Item C22t
xr) Pico My 9 0 DIVA MOO oil M
Meeting Date: _September 1177.,.20014
Bulk Item: X No
Division: Employee Services
Department: an Resources
11 11'111��i
AGENDA ITEM WORDING: Approval to Amend contract with Key West Urgent Care, Inc. to
provide testing for Nicotine products.
ITEM BACKGROUND: On May 1, 2014, the BOCC approved to implement a no hire tobacco user
policy for those hired on or after January 1, 2015, in addition to a non -tobacco use policy for Health
Plan participants who are newly enrolled on or after January 1, 2015.
PREVIOUS RELEVANT BOCC ACTION: The BOCC approved the original contract on April
20, 2011; Contract amended and approved March 19, 2014.
CONTRACT/AGREEMENT CHANGES: Amend to include testing for Nicotine products. —
TOTAL COST: Appro -ETED: Yes X No
DIFFERENTIAL OF LOCAL PREFERENCE:
COST TO COUNTY: N/A SOURCE OF FUNDS: Ad Valorem
�!,UIVENUE PRODUCING: Yes — No X AMOUNT PER MONTH — Year
APPROVED BY: County Atty (k J� -
y OPM h/Pulasing — Risk Management�
DOCUMENTATION: Included X Not Required
DISPOSITION: AGENDA ITEM #_
Revised 7/09
CONTRACT SUMMARY
Contract #
Contract with: Key West Urgent Care Effective Date: September 17, 2014
Expiration Date:
Contract Purpose/Description: Second Amendment to include Nicotine Testing.
Contract Manager: Pam Pumar
(Name)
for BOCC meeting on Sent 1
4459 Human Resources
(Ext.) (Department)
Agenda Deadline: Sept 2, 2014
CONTRACT COSTS
Total Dollar Value of Contract: Approx $1,300yr Current Year Portion: $1,100
Budgeted? Yes X No _ Account Codes: 001-06500-510-316-
Grant: $
County Match: $
ADDITIONAL COSTS
Estimated Ongoing Costs: $ /yr For:
(Not included in dollar value above) (eu_ mnintPnnnrr+. „t;T;r;Pa
CONTRACT REVIEW
Changes Date Out
Date In Needed eviewer
Division Director Zlo 4 Yes❑ Nog �� g ,,(a. t�
Risk Management g-26.14 Yes❑ No2f
O.M.B./Purchaasing '� - Zr7 -4 V Yes[:] No]e,rt
IL
County Attorney B 1 i4 Yes[]No[:]{' d`�- Fes" S. 24.20l.
Comments:
— , .,.... •w v.acu 71. 117J ivl%,r ttz-
This is an amendment ("Amendment") dated — is entered into by and
between Monroe County ("County") and Key West Urgent Care, Inc. ("Contractor").
Physical Services ("Agreement")on April 20, 2011,-• -y Weagreed to furnish employment physical services; and
st Urgent
WHEREAS, On March 19, 2014, the Contract was amended to include a
provision that requires the contractor to comply with public records law; and extend the
agreement before the expiration date of April 20, 2014; and
WHEREAS, it is • - - • amend the contract• include testing for
nicotine • •• •
SERVICE
FEE
Urine Testing for
When requested a
$65.00 per test
Nicotine
test for nicotine will
be performed by the
physician and will be
either scheduled or
done on a walk-in
basis.
IN WITNESS WHEREOF, the parties hereto have caused this Amendment to be
executed the day and year first above written.
(SEAL)
Attest: Amy Heavilin, Clerk
Deputy Clerk
X--
Print Name
Title
6=7111-TY-U-MrIty Uommissioners
of Monroe County
Mayor/Chairman
0 0
6101:4 4Lf 2Kin Ji 14 '! k ill4w&-j cof-11.1
This is an amendment ("Amendment") dated March 19, 2014 is entered into by
and between Monroe County ("County") and Key West Urgent Care, Inc. ("Contractor").
WHEREAS, the County and Contractor entered into a Contract for Employment
Physical Services ("Agreement") on April 20, 2011, whereby Key West Urgent Care, In
agreed to furnish employment physical services; and I
WHEREAS, the current contract expires on April 20, 2014 and the Coun
continues to need the services listed in the Agreement; and i
WHEREAS, in accordance with Florida Statutes 119.0701(2) provides that "each
public agency contract for services must include a provision that requires the contractor
to comply with public records law"; and
4OW THEREFORE, in consideration of the mutual covenants contained herein
the parties agree to amend Sections 4, 7 and 8 of the Agreement is revised to read as
follows:
1. Paragraph 4.1 of the Agreement is revised to read as follows:
Following the expiration of the initial term and any subsequent terms listed in
paragraph 4.2, this Agreement 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 paragraph 7 below.
2. Section 7, CONTRACT TERMINATION, in the Agreement is revised to read as
follows:
Either party may terminate this Agreement because of failure of the other party to
perform its obligations under the Agreement. Either party may also terminate this
Agreement without cause, on sixty (60) days' written 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.
