, as necessary, to perform laboratory tests and/or assist in all phases of the
examination.
Section 3. COUNTY'S RESPONSIBILITIES
3.1 Provide all best available information as to the COUNTY'S requirements for the
Scope of Services described in Section One to this Agreement.
3.2 Designate in writing a person with authority to act on the COUNTY'S behalf on all matters
concerning said services.
Section 4. TERM OF AGREEMENT
4.1 The initial Agreement term will be for one (1) year beginning the 20th day of A ril
2011, and renewable at the County's option for two (2) additional consecutive one year
terms.
4.2 The terms of this Agreement shall be from the effective date hereof and continue for
a period of one year. This Agreement shall be automatically renewed for successive one-
year periods until either party gives the other notice of cancellation in accordance with the
terms set forth below. The Contractor must provide the Contractor with at least thirty (30)
days notice of intent to terminate. If either party desires to modify this Agreement, it shall
notify the other in writing at least thirty (30) days prior to the effective date of such
modification. In the case of proposed modification the party receiving the notification of the
proposed modification shall itself notify the other party within ten (10) days after receipt of
notice of its agreement to the proposed modification. Failure to do so shall terminate this
Agreement.
Section 5. COMPENSATION
Compensation to CONTRACTOR is outlined in the Scope of Services — Section One.
Section 6. PAYMENT TO CONTRACTOR
6.1 Payment will be made according to the Florida Local Government Prompt Payment Act.
Any request for payment must be in a form satisfactory to the Clerk of Courts for Monroe
County (Clerk). The request must describe in detail the services performed and the
payment amount requested. The CONTRACTOR must submit invoices to the
appropriate offices marked Human Resources. The respective office supervisor and the
Administrator of Human Resources, who will review the request, note his/her approval
on the request and forward it to the Clerk for payment.
6.2 Continuation of this Agreement is contingent upon annual appropriation by Monroe
County Board of County Commissioners.
Section 7. CONTRACT TERMINATION
Either party may terminate this Agreement because of the failure of the other party to perform its
obligations under the Agreement. COUNTY may terminate this Agreement with or without
cause upon thirty (30) days notice to the CONTRACTOR. COUNTY shall pay CONTRACTOR
for work performed through the date of termination.
Section 8. CONTRACTOR'S ACCEPTANCE OF CONDITIONS
A. CONTRACTOR hereby agrees that he has carefully examined the RFP, his response,
and this Agreement and has made a determination that he/she has the personnel,
equipment, and other requirements suitable to perform this work and assumes full
responsibility therefore. The provisions of the Agreement shall control any inconsistent
provisions contained in the specifications. All specifications have been read and
carefully considered by CONTRACTOR, who understands the same and agrees to their
sufficiency for the work to be done. Under no circumstances, conditions, or situations
shall this Agreement be more strongly construed against COUNTY than against
CONTRACTOR.
B. Any ambiguity or uncertainty in the specifications shall be interpreted and construed by
COUNTY, and its decision shall be final and binding upon all parties.
C. The passing, approval, and/or acceptance by COUNTY of any of the services furnished
by CONTRACTOR shall not operate as a waiver by COUNTY of strict compliance with
the terms of this Agreement, and specifications covering the services.
D. CONTRACTOR agrees that County Administrator or his designated representatives may
visit CONTRACTOR'S facility (ies) periodically to conduct random evaluations of
services during CONTRACTOR'S normal business hours.
E. CONTRACTOR has, and shall maintain throughout the term of this Agreement,
appropriate licenses and approvals required to conduct its business, and that it will at all
times conduct its business activities in a reputable manner. Proof of such licenses and
approvals shall be submitted to COUNTY upon request.
C!
Section 9. NOTICES
Any notice required or permitted under this agreement shall be in writing and hand delivered or
mailed, postage prepaid, to the other party by certified mail, returned receipt requested, to the
following:
To the COUNTY: Human Resources Administrator
1100 Simonton Street, Suite 2-268
Key West, Florida 33040
To the CONTRACTOR: Key West Urgent Care, Inc.
1501 Government Road
Key West, FL 33040
Section 10. RECORDS
CONTRACTOR shall maintain all books, records, and documents directly pertinent to
performance under this Agreement in accordance with generally accepted accounting principles
consistently applied. Each party to this Agreement or their authorized representatives shall
have reasonable and timely access to such records of each other party to this Agreement for
public records purposes during the term of the agreement and for four years following the
termination of this Agreement. If an auditor employed by the COUNTY or Clerk determines that
monies paid to CONTRACTOR pursuant to this Agreement were spent for purposes not
authorized by this Agreement, the CONTRACTOR shall repay the monies together with interest
calculated pursuant to Section 55.03 of the Florida Statutes, running from the date the monies
were paid to CONTRACTOR.
Section 11. EMPLOYEES SUBJECT TO COUNTY ORDINANCE NOS. 010 AND 020-1990
The CONTRACTOR warrants that it has not employed, retained or otherwise had act on its
behalf any former County officer or employee subject to the prohibition of Section 2 of
Ordinance No. 010-1990 or any County officer or employee in violation of Section 3 of
Ordinance No. 020-1990. For breach or violation of this provision the COUNTY may, in its
discretion, terminate this agreement without liability and may also, in its discretion, deduct from
the agreement or purchase price, or otherwise recover the full amount of any fee, commission,
percentage, gift, or consideration paid to the former County officer or employee.
Section 12. CONVICTED VENDOR
A person or affiliate who has been placed on the convicted vendor list following a conviction for
public entity crime may not submit a bid on a Agreement with a public entity for the construction
or repair of a public building or public work, may not perform work as a CONTRACTOR,
supplier, subcontractor, or CONTRACTOR under Agreement with any public entity, and may not
transact business with any public entity in excess of the threshold amount provided in Section
287.017 of the Florida Statutes, for the Category Two for a period of 36 months from the date of
being placed on the convicted vendor list.
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Section 13. GOVERNING LAW, VENUE, INTERPRETATION, COSTS AND FEES
This Agreement shall be governed by and construed in accordance with the laws of the State of
Florida applicable to Agreements made and to be performed entirely in the State.
In the event that any cause of action or administrative proceeding is instituted for the
enforcement or interpretation of this Agreement, the COUNTY and CONTRACTOR agree that
venue shall lie in the appropriate court or before the appropriate administrative body in Monroe
County, Florida.
Section 14. SEVERABILITY
If any term, covenant, condition or provision of this Agreement (or the application thereof to any
circumstance or person) shall be declared invalid or unenforceable to any extent by a court of
competent jurisdiction, the remaining terms, covenants, conditions and provisions of this
Agreement, shall not be affected thereby; and each remaining term, covenant, condition and
provision of this Agreement shall be valid and shall be enforceable to the fullest extent permitted
by law unless the enforcement of the remaining terms, covenants, conditions and provisions of
this Agreement would prevent the accomplishment of the original intent of this Agreement. The
COUNTY and CONTRACTOR agree to reform the Agreement to replace any stricken provision
with a valid provision that comes as close as possible to the intent of the stricken provision.
Section 15. ATTORNEY'S FEES AND COSTS
The COUNTY and CONTRACTOR agree that in the event any cause of action or administrative
proceeding is initiated or defended by any party relative to the enforcement or interpretation of
this Agreement, the prevailing party shall be entitled to reasonable attorney's fees, and court
costs, as an award against the non -prevailing party. Mediation proceedings initiated and
conducted pursuant to this Agreement shall be in accordance with the Florida Rules of Civil
Procedure and usual and customary procedures required by the Circuit Court of Monroe
County.
Section 16. BINDING EFFECT
The terms, covenants, conditions, and provisions of this Agreement shall bind and inure to the
benefit of the COUNTY and CONTRACTOR and their respective legal representatives,
successors, and assigns.
Section 17. AUTHORITY
Each party represents and warrants to the other that the execution, delivery and performance of
this Agreement have been duly authorized by all necessary County and corporate action, as
required by law.
Section 18. ADJUDICATION OF DISPUTES OR DISAGREEMENTS
COUNTY and CONTRACTOR agree that all disputes and disagreements shall be attempted to
be resolved by meet and confer sessions between representatives of each of the parties. If the
issue or issues are still not resolved to the satisfaction of the parties, then any party shall have
Con
the right to seek such relief or remedy as may be provided by this Agreement or by Florida law.
This Agreement shall not be subject to arbitration.
Section 19. COOPERATION
In the event any administrative or legal proceeding is instituted against either party relating to
the formation, execution, performance, or breach of this Agreement, COUNTY and
CONTRACTOR agree to participate, to the extent required by the other party, in all
proceedings, hearings, processes, meetings, and other activities related to the substance of this
Agreement or provision of the services under this Agreement. COUNTY and CONTRACTOR
specifically agree that no party to this Agreement shall be required to enter into any arbitration
proceedings related to this Agreement.
