FY2017 10/19/2016AMY REAVILIN, CPA
CLERK OF CIRCUIT COURT &COMPTROLLER
MONROE COUNTY, FLORIDA
DATE: December 8, 2016
TO: Laura DeLoach-Hartle
Sr. Administrator Grants & Special Projects
FROM: Cheryl Robertson Executive Aide to the Clerk of Court & Comptroller a %_
At the October 19, 2016 Board of County Commissioner's meeting the Board granted approval and
authorized execution of the following item C38 Approval of agreements with Guidance/Care Center for
FYI Baker Act Transportations Services, Community Transportation for the Disadvantaged, the Substance
Abuse Mental Health local match funding and the Jail In -House Program. (a & b).
cc: County At*orney
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 Fax: 305-289-6025
88820 Overseas Highway, Plantation Key, FL 33070 Phone: 852-7145 Fax: 305-852-7146
AGREEMENT
This Agreement is made and entered into this 19th day of October, 2016, between the
BOARD OF COUNTY COMMISSIONERS OF MONROE COUNTY, FLORIDA, hereinafter referred to as
"Board" or "County," and the Guidance/Care Center, hereinafter referred to as "Provider."
WHEREAS, the PROVIDER is a not -for -profit corporation established to provide
transportation services to the citizens of Monroe County, and
WHEREAS, it is a legitimate public purpose to provide transportation services to the
residents of Monroe County, now, therefore,
IN CONSIDERATION of the mutual promises and covenants contained herein, it is agreed
as follows:
FUNDING
1. AMOUNT OF AGREEMENT. The Board, in consideration of the PROVIDER substantially
and satisfactorily performing and carrying out the duties of the Board, shall reimburse the
PROVIDER for providing transportation services as billed by the PROVIDER for clients qualifying
for such services under applicable state and federal regulations and eligibility determination
procedures. The cost shall not exceed a total reimbursement of ONE HUNDRED NINETY-TWO
THOUSAND THREE HUNDRED FIFTY-FIVE DOLLARS ($192,355.00), during the fiscal year 2016-
2017, payable as follows:
a) the sum of ONE HUNDRED FORTY FIVE THOUSAND DOLLARS ($145,000.00) for Baker Act
transportation services pursuant to Chapter 394, Florida Statutes; and
b) the sum of FORTY-SEVEN THOUSAND THREE HUNDRED FIFTY-FIVE DOLLARS
($47,355.00), for Community Transportation Coordinator -related transportation services to
residents of Monroe County.
2. TERM. This Agreement shall commence on October 1, 2016, and terminate September
30, 2017, unless earlier terminated pursuant to other provisions herein.
3. PAYMENT. Payment for Baker Act and Marchman Act transportation services shall be
made according to the rate schedule set forth in Attachment D, subject to the maximum amounts
set forth in Paragraph 1. a. above. Billing Summary Forms, certified monthly financial and service
load reports will be made available to the Board to validate the delivery of services under this
contract. The monthly financial report is due in the office of the Clerk of the Board no later than
the 15th day of the following month. After the Clerk of the Board pre -audits the certified report,
the Board shall reimburse the Provider for its monthly expenses. However, the total of said
monthly payments in the aggregate sum shall not exceed the total amount shown in Paragraph 1,
above, during the term of this agreement. To preserve client confidentiality required by law,
copies of individual client bills and records shall not be available to the Board for reimbursement
purposes but shall be made available only under controlled conditions to qualified auditors for
audit purposes. The organization's final invoice must be received within thirty days after the
termination date of this contract shown in Paragraph 2 above.
Payment will be made periodically, but no more frequently than monthly, as hereinafter
set forth. Reimbursement requests will be submitted to the Board via the Clerk's Finance Office.
The County shall only reimburse, subject to the funded amounts below, those reimbursable
expenses which are reviewed and approved as complying with Monroe County Code of
Ordinances, State laws and regulations and Attachment A - Expense Reimbursement
Requirements. Evidence of payment by the PROVIDER shall be in the form of a letter,
summarizing the expenses, with supporting documentation attached. The letter should contain a
Guidance Care Center -Transportation: Baker Act and CTD FYI 7; page 1
notarized certification statement. An example of a reimbursement request cover letter is included
as Attachment B. The organization's final invoice must be received within thirty days after the
termination date of this contract shown in Article 2 above.
After the Clerk of the Board examines and approves the request for reimbursement, the
Board shall reimburse the PROVIDER. However, the total of said reimbursement expense
payments in the aggregate sum shall not exceed the total amount shown in Paragraph 1, above,
during the term of this agreement.
4. AVAILABILITY OF FUNDS. If funds cannot be obtained or cannot be continued at a
level sufficient to allow for continued reimbursement of expenditures for services specified herein,
this agreement may be terminated immediately at the option of the Board by written notice of
termination delivered to the PROVIDER. The Board shall not be obligated to pay for any services
or goods provided by the PROVIDER after the PROVIDER has received written notice of
termination, unless otherwise required by law.
S. CLAIMS FOR FEDERAL OR STATE AID. PROVIDER and County agree that each shall
be, and is, empowered to apply for, seek, and obtain federal and state funds to further the
purpose of this Agreement; provided that all applications, requests, grant proposals, and funding
solicitations shall be approved by each party prior to submission.
6. PURCHASE OF PROPERTY. All property, whether real or personal, purchased with
funds provided under this agreement, shall become the property of Monroe County and shall be
accounted for pursuant to statutory requirements.
RECORDKEEPING
7. RECORDS. PROVIDER 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 PROVIDER pursuant to this Agreement were spent for purposes not authorized by
this Agreement, the PROVIDER shall repay the monies together with interest calculated pursuant
to Sec. 55.03, F.S., running from the date the monies were paid to PROVIDER.
In addition, if PROVIDER is required to provide an audit as set forth in in Section 9(e) below, the
audit shall be prepared by an independent certified public accountant (CPA) with a current
license, in good standing with the Florida State Board of Accountancy, and maintain malpractice
insurance covering the audit services provided. If the PROVIDER receives $100,000 or more in
grant funding from the County, the CPA must also be a member of the American Institute of
Certified Public Accountant (AICPA). The County shall be considered an "intended recipient" of
said audit.
S. PUBLIC ACCESS. The County and PROVIDER 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 PROVIDER in conjunction with this Agreement; and the County shall have the
right to unilaterally cancel this Agreement upon violation of this provision by PROVIDER.
