The URL can be used to link to this page

1. 06/10/2014 Agreement AMY HEAV. � ► ILIN, CPA CLERK OF CIRCUIT COURT & COMPTROLLER c • Ai,.�• MONROE COUNTY,FLORIDA DATE: September 4, 2015 TO: Pam Pumar, Administrator Human Resources Division ��;;�',,' 'p p FROM: Cheryl Robertson Executive Aide to the Clerk of Court& Comptroller Gin/ /JOhccf 5n1 At the June 10, 2014, Board of County Commissioner's meeting the Board granted approval and authorized execution of Item C6 Contract with Richard L. Dolsey, PHC, Inc. dba Physician's Health Center, Inc. to provide employment physical services. Enclosed is a duplicate original of the above mentioned for your handling. Should you have any questions,please feel free to contact me. cc: County Attorney Finance -- - --- File / 500 Whitehead Street Suite 101,PO Box 1980,Key West,FL 33040 Phone:305-295-3130 Fax:305-295-3663 3117 Overseas Highway,Marathon,FL 33050 Phone:305-289-6027 Fox:305-289-6025 88820 Overseas Highway,Plantation Key,FL 33070 Phone:852-7145 Fax:305-852-7146 AGREEMENT EMPLOYMENT PHYSICAL SERVICES TABLE OF CONTENTS SECTION ONE - Scope of Services SECTION TWO - County Forms and Insurance Forms ATTACHMENTS: A. Post-offer and Fit for Duty Physical Forms (4 pages) B. DOT Physical (9 pages) C. Respirator Physical "Part I" (6 pages) Respirator Physical "Part II" (3 pages) 1 MONROE COUNTY CONTRACT FOR EMPLOYMENT PHYSICAL SERVICES THIS AGREEMENT ("Agreement") is made and entered into this / O day of by MONROE COUNTY ("COUNTY"), a political subdivision of the State of Florid , whose address is 1100 Simonton Street, Key West, Florida 33040 and Richard L. Dolsev, PHC, Inc. dba Physicians Health Center ("CONTRACTOR"), whose address is at 1448 N. Krome Ave, Suite 101, Florida City, FL 33034. 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: 1448 N. Krome Ave. Suite 101 Florida City, FL 33034 Phone: 305-245-0222 Fax: 305-246-3700 D. All urine screens will conform with the standard chain of custody protocols mandated by state and federal regulations. E. 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. F. Appointments will be available throughout the business hours of the facility: Monday — Friday 8:30 a.m. — 5:30 p.m. Walk-ins will also be accepted if an appointment cannot be reasonably scheduled. G. The facility will be available 24 hours a day, 7 days a week for post accident, random and reasonable suspicion alcohol and drug screening. • The Human Resources office will contact PHC after Hours Service. • The authorized Human Resources representative or the authorized supervisor shall complete the appropriate forms either the same business day (or by the next business day if the test is after normal working hours) in order for the physician to perform the required test. • After normal working hours the employee will be tested at a location determined at the time of the call. 2 H. Appointments will be seen by the contractor in a reasonable and timely fashion. I. The Contractor will provide the County with at least a 24 —48 hour turnaround time for the receipt of any drug and/or physical results. J. 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 Department 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 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). K. 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. L. 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 term of this contract will be for one (1) year beginning June 10, 2015 and shall automatically renew for successive one year terms unless and until either party gives the other notice of cancellations in accordance with the terms set forth in Section 7. Section 5. COMPENSATION Compensation to CONTRACTOR is outlined in the Scope of Services— Section One. Section 6. PAYMENT TO CONTRACTOR 3 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. Either party may terminate this Agreement without cause upon sixty (60) days' notice to the other party in accordance with Section 9 of this Agreement. The County shall pay CONTRACTOR for all 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. F. Pursuant to Florida Statute §119.0701, Contractor and its subcontractors shall comply with all public records laws of the State of Florida, specifically to: i. Keep and maintain public records that ordinarily and necessarily would be required by Monroe County in the performance of this Agreement. ii. Provide the public with access to public records on the same terms and conditions that Monroe County would provide the records and at a cost that does not exceed the cost provided in Florida Statutes, Chapter 119 or as otherwise provided by law. 4 iii. Ensure that public records that are exempt or confidential and exempt from public records disclosure requirements are not disclosed except as authorized by law. iv. Meet all requirements for retaining public records and transfer, at no cost, to Monroe County all public records in possession of the contractor upon termination of this Agreement and destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure requirements. All records stored electronically must be provided to Monroe County in a format that is compatible with the information technology systems of Monroe County. 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: Richard L. Dolsey, PHC, Inc. dba Physician's Health Center _..._ 1448 N. Krome Ave., #101 Florida City, FL 33034 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, 5 • 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 an 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. 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 attomey'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. 6 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 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. 7 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 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 bona fide 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. 8 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 9 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 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 10 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. 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 advice 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 11 • 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, attorney's 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. 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 otherpublic 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. 12 IN/WITNESS WHEREOF, the parties hereto have caused these presents to be executed on the Q day o 20/5 BOARD OF COUNTY COMMISSIONERS OF MONROE COUNTY, FLORIDA if �' � �I`' HEAVILIN CLERK �'44 kn.. ° in 1.A 1 I by -a/ ✓ ' IV puty Clerk Ma /Chairman P TE SEAL) ATT ST: Richard L. Dolsey, PHC, Inc. dba �/ Physician's He th Center Print name /f �r� f yt by 0l cs O c. c.. f2 (h W = Jo- C 0. = n. "� `'.