Section 20. NONDISCRIMINATION
COUNTY and CONTRACTOR agree that there will be no discrimination against any person,
and it is expressly understood that upon a determination by a court of competent jurisdiction that
discrimination has occurred, this Agreement automatically terminates without any further action
on the part of any party, effective the date of the court order. The parties agree to comply with
all Federal and Florida statutes, and all local ordinances, as applicable, relating to
nondiscrimination. These include but are not limited to: 1) Title VII of the Civil Rights Act of
1964 (PL 88-352) which prohibits discrimination in employment on the basis of race, color,
national origin; 2) Title IX of the Education Amendment of 1972, as amended (20 USC ss. 1681-
1683, and 1685-1686), which prohibits discrimination on the basis of sex; 3) Section 504 of the
Rehabilitation Act of 1973, as amended (20 USC s. 794), which prohibits discrimination on the
basis of handicaps: 4) The Age Discrimination Act of 1975, as amended (42 USC ss. 6101-
6107) which prohibits discrimination on the basis of age; 5) The Drug Abuse Office and
Treatment Act of 1972 (PL 29-255), as amended, relating to nondiscrimination on the basis of
drug abuse; 6) The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and
Rehabilitation Act of 1970 (PL 91-616), as amended, relating to nondiscrimination on the basis
of alcohol abuse or alcoholism; 7) The Public Health Service Act of 1912, ss. 523 and 527 (42
USC ss. 690dd-3 and 290ee-3) as amended, relating to confidentiality of alcohol and drug
abuse patient records; 8) Title VIII of the Civil Rights Act of 1968 (42 USC ss. 3601 et seq.), as
amended, relating to nondiscrimination in the sale, rental or financing of housing; 9) The
Americans with Disabilities Act of 1990 (42 USC s. 1201), as may be amended from time to
time, relating to nondiscrimination on the basis of disability; 10) Monroe County Code Chapter
13, Article VI, which prohibits discrimination on the basis of race, color, sex, religion, national
origin, ancestry, sexual orientation, gender identity or expression, familial status or age; and 11)
any other nondiscrimination provisions in any Federal or state statutes which may apply to the
parties to, or the subject matter of, this Agreement.
Section 21. COVENANT OF NO INTEREST
COUNTY and CONTRACTOR covenant that neither presently has any interest, and shall not
acquire any interest, which would conflict in any manner or degree with its performance under
this Agreement, and that only interest of each is to perform and receive benefits as recited in
this Agreement.
Section 22. CODE OF ETHICS
COUNTY agrees that officers and employees of the COUNTY recognize and will be required to
comply with the standards of conduct for public officers and employees as delineated in Section
112.313, Florida Statutes, regarding, but not limited to, solicitation or acceptance of gifts; doing
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business with one's agency; unauthorized compensation; misuse of public position, conflicting
employment or contractual relationship; and disclosure or use of certain information.
Section 23. NO SOLICITATION/PAYMENT
The COUNTY and CONTRACTOR warrant that, in respect to itself, it has neither employed nor
retained any company or person, other than a bona fide employee working solely for it, to solicit
or secure this Agreement and that it has not paid or agreed to pay any person, company,
corporation, individual, or firm, other than a bonafide employee working solely for it, any fee,
commission, percentage, gift, or other consideration contingent upon or resulting from the award
or making of this Agreement. For the breach or violation of the provision, the CONTRACTOR
agrees that the COUNTY shall have the right to terminate this Agreement without liability and, at
its discretion, to offset from monies owed, or otherwise recover, the full amount of such fee,
commission, percentage, gift, or consideration.
Section 24. PUBLIC ACCESS
The COUNTY and CONTRACTOR shall allow and permit reasonable access to, and inspection
of, all documents, papers, letters or other materials in its possession or under its control subject
to the provisions of Chapter 119, Florida Statutes, and made or received by the COUNTY and
CONTRACTOR in conjunction with this Agreement; and the COUNTY shall have the right to
unilaterally cancel this Agreement upon violation of this provision by CONTRACTOR.
Section 25. NON -WAIVER OF IMMUNITY
Notwithstanding the provisions of Sec. 768.28, Florida Statutes, the participation of the
COUNTY and the CONTRACTOR in this Agreement and the acquisition of any commercial
liability insurance coverage, self-insurance coverage, or local government liability insurance
pool coverage shall not be deemed a waiver of immunity to the extent of liability coverage, nor
shall any Agreement entered into by the COUNTY be required to contain any provision for
waiver.
Section 26. PRIVILEGES AND IMMUNITIES
All of the privileges and immunities from liability, exemptions from laws, ordinances, and rules
and pensions and relief, disability, workers' compensation, and other benefits which apply to the
activity of officers, agents, or employees of any public agents or employees of the COUNTY,
when performing their respective functions under this Agreement within the territorial limits of
the COUNTY shall apply to the same degree and extent to the performance of such functions
and duties of such officers, agents, volunteers, or employees outside the territorial limits of the
COUNTY.
Section 27. LEGAL OBLIGATIONS AND RESPONSIBILITIES
Non -Delegation of Constitutional or Statutory Duties. This Agreement is not intended to, nor
shall it be construed as, relieving any participating entity from any obligation or responsibility
imposed upon the entity by law except to the extent of actual and timely performance thereof by
any participating entity, in which case the performance may be offered in satisfaction of the
obligation or responsibility. Further, this Agreement is not intended to, nor shall it be construed
as, authorizing the delegation of the constitutional or statutory duties of the COUNTY, except to
the extent permitted by the Florida constitution, state statute, and case law.
Section 28. NON -RELIANCE BY NON-PARTIES
No person or entity shall be entitled to rely upon the terms, or any of them, of this Agreement to
enforce or attempt to enforce any third -party claim or entitlement to or benefit of any service or
program contemplated hereunder, and the COUNTY and the CONTRACTOR agree that neither
the COUNTY nor the CONTRACTOR or any agent, officer, or employee of either shall have the
authority to inform, counsel, or otherwise indicate that any particular individual or group of
individuals, entity or entities, have entitlements or benefits under this Agreement separate and
apart, inferior to, or superior to the community in general or for the purposes contemplated in
this Agreement.
Section 29. ATTESTATIONS
CONTRACTOR agrees to execute such documents as the COUNTY may reasonably require,
including, but not being limited to, a Public Entity Crime Statement, an Ethics Statement, and a
Drug -Free Workplace Statement, Lobbying and Conflict of Interest Clause, and Non -Collusion
Agreement.
Section 30. NO PERSONAL LIABILITY
No covenant or agreement contained herein shall be deemed to be a covenant or agreement of
any member, officer, agent or employee of Monroe County in his or her individual capacity, and
no member, officer, agent or employee of Monroe County shall be liable personally on this
Agreement or be subject to any personal liability or accountability by reason of the execution of
this Agreement.
Section 31. EXECUTION IN COUNTERPARTS
This Agreement may be executed in any number of counterparts, each of which shall be
regarded as an original, all of which taken together shall constitute one and the same instrument
and any of the parties hereto may execute this Agreement by signing any such counterpart.
Section 32. SECTION HEADINGS
Section headings have been inserted in this Agreement as a matter of convenience of reference
only, and it is agreed that such section headings are not a part of this Agreement and will not be
used in the interpretation of any provision of this Agreement.
Section 33. INSURANCE POLICIES
33.1 General Insurance Requirements for Other Contractors and Subcontractors.
As a pre -requisite of the work governed, the CONTRACTOR shall obtain, at his/her own
expense, insurance as specified in any attached schedules, which are made part of this
contract. The CONTRACTOR will ensure that the insurance obtained will extend protection to
all Subcontractors engaged by the CONTRACTOR. As an alternative, the CONTRACTOR may
require all Subcontractors to obtain insurance consistent with the attached schedules; however
CONTRACTOR is solely responsible to ensure that said insurance is obtained and shall submit
proof of insurance to COUNTY. Failure to provide proof of insurance shall be grounds for
termination of this Agreement.
The CONTRACTOR will not be permitted to commence work governed by this contract until
satisfactory evidence of the required insurance has been furnished to the COUNTY as specified
below. Delays in the commencement of work, resulting from the failure of the CONTRACTOR
9
to provide satisfactory evidence of the required insurance, shall not extend deadlines specified
in this contract and any penalties and failure to perform assessments shall be imposed as if the
work commenced on the specified date and time, except for the CONTRACTOR's failure to
provide satisfactory evidence.
The CONTRACTOR shall maintain the required insurance throughout the entire term of this
contract and any extensions specified in the attached schedules. Failure to comply with this
provision may result in the immediate suspension of all work until the required insurance has
been reinstated or replaced and/or termination of this Agreement and for damages to the
COUNTY. Delays in the completion of work resulting from the failure of the CONTRACTOR to
maintain the required insurance shall not extend deadlines specified in this contract and any
penalties and failure to perform assessments shall be imposed as if the work had not been
suspended, except for the CONTRACTOR's failure to maintain the required insurance.
The CONTRACTOR shall provide, to the COUNTY, as satisfactory evidence of the required
insurance, either:
• Certificate of Insurance
or
• A Certified copy of the actual insurance policy.
The County, at its sole option, has the right to request a certified copy of any or all insurance
policies required by this contract.
All insurance policies must specify that they are not subject to cancellation, non -renewal,
material change, or reduction in coverage unless a minimum of thirty (30) days prior notification
is given to the County by the insurer.
The acceptance and/or approval of the Contractor's insurance shall not be construed as
relieving the Contractor from any liability or obligation assumed under this contract or imposed
by law.