3. A new paragraph (F) is added to Section 8 of the Agreement (CONTRACTOR'
ACCEPTANCE OF CONDITIONS), as follows: I
71
10
F. Pursuant to Florida Statutes 119.0701, Contractor and its subcontractors shall
comply with all public records laws of the State of Florida, specifically to:
L Keep and maintain public records that ordinarily and necessarily
would be required by Monroe County in the performance of this
Agreement.
Provide the Dub lie
1KIII&PDR11 NO am -
Statutes,
Chapter 119 or as otherwise provided by law.
Ensure that public records that are exempt or confidential and
exempt from public records disclosure requirements are not
disclosed except as authorized by law.
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.
All other terms and conditions of the Agreement remain in full force and effect.
IN WITNESS WHEREOF, the parties hereto have caused this Amendment to
id the day and year first above written.
M
-D
Board of County Commisisj&ers
Heavilin, Clerk of Monroe County
204
Print Name
Title 0 w lie r-
7
Mayor/Chairman
Key West Urgent Care, Inc.
MONROE COUNTY ATTORNEY
2 A�P �OVED AS TO VORM:
— WYNTHIA THALL
ASSISTANT COUNTY ATTORNEY
Date— 2 5- - •
— 11
1:
MONROE COUNTY
CONTRACTFOR
EMPLOYMENT PHYSICAL SE
THIS AGREEMENT ° SERVICES
THIS A E COUNTY ("Agreement") is made and entered into this 2� day
is 1100 Simonton Street, subdivision subdivision of the State of Florida, rt 2011, by
("CONTRACTOR"), y West, Florida 33040 and KEY WEST URGENT CwhoseARE INCdress
Section 1. )+ whose address is 1501 Government Road
SCOPE OF SERVICES
Ke West FL 33040
CONTRACTOR shall do, perform and car
duties as described in the erf a of Services out in a professional and proper manner certain
made a part of this agree Scope
ent. Section One —
which is attached hereto and
CONTRACTOR shall provide the scope of services in Section
CONTRACTOR warrants that it is authorized by law to engage
activities herein described, subject to the terms and co One for COUNTY.
documents. The CONTRACTOR shall a all timesexerciseco g ge to the Performancethesere the
conditions set forth in these Agreement
and shall assume professional responsibility for the services to to be Provided.
professional r s
Provide services using the following standards, as a minimum requirement:
judgment
be provided. Contractor shall
A. The CONTRACTOR shall maintain adequate st ffing t:
services required under the Agreement. staffing levels to B. The contractor is responsible for obtainin Provide the
employee or prospective employee in order to discuss the re
9 Proper releases from the
Monroe County BOCC.
C. The contractor + cults with
Key West UrgenttlCarre,InChe required services at the location of:
1501 Government Road
Key West, FL, 33040
Phone: 305-295-7550
Fax: 305-296-3010
D. The Contractor will have an employee designated as coordinator or
facilitator to .assist in the communications with the Monroe
primary contact personnel. E. APPointments will be , e County BOCC's
Mondayy available throtaghout the bl.rsiness hours of the facility:
— Friday 8:00 a.m. — 3:30 p°on, "Valk -ins will also he accepted
if an appointment cannot be reasonably scheduled.
F. �'PpointmPnts +.vill be seen b
fashion. y the contractor in a reasonable
and and timely
I he C'c,ittr,lct„r �ti ill I}rc►t icic the (',,only" n ith
furn;u•c, illd tirlic fill- till rcccii1t (It'�lny rc;ulty.
H. rile A.1erlir.� lti Itc,ur
tl R�;vfe+,v Officer'ayil! be ,.tv,tilrtblN for (;ont_t(a b+ � Monroe
("o(1nty Bt3CC ,-)r its Nm Io+
Prescribk, p lees to ln.s+-ver ritloittons ,iboi.1t the Iff;2(,t
J �iru!js. I';lrt ,t°tile tcytlircnt`'ntr , ff.�c;t of
tlrtl.; 1i•`'` 6e„ll� tl;tcc �„ It li+rth !�t• tltc .�;t;
i i licy, +�Iti�lt \Ic+nrnc ('„linty h,l, c°cl��l't`'cir`,Illt,lltltci`Lt
i)+I�;lrlittcIit,It' I't,ut°l,t,ltilt. Ills ('„unit 11111.4 h.lsc i
u till tit ,Ir�l _ I rl4P \I�cli�.11
I cl, r.'Ia IP, ti'� I Ill(: I��nln .r� iI lie \ll't )
It I.�° l-flhot'.It,l•� ~' ,
. t�'.,IIP,ItII'18'►; i\:l.r+.l e I I,,
i
('Vl7e1jty li,(° irtCc�r•ity. uufhc(tti�;ity. t;tlw itco
I;tla rCsttlt5, irtcriticati,(tt ,(t'I,th lus.itit"l�
; r�l', I(l'"xititu,: iitllrrcts
L•(tthl,sy,:r (;ts ,1`tinl•ll by rt(Ics ;uu! rc4,
I th rcli„rC.r t,s the
I• The personnel shall not be employees tof t®r have
with the County. To the extent that Contracor use any contractual relationship
independent contractors,
subcontractors and this Agreement s subcontractors or
have any contractual relationship with pendent Count°rs shallnotspecifically
requires that
J. All personnel engaged !n performing services and an employee of or
qualified, and, if required, to be authorized or permitted unde State shall be fully
to perform such services
r State and local law
Section 2. QUALIFICATIONS NECESSARY OF CONTR
The CONTRACTOR ACTOR
must certify at least annually that all staff members, independent
contractors, subcontracted work, if an
comply with Health Insurance Portability ty alnd Accountabiliservice ty providers
uses, engages or manages,
security rules. ges,
Y Act (HIPAq) privacy and
Physical examinations will be conducted by, or under the
pStWehysician or medicsl doctor currently licensed and
physician
i The direct supervision, e a
trained, as Florida,rich, h examining practicing general medicine !n the
xamin, as necessary, to performpaborartory tests aan "lay nd/®asistants properly licensed and
assist in all phases of the
Section 3. COUNTY'S RESPONS1131LITIES
3.1 Provide aPl best available information as to the COUNTY'S requirements for the
Scope of Services described in Section One to this Agreement.