� MO ROEI COUNTY ATTORNEY 0 4 �c A PRQVED ATI . CLJ CI) .n CYNTHIA L. ALL C. N i ASSISiTANT COUNTY ATTORNEY Date k- 2 ' _ 0I5 13 • 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's review) 10 panel State tech and will be either scheduled or $40.00 Requirement done on a walk-in basis. After hours drug testing for post- $175 plus accident, random, and cost of on- reasonable suspicion drug site screening. services. (which is the cost of test being performed) DRUG SCREEN: When requested, a drug screen will (Collection, Lab, MRO be performed by the physician's review) 5 panel tech and will be either scheduled or $40.00 Department of done on a walk-in basis. Transportation Requirement After hours drug testing for a $175.00 moving violation or an accident plus cost where a fatality occurs. of on-site services (which is cost of test being performed) Medical Review Officer The MRO receives lab reports from $5.00 (MRO) REVIEW the laboratory (as governed by regulations); Reviews lab reports for 14 • 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). BLOOD ALCOHOL When requested, Blood Alcohol (Collection, Lab, MRO Screens will be performed by the review) physician's tech. and will be either $35.00 scheduled or done on a walk-in basis. After hours testing for post-accident, $175.00 plus random and reasonable suspicion cost of on-site alcohol screen. services (which is cost of test being performed) BREATH ALCOHOL When requested,may be used for screening. If breath alcohol screen is $35.00 positive,a blood screen will be performed. After hours testing for post-accident, $175.00 plus random, and reasonable suspicion cost of on-site alcohol screening. If breath alcohol services screen is positive, a blood screen will (which is cost be performed at the rate designated of test being above. performed) PPD-TB screen When requested, a PPD-TB screen will be scheduled and performed by the $25.00 physician's tech. during the facility's normal business hours. HEPATITIS A When requested,a Hepatitis A $82.00 inoculation will be scheduled and performed by the physician's tech. during the facility's normal business hours. HEPATITIS B When requested, a Hepatitis B inoculation(s) will be scheduled and $72.00 x 3 performed by the physician's tech. during the facility's normal business $40.00 Titer hours. TYPHOID When requested, a Typhoid inoculation will be scheduled and performed by the $56.00 physician's tech. during the facility's normal business hours. TETANUS When requested, a Tetanus inoculation $20.00 will be scheduled and performed by the physician's tech. during the facility's normal business hours. 15 • DIPHTHERIA When requested, a Diphtheria inoculation will be scheduled and $27.00 performed by the physician's tech. during the facility's normal business hours. DOT PHYSICAL: When requested, a DOT physical will (SEE ATTACHMENT be scheduled and performed by the $45.00 "B" to be completed by physician during the facility's normal 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 "A" 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. 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 $100.00 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 $45.00 for PART I &II to be business hours. Includes exam and physical completed by employee physician review of employee health clearance to and physician) history and job description. wear Physician may also perform a urine respirator. drug screen if requested separately by Monroe County BOCC. 16 Also required: Chest X-ray and S'iromet . CHEST X RAY Chest X Ray is normally done in conjunction with the Respirator $40.00 physical if there is an issue with the spirometry results. SPIROMETRY Normally done in conjunction with the Respirator physical. All employees who use a respirator will have a $30.00 Spirometry when hired. Normally done in conjunction with the HEARING/AUDIOGRAM appropriate physical. May be $20.00 requested separately by Monroe County BOCC. CHEMICAL Tests Glucose (sugar), kidneys, liver(1 $20.00 PANEL/CMP tube of blood drawn). CBC 2 Test to see if Anemic; if any infections $20.00 within the body; if dehydrated (test from 1 of the tubes of blood drawn). UA DIP Normally done in conjunction with the $15.00 DOT physical. URINE TESTING FOR When requested, a nicotine test will be $10.00 NICOTINE USE performed by the pphysician's tech. and will be either scheduled or done on a walk-in basis 17 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 "RICHARD L. DOLSEY, PHC, Inc. dba PHYSICIANS HEALTH CENTER" (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." (S ! - STATE OF: Fier idu- COUNTY OF: l°oiam, -bad G Subscribed and sworn to (or affirmed) before me on May ow, cQD/S (date) by _ /veVM 7 Pa-y— (name of affiant). He/She is pe sonally known tom or has produced (type of identification) as identification. ro„g.,, iv15 E.VELUNZA />° h. , ; Notary Public-Stare of Fiords NOTARY PUBLIC4 -My Comm.Expires Nov 17,2015 ''; n ;' Commission NEE 147316 //_' —I S • My Commission Expires: / 18 J-1 NON-COLLUSION AFFIDAVIT I, �// VI�1 Pat of the city of MIAn'1 L according to law on my oath, and under penalty of perjury, depose and say that / 1. I am V I FP. P1t iie,i 4- of the firm of 4,+,U4iCian c He& (_JA Cent,'" the bidder making the Proposal for lie project described in the Request for Proposals for and that I executed the said proposal 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. (Sign ure I U t s; �b. /)r STATE OF: FIOrf d�- COUNTY OF: M 14r✓I I — laic l aiG Subscribed and sworn to (or affirmed) before me on Ma3 t,,, aolS (date)by ke V/Y1 J Pay._ (name of affiant). He/She is personally known tom or has produced (type of identification) as identification. t v NOTARY PUBL.I>; s °. IVIS E.VEEUNU //� /� /` ,� ` Notary Public-Stale of Floridai. My Commission Expires: / My Comm.Expires Nov 17,2015 'sire ,V Co•nmissmn k EE 147315 19 .J DRUG-FREE WORKPLACE FORM The undersigned vendor in accordance with Florida Statutes Section 287.087 hereby certifies that: RICHARD L. DOLSEY, PHC, INC. dba PHYSICIANS HEALTH CENTER (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 nob 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. - (S at te: 5 . 