The Monroe County Board of County Commissioners, its employees and officials will be
included as "Additional Insured" on general liability policies.
33.2 General Liability Insurance Requirements For Contract Between County And
Contractor
Prior to the commencement of work governed by this contract, the CONTRACTOR shall obtain
General Liability Insurance. Coverage shall be maintained throughout the life of the contract
and include, as a minimum:
• Premises Operations
• Bodily Injury Liability
• Expanded Definition of Property Damage
The minimum limits acceptable shall be:
$300,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$200,000 per Person
$300,000 per Occurrence
$ 50,000 Property Damage
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An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy, its
provisions should include coverage for claims filed on or after the effective date of this contract.
In addition, the period for which claims may be reported should extend for a minimum of twelve
(12) months following the acceptance of work by the County.
The Monroe County Board of County Commissioners shall be named as Additional Insured on
all policies issued to satisfy the above requirements.
33.3 Workers' Compensation Insurance Requirements
Prior to commencement of work governed by this contract, the CONTRACTOR shall obtain
Workers' Compensation Insurance with limits sufficient to respond to the applicable state
statutes.
In addition, the CONTRACTOR shall obtain Employers' Liability Insurance with limits of not less
than:
$100,000 Bodily Injury by Accident
$500,000 Bodily Injury by Disease, policy limits
$100,000 Bodily Injury by Disease, each employee
Coverage shall be maintained throughout the entire term of the contract.
Coverage shall be provided by a company or companies authorized to transact business in the
state of Florida.
33.4 Professional Liability Requirements
Recognizing that the work governed by this contract involves the furnishing of advise or services
of a professional nature, the Contractor shall purchase and maintain, throughout the life of the
contract, Professional Liability Insurance which will respond to damages resulting from any
claim arising out of the performance of professional services or any error or omission of the
Contractor arising out of work governed by this contract.
The minimum limits of liability shall be:
$250,000 per occurrence and $750,000 aggregate
Section 34. INDEMNIFICATION
The CONTRACTOR does hereby consent and agree to indemnify and hold harmless the
COUNTY, its Mayor, the Board of County Commissioners, appointed Boards and Commissions,
Officers, and the Employees, and any other agents, individually and collectively, from all fines,
suits, claims, demands, actions, costs, obligations, attorneys fees, or liability of any kind arising
out of the sole negligent actions of the CONTRACTOR or substantial and unnecessary delay
caused by the willful nonperformance of the CONTRACTOR and shall be solely responsible and
answerable for any and all accidents or injuries to persons or property arising out of its
performance of this contract. The amount and type of insurance coverage requirements set
forth hereunder shall in no way be construed as limiting the scope of indemnity set forth in this
paragraph. Further the CONTRACTOR agrees to defend and pay all legal costs attendant to
acts attributable to the sole negligent act of the CONTRACTOR.
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At all times and for all purposes hereunder, the CONTRACTOR is an independent contractor
and not an employee of the Board of County Commissioners. No statement contained in this
agreement shall be construed so as to find the CONTRACTOR or any of his/her employees,
contractors, servants or agents to be employees of the Board of County Commissioners for
Monroe County. As an independent contractor the CONTRACTOR shall provide independent,
professional judgment and comply with all federal, state, and local statutes, ordinances, rules
and regulations applicable to the services to be provided.
The CONTRACTOR shall be responsible for the completeness and accuracy of its work, plan,
supporting data, and other documents prepared or compiled under its obligation for this project,
and shall correct at its expense all significant errors or omissions therein which may be
disclosed. The cost of the work necessary to correct those errors attributable to the
CONTRACTOR and any damage incurred by the COUNTY as a result of additional costs
caused by such errors shall be chargeable to the CONTRACTOR. This provision shall not apply
to any maps, official records, contracts, or other data that may be provided by the COUNTY or
other public or semi-public agencies.
The CONTRACTOR agrees that no charges or claims for damages shall be made by it
for any delays or hindrances attributable to the COUNTY during the progress of any
portion of the services specified in this contract. Such delays or hindrances, if any, shall
be compensated for by the COUNTY by an extension of time for a reasonable period for
the CONTRACTOR to complete the work schedule. Such an agreement shall be made
between the parties.
IN WITNESS WHEREOF, the parties hereto have caused these presents to be executed on the
yay of % 20//.
BOARD O O LINTY COMMISSIONERS
71
INY L. KOLHAGE, CLERK
MONROE COUNTY, FLORIDA
by
Deputy Clerk
Mayor/Chairman
Cc�rv�.vf h� 5
(CORPORATE SEAL) JOHN R. VAN TUYL, M.D.
ATTEST: KEY WEST URGENT CARE, C.
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SECTION ONE
SCOPE OF SERVICES
EMPLOYMENT PHYSICAL SERVICES
The scope of services to be provided on an as needed basis by the Provider and may
include, but not be limited to, the following. The forms to be reviewed and completed by the
Contractor are attached to this agreement (Attachments A - C).
All results will include:
• Written interpretation of test results in common terms and written explanation of the
significance of each abnormality or written explanation of those results which are
outside the normal range.
• Examining physician's written recommendation concerning future action on any
condition considered outside the normal range.
• Written recommendation of specific reasonable accommodations in accordance with
the ADA.
SERVICE
FEE
DRUG SCREEN:
When requested, a drug screen will
(Collection, Lab, MRO
be performed by the physician and
review) 10 panel State
will be either scheduled or done on a
S50.00
Requirement
walk-in basis for post accident,
random, and reasonable suspicion
druci screenin .
DRUG SCREEN:
When requested, a drug screen will
S50.00
(Collection, Lab, MRO
be performed by the physician and
review) 5 panel
will be either scheduled or done on a
Department of
walk-in basis.
Transportation
Requirement
BLOOD ALCOHOL
When requested, Blood Alcohol
(Collection, Lab, MRO
Screens will be performed by the
review)
physician and will be either
N/A
scheduled or done on a walk-in
basis.
A testing facility must be available
24 hours a day, 7 days a week for
post accident, random, and
reasonable suspicion alcohol
screening.
BREATH ALCOHOL (if
When requested, may be used for
available)
screening. If breath alcohol screen is
positive, a blood screen will be
N/A
performed.
If Physician wishes to propose other
means of screening method, please
provide testing method explanation and
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accuracy.
A testing facility must be available
24 hours a day, 7 days a week for
post accident, random, and
reasonable suspicion alcohol
screening.
PPD- TB screen
When requested, a PPD-TB screen will
be scheduled and performed by the
physician during the facility's normal
$30.00
business hours.
A PPD-TB screen will be performed
with the new hire Firefighter physical.
HEPATITIS A
When requested, a Hepatitis A
inoculation will be scheduled and
performed by the physician during the
N/A
facility's normal business hours.
HEPATITIS B
When requested, a Hepatitis B
$155 EACH
inoculation(s) will be scheduled and
(series of 3 =
performed by the physician during the
Total =
facility's normal business hours.
$465)
TYPHOID
When requested, a Typhoid inoculation
will be scheduled and performed by the
N/A
physician during the facility's normal
business hours.
TETANUS
When requested, a Tetanus inoculation
Combined
will be scheduled and performed by the
with
physician during the facility's normal
Diphtheria
business hours.
below:
DIPHTHERIA
When requested, a Diphtheria
inoculation will be scheduled and
$75.00
performed by the physician during the
facility's normal business hours.
DOT PHYSICAL:
When requested, a DOT physical will
(SEE ATTACHMENT
be scheduled and performed by the
"B" to be completed by
physician during the facility's normal
$50.00
employee and physician)
business hours. Includes exam and
physician review of employee health
history and job description.
The DOT physical is initially performed
in conjunction with a post -offer
physical. Thereafter, only a DOT
physical is performed by the physician.
Physician may also perform a urine
drug screen if requested separately by
Monroe County BOCC.
POST -OFFER
When requested, a post -offer physical
PHYSICAL:
will be scheduled and performed by the
(SEE ATTACHMENT
physician during the facility's normal
$50.00
14
"B" to be completed by
business hours. Includes exam and
employee and physician)
physician review of employee health
history and job description.
Physician may also perform a urine
drug screen if requested separately by
Monroe County BOCC.
FIREFIGHTER
When requested, Firefighter physical
PHYSICAL (SEE
will be scheduled and performed by the
ATTACHMENTS "F" to
physician during the facility's normal
N/A
be completed by employee
business hours. Includes exam and
and physician).
physician review of employee health
history and job description.
Physician may also perform a urine
drug screen if requested separately by
Monroe County BOCC.
FITNESS FOR DUTY
When requested, a Fitness for Duty
PHYSICAL (SEE
Physical may be requested at any time
ATTACHMENT "A" to be
by the employer in the employee's
completed by employee
respective area of work. The exam will
and physician)
be scheduled during the facility's
normal business hours. Includes
physician review of employee health
history, exam, review of job duties and
medical records if necessary.
Physician may also perform a urine
drug screen if requested separately by
Monroe County BOCC.
RESPIRATOR
When requested, a Respirator physical
PHYSICAL (SEE
will be scheduled and performed by the
ATTACHMENTS "C"
physician during the facility's normal
PART I & II to be
business hours. Includes exam and
completed by employee
physician review of employee health
and physician)
history and job description.