Designate in writing a person with authority to act on the C
concerning said services. g ent.
OUNTY'S behalf on all matters
Section 4. TERM OF AGREEMENT
4.1 The initial Agreement term will be for one
2011 and renewable at the Count s o (1) Year beginning the loth day of April.
terms. Y� Option for two
(2) additional consecutive one year j
4.2 The terms of this Agreement shall be from the effective
a period of one year. This Agreement shall be automaticallyrenewed
cttve date hereof and continue for
year periods until either party gives the other notice of cancell tioninfor successive one -
terms set forth below. The Contractor must provide the Contractorat(on in accordance with the
days notice of intent to terminate. If either
notify the other in writing at least thirty (3 r da s odsfytwith at least thirty all
party desires to modify this Agreement, it shall
modification. In the case of proposed modification the
proposed modification shall itself notify the y prior to the effective date of such
notice of its agreement to the proposed modification party receiving the notification of the
Y other party within ten (10) days after receipt of
Agreement. . Failure to do so shall terminate this
3.2
Sections. COMPENSATION
Compensation to CONTRACTOR is Outlined in the scope
of Ser;ices
Section 6. PAYMENT To of
Section One.
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 of Courts for Monroe
County (Clerk). The request must describe in detail the services performed and the
Payment amount the Clerk
requested. The ONTR
T
CTORmust submit invoicesto the
appropriate Offices marked Human Resoces* he respective Office supervisor and the
onthere and forward it to the Clerk for Payment. 1
Administr-3tor of Human Resources, who will review the request, note h s/her aPProva
6.2 Continuation of this Agreement is contin
County Board Of County Commissioners.
gent upon annual appropriation by Monroe
Section 7. CONTRACT TERMINATION
Either party may terminate this Agreement because of the failure of the other party Perform 1
obligations under the Agreement. COUNTY may terminate thisto pe orm its
Agreement with or without
cause upon thirty (30) days notice to the CONTRACTOR. COUNTY shall pay CONTRACTOR
for work Performed through the date of termination.
Section S. 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
resP.onsibility therefore. The provisions of the he
shall control
Provisions containeb
in the specifications All any inconsistent
specifications have been read and
carefully consideredy CONTRACTOR wh' understands the same and agrees to their
sufficiency for the work to be done. U
shall this Agreement b Under no circumstances, conditions, or situations
CONTRACTOR. e more strongly construed against COUNTY than against
13. 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
the terms of this Agreement n
by CONTRACTOR shall not Operpep
as a waiver by COUNTY Of strict compliance with
, and sifications covering the services.
D. CONTRACTOR agrees that County Administrator or his designated representstives may
visit CONTRA
CONTRACTOR'S facility (ies) periodically to conduct random
services during CONTRACTOR'S normal business hours. evaluations of
E. CONTRACTOR has, and shall maintain throughout the term
appropriate licenses and approvals required
activities in' business, and that it will at all
times conduct its business to conduct its bu Of this Agreement,
approvals shall be submitted to CO a reputable manner. Proof of such
COUNTY upon request. . licenses and
Section 9. NOTICES
Any notice required or permitted under this agreement shall be i
mailed, postage prepaid, to the other art b
Following:
party y certified mail, returned treceiptrequestedhand 1,Jto th °r
e
To the COUNTY: Human Resources Administrator
1100 Simonton Street, Suite 2-268
Key West, Florida 33040
To the CONTRACTOR:
Key West Urgent Care, Inc.