Pursuant to F.S. 119.0701, PROVIDER and its subcontractors shall comply with all public records
laws of the State of Florida, including but not limited to:
(a) Keep and maintain public records that ordinarily and necessarily would be required by
Monroe County in order to perform the service.
Guidance Care Center —Transportation: Baker Act and CTD FY17, page 2
(b) Provide the public with access to public records on the 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.
(c) Ensure that public records that are exempt or confidential and exempt from public records
disclosure requirements are not disclosed except as authorized by law.
(d) 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 the contract 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.
9. COMPLIANCE WITH COUNTY GUIDELINES. The PROVIDER must furnish to the
County the following (items A-J must be provided prior to the payment of any invoices):
(a) IRS Letter of Determination and GUIDESTAR printout indicating current 501(c)(3) status;
(b) Proof of registration with the Florida Department of Agriculture as required by Florida
Statute 496.405 and the Florida Department of State as require by Florida Statute
617.01201 or proof of exemption from registration as per Florida Stature 496.406.
(c) List of the Organization's Board of Directors of which there must be at least 5 and for each
board member please indicate when elected to serve and the length of term of service;
(d) Evidence of annual election of Officers and Directors;
(e) Unqualified audited financial statement from the most recent fiscal year for all
organizations that expend $150,000 a year or more; if qualified, include a statement of
deficiencies with corrective actions recommended/taken;
1. If the PROVIDER receives $100,000 or more in grant funding from the County
an audit shall be prepared by an independent certified public accountant (CPA):
a. The CPA must have a current license, in good standing with the Florida
State Board of Accountancy;
b. The CPA must be a member of the American Institute of Certified Public
Accountant (AICPA);
c. The CPA must maintain malpractice insurance covering the audit services
provided and
d. The County shall be considered an "intended recipient" of said audit."
(f) Copy of a filed IRS Form 990 from most recent fiscal year with all attached schedules;
(g) Organization's Corporate Bylaws, which must include the organization's mission, board and
membership composition, and process for election of officers;
(h) Organization's Policies and Procedures Manual which must include hiring policies for all
staff, drug and alcohol free workplace provisions, and equal employment opportunity
provisions;
(i) Specific description or list of services to be provided under this contract with this grant
(see Attachment C);
(j) Annual Performance Report describing services rendered during the most recently
completed grant period (to be furnished within 30 days after the contract end date.) The
performance report shall include statistical information regarding the types and
frequencies of services provided, a profile of clients (including residency) and numbers
served, and outcomes achieved (see Attachment G);
(k) Cooperation with County monitoring visits that the County may request during the contract
year; and
(I) Other reasonable reports and information related to compliance with applicable laws,
contract provisions and the scope of services that the County may request during the
contract year.
Guidance Care Center -Transportation: Baker Act and CTD FYI 7; page 3
RESPONSIBILITIES
10. SCOPE OF SERVICES. The Provider, for the consideration named, covenants and
agrees with the Board to substantially and satisfactorily perform and carry out the duties of the
Board in rendering counsel in the matter of mental health and guidance to the citizens of the
Monroe County, Florida. The Provider shall provide Baker Act transportation services in
compliance with Florida Statutes Chapter 394. Baker Act and Marchman Act transportation
services which are covered under this agreement may be subcontracted, but are subject to the
rates set forth in Attachment D, and the limitations above. The subcontractor shall be subject to
all of the conditions of this contract, including but not limited to insurance and hold -harmless
requirements, as is the Provider.
11. ACCESS TO FUELING FACILITIES. The County shall provide access to the
Provider's vehicles at all County fueling facilities. The County shall grant the Provider a license for
the use of the real property and its improvements for each fueling site.
The Provider agrees that only those individuals authorized by the County to use the fueling
sites designated in this agreement shall have twenty-four hour access to said sites, and that they
shall either be maintained open or access otherwise provided to them by a uniform key system on
such a twenty-four hour basis.
The County shall bill the Provider for fueling and other related services and materials
utilized by the Provider at the fueling sites within the County's immediate control and as
previously set forth in this agreement. Said billing by the County to the Provider shall include an
administrative surcharge, as adopted by the Monroe County Board of County Commissioners
annually, for processing, servicing, and handling. The Provider shall reimburse the County within
thirty (30) days of the date of issuance of the bill.
Access to the Fuel Sentry System shall be provided by an electronic memory key, which
shall be issued by the County to all authorized designated users of the fueling sites, and as
contemplated by this Agreement. For purposes of uniformity, the Monroe County Fleet
Management Department shall be responsible for establishing a uniform electronic key system for
use by both the County and the Provider under this agreement, and shall establish and maintain
policies and procedures for identification, control, and distribution of all keys issued.
12. ATTORNEY'S FEES AND COSTS. The County and PROVIDER 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, court costs, investigative, and out-of-pocket expenses, as an award
against the non -prevailing party, and shall include attorney's fees, courts costs, investigative, and
out-of-pocket expenses in appellate proceedings. 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.
13. BINDING EFFECT. The terms, covenants, conditions, and provisions of this
Agreement shall bind and inure to the benefit of the County and PROVIDER and their respective
legal representatives, successors, and assigns.
14. 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.
Guidance Care Center -Transportation: Baker Act and CTD FYI 7; page 4
15. NO SOLICITATION/PAYMENT. The County and PROVIDER 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 PROVIDER 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.
16. INDEPENDENT CONTRACTOR. At all times and for all purposes hereunder, the
PROVIDER is an independent contractor and not an employee of the Board. No statement
contained in this agreement shall be construed so as to find the PROVIDER or any of its
employees, contractors, servants or agents to be employees of the Board.
COMPLIANCE ISSUES
17. COMPLIANCE WITH LAW. In providing all services pursuant to this agreement, the
PROVIDER shall abide by all statutes, ordinances, rules and regulations pertaining to or regulating
the provision of such services, including those now in effect and hereinafter adopted. Any
violation of said statutes, ordinances, rules and regulations shall constitute a material breach of
this agreement and shall entitle the Board to terminate this contract immediately upon delivery of
written notice of termination to the PROVIDER.
18. PROFESSIONAL RESPONSIBILITY AND LICENSING. The PROVIDER shall assure
that all professionals have current and appropriate professional licenses and professional liability
insurance coverage. Funding by the Board is contingent upon retention of appropriate local, state
and/or federal certification and/or licensure of the PROVIDER'S program and staff.