Physician may also perform a urine
drug screen if requested separately by
Monroe County BOCC.
In addition, requires Chest X-ray and
EKG Normally done in conjunction with the
Firefighter physical.
CHEST X RAY Chest X Ray is normally done in
conjunction with the New Hire
Firefighter and Respirator physical if
there is an issue with the EKG or
spirometry results.
13
S50.00
$50.00
$50.00
Physician
provides
order to Key
West
Diagnostics.
Key West
Diagnostics
bills County
directly
($75.00)
SPIROMETRY
Normally done in conjunction with the
Respirator physical. All Firefighters
and employees who use a respirator will
590.00
have a Spirometry when hired.
Normally done in conjunction with the
HEARING/AUDIOGRAM
appropriate physical. May be requested
N/A
separately by Monroe County BOCC.
STRESS TEST (SEE
Normally done in conjunction with the
ATTACHMENT "E" for
new hire Firefighter physical.
N/A
explanation of services to
Performed thereafter for firefighters as
be performed by
needed.
physician)
CHEMICAL
Tests Glucose (sugar), kidneys, liver (1
540.00
PANEL/CMP
tube of blood drawn).
Firefighter Physical
CBC
Test to see if Anemic; if any infections
$40.00
within the body; if dehydrated (test
from I of the tubes of blood drawn).
Firefighter Physical
LIPIDS
Tests good cholesterol and bad
N/A
(CHOLESTEROL)
cholesterol ( one of the tubes of blood
drawn)
Firefighter Physical
UA DIP
Normally done in conjunction with the
S 10.00
DOT physical
UA WITH MICRO
Normally done in conjunction with the
N/A
Firefighter Physical
The Contractor shall retain all records pertaining to this contract for a period of four (4)
years after the termination of this contract.
The County, the Clerk, the State Auditor General, and agents thereof shall have access
to Contractor's books, records, and documents required by this contract for the purposes
of inspection or audit during normal business hours, at the Contractor's place(s) of
business.
16
SECTION TWO: COUNTY FORMS AND INSURANCE FORMS
LOBBYING AND CONFLICT OF INTEREST CLAUSE
SWORN STATEMENT UNDER ORDINANCE NO. 010-1990
MONROE COUNTY, FLORIDA
ETHICS CLAUSE
"KEY WEST URGENT CARE. INC."
(Company)
"...warrants that he/it has not employed, retained or otherwise had act on his/her behalf any
former County officer or employee in violation of Section 2 of Ordinance No. 010-1990 or any
County officer or employee in violation of Section 3 of Ordinance No. 010-1990. For breach or
violation of this provision the County may, in its discretion, terminate this Agreement without
liability and may also, in its discretion, deduct from the Agreement or purchase price, or
otherwise recover, the full amount of any fee, commission, percentage, gift, or consideration
paid to the former County officer or employee."
(Signture)
Date:
STATE OF:�
COUNTY OF:
Subscribed and sworn to (or affirmed) before me on
Ii� C�rC a/ ao
(date) by V U � (name of affiant). He Sh is
personally known to me or has produced
(type of identification) as identification.
NOTARY PUBLI — — — — — — — — —
r n'' PAMEtA L. PUMAR
My Commission Expires. ?r° Notary Public - State of Florida
• scion Expires Nov 27, 2011n # DD 737309 r
s i
Commissio
.;�� •w atloiulNofrygAssn.
I.7 BW&dThro*N
NON -COLLUSION AFFIDAVIT
1, ,Ya ae F Va , ZZ, of the city of Pe- esf according to law on
my oath, and under penalty of perjury, depose ands y that
1. I am ne f Q A. t a of the firm of
es r re 7nQ__ the bidder making the
Prop sal for the projec escribed in the Request for Proposals for
h 51'CA1 s and that I executed the said
propbsaf with full authority to do so;
2. The prices in this bid have been arrived at independently without collusion,
consultation, communication or agreement for the purpose of restricting
competition, as to any matter relating to such prices with any other bidder or with
any competitor;
3. Unless otherwise required by law, the prices which have been quoted in this bid
have not been knowingly disclosed by the bidder and will not knowingly be
disclosed by the bidder prior to bid opening, directly or indirectly, to any other
bidder or to any competitor; and
4. No attempt has been made or will be made by the bidder to induce any other
person, partnership or corporation to submit, or not to submit, a bid for the purpose
of restricting competition; and
5. The statements contained in this affidavit are true and correct, and made with full
knowledge that Monroe County relies upon the truth of the statements contained in
this affidavit in awarding contracts for said project.
S64'j
(Si nature)
Da2 .d
STATE OF:
COUNTY OF:
Subscribed and sworn to (or affirmed) before me on
Ala-"
(date) by GCK 7, , H /S
( )
name of affiant . h
personally known tome or has produced
(type of identification) as identification.
NOTARY PUBLIC
My Commission Expire PAMELA L. PUMAR
taEy blic • State of Florida
18 ' e" MY Commission Expires Nov 27, 2011
'�•;.� Commission # DD 737309
Bonded Throuoh National Notary Assn
DRUG -FREE WORKPLACE FORM
The undersigned vendor in accordance with Florida Statutes Section 287.087 hereby certifies
that:
KEY WEST URGENT CARE. INC.
(Name of Business)
1. Publishes a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession, or use of a controlled substance is prohibited in the workplace
and specifying the actions that will be taken against employees for violations of such
prohibition.
2. Informs employees about the dangers of drug abuse in the workplace, the business'
policy of maintaining a drug -free workplace, any available drug counseling, rehabilitation,
and employee assistance programs, and the penalties that may be imposed upon
employees for drug abuse violations.
3. Gives each employee engaged in providing the commodities or contractual services that
are under bid a copy of the statement specified in subsection (1).
4. In the statement specified in subsection (1), notifies the employees that, as a condition
of working on the commodities or contractual services that are under bid, the employee
will abide by the terms of the statement and will notify the employer of any conviction of,
or plea of guilty or nolo contendere to, any violation of Chapter 893 (Florida Statutes) or
of any controlled substance law of the United States or any state, for a violation
occurring in the workplace no later than five (5) days after such conviction.
5. Imposes a sanction on, or require the satisfactory participation in a drug abuse
assistance or rehabilitation program if such is available in the employee's community, or
any employee who is so convicted.
6. Makes a good faith effort to continue to maintain a drug -free workplace through
implementation of this section.
As the person authorized to sign the statement, I certify that this firm complies fully with the
above requirements.
(Signa, ure)
e�
Date:
STATE OF:��/�
COUNTY OF:
Subscribed and sworn to (or affirmed) before me on (date) by
l �
r �v(name of affiant). H he is personally known
to me or has produced
(type of identification) as identification.
NOTARY PUBLIC
My Commission Expi e
�``"r r ��• PAMELA L. PUMAR
J l►R 6
19 t+= Notary Public - State of Florida
• ' ? My COfMnisaipn Expires Nov 27, 2011
Commisslon # DD 737309
iFOF F�`�
""""'� Bonded Through National Notary Assn.
PUBLIC ENTITY CRIME STATEMENT
"A person or affiliate who has been placed on the convicted vendor list following a conviction for
public entity crime may not submit a bid on a contract to provide any goods or services to a
public entity, may not submit a bid on a contract with a public entity for the construction or repair
of a public building or public work, may not submit bids on leases of real property to public
entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or
CONTRACTOR under a contract with any public entity, and may not transact business with any
public entity in excess of the threshold amount provided in Section 287.017, Florida Statutes, for
CATEGORY TWO for a period of 36 months from the date of being placed on the convicted
vendor list."
I have read the above and state that neither KEY WEST URGENT CARE INC. (Contractor's
name) nor any Affiliate has been placed on the convicted vendor list within the last 36 months.
(Signature)
IJ
STATE OF: Al
COUNTY OF:
Subscribed and sworn to (or affirmed) before me on I Jt ,�,)O / l
(date) by �� (name of affiant). H / he s personally known to me
or has produced (type of
identification) as identification.
NOTARY PUBLIC
My Commission Expires:
20
PAMELA L. PUMAR
Notary Public - State of Florida
.o,`My Commission Expires Nov 27, 2011
" Commission #1 DD 737309
Bonded Through National Notary Assn.
MONROE COUNTY, FLORIDA
RISK MANAGEMENT
POLICY AND PROCEDURES
CONTRACT ADMINISTRATION MANUAL
Indemnification and Hold Harmless
For
Other Contractors and Subcontractors
The Contractor covenants and agrees to indemnify and hold harmless Monroe County Board of
County Commissioners from any and all claims for bodily injury (including death), personal
injury, and property damage (including property owned by Monroe County) and any other
losses, damages, and expenses (including attorney's fees) which arise out of, in connection
with, or by reason of services provided by the Contractor or any of its Subcontractor(s) in any
tier, occasioned by negligence, errors, or other wrongful act of omission of the Contractor or its
Subcontractors in any tier, their employees, or agents.
In the event the completion of the project (to include the work of others) is delayed or
suspended as a result of the Contractor's failure to purchase or maintain the required insurance,
the Contractor shall indemnify the County from any and all increased expenses resulting from
such delay.