11./I� STATE OF: FIOY1Lkw COUNTY OF: fri IAM-- CIe Subscribed and sworn to (or affirmed) before me on iic26//J~ (date) by ke ✓%Jn J. `eLcc (name of affiant). He/She is ersonally know to me or has produced ,-1 (type of ide tification) as identification. rr �(p�l/l J • NOTARY PUBL iltMS E.MEEUNZA My Commission Expires: II—I")—/� Notary Pub!c-State of Florida .i My Comm Expires Nov 17.2013 ccmmiss,un N FE 147316 20 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 RICHARD L. DOLSEY, PHC, INC. dba PHYSICIANS HEALTH CENTER (Contractor's name) nor any Affiliate has been placed on the convicted vendor list within the last 36 months. (Si at STATE OF: P F7Y1 d l& COUNTY OF: M/amt—Lari-e Subscribed and sworn to (or affirmed)ff before me on gJ—�&45-- _ 0'Q(date) by KeV,'n 3. L.JS (name of affiant). He/She ics�personally kno� n t me or has produced (type of identification) as identification. NOTARY PURL + '"" IVIS E.VELUN2A I 1 /'J4S' 'E. _ Notary Public-slate oI Florida My Commission Expires: ' di My Comm.Expires Nov 17.2015 ▪;;!m..1f.' Commission x EE 147316 21 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. 22 WORKERS' COMPENSATION INSURANCE REQUIREMENTS FOR EMPLOYMENT PHYSICAL SERVICES BETWEEN MONROE COUNTY, FLORIDA AND RICHARD L. DOLSEY, PHC, INC. dba PHYSICIANS HEALTH CENTER 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. 23 GENERAL LIABILITY INSURANCE REQUIREMENTS FOR EMPLOYMENT PHYSICAL SERVICES BETWEEN MONROE COUNTY, FLORIDA AND RICHARD L. DOLSEY, PHA, INC. dba PHYSICIANS HEALTH CENTER 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*hitt 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. 24 INSURANCE REQUIREMENTS Worker's Compensation $ 100,000 Bodily Injury by Acc. $ 500.000 Bodily Inj. by Disease, policy Writs $ 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 $250,000 per Occurrence and Including errors and omissions $750,000 Aggregate The Monroe County Board of County Commissioners shall be named as Additional -- _ insured on general liability policy. 25 47r1CNMal n . •. NO.OF ATTACHED SHEETS: MEDICAL RECORD REPORT OF MEDICAL HISTORY DATE OF EXAM NOTE: This Information is for official and medically-confidential use only and will not be released to unauthorized persons 1.NAME OF PATIENT(Last first,middle) 2 IDENTIFICATION NUMBER 3 GRADE 4a.HOME STREET ADDRESS(Street orRED.City or Town;State;and ZIP Code) 5 EXAMINING FACILITY 4b.CITY 4c.STATE 4d ZIP CODE 6 PURPOSE OF EXAMINATION T.STATEMENT OF PATIENTS PRESENT HEALTH AND MEDICATIONS CURRENTLY USED(Use additional pages if necessary) a PRESENT HEALTH b.CURRENT MEDICATION REGULAR OR INTERM. c.ALLERGIES(Include insect bites/sings end common roods) tl.HEIGHT e WEIGHT 8 PATIENTS OCCUPATION 9.ARE YOU(Check one) ❑RIGHT HANDED ❑LEFT HANDED 10. PAST/CURRENT MEDICAL HISTORY CHECK EACH ITEM YES NO DON'T CHECK EACH ITEM YES NO DON'T CHECK EACH ITEM YES NO DON'T KNOW KNOW KNOW Household contact with anyone Shortness of breath Bone,joint or other deformity with tuberculosis Pain or pressure in chest Loss of linger or toe Tuberculosis or positive TB test Chronic cough Painful or"trick"shoulder or elbow Blood in sputum or when coughing Palpitation or pounding heart Heart trouble Recurrent back pain or any back Excessive bleeding and injury or High or low blood pressure irNry dentai work Cramps in your legs 'Trick"or locked knee Suicide attempt or plans Frequent indigestion Foot trouble Sleepwalking Stomach,liver or intestinal trouble Nerve Injury Wear corrective lenses Paralysis(including infantile) Eye surgery to correct vision Gall bladder trouble or gallstones Epilepsy or seizure Lack vision in either eye Jaundice or hepatitis Car,train,sea or air sickness Wear a hearing aid Broken bones Frequent trouble sleeping Stutter or stammer Adverse reaction to medication Depression or excessive worry Wear a brace or back support Skin diseases Loss of memory or amnesia Scarlet fever Tumor,growth,cyst,cancer Nervous trouble of any son Rheumatic fever Hernia Periods of unconsciousness Swollen or painful joints Hemorrhoids or rectal disease Parent/sibling with diabetes,cancer, Frequent or severe headaches Frequent or painful urination stroke or heart disease Dizziness or fainting spells Bed wetting since age 12 X-ray or other radiation therapy Eye trouble Kidney stone or blood in urine Chemotherapy Hearing loss Sugar or albumin in urine Recurrent ear infections Sexually transmitted diseases Asbestos or toxic chemical exposure Chronic or frequent colds Recent gain or loss of weight Plate,pin or rod in any bone Severe tooth or gum trouble Eating disorder(anorexia bulimia. Easy fatigability Sinusitis etc.) Been told to cut down or criticized Hay fever or allergic rhlnl0s for aicohd use Head injuryArthritis.Rheumatism.or Bursitis Used illegal substances Asthma Thyroid trouble or goiter Used tobacco NSN 7540-00-181-8368 STANDARD FORM 93(REV.a-Be) Previous edition not usable Prescribed by ICMWGSA FIRMR(41 CFR)201-9 202.1 • 11.FEMALES ONLY DON'T DATE OF LAST MENSTRUAL DATE OF LAST PAP SMEAR DATE OF LAST MAMMOGRAM CHECK EACH ITEM YES NO KNOW PERIOD Treated for a female disorder Change in menstrual pattern CHECK EACH ITEM IF"YES"EXPLAIN IN BLANK SPACE TO RIGHT.LIST EXPLANATION BY ITEM NUMBER. ITEM YES NO 12.Have you been refused employment or been unable to hold a job or Y 1 stay in school because of. a.Sensitivity to chemicals,dust,sunlight.etc b.Inability to perform certain motions. G.Inability to assume certain positions. • d.Other medical reasons(If yes,give reasons) 13,Have you ever been treated for a mental condition?(Ryes,specify uvhen.where.and give details) 10_Have you ever been denied life insurance,(Dyes,state reason and give details) 15.Have you bad,or have you been advised to have,any operation. (If yes.describe and give age at which occurred) 16.Have you ever been a patient in any type of hospital?(If yes,specify when,where,why,and name of doctor and complete address of hospital 17.Have you consulted or been treated by clinics,physicians,healers,o other practitioners within the past 5 years for other than minor illnesses? (If 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 refection) • 19.Have you ever been discharged from military service because of physical,mental or other reasons?Or yes,give date,reason.and type of discharge;whether honorable,other than honorable,for unfitness or unsuitability) 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, granted by whom.and whet amount,when.why) 21.Have you ever been arrested or convicted of a crime,other than minor traffic violations.(If yes.provide details.) 22.Have you ever been diagnosed with a learning disability?Of yes.give type.where,and how diagnosed.) 23.LIST ALL IMMUNIZATIONS RECEIVED I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my knowledge. I authorize any of the doctors,hospitals,or clinics mentioned above to furnish the Government a complete transcript of my medical record for purposes of processing my application for this employment or service. I understand that falsification of information on Government forms is punishable byline and/or imprisonment. 