19. NON-DISCRIMINATION. County and PROVIDER 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. County or PROVIDER 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 VI of the Civil Rights Act of 1964 (PL 88-352) which prohibits discrimination on the basis of
race, color or 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 92-255), 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 s. 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 Note), as maybe amended from time to time, relating to
nondiscrimination on the basis of disability; 10) Any other nondiscrimination provisions in any
Federal or state statutes which may apply to the parties to, or the subject matter of, this
Agreement.
AMENDMENTS, CHANGES, AND DISPUTES
Guidance Care Center —Transportation: Baker Act and CTD FY17; page 5
20. MODIFICATIONS AND AMENDMENTS. Any and all modifications of the services
and/or reimbursement of services shall be accomplished by an amendment, which must be
approved in writing by the COUNTY.
21. AD3UDICATION OF DISPUTES OR DISAGREEMENTS. County and PROVIDER
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 no resolution can be agreed upon
within 30 days after the first meet and confer session, the issue or issues shall be discussed at a
public meeting of the Board of County Commissioners. 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.
22. 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 PROVIDER 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 PROVIDER
specifically agree that no party to this Agreement shall be required to enter into any arbitration
proceedings related to this Agreement.
ASSURANCES
23. COVENANT OF NO INTEREST. County and PROVIDER 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.
24. NO ASSIGNMENT. The PROVIDER shall not assign this agreement except in writing
and with the prior written approval of the Board, which approval shall be subject to such
conditions and provisions as the Board may deem necessary. This agreement shall be
incorporated by reference into any assignment and any assignee shall comply with all of the
provisions herein. Unless expressly provided for therein, such approval shall in no manner or
event be deemed to impose any obligation upon the Board in addition to the total agreed upon
reimbursement amount for the services of the PROVIDER.
25. NON -WAIVER OF IMMUNITY. Notwithstanding the provisions of Sec. 768.28,
Florida Statutes, the participation of the County and the PROVIDER 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 contract entered into by the County be required to
contain any provision for waiver.
26. ATTESTATIONS. PROVIDER agrees to execute such documents as the County may
reasonably require, to include a Public Entity Crime Statement, an Ethics Statement, and a Drug -
Free Workplace Statement.
27. 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.
INDEMNITY ISSUES
28. INDEMNIFICATION AND HOLD HARMLESS. The PROVIDER 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
Guidance Care Center -Transportation: Baker Act and CTD FY17; page 6
attorney's fees) which arise out of, in connection with, or by reason of services provided by the
PROVIDER occasioned by the negligence, errors, or other wrongful act or omission of the
PROVIDER'S employees, agents, or volunteers.
29. 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.
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.
31. 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.
32. 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 PROVIDER agree that neither the County nor the PROVIDER 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.
GENERAL
33. 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.
34. NOTICE. Any notice required or permitted under this agreement shall be in writing
and hand -delivered or mailed, postage pre -paid, by certified mail, return receipt requested, to the
other party as follows:
For Board:
Grants Administrator and Monroe County Attorney
1100 Simonton Street PO Box 1026
Key West, FL 33040 Key West, FL 33041
For PROVIDER
Frank Rabbito, Senior Vice President
Guidance/Care Center Inc.
Guidance Care Center -Transportation: Baker Act and CTD FY17; page 7
1205 Fourth Street
Key West, Florida 33040
3S. 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 contracts 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 PROVIDER agree that venue will
lie in the appropriate court or before the appropriate administrative body in Monroe County,
Florida.
The County and PROVIDER agree that, in the event of conflicting interpretations of the
terms or a term of this Agreement by or between any of them the issue shall be submitted to
mediation prior to the institution of any other administrative or legal proceeding.
36. NON -WAIVER. Any waiver of any breach of covenants herein contained to be kept
and performed by the PROVIDER shall not be deemed or considered as a continuing waiver and
shall not operate to bar or prevent the Board from declaring a forfeiture for any succeeding
breach, either of the same conditions or covenants or otherwise.
37. 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 PROVIDER 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.
38. ENTIRE AGREEMENT. This agreement constitutes the entire agreement of the
parties hereto with respect to the subject matter hereof and supersedes any and all prior
agreements with respect to such subject matter between the PROVIDER and the Board.
[THIS SPACE INTENTIONALLY LEFT BLANK WITH SIGNATORY PAGE TO FOLLOW]
Guidance Care Center —Transportation: Baker Act and CTD FYI 7: page 8
IN WITNESS WHEREOF, the parties hereto have caused these presents to be executed as
of the day and year first written above.
HEAVILIN, CLERK
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Guidance Care Center —Transportation: Baker Act and CTD FY17; page 9
BOARD OF COUN COMMISSIONERS
OF MONROE Co TY, F RIDA
By-
/May6pfrChairman
GUIDANCE/CARE CENTER
(Federal ID No. S t ^)'f5032q )
By _
Di rector
Guidance/Care Center
MONROE COUNTY ATTORNEY
APPROVED AS TO FORM:
C®RIS41C RISTI M. LIMBERT-BARROWS
ASSIST T C UNTY ATTORNEY
Date
ATTACHMENT A
EXPENSE REIMBURSEMENT REQUIREMENTS
This document is intended to provide basic guidelines to Human Service and Community -Based
Organizations, county travelers, and contractual parties who have reimbursable expenses
associated with Monroe County business. These guidelines, as they relate to travel, are from the
Monroe County Code of Ordinances and State laws and regulations.
A cover letter (see Attachment B) summarizing the major line items on the reimbursable expense
request needs to also contain the following notarized certified statement:
"I certify that the above checks have been submitted to the vendors as noted and that the
attached expenses are accurate and in agreement with the records of this organization.
Furthermore, these expenses are in compliance with this organization's contract with the Monroe
County Board of County Commissioners and will not be submitted for reimbursement to any other
funding source."
Invoices should be billed to the contracting agency. Third party payments will not be considered
for reimbursement. Remember, the expense should be paid prior to requesting a reimbursement.
Only current charges will be considered, no previous balances.
Reimbursement requests will be monitored in accordance with the level of detail in the contract.
This document should not be considered all-inclusive. The Clerk's Finance Department reserves
the right to review reimbursement requests on an individual basis. Any questions regarding these
guidelines should be directed to 305-292-3534.
Data Processing, PC Time, etc.
The vendor invoice is required for reimbursement. Inter -company allocations are not considered
reimbursable expenditures unless appropriate payroll journals for the charging department are
attached and certified.
Payroll
A certified statement verifying the accuracy and authenticity of the payroll expense is needed. If
a Payroll Journal is provided, it should include: dates, employee name, salary or hourly rate, total
hours worked, withholding information and paid payroll taxes, check number and check amount.