The first ten dollars ($10.00) of remuneration paid to the Contractor is for the indemnification
provided for above.
The extent of liability is in no way limited to, reduced, or lessened by the insurance requirements
contained elsewhere within this agreement.
21
WORKERS' COMPENSATION
INSURANCE REQUIREMENTS
FOR
EMPLOYMENT PHYSICAL SERVICES
BETWEEN
MONROE COUNTY, FLORIDA
AND
JOHN R. VAN TUYL, M.D.
KEY WEST URGENT CARE, INC.
Prior to the commencement of work governed by this contract, the Contractor shall obtain
Workers' Compensation Insurance with limits sufficient to respond to the applicable state
statutes.
In addition, the Contractor shall obtain Employers' Liability Insurance with limits of not less than:
$100,000 Bodily Injury by Accident
$500,000 Bodily Injury by Disease, policy limits
$100,000 Bodily Injury by Disease, each employee
Coverage shall be maintained throughout the entire term of the contract.
Coverage shall be provided by a company or companies authorized to transact business in the
state of Florida.
If the Contractor has been approved by the Florida's Department of Labor, as an authorized
self -insurer, the County shall recognize and honor the Contractor's status. The Contractor may
be required to submit a Letter of Authorization issued by the Department of Labor and a
Certificate of Insurance, providing details on the Contractor's Excess Insurance Program.
If the Contractor participates in a self-insurance fund, a Certificate of Insurance will be required.
In addition, the Contractor may be required to submit updated financial statements from the fund
upon request from the County.
22
GENERAL LIABILITY
INSURANCE REQUIREMENTS
FOR
EMPLOYMENT PHYSICAL SERVICES
BETWEEN
MONROE COUNTY, FLORIDA
AND
JOHN R. VAN TUYL, M.D.
KEY WEST URGENT CARE, INC.
Prior to the commencement of work governed by this contract, the Contractor shall obtain
General Liability Insurance. Coverage shall be maintained throughout the life of the contract and
include, as a minimum:
• Premises Operations
• Products and Completed Operations
• Blanket Contractual Liability
• Personal Injury Liability
• Professional Liability
• Expanded Definition of Property Damage
The minimum limits acceptable shall be:
300 000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$ 200,000 _ per Person
$ 300,000 per Occurrence
$_ 50,000 Property Damage
An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy, its
provisions should include coverage for claims filed on or after the effective date of this contract.
In addition, the period for which claims may be reported should extend for a minimum of twelve
(12) months following the acceptance of work by the County.
The Monroe County Board of County Commissioners shall be named as Additional Insured on
all policies issued to satisfy the above requirements.
23
INSURANCE REQUIREMENTS
Worker's Compensation $ 100,000 Bodily Injury by Acc.
$ 500.000 Bodily Inj. by Disease, policy Imts
$ 100,000 Bodily Inj. by Disease, each emp.
General Liability, including
$ 300.000 Combined Single Limit
Premises Operation
Products and Completed Operations
Blanket Contractual Liability
Personal Injury Liability
Expanded Definition of Property Damage
Professional Liability
Including errors and omissions
$250,000 per Occurrence and
$750,000 Aggregate
The Monroe County Board of County Commissioners shall be named as Additional
insured on general liability policy.
24
EMPLOYMENT PHYSICAL SERVICES
A' IACHMENT A
NO, OF ATTACHED SHEETS:
MEDICAL RECORD REPORT OF MEDICAL HISTORY DA It OF EXAM
Is information is for official an tnedica y-con i ential use only-an-d will not be re eased to unauthorized persons
1 NAME OF PATIENT (Lost, his!, reidd/e) 2 IDENTIFICATION NUMBER
Position
Sa. HOME STREET ADDRESS -SVFD
eet or R,, Gty or Town, .State, and !lP Corte/ 5 EXAMINING FACILITY
4b CITY c. STA TE .4d. ZIP CODE
5 PURPOSE OF EXAMINA rION�-"-
T STATEMENT OF PATIENT'S PRESENT HEALTH AND MEDICATIONS CURRENTLY USED /Use additional pages itnecessary)
a. PRESENT HEALTH J- b. CURRENT MEDICATION
REGULAR OR tNTERM.
c. ALLERGIES [Include insect Dtresistings and common toods/
TIENT'S OCCUPA rION
HANDED
1 n MA crrnr inns -A RIGHT
LEFT HANDED
CHECK EACH ITEM
YES
NO
DON'T
KNOW
CHECK EACH ITEM
YES
NO
DON'T
CHECK EACH ITEM
T"
DON'T
KNOW
YES
NO
KNOW
Household contact with anyone
with tuberculosis
Shortness of breath
Bona, joint or other de}ormily
Pain or Pressure in chest
Loss of finger or toe
Tuberculosis or Positive TB test
Chronic cough
P..Ilnful or "tackshoulder
or elbow
Blood in sputum of when
Palpitation or pounding heart
coughing
Heart trouble
Returner, back pain or any
back injury
E xcessrve bleeding after injury or
High or tow blood pressure
dental work
Cramps in your legs
'Trick" or locked knee
Swode attempt or plans
Frequent indigestion
Sleepwalk mg
Stomach, jiver or intestinal trouble
Foot trouble
Wear corrective lenses-
Nerye Injury
___
_
_ ___
. all bladder trouble or
Paral sis hi+c/udin
Y g intannle)
Eye surgery to correct vision
gallstones
Lack vision m either eye
Epilepsy or selZure
-_-`
--
Jaundice or hepatitis
Car, train, sea or air sickness
Wear a hearing ad
,
___ _
Broken-
-
Stutter or stammer
1
Adverse reaction to mMic anon
Frequent trouble sleeping
Wear a brace or back support
Skin diseases
Depressio n or excessive worry
Loss of memory or amnesia
Starlet fever
Tumor, growth, cyst, cancer
Nervous trouble of any sort
Rheumatic Inver
i
_ __
Hernia
-
Periods of unconsciousness
Swollen or painful pints
I
Hemorrhoids rectal disease
Parent/s-blmg with diabetes,
cancer,
Frequent or severe headaches
Frequent or
Dizziness or fainting spells
-�
I
painful urination
Bed wetting since age 12
stroke or heart disease
Etrouble
X-ray or other radiation therapy
Kidney stone a blood in wine
Chemotherapy
_ye
------ - _-- --
Heanng joss
__
i
Sugar or albumin in urine
exposuoe or toxic _hemicai
Recur ent ear nfecirons
,Sexually
(ransmrtted diseases
Chronic or freguenl colds
__
Se ere tooth or um trouble
-c _ t g - r loss
Recent gar or loss of weigh!
. -
-�
- --" --
Pfate. Pin or rod to any bone-- ---
- __
Snuvns -"
_
'
--
--E�,1h'mis
Eating disorder tanorexia bulimia,
etc
----- -- -
. RheumatismorHeatl
_..I--
Easy fat�gabAy
Been told to cut down or
cntic¢ed for alcohrzl
-+
Hay }ever or alle rgK rhmrtrs
mlwry-�
-- -
---'�'
i------
Bursitis
Used Alegal
--v
Asthma---_--- --
substances
I
Thyroid trouble or goiter
Used tobacco fi--"
--
NSN 714000.161 8368
Prescribed by ICMR/GSA 7J .illy b viol
FIRMR 141 CFRI 201 9 20, 1
-- 11 . FEMALES ONLY
CHECK EACH ITEM YES NDON'T DATE OF LAST MENSTRUAL DATE OF LAST PAP SMEAR DATE OF LAST MAMMO
O KNOW (PERIOD I IGRAM
Treated for a female disorder N1 N/A
Change �n menstrual pattern ; N/
----------------------
CHECK EACH ITEM. IF 'VE , EXPLAIN IN BLANK SPACE TO RIGHT. LIST E
ITEM YES NO
12 Have you been refused employment or been unable to hold a job or
stay in school because of: '�,.:::
a. Sensitivity to chemicals, dust, sunlight, etc.
b Inability to perform certain motions.
c. Inability to assume certain positions.
of Other medical reasons (1f yes, give reasons.)
13, Have you ever been treated for a mental condition? lit yes, specify
when, where, and give details.)
14 Have you ever been denied life msurancs7 (it yes, stata reason and
give details.)
15 Have you had, or have you been advised to have, any operation.
Ill yes, describe and give age at which occurred,)
18. Have you ever been a patient in any type of hospital? 0 yes,
specify when, where, why, end name of doctor and complete address
of hospital.)
17. Have you consulted or been treated by clinics, physicians, healers,
or other practitioners within the past 5 years for other than minor
illnesses? Ilf yes, give complete address of doctor, hospital, clinic, and
details.)
18 Have you ever been rejected for military service because of
Physical. mental, or other reasons) (If yes, give date and reason for
rejection.)
19. Have you ever been discharged from military service because of
Physical, mental, or other reasons? IIf yes, give date, reason, and
type of discharge; whether honorable, other then honorable, for
unfitness or unsuitability_I
20. Have you ever received, is there pending, or have you ever applied
for pension or compensation for existing disability? (If yes, specify
what kind, grantedby whom, and what amount when why,)
i
22. Have you ever been diagnosed with a learning disability? (If yes, —
give type, where, and how diagnosed.)