24a.TYPED OR PRINTED NAME OF EXAMINEE 24b.SIGNATURE 24c.DATE NOTE: HAND TO THE DOCTOR OR NURSE,OR IF MAILED MARK ENVELOPE"TO BE OPENED BY MEDICAL OFFICER ONLY. 25.PHYSICIAN'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA(Physician shall comment on all positive answers in Items 7 through It Physician may develop by interview any additional medical history deemed important,and record any significant findings here) 28a.TYPED OR PRINTED NAME OF PHYSICIAN OR EXAMINER 26b SIGNATURE 25c.DATE STANDARD FORM 93 REV 6-96)BACK MEDICAL RECORD REPORT OF MEDICAL EXAMINATION DATE OF EXAM 1. LAST NAME-FIRST NAME-MIDDLE NAME 2 IDENTIFICATION NUMBER 3 Position 4. HOME ADDRESS(Number,street orRFD,[Vol-bun.stateardZ/P Code) 5. EMERGENCY CONTACT(Nane and address ofcontact) S. DATE OF BIRTH 7. AGE 8. SEX 9. RELATIONSHIP OF CONTACT n FEMALE n MALE �I 10.PLACE OF BIRTH 1�WHITE n BLACK 1. CE n A1ASKAANN ATIVE N (1 Hyyj PENIC I BLACK IC S NDERLA IFIC I2a.AGENCY 12b.ORGANIZATION UNIT 13.TOTAL YEARS GOVERNMENT SERVICE a MILITARY b. CIVILIAN 14.NAME OF EXAMINING FACILITYCR EXAMINER,AND ADDRESS 15.RATING OR SPECIALTY OF EXAMINER 16.PURPOSE OF EXAMINAPON 17.CLINICAL EVALUATION sue-M (Cheek each Rem in appmprare column,enter"NP rf not evaluated AF9rr PMAL AtlNUH- MnL IK (Check each ttem In epploprbfBCWumn,Bnler'NE'Nnol evaluated SMAL NO A.HEAD,FACE,NECK AND SCALP O.PROSTATE(Over 40 or dlncally indicated) B.EARS-GENERAL(INTERNAL CANALS) P.TESTICULAR (Auditory acuity under items 39 end 40) C DRUMS(Perloralbn) R.ENDOCRINE SYSTEM D.NOSE S GU SYSTEM E.SINUSES T.UPPER EXTREMITIES(Sfreng!h range of mottos) F.MOUTH AND THROAT U.FEET IC EYES.GENERAL(V.'saJ easy ars resacwn u,Ee-Jan.,ZS 29 and 36) V.LOWER EXTREMITIES(Except feet)(Strength,range a/motal) H.OPTHALMOSCOPIC W SPINE,OTHER MUSCULOSKELETAL I. PUPILS(Equality and reaction) X.IDENTIFYING BODY MARKS,SCARS.TATTOOS J.OCULAR MOTILITY(Asmlated parallel mavements nysttagmus) Y.SKIN.LYMPHATICS K.LUNGS AND CHEST 2.NEUROLOGIC(Equihbnum tests Ins/estrum 41) L.HEART(Thrvsl,size.Mythm wunds) AA.PSYCHIATRIC(specify any personalitydevialten) M.VASCULAR SYSTEM(Varinsrtis,era) — N.ABDOMEN AND VISCERA(Include hernia) NOTES- (Desenbe every abnormality in detail Enter pertinent dam number before each comment Continue in item 42 and use a Jilroral sheets i(necessary.) 18.DENTAL(Place appropriate symbols,shown re examples,above or below number of upper and lower teeth) REMARKS AND ADDITIONAL DENTAL 2 3 Renonele p Non- pX vng 1 3 Repated 1 2 nee DEFECTS AND DISEASES IS ]] 51 3� Teeln 32 31 9 peen Jt l seenertores 92 Xt 90 CenWss O x % R L I 1 2 3 4 5 6 7 8 9 ID 11 12 13 14 15 16 E 32 31 30 29 20 27 26 25 24 23 22 21 20 19 16 17 7 T 19.TEST RESULTS Copes of results are preferred as attachments) A.URINALYSIS: (1)SPECIFIC GRAVITY B CHEST X-RAY OR PPD(Place,date,rum number and result) (2)URINE ALBUMIN (4)MICROSCOPIC (3)URINE SUGAR C SYPHILIS SEROLOGY(Sµeiyteat used D.EKG E.BLOOD TYPE AND RH F OTHER TESTS and results) FACTOR NSN 2540-00£34-4038 88-126 STANDARD FORM 88(Rev.10-94)(EG) Designed avn9 perm),vm v»1v910R,an 97 Prescribed by GSASCMR FIRMR(41 CFR)201-9.202-1 i NAME CERTIFICATION NUMBER NO.OF SHEETS ATTACHED MEASUREMENT;AND OTHER FINDINGS 20.HEIGHT 21.WEIGHT 22.COLOR HAIR 23.COLOR EYES 29 BUILD 25.TEMPERATURE nSLENDERn MEDIUM n HEAVY n OBESE 26.BLOOD PRESSURE(Ann at heart level) 22.PULSE(Aim ahead level) A. SYS. B.RECUM SYS. C. SYS. A.SITING B.RECUMBENT C.STANDING RFT AER EXERCISE E.2 MINS.AFTER SITTING STPNOING (3m/ns) DIAS. BENT DIAS. (5 mins) DIAS. 26.DISTANT VISION 29.REFRACION 30.NEAR VISION RIGNT 20/ CORR.TO 20/ BY S. CX CORR.TO BY LEFT 20/ CORR.TO 20/ BY 5. CX CORR.TO BY 31.HETEROPHORIA(5peclry distance) ESO EXO R.H. LH. PRISM DIV. PRISM CONY. pC PD CT 32.ACCOMMODATION 33.COLOR VISION(Test used and result) 34.DEPTH PERCEPTION UNCORRECTED RIGHT LEFT (Testa H and scare) CORRECTED 35.FIELD OF VISION 36.NIGHT VISION(Test used and score) 37.RED LENS TEST 38.INTRAOCULAR TENSION RIGHT LEVI' RIGHT LEFT 39.HEARING 40.AUDIOMETER 41.PSYCHOLOGICAL ANC/PSYCHOMOTOR(Tests used and more) RIGHT VJN /155V /tg 250 500 1000 2000 3000 4000 6000 8000 256 512 1024 2048 2096 4096 6149 8192 LEFT WN 1155V RIGHT • LEFT 42.NOTES(Continued)AND SIGNIFICANT OR INTERVAL HISTORY (Use additional sheets it necessary) 43 SUMMARY OF DEFECTS ANC)DIAGNOSES(L sto/agnoses with Rem numbers) 44.RECOMMENDAIOIIS•FURTHER SPECIALIST EXAMINATIONS INDICATED(Speck)) 45A.PHYSICAL PROFILE P U L H I E S 46.EXAMINEE(Check) A El IS QUALIFIED FOR In accordance with attached job 45B.PHYSICAL CATEGORY B IS NOT QUALIFIED FOR description 47.IF NOT QUALIFIED,LIST OISWALIFYING DEFECTS BY ITEM NUMBER A B C E 48.TYPED OR PRINTED NAME OF PHYSICIAN S.GNATURE 49 TYPED OR PRINTED NAME OF PHYSICIAN SIGNATURE 50.TYPED OR PRINTED NAME CF DENTIST OR PHYSICIAN(Indiatewhih) SGNATURE 51.TYPED OR PRINTED NAME OF REVIEWLNG OFFICER OR APPROVING AUTHORITY SIGNATURE STANDARD FORM 88(Rev 10-94)BACK m o ° o -1 _.. j n.. 0 i,. I m a m `Z' s o y coI g m m 3 O j _. --__ 06 K m 03 o m Nix N 53 3St , �n qz 3 ' c _a' _ 4i CO Q N N ggnm wc - 2ga am O C O. 5 N p_ m ii 3 '' a-5 on I 3m O m a ea_ - 0 m e O m = o ° 3 = _lIO N O N J C qvP - N _--i p J n a ems O nl J N S O co N _ ho v- `G 3 < 3 v o 8 v CO a N g• N_ 'O N - b. 5 n ToN I 3 T n2 in g 'Zd $ a k 0m - 0 m o � 2 8 - 3 NI A p = O _ N 'O ' -- O N.2 C a N 2' g 0 O O '',.0 3 1 £ ~ 3 C A a v2 `° " � com m ID am ' 0= m 3 < a. m -o - � y Zr 3 d Da cod , - I z o1 rWy cn N 3 5- -L.-d - - m 0 0 .71 RI N O. J N J 3 c c - N - X 11 N2 ' - 3 � H m3 c 3 m 3 - 3 m m .� • < m m - z La • m n - ? N -< m' T1 G N• m m N - 33 CO m n73 a 0 m 09 n - H n i RIB c m' 3 n d - - P. mm `_ w l - n O Zml 111 = _ 1 — n _. CWO Z N a a) Fm m - _ s J TKx - o 3 _ H n m — 0 J E ' o o m m 11 z 3 _ 0 £ w .03 J £ aO1. ,= I r = _N 3 r ' __- - m IO d 3I N < _ o m 0 m gym a �+ '.. - w m — z X n CD=3N � s0s_ 0 0 . CO m co 5 = F mg3o -905 1 ; 0I 0m a aF =ard -g - y � o a N 0 0 Di c - - Rp mill m • =o a) a na - I N � I m a J `Ja a " m = 3 0. T rri O `J COa _ O� _1 0 ([llJ • . 0 Z ' 553 w Z m 2 • mqomN Zc o m• pncao 5A c-.0 O NA W • ^ A 3 np • m CO '^ C N CO y=N C o N o co A m I "0 c * A m ar £ o n NA o mm -I c < = eT m !m • n en m 0 sna .0 Xo mmmI0 Foti (n Z m 0N o o m c M O a ' yj a o da0 O 0 0 ' ' yO = m mm m0 3 ^ z Z- - l I A mma • m IA arN • ) C a o 3" a co n No w CD- -- mAa N oNa . of a m dm �� coCD O , o o o O' m ^ m 0 io v m ' ° Omo • ao c m3 ,3a ico A3 O ,<m 0s mm 8 m. c m 3N Nna ' co .. ._ 8IIn °. 8 OtZ PA m o a !cc ` O. m5 O . ca ^ asKm a ,Q - Q 0 0 co = m 'n o oc N < 6 co or -Pc it wF ° m0 "0 WQa l CID o a - 8 -, o n o Imm 3 -_ c O •• A a o m m 3 a N., NJv 07 n n N ,CM 5 5 D mo S. o a 0020 .. d a)m -I s' -0 m An ° Zm Ommn m 31 A om m >• a co,.y a a3 m a I ON' na �' 0 nNom ,v I � .A j ' ' �' CD O AO I �O az 3 CD 0 ? a ID m CT- ' I CM I 3' ^ a ' o as� o < cao a CDm 0 p� 'I 0 � w O . • 5aHg In O 3co a O co .. 