If a Payroll Journal is not provided, the following information must be provided: pay period, check
amount, check number, date, payee, and support for applicable paid payroll taxes.
Postage, Overnight Deliveries, Courier, etc.
A log of all postage expenses as they relate to the County contract is required for reimbursement.
For overnight or express deliveries, the vendor invoice must be included.
Rents, Leases, etc.
A copy of the rental or lease agreement is required. Deposits and advance payments are not
allowable expenses.
Reproductions, Copies, etc.
A log of copy expenses as they relate to the County contract is required for reimbursement. The
log must define the date, number of copies made, source document, purpose, and recipient. A
reasonable fee for copy expenses will be allowable. For vendor services, the vendor invoice and a
sample of the finished product are required.
Supplies, Services, etc.
For supplies or services ordered, a vendor invoice is required.
Guidance Care Center —Transportation: Baker Act and CTD FY17; page 10
Telefax, Fax, etc.
A fax log is required. The log must define the sender, the intended recipient, the date, the
number called, and the reason for sending the fax.
Telephone Expenses
A user log of pertinent information must be remitted including: the party called, the caller, the
telephone number, the date, and the purpose of the call.
Travel and Meal Expenses
Travel expenses must be submitted on a State of Florida Voucher for Reimbursement of Travel
Expenses. Travel reimbursement requests must be submitted and will be paid in accordance with
Monroe County Code of Ordinances and State laws and regulations. Credit card statements are
not acceptable documentation for reimbursement. If attending a conference or meeting, a copy
of the agenda is needed. Airfare reimbursement requires the original passenger receipt portion of
the airline ticket. A travel itinerary is appreciated to facilitate the audit trail. Auto rental
reimbursement requires the vendor invoice. Fuel purchases should be documented with paid
receipts. Taxis are not reimbursed if taken to arrive at a departure point: for example, taking a
taxi from one's residence to the airport for a business trip is not reimbursable. Parking is
considered a reimbursable travel expense at the destination. Airport parking during a business
trip is not.
A detailed list of charges is required on the lodging invoice. Balance due must be zero. Room
must be registered and paid for by traveler. The County will only reimburse the actual room and
related bed tax. Room service, movies, and personal telephone calls are not allowable expenses.
Mileage reimbursement shall be at the rate established by ARTICLE XXVI, TRAVEL, PER DIEM,
MEALS, AND MILEAGE POLICY of the Monroe County Code of Ordinances. An odometer reading
must be included on the state travel voucher for vicinity travel. Mileage is not allowed from a
residence or office to a point of departure. For example, driving from one's home to the airport
for a business trip is not a reimbursable expense.
Meal reimbursement shall be at the rates established by ARTICLE XXVI, TRAVEL, PER DIEM,
MEALS, AND MILEAGE POLICY of the Monroe County Code of Ordinances. Meal guidelines state
that travel must begin prior to 6 a.m. for breakfast reimbursement, before noon and end after 2
p.m. for lunch reimbursement, and before 6 p.m. and end after 8 p.m. for dinner reimbursement.
Non -allowable Expenses
The following expenses are not allowable for reimbursement: capital outlay expenditures (unless
specifically included in the contract), contributions, depreciation expenses (unless specifically
included in the contract), entertainment expenses, fundraising, non -sufficient check charges,
penalties and fines.
Guidance Care Center —Transportation: Baker Act and CTD FY17; page 11
ATTACHMENT B
ORGANIZATION
LETTERHEAD
Monroe County Board of County Commissioners
Finance Department
500 Whitehead Street
Key West, FL 33040
Date
The following is a summary of the expenses for (Organization name) for the time period
of to
Check #
Payee
Reason
Amount
101
Company A
Rent
$ X,XXX.XX
102
Company B
Utilities
XXX.XX
104
Employee A
P/R ending 05/14/01
XXX.XX
105
Employee B
P/R ending 05/28/01
XXX.XX
(A) Total $ x,xxx.xx
(B) Total prior payments $ X,XXX.XX
(C) Total requested and paid (A + B)
(D) Total contract amount
Balance of contract (D-C)
$ X,XXX.XX
$ X,XXX.XX
�X.XXX.XX
I certify that the above checks have been submitted to the vendors as noted and that the
expenses are accurate and in agreement with the records of this organization. Furthermore,
these expenses are in compliance with this organization's contract with the Monroe County Board
of County Commissioners and will not be submitted for reimbursement to any other funding
source.
Executive Director
Attachments (supporting documentation)
Sworn to and subscribed before me this
who is personally known to me.
Notary Public
day of 20_ by
Notary Stamp
Guidance Care Center -Transportation: Baker Act and CTD FY17; page 12
ATTACHMENT C
Services to be provided:
Baker Act/Marchman Act transportation services and Community Transportation
Coordinator related services.
Guidance Care Center —Transportation: Baker Act and CTD FY17; page 13
ATTACHMENT D
Copy of the Sub -Contract for Baker Act transportation services. See attached.
Guidance Care Center —Transportation: Baker Act and CTD FYI 7, page 14
GUIDANCE/CARE CENTER, INC.
3000 41ST STREET, OCEAN
MARATHON, FL 33050
(v) 305/434-7660 / (f) 305/434-9040
September 15, 2016
Lee Connell
800 14th Street
Key West, FL 33040
RE: LETTER OF AGREEMENT 2016-2017
Dear Mr. Connell:
The Guidance/Care Center, Inc. (G/CC) hereby enters into an agreement with Elanjess LLC
to provide coordination and transportation services for Baker Act/Marchman Act (BA/MA)
clients throughout Monroe County to/from Miami -Dade County as well as other destinations.
The terms and conditions of this agreement are effective October 1, 2016, and will continue
through September 30, 2017.
G/CC will supply Elanjess with two Ford Crown Victoria vehicles, meeting Elanjess
maintenance specifications; one to be stationed in Key West at an Elanjess location and the
other in Marathon at G/CC headquarters.
G/CC will pay for the fuel and maintenance of the two vehicles used for BA/MA
transportation. Elanjess will coordinate the maintenance for the Crown Victoria located in
Key West. Invoices for routine maintenance (labor and parts) on the Crown Victoria will be
forwarded quarterly to G/CC's Transportation Coordinator for payment. Elanjess will not
charge an extra fee for coordinating the maintenance of the vehicle. Elanjess must obtain
prior approval from the G/CC Transportation Coordinator to initiate major vehicle repairs.