23. UST ALL IMMUNIZATIONS RECEIVED
N/A
TION BY ITEM NUMBER.
N/A
certify that I have reviews t e oregoing in ormaoon sup ie y me an t at it is true a com ate tote est o m now e
or clinics mentioned above to furnish the Government a complete transcript of m p Y ge. au t onze any o t e actors, ospta s,
understand that falsification of information on Government forms rs punishable by fine aanrdlorr imprisonrmeen Poses of processing my application for this employment or service. I
24a. TYPED OR PRINTED NAME OF EXAMINEE �.� ...,....�...._
NOTE: HAND TO THE DOCTOR OR NURSE, OR IF MAILED MARK ENVELOPE !71i:: BE OPENED BY MEDICAL OFFICER ONLY"
develop by interview any .
25. PHYSICIAN'S SUMMAR
Y AND ELABORATION a ALL PERTINENT DATA (physician shall ciammen( on all positive answers in Items 7 through I 1 Physician may
eddnonel medics! history deemed important, end record any signihc4it findings here.)
26a. fVFFb OR PRINTED NAME OF PHYSICIAN OR EX
OA
STANDARD FORM 93 (REV 6 961 BACK
MEDICAL RECORD
1 LAST NAME -FIRST NAME - MIDDLE NAME
REPORT OF MEDICAL EXAMINATION i DATE OF EXAM
2. IDENTIFICATION NUMBER 3 POS i t iOII
4. HCME ADDRESS (Number, street or RFD, city at town, state and ZIP Gale)
5. EMERGENCY CONTACT (Name and ack"ss of cnntad)
B. DATE OF BIRTH
7 AGE
8, SEX
FEMALE MALE
9. RELATIONSHIP OF CONTACT
W PLACE OF BIRTH
11, RACE
WHITE BLACK
AMERICAN INDIAN/ HISPANIC HISPANIC ASIANlPACIFIC
ALASKA NATIVE WHITE I BLACK ISLANDER
12a. AGENCY
12b.ORGANIZA11ON UNIT
13 TOTAL YEARS GOVERNMENT SERVICE
a. MILITARY
b. CIVILIAN
14 NAME OF EXAMINING FACILITY OR EXAMINER, AND ADDRESS
15. RATING OR SPECIALTY OF EXAMINER
16. PURPOSE OF EXAMINATION
MAL
(Check each Item In approprIale Column, enter "NE" if not evalrated.)
rAnl
MAL
(Check each item In approprm to column, enter 'NE' If not evaluated.)
3W "
MAL
A. HEAD, FACE, NECK At40 SCALP
O. PROSTATE (Over 40ordlnlcally/ndlcated)
B. EARS • GENERAL (INTERNAL CANALS)
(Auditory ectilty under items 39 and 40)
P, TESTICULAR
--
R. ENDOCRINE SYSTEM
C DRUMS (Perforation)
D. NOSE
S. G•U SYSTEM -
E. SINUSES
T. UPPER EXTREMITIES (Strength, rangeotmotion)
F. MOUTH AND THROAT
U. FEET
G EYES -GENERAL (vr.^wt acwy snd M x+on urdwr Ae m 28, 29, a d Ja)
V LOWER EXTREMITIES (Except feet) (Strength, range ofmotion)
H OPTHALMOSCOPIC
W. SPINE, OTHER MUSCULOSKELETAL
I. PUPILS (Equalltyand reactlon)
X. IDENTIFYINGBODY MARKS, SCARS, TATTOOS
J. OCULAR MOTILITY (Associated parallel movements nystagmus)
Y. SKIN, LYMPHATICS
K. LUNGS AND CHEST
Z. NEUROLOGIC (Equilibrium tests under item 41)
L. HEART (Thrust, size, rhythm, sounds)
AA. PSYCHIATRIC (Specfyany personek'tydeviaton)
- -
M. VASCULAR SYSTEM (Vadcosibes, etc.)
NOTFS
N ABDOMEN AND VISCERA (Includehemia)
18. DENTAL (Place approprals symbols, shown In examples, above or below number of upper and beer teeth)
REMARKS AND ADDITIONAL DENTAL
A1` (t �cL
' ` 1 77 3�"S
t1�n __i_� 2rt b�
T--
��x M.d.g �- 2 -� RCpb(��
'sue i
T1-" -T9
Pa
DEFECTS AND DISEASES
32 reau,
r
31rem 'iT'3r'Sd'
X X X X Canturee
'7�3�
Dentures
( X I
R
1 2
G
3 4 5 6 7
8 9 10 11 12 13 14
15 16
E
32 31 30 29 28 27 26 25
H
24 23 22 21 20 19 18 17
F
T
T
19. TEST RESULTS (Copies of results are preferred as attachments)
A URINALYSIS 0) SPECIFIC GRAVITY
B CHEST X-RAY OR PPD (PFyoe, Date, .Mm numberand result)
(2) URINE ALBUMIN
(4)MICROSCOPIC
��
rA
'IS
f V
VIA
(3) URINE SUGAR
C SYPHILIS SEROLOGY (Spec Ay /est used
D, EKG
E. BLOOD TYPE AND RH
F.OTHE TTESTS
and nasulls) _- - �
� `
� � t �
FACT �
I
6a 126 STANDARD FORM 88 (Rev 10-94) (EG)
r:es19-d 19 Perform Prescribed by GSAnCMR FIRMR (41 CFR) 201.9 202-1
NO OF
20 HEIGHT
21 WEIGHT
men-�uKEMENTS AND OTHER FlNp�(yGg
22. COLOR HAIR
23 COLOR EYES
24 BUILD
25 TEMPERATURE
26 BLOOD PRESSURE (Arm at heart ievet)
SLENDER {L1 EOIUM HEAVY OBESE
_`
A SYS, B.
SYS
C.
27. PULSE (Atmetheegwml)
SITTING DIAS RECU
BEN�.
01
STANDING
SYS A. SITTING
B RECUMBENT
C. STANDING D_ AFTER EXERCISE E_ MINS.
2
O miss.)
OCAS
(3 mtns) AFTER
_ 28. DISTANT VISION
29. REFRACTION
RIGNT 20r CORR. TO NY
gy
S
30 NEAR VISION
LEFT 201 CORR. TO 20r
By
S CX
CORR. TO BY
31 HETEROPHORIA,Spce,Aydstaixe)
N
CX
CORR.To BY
ESO EXO
R H,
L H PRISM OIV
PRISM CONY
CT PC PD
32 ACCOMMODATION g1f,
33 COLOR VISION (lest usedandresulo
34. DEPTH PER E
RIGHT LEFT
O
(Test usedandsmre)�f a
UNCORRECTED
35. FIELD OF VISION
36 NIGHTVISION(rest usedandsc,
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EMPLOYMENT PHYSICAL SERVICES
ATTACHMENT
ReS irat or Medical Evaluation .
Ouestio
Co the employer. ,\nswer� to questions in So, tion I, and to question 9 in Svt lion 2 of Part A, do not require a ntedi, al
ox,inimation.
fo the employee: C.cn 'you re ,id? (, liv, k one):.......... ........................................................................................ ' J Yes r our em to cr must allow you to answer this qw-,tionnaire dunnl; normal working; hours, or at a time and plat-(, thot is o
lf
ottt e nu nt to you. 1'o maintain your confidentiality, your employer or sup-rvisor must not look at or review dour answer~,
and your employer must tall you how to deliver or send this questionnaire to the health care professional who will nwiew it.
The following; information must he provided by every employoe who has he,en swlec ted to use any type of respirator
(please print).
Name:
Age (to nearest year):
Height: feet J irx-hes Weight: Its.
Phone number where you can be reached by the health
care person who reviews this (include area code); _
The best time to can you at this number.
Has your employer told you how to contact the health care
person who will review this (check one): Ll Yes I] No
Job Title:
Sex ((he(k one) 0 tilale 0 Female Date:
Check the type of respirator you will use (you can check
more than one category):
a. 0 N, R, or P disposable respirator (filt(-r-mask,
non-carMdge type only).
a. 0 Other type (for example, half- or fu(1-facepiece
type, powered -air purifying, supplied -air, self-contained
breathing apparatus).
Have you worm a respirator. ❑ Yoe U No
if "yes," what type(s);
Part A — Section 2 (Mandatory)
Questions 1 through 9 be tow must he answered by every employee who has been selected to use any type of respirator
(please check "yes" or "no").
L Do you currently smoke tobacco, or have you smoked tobacco in the last month?
..............
2 Have you ever had any of the following conditions?
a. Seiiures (fit-,): .................................................
h. Diabetes (sugar disease) :...............................
............................... 0 Yes
0 No
..............................................................................
o'. Allergic reactions that interfere with breathin g:...............................................................
""' 0 Yes
0 No
d. Claustrophobia (fear of closed -in places):
. 0 Yes
0
No
e. Trouble smelling odors: ................................................
..................... 0 Yes
❑ No
...
3. Have you ever had any of the following0
rpulmon y or lung
.............................................................................. Yes
problems?