3 5. NIp cc o x m o Cr Z LI maaN m Oo A m a N 3N mN y W am o ON zF o m .f zs m n m 0 o0mO0.. . 3 m ?a n = 3m rn • Zmmm7S €nm O T = m W O O O - NaN a 0O O m N C i m , m D- la (n fn (/ to cco o < CD0 0 O 'W IA CD A Oa aDo A, oI o o O_, Cro- < _N Co 3CDN ij m N _ CO N CD (0WN O O n S J go 0 N O a Q it _ O alv a .. 23 O Sn co 3 O 9 C m :CraNQ m ] aa_ � m°oO xae3 o D F o ' o ' .�m 9 3 nx N0. "° mF Ncfn v � a dim . N o m oo Con _ - rma3 M 8 g M oo � ^ i cil a „ O a Z a m ^ ! N n 3 M a x r.m o ms r 0 c' m a ' 0. ' w m a a >1 o 0 o mm <-. m 0 zn 0 0 3 - ? » m P. o < N � ono Co .^ C li o o �+ co M o a m m o c s F g m n• 3 X co m - 2 a a Z. - m p1 m ...0o 0. y N3 (O m c ' o.' ' m0 m y3 0 c co mmnm i " �^ m x m,A = a 0 ' >m ' E m ?' m, m > 3 c9m ai O to -T. 0 A 0 0 0l Z c n m °. 0 3 n ' m N ^ o ' No V N o N 5- m m' Z� Z O E C a al O d ry m I CD mill 7 0 O < -Sa ON CO a I 'm O No m a W O O O a • .. 2 N N" co =l a A 0) fO.< m 'a N 0 N F O. n 0 <. N wv — 3 m A 'mm ''.n m m m o a2 00 v 3 m coma a c 3 F 3od c x O = •• A m a 'o m 0 -. i0 o a' 0 m a o_ ; n 3 _. 0' c, 3 m 0 l-` v m H o m C � S a a o ' o o. 0 Z a N• .� n (• O I'J 10 o yco 0 y N O R H O N N ` _ _ O O M N m a 0 J a to < O 3 5 c c � O 3 w 9 g 0 .°. ¢ d AI, 0 - 3 0 L e - o al co in N w In m :5 al I G) o m o o y COAy c D ap. - 0 0. a4a A 0 • 2 w 3 m Er. 3 j -,o g mO .i �. o < am o I -1 D D P. -I ., oa• Cu o'. a n oN o a r N a2 UI � I 3 � a = NI N Et - - 0 ° N CO � w co y ,' oorv3 Nom co a o' v a- o - .> > m ao 2om xm '^o m a m n 3 n c _ 3 3 m w N m w m m m 3 a a aamv C mm � o00 d 7 o m » a m m.'o 3 _ .D 3 3 - m a 3 m n 0 �.1 N a o Z it i x ' ° a a a � � y�' m ,- �a - ill hn 3 3 ° p mm 3 f m 507 .5 n d Znn = nXo — 7 c ma - oaATnm o a m m dN . a - m % ' aQ o o ^w m cnm °a ° T ' z.�°' v o coca ¢m mw - Omo <m m d a � - a �m 0 3n _ x 3 an O. Oo - cmAl o o ' 0 » . ao da D33_Z o om m 3 o o< F 0 3 a “ 10 ) m3 �5 � .Z 53 3 amcom 1 9 :»m o ^ o mvm � m °CI n o lom 0^ o 3 U • o m �"' y m 3 3 z 30 m o F o 32 lapo _ m m m m a0} _ ' m ° maH m n mm ,. m v P m3m a to 3 o a v mm rvox a - m xc cca -m n oF qmm- m N m ° ° mo 'c a o omo3 m CD ID .v . Ou n " m d F o O ma- - ° m 3 ` m I° ° n 0 3 3 m � l s I3 v03 m - 0 a' Oc L - 3md 3 < o CD a au a 0 5- 70 A • , 5 a. w33' mm - o om m m mm_ m 3 m ma o m - °7 o ` l m - Dma ; 77 w auZom ac 356- J m m a °O' m m o p. N S m m °_ O ' m• < a a Z o .. 3 N m °CD 3 I to - + n NIP _ o oy> KK 38- - - m c o.2 oad0- N - om _m mr r Nmm� z• 3m cmm31^ m m m o5fa3a 3 ; 0 co m 3.3opx" n � m oo a°im mo3 '� N h• a a am' 'a > °' ' mmm �°a m m a N m _ 3 m 3 m m _ <_. a o 3 m m '� o p u N i m 5 0) . m m o oiti a. Cr ?HaFoo?10° o 5cnm3 cn 3 < m11 ' mq mm' m �Q 0 0 0 - - m 3 Cr 3 - a 'n 3 r o - m 3 m <-( ° - m7 ' mm mm <m mQ ''om ° o 3 . 2 m m m a 3 m m v 3 3 v _ __,L„a x a o 2 m m S jam 0k- o 4 S7 T 3 ��, a a m m d 3a. - i � o - 3 v5 (m7 ''. m m g o ao ° @ - m � Nmg _ _ T� . Bn $o 3 �cti 7m _ m_2 =E A7 3 m .. H� CD at> F _ _03 8a om Tm _ m o la " 3o - 3 o- �Cr * ow m-mmm, � aotic 3 a 32 m ^ m CO m 'm 3 '�° - - - d - m m' 3, coam m =a- H _ gag a ' 3 " mm O 3 _ 3- va a -3 o o m m m o - '" 30 _ ''_Fa3 w cm o 0 m a m <. m 3ni oo - m2 ON mo' 0DC o Na a m m CO m3 o njam ' mw m °0 3a m z m m m 0 R - ° _ -Q F o P m w w s er j.q � 2 _ K F FTn _ m�. o 5 v ° u o ° o F = .- _ c _ _ 4 6 .7. Q „ o g vo ^ o o o O _ - - ' 3 $ 3— - - _ - 2 -0 _- o =ae 4 ° 0 o a 3tt n o c m T w 0. _ - 3 3 - ? v 0 T . ; 0 y 6 � G n £ "' ='52 - 'u O 9: 1 3- n _ _ _ _ err o ' r v = w `= v y 3 0. °' - 0 A W n O o9 5 . y _59 ua ' = c = =, " ono 7' O6 FA" 3 co -I a < oo eC ' - - = ri,aE; T a n n G 0 2 0 _ _ ED'!A i � n4 533255. Y8 c F _ 3 3 5 4o w (' Ta � 8 i a_ E. 3 0 _ _ 2. _ < p o m o 3� s ? = 2 o f '/i . - » 0, 0 � x � '� osa UP <� rJ 2- _J o 0 i R F n ^$ ft v £ x > v £ n° wgr. S F" a Vi y _ 6 j d F ° 0. 5 G O. y fR C w. G ° w y - - w 3 -i S 9 P a 5 e c _ Z'' 2 = - _ ' _ - o < c = w a E e_ o - <£ 6 r S r�o v T 0. .`°` - - ? `3° � 0 as ° V w_ _ _ - _ 3 T F u ° S o 3 n 3 w w 3 " eD n nw Ni 7; ,1 F i9 0 3 n a 3 m o n 3 '^o y 5 m a aa g 3 w 'm F 3 .3 n o r m 01 3 m o m S % o 3 3 "3 r2ac co o m A 3 n.< j =9,n 3 S 9 °3 n a oc 3 m = a a -,Sao 2.0 a a 3 ( w ^ 3 c v m m F m. m 3 3;a O . 0 m ' c D m g E o a m m y m WM 0 m `° m 3 = m' n _' m a u m m aaa,m a-. 4 m m@ m o'm - ° cn w ° o -'c o m + x o a ^m m w m 0 3 m » o _ 0n a- m + m 0 3. m'� m 3 fO o. v S v 3 w ° o =--3 a s 3 = 0 3 _N m' " m x o a o 0 w a a 0 ° m -o <m a oT <' n n m a n o m o m m m < �' " m m a m w a 9 0 3 a=.3.0 3 0.0o S u CD o< < ma�+nmi oowoo on10 '^.g3x caomaa - ° om'^a0 < . < 0m a '"o A - a35° 0 to a 2. a > > a 0 a cam - m mo m s N_ ? nm,m � xa oom _.mmam ^a x ^.,<m ? d 'im' ^ c3 oo' a,� onmva � » vs' E. o � 30 5' . x a 0 m 3 m`: w 3 _ w o 9' » o_� tD m oa a a o o ? m 1° n x n _, 3 _^ 3 ama xio nm $om , ca a w _ 3 7 23d' 3om10m ^Naar ' o . a3 <- m nyna- .» m - m < 3. a��1° otDTm33w aaa -. a °33 a 3w _aNm =+mn m^ M' cmm `a° mmm `,° w2 ° 3, c3 ° .. ^ 05 3 -^'.d - n^ m uoa m o' a^'z .� _ ^ .. a.-am-. no - - m ° nip F o o d D H ^ » a m �' 3 1 a �' a m <S N �, m ° - ti ? j F 3 m moo. aN S "- m _ 5 o `-' °' 3 yggg -g1rm cm'O o m m o gm F Na „ 3 oo o .. tm " o agoa - a a a w- m =o +" ° ^ a. a a ff F S a -o a g nano mm a m H O lg m 0 " o m v - 3 g m N n 3 m o »820 o a N ^ m N `°< `° 3 3 o a N-' 3 o.Z m £3 7 m m '3. 0 o x o < a w v m m m ti'^ 1 '^ m F m n - ° a a 3 am 'm,2 n m = m '^ a m o n g am 33mD^a m0mm <. 0 n ?" < _ .- �o o < om om33 pm mm 'mmma a Souwi �3e : c3 'g rTh5— - �o ox rm Sm mn 0< m w w a m a a - `R ". �oa a n m H am o w o » �' 3 F - a x o `° �o g m m '�»',2 3• 3 n ° o. w n ^ m a in,^�, 3 m c m o }a m en m a p< h ? a - o v o a Q m m N q _ c a v F F 3 3.3 0 oa w m 3 3 `aO a Z w m w o 3 m n . r- Q m c D m a R4; m m a m y n co H °m' ° ^ m n =o m 3 ' ^ v o c m m » a^ m 3 < m ° m a o. a m C agog° 3ao^ 3 `3m m3d3a , a35 ag33 _ m $ om ° - �`3 a , mo ;4 Z _ 3 " a.^y_ _ a33yaaa-gaga _a "5"m"F� 'F8�g a gg-_E m=„ �'--03 -1 3 3 a03. 3 a 0 . a.3 3 �'a _ m5 3� $ c gF mw -E 3 ° m mFo > c $ $ H $ 3=mm'n am"� 3 a ^3 '3Dm acorn a� 33 oe"£D •'°3' o Ill -'^gouggg°1 ,°'sm =w-< - -gamP-a » wm< (Ci mog03ta Imo m 3 0 3 3 g� o c ` a0 3 »3 F w 33`m y3 ° a D 3 n = a m x y v $ o o e 3 m o 3 3 r _�¢w -3c < maan ( nc3o - .-� ?o nN= ?cv =Wn. 3 nN 3 SE ° Ill 'm '-'- ona = was ° a ° 3 n-°Tnm'�s a as m < X a lig aS60So_¢ D -.za °40 yrvw33o 3ed3 aa'c9.9 ' oa 3 0) 0 m o3 .Zm e s cc ° N c w m 5p ow M wv3an T2 a <nin. 3 _ . 0 '3 H " -03 �°ww 0!..` 9S0 00 Deo_ '-m �d00=1wo my <-303 ; “._ mxcCmw aagFa - .= - +w . ° vo - a "m g3gad ' 3d ° .1 _ „„ a gaaaa-e aows3 .0ao, -aa-v 0 0m _0s -Eca- m $ gym�Facavra ^oo8' a- -2,� u_ Dn Foa °.3 - --,-7 « am_ °m 3 3 - 3 a 0800 ,, t o a p o a 3 3 ° C V a o 3 _ - °„c m ��ym o_a - na ° - - oo3 < n - _ a o O m3_ _ S m - c a m mmo. l 2 cm _ m m a _ m ;3 O a Batt o m = 0 - m S' - g. 3d0omn .F owao -g ° a.o a, Q . a. O a P 0c2 w 3o ° D a ' a 3 3 - _3 o 3 w F3a w 0 Be33 3 ma_ w ^ 009 3 awn o ' 0 b (rwa ° mm Hon m $ -3 0000aa $" oo ” , 3 3 "a an? - _ a= 0 mmm a aa<a _ -• a mmo _ o ammo m„ 2v: a;;m " 3�� ma,3p na 7° E3 _g -O .,n m mo oom m 55aBam3a=73R ¢$ m . o na 3 n, as 3 .3 4 3 �d3 3 .