1501 Government Road
Key West, FL 33040
Section 10. RECORDS
CONTRACTOR shall maintain all books, records, and documents
Performance under this Agreement in accordance with generally direct) consistently applied. Y accepted accountingprinciples
to
Each party to this Agreement or their authorized representatives
shall
have reasonable and timely access to such records of each of
Public records purposes during the term of the agreement and es shall
termination of this Agreement. If an auditor employed her party to this Agreement for
for fairy years following the
monies paid to CONTRACTOR p ®Yed by the COUNTY or Clerk determines that
authorized by this Agreement, the CONTRACTOR shall reps the
Pursuant to this Agreement were spent for purposes not
calculated pursuant to Section 55.03 of the Florida Statutes, running Y monies together withthe interest
were paid to CONTRACTOR. nrng from the date the monies
Section 11. EMPLOYEES SUBJECT TO COUNTY ORDINANCE
The CONTRACTOR warrants that it has note NOS. 010 AND 020-1990
behalf any former County officer or employee subject #o t
employed, retained or otherwise had act on its
Ordinance No, 010_1990 ®r an he prohibition of Section 2 of
Ordinance N® Y County officer or employee in violation of Section 3 of
020-1990. For breach or violation of this provision the COUNTY
discretion, terminate this agreement Without liability and may also,in its discretion, deduct from
the agreement or purchase price, or otherwise recover the full a may, in its
m
percentage, gift, or consideration paid to the former County officer orue t of any fee, commission,
Section 12. mployee.
CONVICTED VENDOR
A person or affiliate who has been placed on the convicted vendor list following a conviction for
public entity crime may not submit a bid on a Agreement witha
or repair of a public building or public entity for the construction
supplier, subcontractor, or CONTRACTOR, underAgreemen
Perform work as a CONTRACTOR,
y, and May not
transact business with an t with an
Y Public entity in excess of the threshold amount Public
protvided in Section
287.017 of the Florida Statutes, for the Category Two fora period
being placed on the convicted vendor list. P od of 36 months from the date f
Section 13. GOVERNING LAW, VENUE, INTERPRETATION, COSTS
This Agreement shall be governed by and construed i AND FEES
Florida applicable to Agreements made and to be performed entree intt the laws of the State of
In the event that any cause of action or administrativey he State.
proceeding is instituted for the
enforcement or interpretation of this Agreement, the COUNTY and CONTRACTOR
venue shall lie in the appropriate court or before the appropriate administrative body agree that
County, Florida. body in Monroe
Section 14. SEVERABILITY
If any term, covenant, condition or provision of this Agreement (or the a
circumstance or person) shall be declared invalid or unenforceable to a
ny competent jurisdiction, the remaining terms, covena application thereof to any
Agreement, shall not be affected thereby;nts, conditions and
by a court circumstanceof this f
Provision of this Agreement shall be valid and hall be en oarce�able toterthe fullest ,condition and
by law unless the enforcement of the remaining terms, covenants, conditionsfullest extent permitted
this Agreement would prevent the accomplishment of the original intent o
COUNTY and CONTRACTOR agree to reform the Agreement and provisions of
with a valid provision that comes as close as possible to
9meat to replace any stricken provision
f this Agreement. The
Section 15. ATTORNEY'S FEES AND COSTS the intent of the stricken provision.
The COUNTY and CONTRACTOR agree that in the event any cause of action
proceeding is initiated or defended by any party relative to the enforcement or i administrative
of
this Agreement, the prevailing party shall be entitled to reasonable atto
costs, as an award against the non-prevailingouter, and interpretation court
conducted pursuant to this Agreement shall be in accordance withrney's fees, and court party. Mediation proceedings initiated and
Procedure and usual and customary procedures required by the Circuit
County. the Florida Rules of Civil
Court of Monroe
Section 16. BINDING EFFECT
The terms, covenants, conditions, and provisions of this Agreement shall
benefit of the COUNTY and CONTRACTOR and their respective I
b+nd and inure to the
legal representatives,
successors, and assigns.
Section 17. AUTHORITY
Each party represents and warrants to the other that the execution, delivery
this Agreement have been duly authorized by all necessary
required by Iavv and performance of
ry County and corporate action, as
Section 18. ADJUDICATION OF DISPUTES OR DISAGREEMENTS
COUNTY and CONTRACTOR agree that all disputes and disagreements
be resolved by meet and confer sessions between representatives of each
isslie or issues are still not resolved to the satisfaction of the hall be attempted to
parties, the
meetshall
the parties.