NO
a. Ashestosis: ............................................
..............................................
Yes
) No
c. Chronic hntnc hitis :..............................................................
0 Yew............................
7 No
d. Fmphysertta:..................... ............................ ....................
J Yt-s
JNo
e. Prmumonia:........... ..
.............................. ...........
.. ................ ❑ Yes
J No
...............
f. ruh,�n ulosis: ............. ........................... .............................
.......... ......... ...._. 0 Ytw
J No
. ............................
} tiilic osix ................................................................................
................................ Ycw
-2 No
t. Pneuntoth rr,ix ((oll-11-wd lung:): ... ......... ...
..........................
.... J Yo.s
j o
i. u n ; o aru or: .....
g ..........................
.. ............ Yes
'..;1 No
Broken nhs:.........:... ......
.................................
.............J� es
_j \o
k. \n� � hest utluritw or ,ur};eritw: ....................
. ........ ..j Yes
JNo
....
„th,•r Iting pro,hlent that �ou'u I><Kvt told ,dv,ut: .........
_.............. , Yo s
No_....
• . _....... ................. '_j Ytw
.j �o
rrcmsue i
MCA Irbt.
35M. t Daie May 8. 20M
�. Do you currently have any of the following symptoms of pulmon.uy or lung illness?
a.
Shortness of breath: .....
h.
1,hortnEKs of breath when walking, fast on level ground or walking; up a slight hill int line:..........
J Yvs
.d No
r.
or
5hortn;ws of breath when walking; with other people at an ordinary pace on level
, yos
J No
d.
ground: .............
I lava to stopfor bwath when walking at your own pay e �,n level
_I Yrs
J"
"1 �'"
C.
),round: ...................... .........
Shortness of hreath tivhen washing or dressing yourself ............................................
...... ] Yes
7 No
f.
Shortrnwti of breath that interferes with your job: .............................
g;.
...................
C otwhing that pmduces phlegm (thick sputum) : ............
IJ No
h.
........................................................................
Coughing that wakes you early in the morning,: .......................
Yes
> No
i.
.................
Coughing; that ,xrurs mostly when you are lying, down: ..................................
J Yes
0 No
j.
.
Coughing, up blood in the last month:
k.
........................ I.. .........
................................. ....................................
VVhev/ing:.............................................
'> Yes
J No
I.
..................................................................................
Wheezing that interferes with your job: ...........................................
0 Yes
❑ No
m.
............................................................
Chest pain when you breathe deeply:
`J Yes
❑ No
n.
.............................. ............................................................. ...............
Any other symptoms that you think may be related to lung; problems:
roblems:................................................
,� Yes
0 No
...........................................
....0 Yes
❑ No
S. Have you ever had any of the following cardiovascular or heart problems?
a.
Heart attack:b. ................................
..................................................................... ...... 0 Yes
.........................................
Stroke:
�] No
C.
................................
An ...................... ............... Yes
guia:........................................................................................
❑ No
d.
............................................................... 0 Yes
Heart failure : ...........................................................................................................................................
0 No
e.
Swelling in your legs or feet (not caused b walking): •.... • 0 Yes
y �:.................................................................
❑ No
f.
0 Yeas
Heartarch thmia """"""'
Y (heart heating irregularly):
❑ No
g.
High blood pressure: 0 Yes
...................... ............................................................................
0 Noh.
................................... .
Any other heart problem that you've been told about:O Yes
0 No
................ ........................................... ........ O Yes
0 No
6. Have you ever had any of the following cardiovascular or heart symptoms?
a.
Frequent pain or tightness in your chest: .............
b.
Pain or tightness in your chest during physical activity: ...............................................
ctivity:...............................................
C.
........................ ❑Yes
Pain or tightness in your chest that interferes with your job: ................ .
❑ No
d.
In the past two years, have you noticed your heart skipping or
e.
missing a beat: ................................... 0 Yes
He uthurn or indigestion that is not related to eating: ......................
❑ No
f.
0 Yes
Any other symptoms that you think may be related to heart or
0 No
emulation problems: ...................... ❑Yes
0 No
7. Do you currently take medication for any of the following problems?
a. Breathing or lung problems:b.
........................................ Part trouble: ........... 0 Yes
................................... .
0 No
...................................................................
.................. O Yes J No
C. Bkwd pn-ssure: ...............................................................................................................................................
d. Seizures (fits):O Yes > No.........
..................... ......................
0 Yes 0 No
S. If you've used a respirator, have you ever had any of the following problems?
(If t nu've never used a respirator go to (luestiun 9)
a. Eve irritation:...........
- do ................................................................".........'_1 Yew J�. Skin .illerg;ie•s or rashes: .............................
.............................
........................................ ....I... U Y� s � . nrietY J do
..........._..... ... Yes J No
d. .....
l ,enenil we.,k�x��s .. ..... ...
................
.....] �� Cnther pmhl('m that ntterfen� w tth �-our respirator use• :.......... _......... ... ... .. .... Ye ti , No). .. , Y, •s 'J ;No
Ercbsue 3
WA last 38031 DMe May 8. 2bt
9. Would you like to talk to the health c-ue professional who will review this questionnaire about your
.111SW(Irs to this yue-Aionnaire:.......................................................................................................... '.a Yes J No
............................
Qu(wtiorts 11) to 13 helow must Imo, .inswi,red by every employiv- who has hvvn selkti led t1, use wither a full -fat Wpiete respirator
or
a self-.ontained breathing apparatus (SCBA). For employ,v,% who havo bvo�n selettrd to use other type% of respirators,
answenng these questions is voluntary.
10. Have you ever lost vision in either eye (temporarily or permanently):....................................................... J Yes J No
11. Do you currently have any of the following vision problems?
a. Wear i ontact lenses: ............................................................................................ I .........................J Y1�s J No
...................
b. hear I;lasses:........................................................................................ .. J Yt-s ❑ No
..........................................................
t. Color blind: ....................................................................................................................................................... 0 Yes J No
d. Other eye or vision pn,blem:......................................................................................................................... ❑ Yes J No
12 Have you ever had an injury to your eats, including a broken ear drum........... ......................................... ❑ Yes ❑ No
13. Do you currently have any of the following hearing problems?
a. Difficulty hearing: ........................................................................................................................................... 0 Yes 0 No
b. Wear a hearing aid: ......................................................................................................................................... ❑ Yes ❑ No
C. Any other hearing or ear problem:............................................................................................................... 0 Yes ❑ No
14. Have you ever had a back injury......................................................................................................................... 0 Yes ❑ No
15. Do you currently have any of the following musculoskeletal problems?
a.
Weakness in any of your arms, hands, legs, or feet: ..................................................................................
0 Yes
❑ No
b.
Back pain: ..........................................................................................................................................................
J Yes
0 No
C.
Difficulty fully moving your arms and legs: ..............................................................................................
0 Yes
0 No
d.
Pain or stiffness when you lean forward or backward at the waist: .......................................................
❑ Ycs
❑ No
e.
Difficulty fully moving your head up or down: ........................................................................................
❑ Y(-
❑ No
f.
Difficulty fully moving your head side to side: .........................................................................................
❑ Yes
❑ No
g.
Difficulty bending at your knees: ..................................................................................................................
J Yes
0 No
h.
Difficulty squatting to the ground:..............................................................................................................
❑ Yes
❑ No
i.
Climbing a flight of stairs or a ladder carrying more than 25 lks.:...........................................................
0 Yes
❑ No
j.
Any other mclscle or skeletal problem that interferes with using a respirator: ......................................
0 Yes
0 No
Pad B
,any of the following questions, and other questions nc)t listed, may be added to the questionnaire at the disk retion of the health
t'"V professional who will review the questionnaire.
1. In your present job, are you working at high altitudes (over 5,WO feet) or in a place that has lower
than11()nnal amounts of ................................................................................................................................. J 1es J No
or other s� mptoms when y(u're working under tht-we conditions:.................._.................................................... J yos J No
2. At work orat home, have you ever been exposed to hazantous solvents, haz.tMous airborne chemic.ds
(e.g. 1,a.es, 1"mocN, or Just), )r h.1ve you c omr into .km < oola, t ,% ith har.lydouti , hennc.11s:.......................... . J
Name
Home Address
Telephone
Length of Employment
RESPIRATOR USE
PHYSICAL
Age
Occupation
Sex
1 agree to the release of this information for State and Federal regulatory purposes to the
extent provided by applicable laws.
DATE SIGNED
❑ Follow-up Medical Evaluation Physical
NIPLOYER Required. (Positive response —
p Question 1-8).
❑ Post -Offer Physical: Medical Evaluation
Physical Required.
9. CVould you like to talk to the health rare professional who will review this questionnaire about your
amswers to this questionnaire: ..............
...............................................
Qut-stions 10 to 13 below must be answered by evert,• enlployr,! who has been selated to use rather afull-fa.:epirtir n spirator ur
Self. ontain�ai bn,athint; apparatus (SCSA). For employee who have been self-vao l to use other tvpis of n spiratem arLSwenng
th<� questions LS voluntary.
10. Have you ever lost vision in either eye (temporarily or permanently). .............
11. Do you cunently have any of the following vision problems?
a. Wear contact lenses. *..............