G/CC will coordinate the maintenance for the Crown Victoria located in Marathon.
G/CC will maintain insurance on both of the vehicles. Elanjess will also be named as an
"additional insured" for these two cars. All Elanjess drivers operating G/CC vehicles will hold
a minimum of a Class E Florida Driver's License and be approved for G/CC insurance
coverage by the Transportation Coordinator. Upon execution of this agreement, Elanjess will
fax/email to G/CC's Transportation Coordinator a current list of drivers - including a copy of
the driver's license and social security number for each driver - for approval to operate G/CC
vehicles. Prior to adding a driver, Elanjess will fax or email to G/CC's Transportation
Coordinator or designee a copy of the driver's license, social security number and signed
"Request for Check of Driving Record" form of the person. G/CC will initiate procedures to
add the driver to G/CC vehicle insurance. Elanjess cannot use the driver for BA/MA
transports until it has received written notification that the driver has been added to the G/CC
insurance coverage.
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All drivers are required to have at minimum 3-year clean driving record. Additionally,
Elanjess will fax a copy of picture identification and social security number for each escort to
G/CC's Transportation Coordinator or designee. Elanjess cannot use the escort for BA/MA
transports until it has received written notification that the escort has been approved by
G/CC. All BA/MA approved drivers must read and sign the acknowledgement of reading and
receiving (Attachment 1) Transportation Protocol.
Elanjess will report and document accidents involving G/CC vehicles and incidents involving
clients to the proper authorities and immediately thereafter contact G/CC. Following an
accident, GCC Vehicle Incident protocol must be followed. A Vehicle Incident Kit
(Attachment 4) has been provided for each vehicle with instructions. Additionally, anyone
involved in an accident with a GCC vehicle MUST BE DRUG TESTED as soon as possible
following the incident. Drug testing forms are included in the kit.
Any citations received while driving a GCC vehicle will be the responsibility of the driver.
Refusal or failure to accept responsibility for citations may result in removal of driving
privileges.
All drivers will be required to complete a verbal de-escalation training within 30 days of
approval to drive. GCC will provide details for accessing the training which will be available
online. All BA/MA approved drivers must read and sign the acknowledgement of completing
the assigned training (Attachment 5).
Elanjess will follow the transportation protocol and complete the documentation provided as
Attachment 1-3 herein.
Elanjess, upon approval of drivers, will issue an identification badge.
The followina fee structure is established for the period of the agreement:
Estimated
Elanjess
# Roundtri s*
Client Pickup Point
Client Drop-off Point
Pa ment
Key West
Key West
$115
Marathon
Marathon
$115
450
Key West
Marathon
$145
Marathon
Key West
$145
Marathon
Key Largo
$145
Key Largo
Marathon
$145
40
Marathon
Miami -Dade County
$385
Key Largo
Miami -Dade County
$385
40
Key West
Miami -Dade County
$385
G/CC Preauthorization Required for All Trips Below
`Approval for below fees will be granted only when the Marathon BA/MA vehicle is engaged
with another BA/MA trip that would preclude another pickup within a reasonable period of time.
Estimated
Car Client Pickup
Elanjess
# Roundtri s
Location Point
Client Drop-off Point
Payment
5
Key West Marathon & North
Marathon
$145
5
Marathon Key West
Marathon
$145
2
Key West Marathon & North
Key Largo
$225
3
Key West Marathon & North
I Miami -Dade Count
$385
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G/CC Preauthorization Re wired for AH Trips Below
Estimated
Elanjess
# Roundtri s*
Client Pickup Point
Client Drop-off Point
Payment
Key Largo
Avon Park (Area)
$770
1
Marathon
Avon Park (Area)
$770
Key West
Avon Park Area
$770
Key Largo
Up -State (McClenny Area)
$1,200
1
Marathon
Up -State (McClenny Area)
$1,200
Key West
Up-State(McClenny Area
$1,200
Timely payment for services rendered is ensured by adherence to the following invoicing
procedures:
• Elanjess will submit one statements/invoice per month, within 5 business days after
the end of the billing period.
• Elanjess will include required documentation with each statement/invoice.
• Elanjess statements/invoices for BA/MA trips will be submitted to the attention of
G/CC Inpatient Unit Coordinator.
• G/CC's Inpatient Unit Coordinator will review statement/invoice, mediate any
discrepancies with Elanjess, and forward approved invoice to G/CC Finance
Department.
• Elanjess will submit vehicle maintenance bills for the KW car quarterly to the
Transportation Coordinator
• G/CC will mail payment to Elanjess within 14 working days (Finance Department)
upon receipt of statement/invoice by the Inpatient Unit Coordinator.
The agreement can be cancelled by either party with 30 days written notice.
G/CC and Elanjess enter into this agreement including Attachments 1-5 by affixing
signatures below:
Maureen emp , NCC, LMHC Date
Area Director, Guidance Care Center
EIS LC Lee- Co wtie l 1 Date
Co -Signer (print name/title)
Date
Attachments:
1. G/CC Transportation Protocol
2. G/CC Transportation Record and Payment Authorization Sheet
3. Statement
4. Vehicle Incident Kit
5. De-escalation attestation
Rvsd/rvwd: Ifm 09*16
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ATTACHMENT 1
GUIDANCE /CARE CENTER TRANSPORTATION PROTOCOL:
THE TRANSPORTATION OF BAKER ACT AND MARCHMAN ACT CLIENTS
A. Client Related Rules:
1. Confidentially of a client and client related information shall be maintained at all
times.
2. Each client shall be treated with respect and dignity at all times.
3. No information with client information shall leave the clinic unless part of a client
transfer packet to a designated facility. (No driver/escort shall maintain a personal
copy of the Transportation Record and Payment Authorization Sheet.)
4. Client transportation within Monroe County may be conducted with a driver and an
escort.
5. Client transportation outside of Monroe County must be made with one driver and
one escort.
6. A client must be observed for any unusual behaviors including hurting self/others or
sudden medical conditions. Respond to a medical emergency by calling 911.
Otherwise, contact the nurse at the transferring (pick-up) facility for consultation.
7. At the time of pick up for a Baker Act or Marchman Act client, a driver must obtain
the original Baker Act or Marchman Act paper work from the Pick Up facility. If the
original paper work is not available the driver must immediately report this
information to the G/CC Nurse on Duty for further instructions.
8. A female client requires a female escort or a female driver.
9. A parent is not allowed to travel in the Baker Act vehicle with a Baker Act or
Marchman Act minor.