h
p tP �s, then any party ;;hall have
6
a 4
' 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 proceedingis in
i the formation, execution,
CONTRACTOR agree performance instituted against either party relating to
e or breach of this Agreement,
proceedings, heart 9 s to participate, to the extent required b COUNTY and
9 , processes, meetings, and other activities related to the subst
Agreement or provision of the services under this Agreement. y the other party, in all
specifically agree that no 9 ment. COUNTY and ce Of this
n al party to this Agreement shall be required to enter into an orb
proceedings related to this Agreement.CONTRACTOR
Y itration
Section 20. NONDISCRIMINATION
COUNTY and CONTRACTOR agree that there Will be n
and it is expressly understood that upon a determination b a
discrimination has occurred, this Agreement automatically no discrimination against sany person,
d
on the part of an Y court of competentjurisdict ®n that
Y party, effective the date of the court order. The
a ically terminates without any further action
all Federal and Florida statutes
t and nondiscrimination. These include but are Holt limited tolocal:
i lances, Parties agree to comply
1964 (PL 88-352 p Y with
which prohibits discrimination in employment VIIapplicable, relating to
f
national origin; 2) Title c of the Education Amendment )Title on h the Civil Rights ace, Act of
national
and 1685-1686 p Yment on the basis of race, color,
), which prohibits discrimination eon the bays s of exas ; 3 Section
USC ss. 16the
Rehabilitation Act of 1973, as amended (20 USC s. 794
basis of handicaps: 4) The A ), which prohibits discrimination on the
6107) which 9e Discrimination Act of 1975, as amended isc USC on n the
prohibits discrimination on the basis of age;
Treatment Act of 1972 P 01-
drug abuse; 6 ( L 2g-255 g 5) The Drug Abuse Office and
), as amended, relating to nondiscrimination on the basis
The Comprehensive Alcohol Abuse and Alcoholism Pre
Rehabilitation Act of 1970 p of
of alcohol abuse or alcoholism; 97-616), as amended, relating to nondiscrimination ron t Treatment and
USC ss. 690dd-3 and 290e) The Public Health Service Act of 1912, ss. 523 and 527
abuse patient records; 8 n the basis
as amended, relating to confidentiality of alcohol and (42
amended, relating to ) Title Vill of the Civil Rights Act of 1968 (42 USC ss. 360
g nondiscrimination in the sale, rental or financing of ho • drug
Americans with Disabilities Act of 1990s. 1 et se
time, relatingq•}, as
to nondiscrimination on the (bas basis disability; 10 M using; time
The
13, Article nl, which prohibits discrimination on the ); 10 may be amended from time to
r
origin, ancestry,basis of race, colors, sexnrelig religion, Chapter
any other nondiscrimination provisions in a
gender identity r expression, familial status or age; national
and 11)
parties to, or the subject matter of, this Agreement.
any Federal or state statutes which may apply to the
Section 21. COVENANT OF NO INTEREST
COUNTY and CONTRACTOR covenant that neither
acquire any interest, which would conflict in an
this Agreement, and that only interest conflict
each is to presently degr has any interest, and shall not
y manner or degree with its performance under
this Agreement. perform and receive benefits as recited in
CODE OF ETHICS
COUNTY agrees that officers and employees of the COUNTY recognize and `,vela be required to
c:ori'pPy with the standards of conduct For public officers and employees
1 1
2.313, Florida Statutes, regarding, but not limited to .3
solicitation
oorr as delineated in Section
acceptance of gifts; Bang
7
° business with one's agencunauthorized compensation; misuse of
relationship; and disclosure or use of certain lbformatiolnlic �, Conflicting
Section 23. N® SOLICITATION/PAYMENT
The COUNTY and CONTRACTOR warrant that, in respect
retained any company ®r p t to itself, it has neither employed
Person, other than a bona fide employee working solely for it, to
or secure this Agreement and that it has not paid or agreed nor
corporation, individual, or firm, other than a bonafide employee solicit
commission, percentage, gift, ,other consideration contingent to pay any person, ant' fee,
or making n, this Agreement. For the breach or violation y working solely for it, a company,
tangent upon or resulting from the award
agrees that the COUNTY shall have the right to terminate this Agreement
its discretion, to offset from monies owed, or otherwise n °f the provision, the CONTRACTOR
commission erwise recoverthefull almount ofthout �lsuC and,
1 percentage, gift, or consideration.
Section 24. PUBLIC ACCESS e,
The COUNTY and CONTRACTORof, shall allow and
papers, letters or other materials in its possession or under its control
to the provisions of Chapter 119, FPorida Statutes permit reasonable access to, and inspection
CONTRACTOR in conjunction with this Agreement; and # and made he COUNTY shall have the right to
the COUUNTY and
subject
C received by
unilaterally cancel this Agreement upon violation of this rovis'
Section 25. NON -WAIVER OF IMMUNITY p®n by CONTRACTOR.
Notwithstanding the provisions of Sec. 768.28, Florida
COUNTY and the CONTRACTOR in this Agreement and
liability insurance coverage, self-insurance coverage, Statutes, the participation of the
Pool coverage shall not be deemed a waiver of immunity the acquisition of any commercial
shall an q 9 or local government liability insurance
Y Agreement entered into b n�ty t® the extent of liability coverage, nor
waiver. y the COUNTY be required to contain any provision for
Section 26. PRIVILEGES AND IMMUNITIES
All of the privileges and immunities from liability, exemptions
and pensions and relief, disability, workers' compensation, and
activity of officers, agents, or employees of an p ns from laws, ordinances, and rules
or
when performing their respective functions under this q other benefits which applyto the
the COUNTY shall a Y public greem nt employees of the COUNTY,
to the same degree and extent to the nt within the territorial limits of
apply
and NTYdutieof such officers, agents, volunteers, or employees performance of such functions
COUNTY.
Y outside the territorial limits of the
Section 27. LEGAL OBLIGATIONS AND RESPONSIBILITIES
Non -Delegation of Constitutional or Statutory
shall it be construed as, relievinganparticipating
Duties. This Agreement is not intended Po no
shall t upon the entity by law except an t®atrti a feint a tity
9 entity from any obligation or responsibility
i"nPoany participating entity, in �,vhich case the al and time)
obligation participating
ng en responsibility. F performance may y performance thereof by
Further, this Agreement is not intended to, nor shall it be co
as, authorizing the delegation of the constitutional or statutoryy e offered in satisfaction of the
the extent permitted by the Florida constitution, state statute construed
duties of the COUNTY, except to
and case law.