.......................................................................
b. Wear gl.Lsses :............................
.................................................. .O Yes 0 No
............................................. . .........................
c. Color blind: ........................................................................ ............................................. 0 Yes 0 No
d. ...................................
Other eye or vision problem: ..................
.........
................................................... .............................................❑ Yes O Flo
1Z Have you ever had an injury to your ears, including a broken ear drum:........................................................ ❑Yes ❑ No
13. Do you currently have any of the following hearing problems?
a. Difficulty hearing: ...........................................................................0 Yes ❑ No
..................................
b. Wear a hearing aid:
...................................................
❑ Yes ❑ No
c. y other hearing or ear problem :........................................ ................................ ........0 Yes Cl No
14. Have you ever had a back injury: ........................
.......................... 0
................................................. ........................ Yes ❑ No
15. Do you currently have any of the following musculoskeletad problems?
a. Weakness in any of your arms, hands, legs, or feet ...................
b. Back Pain: ..........................❑ Yes
....................................................
❑ No
C. Difficulty fully moving your arms and le ............................. 0 Yes
O No
gs:.................................................................................................0 Yes
d. Pain or stiffness when you lean forward or backward at the waist
0 No
...............•...._...........
e. Difficulty fully moving your head up or down;.......................... ............... 0 Yes
0 No
............0 Yes
f. Difficulty fully moving your head side to side:
0 No
.................................................................. ......... ❑Yes
g. Difficulty bending at your knees: ..................
0 No
........................................... ............................. ❑Yes
h. Diffic-udty squatting to the ground:
D No
....................................................................... ❑Yes
i. Climbing a flight of stairs or a ladder carrying than
❑ No
more 25N.: ...............................................................0 Yes
j. Any other muscle orskeletal problem that interferes with using
❑ No
a respirator ...........................................❑ Yes
❑ No
Part B
Any of the following questions, and other questions not listed, may be added to the questionnaire at the disczetion
care professional who will review the the health
questionnaire. of
1. In your present job, are you wodcing at high altitudes (over5,000 feet) or in a place that has lower
than normal amounts of oxygen ............................................................................................... ..... or othersymptoms when you're working under these conditions: 0 Yes ❑ No
......................
.................. .......❑ Yes ❑ No
2 At wodc orat home, have you ever been exposed to hazardous solvents, hazardous airbome hemica,s
(e.g. gases, fumes, or dust), or have you come into skin contact with hazardous chemicals: ..............................0 Yes 0 No
wCk I"'wwoWit, xmL, IN)
Z\-H^veyou ever wo6^edwith any *fthe olate6-ds,vrtinder any *f the conditions, listed below:
........................... .................................................. ...............................
[]\\-i
0N"
k
�7,i&^(^g'.inwoJhU^m`k,,): _________________________________-----.�]Y,o
C.
Tun�;sxcn/."k'lt(cy}g7inJin8o,weld u`Xthis onu,ri^[:------------'-----------�]Y,,
No
]�o
J.
B,ryUv/nr--�-
,�
_-----]Y,y
�|uminum�--____
]N\,
..................................................Y,»
[JNo
L
Coal (for oumplo,m'mm�
�;.
,'_________________________________----]Y~y
6n,c.......................................
[JNn
h.
.............................................................. .............................................................
Tin: ..... .......
]Y,s
[]%*
....................................................................................................... _____—_-------'[3Y,y
]Nn
i
Ouoty,nvbnnmmnts:
/.
..........................................................
Other 6azaodous,xposuns: --
ONo
�^��
, _____LJY��
d�Mket��e`pm��
0Qo
4. List any second jobs orside businesses you have-
5. List your previous occupations:
6. Listymurcurrent and previous hobbies:
THave you been in the ����y.
"yes," ' _____________________-__'—_--'-----.[3Ycs []No
If to biological or chLmiical agents (either in training or combat): .................................. C3 yes C] No
S. Have you everworkednma HAZNJATteam?
9. Other than medications for bwathing and lung problems, head trouble, blood pressure, and seizures
mentioned eartier in this questioniuire,em you Liking any other medications for any reason
(including over�6e~oun��om*d�ubb���---_-.
. name Lhe medications if you know them:
__ ---------------------------' [JYes ���Jo
Lf
81VVQ8you be using any oKthe f0U0wing items with your
a. REpAFilters: -----_____________
__------_-_--'----.1�Yes
b. (��dxu�n8orexaonp|�gas musky) ---- ---------
0N*
----------------------'----_—_�LJYcy
c �^�ou���------'-_____
[]No
I3Ya/
[3 No
11.Bvw often are you expected to use the respirator(s)?:
a. Escape only (no reyoue):....................................................................................................................................
Q\ex
o cn`ecgeng'nsnuv __._________
[3 No
' -------'-'---'--'--- ��Y,m
c Less than 5hours per °^,�______ ---------�--
C3 No
. '--''-_''_'_----_'--'--_- .-I]Yem
.1 Less than 2hours per 6av--_____ '-----'--
[]N"
^ ------'---.------''---_-_ J]Ycm
u 2ua46ouo�per da�—________._____ ----------
[JNo
_-'--'--'-'--.-''--. -[�Y,s
L {�mr4bour�p�'day: -_____________ -----------
0No
Mc.1 fast - ,4013 Da is 1oam
12 During the period you are using the mspirator(s), is yourwork
effort
J. Li);ht (lass than 2M k.al per hour):.
................................. No
If "y-," how long dot-, this period last during the average shift: hm.
Exannpl(s of a light work effort are sitting while wntin —mires.
lil;lat atisc mbly work or standing «bile c }xrvrfg
:rat rig a do 1 press (l 3 lbs) or contrvlclirng mac hire s-
h. %jodcrate (2X) to �50 kcal per hour): .............................................I....................
If "yes," how lore 0 Yc s ] rued E, dc�c�s this period last during the average sltiG
Examples of mod hrs.— mires.
p Berate work effort arc sitting while nailing or fjhrig driving a truck or bus in
urhan traffic; standing while dril-ling, nailing, performing assembly work, or transferring
a moderate load (alt)ut 35 lln.) at trunk level; walking on a level surface alx)ut 2 mph or down
a 3-des ree )trade ab,)ut 3 mph; or pushing a whet-lbanvw with a heavy load (about 1U01bs.) on
a level surface.
C. Heavy (above ix) kcal per hour):
......... ....... ❑
If "yes," how long does this period last during the av-ee ra'ggee* shift:..................Yes
►�._ ................. mires.
Examples of heavy work are lifting a heavy load (about 30 It's.) from the floor to your waist
or shoulder, working on a loading dock; shoveling; standing while bricklaying or chipping castings;
walking up an 8-de6rree grade about 2 mph; climbing stairs with a heavy load (about �U Ibs.).
13. VVM you be wearing protective clothing and/or equipment (other than the respirator) when you're
usingyour respirator ........................ .............................. .......................... 0 Yes 0 No
If "yes," describe this protective Bathing and/or equipment
••• ...............................
14. Will you be working under hot conditions (temperature exceeding 77PF)
.....0 Yes O 1;
15. WM you be working under humid conditions: ............... ................................ .............. ❑Yes ❑ No
17. Describe any special or hazardous conditions you might encounterwhen you're using your respirators)
(for example, confined spaces, life-tlueaten ng gases);
18. Provide the following Wonn Lion, if you know it for each toxic substance that you'd be exposed to
when you're using your respirators):
Name of the first toxic subi,LUace:
Estimated ma,ximum exposure level per shift:
MCA In%L - WU Date 10200
D'ur,tuon of (�xfx),Sure [Vrshilt:
Name of the second tonic substance:
Estimate-d maximum exposure level per shift:
Duration of exposure per shift:
Name of the third toxic substance:
Estimated mum exposure level per shift:
Duration of exposure per shift:
The name of other toxic substances that you'll be exposed to while using your respirator
any
of rs for a am le, rescue,
responsibilities you71 have while using your mpimtoq,,) that may affect the safety and well-being of
r.iwnAWc J
11C:� Irrt - %13 Rue I(V12(X)
PLHCP Follow., MedicalExaminadoll
employee Name:
Copy of recommendation given to employer? ❑ yes No
Job title:
Recommend itions ahout employee use of LIv respirator.
Date of this follow -up -_Limitations -
Reasons forfollow-up
Actions:
[Need for follow-up medical evaluatior►s-
Date signed:
Signed-
Date given
RESPIRATOR USE
PHYSICAL
See Attached Job Description
NAME AGE SEX
HOME ADDRESS
TELEPHONE OCCUPATION
LENGTH OF EMPLOYMENT
I agree to the release of this information for State and Federal regulatory purposes
DATE
SIGNED
CARI)IO-PULMONARY EXAMINATION
1. HEIGHT WEIGHT
2. HEART:
Murmers: Rate Rhythm Enlargement
3. LUNGS:
Pulmonary Function Within Normal Limits Outside Normal Limits
4. PA CHEST X-RAY:
Within Normal Limits Outside Normal Limits
5. RECOMMENDATIONS:
It is my opinion that the above named patient is is not _
qualified to wear a Respirator in the performance of his/her duties.
PHYSICIAN
medically