< oaw3m,Otm -i�'oan ..gyca 0nb 3 3 _ o o 3 a o 3 3 n �Z * 0 53 3 -� d � 0°N c a 3 0 -0 3 a 3Foo.z 3 2 3 m m a a3n = 33 oacoom a cicc- ' am 3 a a 30 �, vo �R ' 3 = 3m3 `3533 ono ' "i a- 3.2 - am' a, ° oegm m'5a o l 3- os m n v2a3 d $_ 3 _ 39a3c3 g m 50a a3T 3 3 o3y 3, - o jo _, A g.n <�� m de �m 2 mm ' 37m N,z oca 3,n ,5-0 °2 03F=° c� o ° ^' ma° Z 90 Glo m m :o m 3n -`oQ.w i -£ n° - _ - ° '° 3mo5� d 'rv , m 3 " = ma � mao wro > 3 ; 3 £Lb a -_ 3 3ao_p 3oa3 aam d.� g c ww cm Mr/5 N m aac o 0 3 m - _ _ _ - - a - av Ql _ a m n ° o_m -o - m . .' m- am `om a9m'° - 3 'nm -' 7a Ie1,no a7,14Z1i :cif 333 _ v moa = 3vo o -o - m _ m , - _`m monaada m^S - v - am3aooa ' 3a5>35two oo _nadao3m_a3mmoa3o ¢9m^$ 0mRT mo ,n --m ,o Fo n 3 3 53m mo a.� 3n m ff 9 � � 091 o os� az gm 7a > aaarIa £ " o' 3_'m 6� a = oa - a °� y=_a =_�Q+ a - m' 3a= nn _°'°a`�v°mmm - _ =a ,3 dim =Oa ° 3 P ¢yna -Sad n} a7-7 gg pna = aam m 0“.3� £ o c m = ma $ ^m0� ,m - _ _ opom on - na _ m _ 3 a� 3` _ Pa aaaapas7 -a 3m° a= m3 a oo 3 a 33aE3 ~ 3 m ° _ n 3 3 x -13 m` m c -02 oa � U Ugo a m o3o(n 3 ma 'gN 3 �n o 3 ,.ana 3� $ _ aclKs a° H. oRE m 3 0 --_ 3m 3 '$° `om oK° o .m o n 3 a o 3 _ _ - a0(� m =3m n anal - - m _=-93O w-oa°EwEa v 0 ,%, n n 0 03 o as Ry namn - KR ° 3 am `°ma graFg �Q - ma `=° m _ ° .. - - a op 3ooa dc^ao ° ^m 3 _ -5KiK K a Sao m am iial _mma.3i a zaoamn =o3ma c3 mao a^6os==° mamrvamR ° 3cR1 1 -S° 12E an d 850 K° ° 033 y3m3a 3.na a5 = m ° arcOd sK a 35mw=dmua, ° _ �'Ko3a3-- o - om ' ' nn'm n 3" 02o ov3w a> a a , cy 3 =En sK8 Rni EER] RKE -005 a'3 >a 3 o R9- m3 3 r° a ° k 0 3 a c o a:3 CT 0 3 3 � m n 4 ° a; x39 m n m3o _ ,° sN - 3 - m n 3 a3a = dam, y . _v £ 354 co gri ms,, mm3 aassss mew Fa Fa a-ago -3oog. ? H - s3 w.3 m 3 o°ivo a s c'm n 3 - 39m saE ° 3 3 '3-° 'am m9ir - - a3 '°" " aE_?3Em � 0geag 3o &_ - 0o a3o rvN m3jv " 5nzv _ o'mo P `" moan OREa-a 3J _ m 5 -m - m¢ - m P �� _ a �a��a^mmm � o ;n 33a 35cF £ m-va 'm3 8 __ __ ooF�Daa m' v '0 .0 3 ?-a - 3.20 mmc m c0, 0 m� 7-2 m °°.3 - v. 3 m.3 2 3 F m 3 a:il m. 3o0-- sm, - - m -m ai s-i ` vc o - emaa _ o a£ agac m - Vt _ gym _n cm ° o _ °T aa3m _ a3 ?- _ _ � m g3E3 zo`_m 3 a " o n 3 3 n - ¢£� "= 3e dam_ asa = - `. H , m „ no _ 3 'm m3 __ _ H j - 01om q 'm F `m _ aka �. 3 n<n � mmnm oi3 -_ __ - m o '?m a mm am mm `to m 2 oNaa _ _ - _°' ma_ 55FN _ _ vo£ " - _ c-- cb3c >ro o m0 3 _g m .3a33m .naai 2m :3 'R3m 'o 3r3 'a" 8mNFi.m _gx - E,3y _ m.3¢o£ gi za.3 n.om a o33mn�'Z'z° _ _ - - _n0 ' _2 . o - n (°° 36 xd ' = - vnMo9. _ mmsona°- - �33a - n33o 3 - 333 mm _ - - - _ n No mma � 3333y 3 33 _ m3 33 o m _da mFao a.- - mm N "a � 3 = a 'j w a 3n5amo � v -£ 3iSa 3 am Q ¢ 3 3 3 -m - _33n.nv.fo3 - -- mmva=- HDa3 a" 3 Hma . d - _ o:- _ xtnm3 _`m dn< v _ as la Cm. xynD �Em � m'?� D�x =yam ono - - - S0a-" y ' g3 #m m F oa� DCDG 3 z� 0 v� mn n (il a m ?� 3m< �v 'oan a3 m 'o v a '� n" 2p� F3 -a - 3',3,t � a < m G 3 and F nF.3'-z= m um �� 3a - 3 v 3m " m m 1 F u 1 o g� m 3 - o a "'aNa 0 3 D3t” u - • d3 F ' 33 _ o 33 ,ZPa 3 yP < m 39 ry 0 -0 i0< aD N3 _� n¢n oFa 3 a ?F " C J -`_tonne " _ ! ¢ Di 3 : 33s'm'e - m l"5N 3CN - =o. o _ mo- 3 - 3 3 m Z2 � 3m3 m330mda_ Hg,mov: a m u3 ma_ _ _ nm °3 "0m � nNNQ _ amz'nam m3 _ v a ' "3.'-'c � g3›.5N Fm 'nm � - 3d. c3 °' __ m3o3`aao mmnoFco io - a `93g,3, m a 03 3gmm 3 mi _m ,fl m' 3 3 j 3 3 } ? .Z_ 3 - °amp o m'm ¢ - 3 o w - 0000 - - 30 am a2 �Q' mvamo� 3 _ P 43 a- rv''va fm n o0olm 3 °< v'g - ary _ 6m 2323 - - -<- ° >m ' mom a P. 539 - m �" o.a� -` m � ma i �.3n •-�n3;a 22:° , "� zm '� m m �� m ° ° ea m tea" vaF = �:noo no Dw0 s <^ - a d - m = 3 'em a. -m - oc8 . m= Ac0m �a 30 r. ( pa m_n,am g-`e' un = w n wCip= wmma � C 02 0v3ao F wx3 `Daaa3� �aa ._ < v _ew ojoc m_aO » am0 °, a m c.d - .. o Q.)„,„ m w3 - mm ^ 3o - a30. a `m i'a ._( amm a % � N m c o - '" ° 0 d - 3 d `n 3 o F E ac m m w n 3 0 o d v N 3 a a o a - ° -• m d o m °'� 0-a co am(0a3ao o �° a' m� oF `Do''oa a, co o < d nn °com Qa'o o w � mom o_m ^ 3d a 'o O• o a o 7 j m = • _ o - v < d m x 4 cp N m' ma o 7 wn oirnaw D3 a c � ' 35-c° nav Nn° as Si. o _avp 3. d cp- d wA n (CI 3 w `" 3v F'So 3 a a o 8a << aDa 3:30 =.3 , 3 m -co 3 co -. 3co 3 N d d O '^ < 0 0 O 0 od a a 5 2 m o - ° do o a 6 a 3 » - 'm a c_ Nd d 0 .»a 3 d Jd 8p o ivy, 9 Oo.03 '° d .—, m 5 n.Z - a o » 0 � m 5a 5 o _-co ,5 a, ? 6N vo oo op " coac5csm 'dcfa8 Q = Saccrmoco5 = w -1~ 4 = N n 3o ¢ca» c000.7 " o a o d d d d a m m 3" =n m m» a y m d'o 3 m 3 5 = m' =4 d a a m..` m '^ c r 0 0 dm3. 0 a 0 _ m-i. ... 3. d a 1D o 2022 N < d o O N r a. a O O tl 5 w O a ° d O_ _ 6 0 d -d 0 _ 'm a d 3 *= 8 n o-a 3 N T 0 w 0- 5 3 r- c wo 8a .3 "£' o m'o a- CD m 3 0 5a oa0 a O O 3 = O. d w(0 O o o - O 0 0 N...5.D N N.o N < 'C" `F.,- 5,3 3 3 d = 0 _ N a a N a O a a- o d d w d - =N w N ° a a N 3--a O d a Qv,: 0 (di C ._1 (Oi C C O d C o p a a, a g as `m m n C) O•Z d= 3 a o A.n o w 'ao p w d = ° 3 t`o uJ B. d a.a S,m o n O¢ O °d °' j ° a O^ n c 3 N j> 3 O. d. CD " a 3 a °i o r 3 a co o=_ 3 m �' °d� a d a cD a� 3 ---F -. d ..m w ^ d.a LT 3 Q 0 o' 5a. 3 0 5 3 3 ^5.N e o F m " 3 a� awn 5. 2 a=o_, w 0 3 o - m � 3 -'3 m' g-yig °- 8 '-m oo a w = m 3 S E. 0- C6Z3On CD o a m n o w o - -ow 2 0 D w D = = n y vi x o o as w 'm ma °.ana0 -in o o 3 .. n3 ma3o33am °n c3 m 532-..a 0=nm ° 3 ±v = 3 oc _.arya N 3 3 v oN ^ d O o 3 5 o y `� & o o '° m Z'¢ v 3 c�o '< . roc a n30co5x3 Sz Fmma � o rm co 7 a moN aa0o; g& c a goo `° dm'3_m 3mQ o a`a°L0 = 2om w a � w '35 Son_ _ .. . _ oN� Nd� cmS v o. m ,3 w 0a, ...05, ^ 0.2 �o o .. 3mo- 0 a ° a °1 cZ o v = n2 oc o o o w o _ n a n o woo c o m o `° o w n 'p U. 5 -.- _ dNv ago Nm Nadd`. 3' d Q c m 3 0 w-' 'c Co - o c a r c d5 oS' ao y o a � � 3 dt0 � wem" 2al = _ d5 33w aw ; ww w N d d 3 O d m'O o N 0 0 3 d ... 0 C d ma 5 s N .a l O J,00 O a- O ? Cd O .- 3 0. N d - " " a co w a a i° d j N = d O • MEDICAL EXAMINERS(ERTIFICAI I. in 1 certii that I have examined accordance lb the federal Motor Carrier SahliReg„olations(49 C'FR 391.41-391.49)and nilh Enos ledge of the driving duties,I find this person is qualifie n d,and,if applicable,only n hen: ❑nearing corrective lenses ❑driving ithin an exempt inlracit]zone (49 CI'11391.62) ❑nea ing hearing aid ❑accompanied by a Skill Performance Esalnation Certificate(SPE) ❑accompanied by nanerlex mption ❑qualified b\operation of 49(FR 391.64 'I he information I hate provided regarding this physical examination is trio and complete.A complete examination form with an'attachment embodies my findings completely and correctly,and is on file in my office. SIGN at OF MI'DICAI EXAMINER IIIEPIIONE I)VI I. ]II:DRAL EXAMINER'S NAME(PRINT) ❑.AID — 0 Chiropractor -� ❑00 0 kchanced Praelice Nurse ❑Physician \ssMani 0 Other Practitioner NIEDICAL EXAMINER'S LICENSE OR NAI IONAI.REGIS 11 A NO. CERTIFICATE ATE NO./ISSUING SI:\11( SIGN,ATIRE OF DRIVER INIRAS 1,11E ONI A CDI. DRIVER'S LICENSE NO. STATE ❑\ES ❑IFS ❑NO ❑NO ADDRESS OF DRIVER MEDICAL CERTIFICATION EXPIRATION 0\TE A rrp omaxi ,r ►, V ^,L I ET, ;1 - f Search i'g �. .