4
Section 28. NON -RELIANCE BY NON-pARTI
No person or ES
enforce or attempt
entity be entitled to rely u
Program contemplated hereunrce der third-party
upon the terms, or any of them, of this Agreement
the COUNTY party claim or entitlement to or benefit of an g mint to
authority contemplated
CONTRALTO e COUNTY and the CONTRACTOR
R or anagent,ACTOR Y service or
individuals, entity or entities, ha, counsel or eentitlements
t tP otherwise indicate ate thatfatner, or employee agree that neither
p vie of either shall have the
apart, inferior to ements or benefits under this individual
Ag eemen r group to
this Agreement. ° ®r superior to the community inof
t separate and
general or for the purposes contemplated in
Section 29. ATTESTATIONS
CONTRACTOR agrees to execute such documents
including, but not being limited to ments as the COUNTY
Drug -Free but
not being
Statement I a Public Entity may reStatem l Agreement. I Lobbying and Conflict
t of IntereStatemenst Y require,
Ethics Statement, and a
Section 30, N®P Clause, and Non -Co
ilusion
PERSONAL LIABILITY
No covenant or agreement contained herein shall
any member' officer, agent ore all be deemed no member, officer, a employee ®f Monroe Countyn h sbor her individual
Agreement or be subject to an employee a covenant or agreement of
ployee of Monroe Count capacity, and
Y y reason ofethe execution on ois
f
Section 31. EXECUTION IN COUNTERPART
This Agreement
greement may be executed in
regarded as an original, all of which taken together s
and an any number of counterparts each of
y of the parties hereto help constitute one and the same
shall be
may execute this Agreement by signing any such
Section 32. SECTION®instrument
HEADINGS counterpart.
Section headings have been inserted in this
Agreement as a matter of convenience of reference
only, and it is agreed that such section headin s ar
used in the interpretation of anyprovision of this A ree t a part of this Agreement and will not be
Section 33. INSURANCEg mint.
POLICIES
33.1 General Insurance
As a pre -re Requirements for Other Contractors and Su
expense, pre -requisite of the work P ,insurance as specified governed, the CONTRACTORSubcontractors.
contract. The CONTRALTO any attached schels,shall obtain
all Subcontractors en R will ensure that the insurance obtained will at his/her own
gaged by the CONTRACTOR which are made Part of this
require all Subcontractors to obtain insurane extend CONTRACTOR is solely res ' As an alternative, the CONTRACTOR Protection to
consistent with the attached schedules; he however
proof of insurance to responsible to ensure that said insurance is obtained y
termination of this Agreement,
Failure to
provide proof of insurance and shall submit
The CONTRACTOR Shall be grounds for
satisfactory R Will not be permitted to co
beloay. y evidence of the required insurance has been
Work governed by this Delays in the commencement of � en furnished to theCOUNTY
Work, resulting from the failure of the C ®nt AC until
Y as specified
CONTRACTOR
0
• g
. to provide satisfactory evidence of the required insurance, shall
in this contract and any penalties and failure to perform assessments shall be imposed as if the
not extend deadlines specified
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
contract and any extensions specified in the attached schedules. F '
Provision may result in the immediate suspension of al the entire term of this
been reinstated or replaced and/or termination of this allure to comply with this
COUNTY. Delays in the completion of work I q Ark until the required insurance has
greement and for damages the
resulting from the failure of the CONTRACTOR
R to
maintain the required insurance shall not extend dea
penalties and failure to perform assessments shall belineimposedas
specified in this contract and any
the work had not been
suspended, except for the CONTRACTOR's failure to maintain the re uir
The CONTRACTOR shall provide, to the COUNTY, as satisfactory q reed insurance.actory 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 c®PY ®f any or all insurance
Policies required by this contract.
All insurance policies must specify that they are not subject to cane
material change, or reduction in coverage unless a minimum of thirty 3
is given to the Count b cancellation, non -renewal,
Y Y the insurer. Y ( 0) days prior notification
The acceptance and/or approval of the Contractor's insurance shall
relieving the Contractor from any liability or obligation assumed under re law. not be construed ias
mposed
. r this contract or imposed
The Monroe County Board of County Commissioners its employees and officials will be
included as "Additional Insured on general liability
,
rr
33.2 General Liability Insurance Requirern enpolicies.
Contractor ts For Contract Between County And
Prior to the commencement of work governed by this contract, the CONTRACTOR shall obtain
General Liability Insurance. Coverage shall be maintained thro
and include, as a minimum: ughout the life of the contract
• Premises Operations
• Bodily Injury Liability
• Expanded Definition of Property Damage
The minimum limits acceptable shall be:
'$300,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be
:
3200,000 per Person
;5300,000 per Occurrence
:3 50,000 Property Damage
An Occurrence Form policy is preferred. If coverage is Provided
provisions should include coverage for claims filed on or after t
In addition, the period for which claims may p voded on a Claims Made this
policy,
In a months following the acceptance of he effective date of this contract.
work b reported should extend for a minimum of twelve
y the County.