• When a parent or other responsible party reports he/she plans to follow the
Baker Act vehicle, the Baker Act driver advises the parent/party that our
primary responsibility is to the child and ensuring the safety of the child
therefore following our vehicle as a method of direction is not encouraged.
10. Only one client may be transported at a time in the Baker Act vehicle.
11. Drivers, Escorts and Clients are not to smoke in the car at any time.
12. Clients are not to be placed in handcuffs or any type of restraints for any reason by a
driver or escort — or to be placed in the vehicle by others (i.e. Law Enforcement) in
handcuffs or any type of restraints
13. A client's movement is not to be impeded with any physical restraint unless directed -
by a nurse/MD/law enforcement officer.
14. If a client is violent during transport and poses a threat to safety, stop the vehicle and
call 911, than notify the Nurse on Duty of the situation at (305) 434-7660 ext. 31123
15. A client shall not be left alone in the vehicle during the trip for any reason.
16. A client shall be under the observation of the driver or escort at all times during the
transport.
17. Client is encouraged to use restroom facilities prior to departure. If the trip is
generated from Key West and a stop is required, the G/CC may be used for that
purpose.
Rvsd/lfm 9.2016
18. A client may not use aluminum/metal cans. Items for drinking shall be provided only
in a plastic container.
19. Clients may not have any metal utensils, glass or other hard products such as
pencils or pens.
20. A client may not shop during a stop. All efforts should be made to avoid stops. If a
stop is required, it should be short and without delay.
21. If a client must use a public facility, the dlient must be escorted to the restroom and
the driver must remain outside the restroom door until the client leaves the restroom.
The driver will remain in conversation with client while the client is in the restroom.
B. Coordination of Transportation Rules:
1. Transportation arrangements for Baker Act and Marchman Act clients are under the
direction of the Unit Nurse on Duty/G/CC per contractual arrangement Elanjess LLC.
No other agency is authorized to contact Elanjess directly for transportation.
2. Final decision for a driver to transport is made by the nurse on duty. The nurse may
request a BAL be conducted or send a drivers/escort home if he/she has a concern.
3. "A driver shall not be permitted or required to drive more than 12 hours in any one
24-hour period, or drive after having been on duty for 16 hours in any one 24-hour
period. "
4. All trips will be made within the approved fee structure.
5. All trips will be made using the closest vehicle and the shortest distance unless
preauthorization is obtained from the Unit Nurse on Duty at the G/CC.
6. Clients may be picked up at only approved locations. The G/CC Nurse on Duty will
communicate the pick up location. Approved locations will include:
Hospitals, Detention Facility
Mental Health Clinics, Anchor Away
With a G/CC staff member
Or otherwise authorized by the G/CC IP Unit Coordinator
7. Depoo Hospital : Pick-up / drop-off is now located in the rear next to the handicap
parking. Upon arrival, call the nurse's station directly from the vehicle at 305-294-
5531 x8330. Hospital staff will escort the client to/from the building.
8. Pick-up / drop-off is at the ER entrance. Upon arrival, call 305-294-5531 x3202.
Hospital staff will escort the client to/from the building.
9. At G/CC: Use the telephone call box next to the elevator.
10. At G/CC, staff members shall place the client in the vehicle for departure and will
assist the client from the vehicle at time of arrival.
11. The facility responsible for the departing client for a trip longer than 2 hours shall
provide a brown bag snack. All minors shall be supplied with a snack for any trip
over 1 hour.
12. When a driver reports a client is too dangerous to transport, the nurse on duty shall
work with the Sheriffs department to transport the client
13. If a client absconds at time of or during transport, immediately report the information
to the G/CC Nurse on Duty. Do not go after the client.
14. Neither Drivers nor Escorts are permitted to physically restrain a client.
15. "Jail Hold" clients from the Monroe County Detention Facility shall be picked up from
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the Sallyport area only. To access the Sallyport area, the driver must drive the car
within 1 foot of the Sallyport entrance. If the door does not open, the escort must use
the speaker mounted on the wall next to the Sallyport entrance to request entrance.
Once inside, Detention Facility staff will bring the client to the car. When the client is
inside the car and the doors are locked, the Sallyport area exit doors will open.
16. The driver/escort must determine from the Pick Up facility if the client has been
searched and encourage staff to conduct a search prior to transport. If the client is
not searched prior to transport, the driver must communicate this information to the
Duty Staff Member prior to opening the client door at the Designation point.
17. Driver/escort MUST respond to the pick up point within a maximum time frame of
1 hour and 15 minutes.
C. Reimbursement related rules
1. All cancelled and otherwise diverted trips will be reported on the Transportation
Record and Payment Authorization Sheet.
2. Transportation Record and Payment Authorization Sheets and a Statement of
services rendered will be faxed to the IP Unit Coordinator on the first and sixteenth
of each month.
3. G/CC does not reimburse Elanjess for cancelled trips. Compensation to the
drivers/escorts for cancelled trips is at the discretion of Elanjess.
4. If the driver arrives without the original Baker or Marchman Act paperwork, Elanjess
will obtain the paper work without charge to the G/CC.
D. Other
1. Drivers must wear their Elanjess issued ID badge at all times
I acknowledge I have received and read the above BA/MA Transportation Protocol.
Driver/Escort Signature
Printed Name
Rvsd/lfm 9.2016
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Date
ATTACHMENT 2
GUIDANCE/CARE CENTER
3000 41ST ST. Ocean
Marathon, FL 33050
Voice 305-434-7660 • Fax 305-434-9040
TRANSPORTATION RECORD AND PAYMENT AUTHORIZATION SHEET
Transportation Type:
Date:
Time Called:
o Baker Act ❑ Marchman Act
Client Name: DOB:
Time of Pick Up:
Time of Drop Off: Time van returned to Duty:
Vehicle: KW vehicle Mar vehicle
Place of Pick Up:
(Where did you pick up the Client: Facility Name/City)
Authorized Staff Signature at Pick Up Facility:
Time:
Destination:
(Where did you take the Client: Facility Name/City)
Authorized Staff Signature at Designation Facility:
Time:
(Staff member accepting client)
Driver Name:
Escort Name:
Beginning Miles:
Drop Off Miles:
FOR G/CC USE ONLY:
Amount to be paid:
Unit Director Signature:
Pick Up Miles:
Ending Miles:
\\westcare.local\Files\FL-GCC\Global Share\Transportation\Baker Act\16-17 elanjess\16-17 Attachment 2 - auth sheet.doc
RVSDO912
Attachment 3
Statement
Date:
Elanjess LLC
800 14th Street
Key West, Florida 33040
Inpatient Unit Coordinator
Guidance/Care Center
3000 41st St. Ocean
Marathon, FL 33050
Re: Baker Act and Marchman Act transportation
The following is a break down for trips from
to
Date Name Pick Up Cost Vehicle
Designation 1 2 13
TOTAL
Elanjess LLC Representative Signature G/CC Finance Director or Designee Signature
\\westcare.local\Files\FL-GCC\Global Share\Transportation\Baker Act\16-17 elanjess\16-17 Attachment 3 -Statement for Elanjes.doc
Rvsd: 10/10 rvwd:0914
Vehicle Incident Kit
Contents:
Vehicle Incident- Protocol and Reporting Policy
Vehicle Incident Report Form
Vehicle Incident- Passenger/Witness Statement Forms*
Vehicle Incident Traffic Diagram
Disposable Camera
12 Pens
*Number of Statement Forms Required is to equal vehicle passenger capacity
plus an additional two for other witnesses.