� I iJ j( AtoZ Index l En Espafiot'contact Us lFAQsI About OSHA OSHA Newsletter RSS Feeds Menu Occupational Safety Pr Health Administration We Can Help ©Regulations(Standards-29 CFR)-Table of Contents •Part Number: 1910 • Part Title: Occupational Safety and Health Standards •Subpart: 1 •Subpart Title: Personal Protective Equipment •Standard Number: 1910.134 App C •Title: OSHA Respirator Medical Evaluation Questionnaire(Mandatory). •GPO Source: e-CFR Appendix C to Sec. 1910.134: OSHA Respirator Medical Evaluation Questionnaire(Mandatory) To the employer:Answers to questions in Section 1,and to question 9 in Section 2 of Part A,do not require a medical examination. To the employee: Your employer must allow you to answer this questionnaire during normal working hours,or at a time and place that is convenient to you.To maintain your confidentiality,your employer or supervisor must not look at or review your answers,and your employer must tell you how to deliver or send this questionnaire to the health care professional who will review it. Part A. Secton 1.(Mandatory)The following information must be provided by every employee who has been selected to use any type of respirator(please print). 1.Today's date:__ 2.Your name: 3.Your age(to nearest year):_ 4, Sex(circle one): Male/Female 5.Your height 6.Your weight: lbs. 7.Your Job title: 8.A phone number where you can be reached by the health care professional who reviews this questionnaire(include the Area Code):_ 9.The best time to phone you at this number: 10. Has your employer told you how to contact the health care professional who will review this questionnaire(circle one):Yes/No 11.Check the type of respirator you will use(you can check more than one category): a. N, R,or P disposable respirator(filter-mask,non-cartridge type only). b. Other type(for example,half-or full-facepiece type,powered-air purifying,supplied-air,self-contained breathing apparatus). 12. Have you worn a respirator(circle one): Yes/No If"yes,"what type(s): Part A.Section 2. (Mandatory)Questions 1 through 9 below must be answered by every employee who has been selected to use any type of respirator(please circle yes"or"no"). 1.to you currently smoke tobacco,or have you smoked tobacco in the last month: Yes/No 2, Have you ever had any of the following conditions? a. Seizures: Yes/No b. Diabetes(sugar disease):Yes/No c.Allergic reactions that interfere with your breathing: Yes/No d.Claustrophobia(fear of closed-in places):Yes/No e.Trouble smelling odors:Yes/No 3. Have you ever had any of the following pulmonary or lung problems? a.Asbestosis:Yes/No b.Asthma: Yes/No c.Chronic bronchitis:Yes/No d. Emphysema:Yes/No e. Pneumonia: Yes/No f.Tuberculosis:Yes/No g.Silicosis: Yes/No h. Pneumothorax(collapsed lung): Yes/No i. Lung cancer:Yes/No j.Broken ribs:Yes/No k.Any chest injuries or surgeries: Yes/No I.Any other lung problem that you've been told about: Yes/No 4. Do you currently have any of the following symptoms of pulmonary or lung illness? a.Shortness of breath:Yes/No b.Shortness of breath when walkng fast on level ground or walking up a slight hill or incline:Yes/No c.Shortness of breath when walking with other people at an ordinary pace on level ground:Yes/No d. Have to stop for breath when walking at your own pace on level ground:Yes/No e.Shortness of breath when washing or dressing yourself:Yes/No Shortsess of bread-,that interferes with your job:Yes/No g. Coughing that produces phlegm(thick sputum):Yes/No h. Coughing that wakes you early in the morning:Yes/No I.Coughing that occurs mosey when you are lying down: Yes/No j.Coughing up blood in the last month:Yes/No k.Wheezing:Yes/No I.Wheezing that interferes with your job:Yes/No m.Chest pain when you breathe deeply:Yes/No n.A,y dtller symptoms that you think may be related to lung problems:Yes/No 5.Have you ever had any of the following cardiovascular or heart problems? a. Heart attack:Yes/No b.Stroke:Yes/No c.Angina:Yes/No d.Heart failure:Yes/No e. Swelling in your legs or feet(not caused by walking): Yes/No f, Heart arrhythmia(heart beating irregularly): Yes/No g.High blood pressure:Yes/No h.Any other heart problem that you've been told about: Yes/No 6. Have you ever had any of the following cardiovascular or heart symptoms? a. Frequent pain or tightness in your chest: Yes/No b. Pain or tightness in your chest during physical activity:Yes/No c.Pain or tightness in your chest that interferes with your job: Yes/No d.In the past two years,have you noticed your heart skipping or missing a beat: Yes/No e. Heartburn or indigestion that is not related to eating: Yes/No O.Any other symptoms that you think may be related to heart or circulation problems: Yes/No 7.Do you currently take medication for any of the following problems? a.Breathing or lung problems: Yes/No b.Heart trouble: Yes/No c.Blood pressure:Yes/No d.Seizures:Yes/No 8.If you've used a respirator,have you ever had any of the following problems?(If you've never used a respirator,check the following space and go to question 9:) a. Eye irritation:Yes/No b. Skin allergies or rashes: Yes/No c.Annety: Yes/No d.Generakweakness or fatigue:Yes/No e.Any other problem that interferes with your use of a respirator:Yes/No 9.Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire: Yes/No Questions 10 to 15 below must be answered by every employee who has been selected to use either a full-facepiece respirator or a self-contained breathing apparatus(SCBA). For employees who have been selected to use other types of respirators,answering these questions is voluntary. 10.Have you ever lost vision in either eye(temporarily or permanently):Yes/No 11. Do you currently have any of the following vision problems? a.Wear contact lenses:Yes/No b.Wear glasses:Yes/No c.Color blind:Yes/No d.Any other eye or vision problem:Yes/No 12.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:Yes/No b.Wear a hearing ard:Yes/No c.Any other hearing or ear problem:Yes/No 14.Have you ever had a back injury:Yes/No 15,Do you currently have any of the following musculoskeletal problems? a.Weakness in any of your arms, hands, legs,or feet:Yes/No b. Back pain: Yes/No c. Difficulty fully moving your arms and legs:Yes/No d. Pain or stiffness when you lean forward or backward at the waist:Yes/No e. Difficulty fully moving your head up or down:Yes/No f.Difficulty fully moving your head side to side: Yes/No g. Difficulty bending at your knees:Yes/No h. Difficulty squatting to the ground:Yes/No i.Climbing a flight of stairs or a ladder carrying more than 25 Ibs: Yes/No j.Any other muscle or skeletal problem that interferes with using a respirator: Yes/No Part B Any of the following questions,and other questions not Ilsted, may be added to the questionnaire at the discretion of the health care professional who will review the questionnaire. 