The Monroe County Board of County Commissioners shall
be named as Additions! 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
statutes. CONTRACTOR to resp®nd to the a
In addition, the applicable stake
than:shall obtain Employers' Liability Insurance with limits of not less
$100,000 Bodily Injury by Accident
$500,000 Bodily Injury by Disease
policy $100,000 Bodily Injury by Disease, each employee
Coverage shall be maintained throughout the entire term of t
Coverage shall be provided by a company he contract.
state Florida,or companies authorized to transact business in the
33.4 Professional Liability Requirements
Recognizing that the work governed b
of a professional nature, the Contractor shall purchase and
y this contract involves the furnishing of advise or services
contract, Professional Liability Insurance which will respond to
claim arising out of the performance of professionals maintain, throughout the life of the
Contractor arising out of work governed by this contract. damages resultinyg
services or anerror or omissifrom any
on of the
The minimum limits of liability shall be:
$250,000 per occurrence and $750,000 aggregate
Section 34. INDEMNIFICATION
The CONTRACTOR does
COUNTY, its Mayor, the Boardhereby consent n Comm ssio
Officers, and the Employees, and any other agents, agreeto indemnify and hold harmless the
suits, claims, demands, actions, costs, obligations Hers, appointed Boards and Commissions,
individually and collectively, from all fines,
out of the sole negligent actions of the CONTRACTOR or substantial
attorneys fees, or liability of any kind arising
caused by the Willful nonperformance of the CONTRACTOR and
cause by for an be
unnecessary respons
y and all accidents or injuries to shall be solely responsible and
performance of this contract. The amount and t
forth hereunder shall in tr way be construed as limiting persons or property requirements
type of insurance coverage y set a forth
in tset
Paragraph. Further the CONTRACTOR agrees to defend and
tIcts attributable to the sole negligent act of theting the scope of indemnity set Forth in this
CONTRACTOR. pay all legal costs attendant to
' At all times and for all purposes hereunder, the CONTRACTOR
and not an employee of the Board of County Commissioners. No statement contained in this
agreement shalt be construed so as to fond the CONTRACT is an independent contractor
OR or any of his/her em to
the @
MonroeCounty. As an independent contractor the CONTRACTOR of County Commi
Provided.
ssionersfor
professional judgment and comply with all federal, state, and local
and regulations applicable to the services to beOR shall provide independent,
contractors, servants or agents to be employees of
statutes, ordinances, rules
The CONTRACTOR shall be responsible for the completeness
and supporting data, and other documents prepared or compiled under itobliaccuracy ti of its work
and shall correct at its expense all significant errors or amiss' � plan,
disclosed. The cost of the work necessary ®bhg therein
for this project,
CONTRACTOR and any damage incurred by
therein which may be
g ry to correct those errors attributable to
caused by such errors shall be chargeable to the CONTRACTOR. This the
Y the COUNTY as a result of additional costs
to any maps, official records, contracts, or other data that May b
other public or semi-public agencies. s provision shall not apply
Y e provided by the COUNTY ®r
The CONTRACTOR agrees that no charges or claims fo
for any delays or hindrances attributable to the COON
Portion of the services specified t this con r damages shad) g made a it
be compensated for by the COUNTY b COUNTY during the progress , any
tract. Such delays or hindrances, if any, shall
the CONTRACTOR to complete the work schedule Suc a for a reasonable period for
between the parties, h an agreement shall be made
IN -WITNESS WHEREOF, the parties
(SEAL) hereto have caused these
66 day of e5 r 20� presents to be executed on th
e
Attest: DANNY L. KOLHAGES CLERK
OF MONROE COUNTY,
FLORIDA
By JL
L /!,
r
i
(CORPORATE SEAL)
A (• TES T:
12
BOARD OF COUNTY COMMISSIONERS
by
ayor/Chairman
.JOHN R. VAN F[JYL, M.O.
KEY WEST IJRGEN r FARE, INC,
by dw�.
Title:
I
SECTION ONE
SCOPE -OF SERVICES
EMPLOYMENT PHYSI
The scope of services to be provided on an as needed
include, but not be limited to, the provided
on
The forms to be rby
e
Contractor are attached to this agreement q basis rethe
and completed by the
the Provider and may
'1ll results will include: ( Attachments q _ C
• Written interpretation 'If test results in common
signiticanee ut°ea`h abnormality ur written explanation tand written explanation a)f the
outside the normal range. ofthoae results Which are
• Eraminin
b physician's written recommendation concerning , . ,
condition considered outside the normal range.
• Written recommendation of specific reasons b htturc, action on any
the Ape; reasonable accommodations in accordance with
SERV'10E
D R U 6 SCREEN:
(Collection, Lab, wiRO
review) 10 panel State
Requirement
DRUG SCREEN:
(Collection, Lab, IVIRO
review) 5 panel
Department of '
Transportation
Rc uiremcnt J
BLOOD AL HOC OL
(Collection, Lab, VIRO
review)
i
When requested, a drug • • F E
be performed b b screen will
y the physician and
will be either scheduled or done on a walk-in basis for post accident, SStI.Ut)
random, and reasonable suspicion
dru screenin .
When requested, a drug screen will be pertormed by the physician and51>•t)t)
will be either scheduled or done on a walk-in basis.