"Drivers are responsible for making sure this kit is complete at all times.
Vehicle Incident Protocol and Reporting Policy
(Vehicle Incident Kit Copy)
DO IIVEVIEDIATELY:
1. Immediately after the incident, examine and question persons for bodily injury and then
examine vehicle for damage.
2. If there is an accident involving another vehicle or if persons involved require immediate
medical attention, call 911 or 311 accordingly.
3. If involved persons do not report injury, authorities still need to be contacted and a police
report requested. If the request for a police report is declined, the reason and dispatcher name
and badge number need to be noted.
4. After authorities have been called, your supervisor needs to be called.
DO NOT:
1. DO NOT admit fault if you are truly not at fault.
2. DO NOT leave the scene of an accident.
3. DO NOT drive the vehicle if you feel it is unsafe.
4. DO NOT drive the vehicle if you feel physically incapable of driving safely.
5. DO NOT discuss the .incident with anyone other than law enforcement authorities, your
supervisors, or a claims adjuster from York Claims Service Inc.
GATHER INFORMATION & COMPLETE INCIDENT REPORT:
1. An incident will be defined as any occurrence that resulted in damage to the vehicle and/or
injury to any person. Damage to a vehicle will be defined as anything that resulted in the
property not being left in the same condition as before the incident.
2. Locate and complete the Vehicle Incident Form, complete all the information requested
regarding incident and parties involved and take photos of damage with camera provided.
3. All passengers and other available witnesses, if applicable, need to complete the statement
form.
4. After police report has been completed (if it was not declined), persons have been cared for
(if injury occurred), and vehicle is operational, return to the office.
5. Any and all vehicle incidents must also be reported electronically upon return to the office
by attending supervisor by transferring information from Vehicle Incident Form. The
incident report.will be completed online by logging into the Westcare Intranet at
https://secure.westcare.com/intra/.
6. An additional email must also be sent by the attending supervisor to the following
management staff summarizing the incident and action taken; Program Director/Coordinator,
Area Director and/or Vice President, and Michael Lavin, Sr. VP of Operations.
7. Supervisor will await further instructions by Program Director/Coordinator and/or Area
Director/Vice President and Michael Lavin, Sr. VP of Operations.
MANDATORY DRUG TEST
The driver of the vehicle involved MUST immediately take a drug test upon completion of the
Vehicle Incident Report Form. The driver's supervisor will provide the documents needed for
the designated laboratory.
Approved by Senior Management 712009
Pagel of 3
Westcare Vehicle Incident Report Form
This form is to be completed by driver immediately after a vehicle incident, when all persons involved have
been checked for injury and provided medical attention (if applicable), and while all parties are still present.
Basic Information:
Incident Date and Time:
Incident Location:
Were Authorities called? Yes / No
If no, explain why?
If yes, was a police report request granted? Yes / No
If yes, list police report number and attending officer name:
If no, list reason why it was declined?
Dispatcher Name and Badge Number:
Was citation issued? Yes or No If yes, to whom:
Westcare Vehicle Information:
Year/Make/Model:
UM
Plates: State:
Description of Damage:
Please talce pictures of damage with disposable camera provided in Vehicle Incident Kit.
Driver Information:
Driver Name and Job Title:
Driver License Number:
Involved Party 1:
Year/Make/Model:
Role in Incident:
Description of Damage:
State:
Please take pictures of damage with disposable camera provided in Vehicle Incident Kit.
Insurance Company: Claims Phone:
Policy # License # State:
Driver Name:
Injured? Yes or No If yes, explain:
Passenger I Name:
Injured? Yes or No If yes, explain:
Phone:
License #
State:
Passenger 2 Name:
Injured? Yes or No If yes, explain:
Page 2 of 3
License # State:
Passenger 3 Name:
Injured? Yes or No If yes, explain:
(Attach sheet if more passengers present)
Involved Party 2:
Year/Make/Model:
Role in Incident:
License # _ State:
Description of Damage:
Please take pictures of damage with disposable camera provided in Vehicle Incident Kit.
Insurance Company: Claims Phone:
Policy # License # State:
Driver Name:
Injured? Yes or No If Yes, explain:
Passenger 1 Name:
Injured? Yes or No If yes, explain:
Passenger 2 Name:
Injured? Yes or No If yes, explain:
Passenger 3 Name:
Injured? Yes or No If yes, explain:
(Attach sheet if more parties involved)
Phone:
License #
State:
License # State:
License #
Passengers Present in Westcare Vehicle:
All passengers must complete a Vehicle Incident Passenger Statement Form.
1. Staff or Client
Name: Injured? Yes or No
If Yet_ explain:
2. Staff or Client
Name:
If Yes, explain: _
3. Staff or Client
Name:
If Yes, explain:
4. Staff or Client
Name:
If Yes, explain:
Injured? Yes or No
Injured? Yes or No
Injured? Yes or No
State:
Page 3 of 3
5. Staff or Client
Name:
If Yes, explain: _
6. Staff or Client
Name:
If Yes, explain: _
7. Staff or Client
Name:
If Yes, explain: _
Injured? Yes or No
Injured? Yes or No
Injured? Yes or No
8. Staff or Client
Name: Injured? Yes or No
If Yes, explain:
(Attach sheet if more passengers present)
Detailed Explanation of Incident:
Was this a preventable incident? Yes or No
Explain why or why not:
I confirm the information provided in this report is as accurate to my knowledge and as thorough as possible.
le . 794
Signature:
*This report must be sent to the attending supervisor as promptly as possible. Attending supervisor must complete and
submit an electronic incident report via the Westcare Intranet and email management.