1.In your present job,are you working at high altitudes(over 5,000 feet)or in a place that has lower than normal amounts of oxygen: Yes/No If"yes,"do you have feelings of dizziness,shortness of breath,pounding in your chest,or other symptoms when you're working under these conditions: Yes/No 2.At work or at home,have you ever been exposed to hazardous solvents, hazardous airborne chemicals(e.g.,gases,fumes,or dust),or have you come into skin contact with hazardous chemicals:Yes/No If"yes,'name the chemicals if you know tern: _ 3.Nave-you ever worked-with any of the materials,or under any of the conditions,listed below: a.Asbestos: Yes/No b. Silica(e.g.,in sandblasting):Yes/No c.Tungsten/cobalt(e.g., grinding or welding this material):Yes/No d. Beryllium:Yes/No e.Aluminum:Yes/No f.Coal(for example,mining): Yes/No g. Iron: Yes/No h'Tin': 'Yes/via Dusty environments:Yes/No j.Any other hazardous exposures:Yes/No If"yes,"describe these exposures: 4.fist any second jobs or side businesses you have: 5.List your previous occupations: 6. List your current and previous hobbies: 7.Have you been in the military services?Yes/No If"yes,"were you exposed to biological or chemical agents(either in training or combat):Yes/No B. Have you ever worked on a HAZMAT team?Yes/No 9.Other than medications for breathing and lung problems, heart trouble,blood pressure,and seizures mentioned earlier in this questionnaire,are you taking any other medications for any reason(including over-the-counter medications): Yes/No If"yes,"name the medications if you know them: 10.Will you be using any of the following items with your respirator(s)? a, HEPA Filters: Yes/No b.Canisters(for example,gas masks):Yes/No c.Cartridges:Yes/No 11.How often are you expected to use the respirator(s)(circle"yes"or"no"for all answers that apply to you)?: a. Escape only(no rescue):Yes/No b. Emergency rescue only:Yes/No c. Less than 5 hours per week: Yes/No d. Less than 2 hours per day:Yes/No e. 2 to 4 hours per day:Yes/No f.Over 4 hours per day:Yes/No 12. During the period you are using the respirator(s),is your work effort: a. Light(less than 200 kcal per hour):Yes/No If"yes,"how long does this period last during the average shift, hrs. mins. Examples of a light work effort are sitting while writing,typing,drafting,or performing light assembly work; or standing while operating a drill press(1-3 lbs.)or controlling machines. b.Moderate(200 to 350 kcal per hour): Yes/No If"yes,"how long does this period last during the average shift: _hrs. mins. Examples of moderate work effort are sitting while nailing or filing;driving a truck or bus in urban traffic; standing while drilling,nailing, performing assembly work, or transferring a moderate load(about 35 lbs.)at trunk level;walking on a level surface about 2 mph or down a 5-degree grade about 3 mph;or pushing a wheelbarrow wit a heavy load(about 100 lbs.)on a level surface.c.Heavy(above 350 kcal per hour): Yes/No Ir'yeip"hoyw long does this period last during the average shift: _. hrs. mins. Examples of heavy work are lifting a heave load(about 50 lbs.)from the floor to your waist or shoulder;working on a loading dock; shoveling; standing while bricklaying or chipping castings;walking up an 8-degree grade about 2 mph; climbing stairs with a heavy load(about 50 lbs.). 13.Will you be wearing protective clothing and/or equipment(other than the respirator)when you're using your respirator:Yes/No If'yes;'describe this protective clothing and/or equipment__... —— 14.Will you be working under hot conditions(temperature exceeding 7/deg.F):Yes/No 15.Will you be working under humid conditions: Yes/No 16. Describe the work you'll be doing while you're using your respirator(s): 17. Describe any special or hazardous conditions you might encounter when you're using your respirator(s)(for example,confined spaces,life-threatening gases): 18. Provide the following information,if you know it,for each toxic substance that you'll be exposed to when you're using your respirator(s): Name of the first toxic substance: Estimated maximum exposure level per shift: Duration of exposure per shift: Name of the second toxic substance: Estimated maximum exposure level per shift: Duration of exposure per shift: ...__— Name of the third toxic substance: Estimated maximum exposure level per shift: Duration of exposure per shift: The name of any other toxic substances that you'll be exposed to while using your respirator: 19. Describe any special responsibilities you'll have while using your respirator(s)that may affect the safety and well-being of others(for example,rescue, security); (63 FR 1152,Jan,8, 1998; 63 FR 20098,April 23, 1998; 76 FR 33607,June 8,2011; 77 FR 46949,Aug 7, 2012] 0 Next Standard(1910.134 App co ©Regulations(Standards-29 CFR)-Table of Contents Freedom of Information Act I Privacy&Security Statement I Disclaimers I Important Web Site Notices I International I Contact Us U.S.Department of Labor I Occupational Safety&Health Administration 200 Constitution Ave.,NW,Washington,DC 20210 Telephone:800-321-0SHA(6742) I IN wwvv.OSHA yov RESPIRATOR USE PHYSICAL NAME: AGE: SEX: HOME ADDRESS: TELEPHONE: OCCUPATION: i agree to the release of thisirrifomrationforthe State and Federal regulatory purposes to the extent provided by applicable laws DATE SIGNED EMPLOYER (]Follow-up Medical Evaluation Physical Required.(positive response-questions 1-8) EPost-Offer Physical:Medical Evaluation.Physical Required PLHCP Follow UP Medical Examination NAME: Recommendations about employee use of the respirator:Limitations- Job Title: Date Of this Follow Up App: _. Reasons for follow-up Actions Need for follow-up evaluations- Signed: Date Signed copy of recommendation give to employee? ❑ yes ❑ no Date Given: t ' RESPIRATOR USE PHYSICAL See Attached Job Description NAME: AGE: SEX: HOME ADDRESS: TELEPHONE: OCCUPATION: I agree to Ih �ie of this informs[ion for State and Federal regulatory purposes DATE SIGNED CARDIO-PULMONARY EXAMINATION HEIGHT: WEIGHT: HEART: MURMERS: RATE: RHYTHM: ENLARGMENT: LUNGS: PULMONARY FUNCTION WITHIN NORMAL LIMITS: OUTSIDE NORMAL LIMITS: PA CHEST X-RAY: WITHIN NORMAL LIMITS: OUTSIDE NORMAL LIMITS: RECCOMENDATIONS It is my opinion that the above named patient is or is not medically qualified to wear a respirator in the performance of his/her duties PHYSICIAN