* *The Driver of the Westcare vehicle must take a drug test, as required by company policy, immediately after the vehicle
incident and attending supervisor needs to know the time of completion.
Approved by Senior Management 712009
Westeare Vehicle Incident Passenger/Witness Statement Form
Name:
Are you Westcare Staff, a Westcare Client, or Other?
Are you a Driver, Passenger or Other Witness?
If Other Witness, please list Contact Information:
Address:
City:
Phone: { ) -
Incident Date and Time:
Incident Location:
Westcare Vehicle Make/Model:
Description of Incident/Event:
Are you injured? Yes or No
If yes, please explain:
I was offered medical evaluation: Yes or No
If yes, I: Accepted or Declined Signature:
St: Zip
I certify that the above information is as accurate to my knowledge and as thorough as possible.
Signature
Date
This form will be forwarded to attending supervisor to be part of the Vehicle Incident Report.
Thank you for your cooperation.
Approved by Senior Management 712009
S. L.
Westcare Vehicle Incident Passenger/Witness Statement Form
Name:
Are you Westcare Staff, a Westcare Client, or Other?
Are you a Driver, Passenger or Other Witness?
If Other Witness, please list Contact Information:
Address:
City:
Phone:
Incident Date and Time:
Incident Location:
Westcare Vehicle Make/Model:
Description of Incident/Event:
Are you injured? Yes or No
If yes, please explain:
I was offered medical evaluation: Yes or No
If yes, I: Accepted or Declined Signature:
St: Zip
I certify that the above information is as accurate to my knowledge and as thorough as possible.
Signature
Date
This form will be forwarded to attending supervisor to be part of the Vehicle Incident Report_
Thank you for your cooperation.
Approved by Senior Management 712009
S. L.
Westcare Vehicle Incident Passenger/Witness Statement Form
Name:
Are you Westcare Staff, a Westcare Client, or Other? _
Are you a Driver, Passenger or Other Witness?
If Other Witness, please list Contact Information:
Address:
City:
Phone:
Incident Date and Time:
Incident Location:
Westcare Vehicle Make/Model:
Description of Incident/Event:
Are you injured? Yes or No
If yes, please explain:
I was offered medical evaluation: Yes or No
If yes, I: Accepted or Declined Signature:
St: Zip
I certify that the above information is as accurate to my knowledge and as thorough as possible.
Signature
Date
This form will be forwarded to attending supervisor to be part of the Vehicle Incident Report.
Thank you for your cooperation.
Approved by Senior Management 712009
S. L.
Westcare Vehicle Incident Passeneer/Witness Statement Form
Name:
Are you Westcare Staff, a Westcare Client, or Other?
Are you a Driver, Passenger or Other Witness?
If Other Witness, please list Contact Information:
Address:
City:
Phone: -
Incident Date and Time:
Incident Location:
Westcare Vehicle Make/Model:
Description of Incident/Event:
Are you injured? Yes or No
If yes, please explain:
I was offered medical evaluation: Yes or No
If yes, I: Accepted or Declined Signature:
St: Zip
I certify that the above information is as accurate to my knowledge and as thorough as possible.
Signature
Date
This form will be forwarded to attending supervisor to be part of the Vehicle Incident Report.
Thank you for your cooperation.
Approved by Senior Management 712009
S. L.
Additional Sheet for More Information
Approved by Senior Management W2004
Trafic=rams
N
w+E
s
Intersection
.Highway/Street
3
Z
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3
5
GUIDANCE/CARE CENTER, INC.
3000 41ST STREET, OCEAN
MARATHON, FL 33050
(v) 305/434-7660 / (0 305/434-9040
I acknowledge 1 have completed DE-ESCALATION TRAINING
http://www bing com/videos/search?q=De+Escalation+Traininq+Video&&view=detail&mi
d=AC9FB1689A985EE5E794AC9FB1689A985EE5E794&FORM=VRDGAR
Driver/Escort Signature Date
Printed Name
ATTACHMENT E
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, 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 Iy ►GUry) (Respondent's name) nor
any Affiliate has been placed on the convicted vendor list within the last 36 months.
(Signature)
Date: Q • '
STATE OF: VA1 F'C
COUNTY OF: MmW
Subscribed and sworn to (or affirmed) before me on G'�1✓� LYE ���
(date) by n�u& Qxlt (name of affiant). He/6
e/ he is personal)
known to me or has produced (type of identification) as
identification.
No
aa,V_zk) .
NOTARY PUBLIC
My Commission Expires:
CAROL A. DOCHOW
Notary Public - State of Florida
' My Comm. Expires Jun 7, 2018
•.1 Commission # FF 104268
Guidance Care Center —Transportation: Baker Act and CTD FY17; page 15
ETHICS CLAUSE
SWORN STATEMENT UNDER ORDINANCE NO.010-1990
MONROE COUNTY, FLORIDA
(Company)
ATTACHMENT F
"...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."
(Signature) G /
Date: ���0�lL
STATE OF: RRAW
COUNTY OF: Mm,
Subscribed and sworn to (or affirmed) before me on `X_t" •[11 Le
(date) by �� Y' (name of affiant). He/&h is perso ly
known to me or has produced
identification) as identification.
O&WQW)�
NOTARY PUBLIC
My Commission Expires:
••�•R� P
CAROL A. DOCtiDW
Notary Public - State of Florida
My Comm. Expires Jun 7, 2018
�"'•','E a �xA'` Commission # FF 104268
Guidance Care Center —Transportation: Baker Act and CTD FYI 7; page 16
(type of
ATTACHMENT G
DRUG -FREE WORKPLACE FORM
The undersigned vendor in accordance with Florida Statute 287.087 hereby certifies that:
CCU CC ZG,E
(Name of Business)
1. Publish 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. Inform 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. Give 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), notify 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. Impose 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. Make 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.
(Signature}
STATE OF:
COUNTY OF: I I�tw&)
Subscribed and sworn to (or affirmed) before me
—%I19 (1/l L (name
or has produced
identification.
•
on /6 GYJ� � (date) by
of affiant). He/ h is personally known to me
(type of identification as
N07ARY" PUBLIC
E
CAROL A. DOCHOW
Notary Public - State of Florida My Commission Expires:
My Comm. Expires Jun 7, 2018
� �'� Commission # FF 104268
Guidance Care Center —Transportation: Baker Act and CTD FY17; page 17