When requested, Blood Alcohol
will be performed by the
physician and will be either
scheduled or dune on a walk-in
basis.
A testing j facilityj 24 hours a day, must be available �
7 days a week for
Post accident, random, and
reasonable suspicion alcohol
131Z E, iTl t A - - _--I screen -in
i°OFli)L (it' `�'Iten I'e�lucsteol, nl;ty •'el used ti)r
;►t;lil;lhlc) __..�.�
screcniutg. lfbreatit alc()hcll screen is
positive, a blood screen ti ill he
pertimiled,
!t' f hvsi� i;lll t6ltilles tO P7rOpl)tie Other ! ntr;ells Ot'.screentn, Ittelh,)d I)Peasc
})rot isle tesl1119 I11etl1Od eel1l;ut;lti01l "Ind i
PPD-
Ff EPr#'fIT[S ##
FIEPATi IT SS B
TYPHO[D
TETANUS
DIPHTH RERE IIA
DOT PHYS[C #L
aCCUra, -
A testing facility must be
I
24 hours a day,available i ! post accident and m, and
a week for J
reasonable suspicion alcohol
screenin
\Vhen re(lucstc(i, a PPD- T_ screen—`-` —
by
he scheduled and perform B the gill
physician during the facility's no
I husiness hours. Y rmal
A PPD-TB screen will be performed
with the new hire Fireti Ater h sical.
When requested, a 11epatitis Ainoculation will be scheduled and
pertornled by the physician during the
tacilit 's normal business hours.
When requested, a Hepatitis B
inoculations) will be scheduled and
performed by the physician during tacilit 's normal business hours. the
When requested, a Typhoid
will be scheduled anermed byttile
physician during the facility's normal
business hours.
When requested, a Tetanus inoculation
will be scheduled and performed by the
physician during the facility's normal
business hours.
When requested, a Diphtheria
inoculation will be scheduled and
performed by the physician (luring the
facility's normal business hours. I
(SEE ATTACHMENT When requested, a DOT h
he scheduled .'ind e p Y'Zy ti will
..®„ to he completed by ,h p rtonmed by the
employee and pllyslcian physician during the facility's normal
hutiin • • I
I
I�
PosI't11►1:R -
{
e.ss lours. Includes eraln and
Physician review ofcnlployee health
history and job description,
The DOT physical is ie onitially Ilertinnc(
' in njtinction with a post-ot'tcr
I phytiicid• Thcreat'ter, only a DOT
physical is perfiwincd by the physician.
I'livsician rll;ly ;glyel I1eg t`1r111 a Ur•ille
elrug screen ifrc(lucsted separately by
_ _\Iunrae ('aunty I3OC-'C'.
:�\Vhen reeluestcd, a pa,t-ul°Ier physical
to ill he scheduled and pert01'?1lVd by the
PhYs.ician during the I,Icilirvl rlarlllal
.SiU,t)()
N_:
•S 15 E.\('I [
Ocrics no
Total
it
{b5)
N,'; \
Colilbined
with
Diphtheria
helow:
y 75.0o
Sj0.I)I)
��t�.11tl
to I)e c;Orntplcted h --- - -- — _
Y ; cntPluyee and Physician) s businc�hours. 1nCludes exam all !
Physician review `afentpluyce health
I history and joh description.
' Physician ntay also Pertbrin a urine
drug screen ifrequested separately by I
FIREF(C;f )yjt ![onroe Collett 11OCC.
I
PIIY'S!C'�®L (SEE When requested, Fireli ,
will be scheduled and I erti nned by the
I ATTACHMENTS '°F" to I physician during the raciM '
Ile comPlcted b p y Y 5 normal N A
y ern to Le business hours. Includes exam and
and physician). Y:.
)h sician review of employee health
!
III -story and job description.
Physician may also perfonn a urine
drug screen if requested separately by
Monroe County BOCC.
FITNESS FOR DUTY When requested, a Fitness for Dot
PHYSICAL (SEE Physical may be requested at any time
ATTACHMENT "A" to be by the employer in the
completed by employee employee's respective area of work. The exam will SSt)•t)t)
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
RESPIRATOR a'lonroe County BOCC.
PHYSICAL (SEE When requested, a Respirator physical
ATTACHr�,IENTS °dC will be scheduled and performed by the
PART [ & [f to he Physician during the facility's normal
business hours. Includes exam and ��t)•t)t)
Lolt,pluted by employee physician review Of employee health
and physician) history and job description.
Physician may also perform a urine
dreg screen if requested separately by
f Monroe County BOCC. I
I
Itr ("liticPPr, P•rdreh-cs C%re°sB :i=P ery° eruct I
S�)iP'�P/1lC'lP'V.
FKG
I
Normally dune in conjunction dvi
Fith the
I — --- rcti �htcr i;tl.tJu
---- _ j C'ltcst !C Ray is normally dc,nc In r
conjunction faith the New liirc
1 irctighter and RcsPir;ttur Physical iF ' I'11� idk s
there is .ut itiSUe to ith the I:
,Pitc,lttetty results.
r?u.til,,
li
I
SPIIZOMETRy'_
i Nut tn4tlly done ill cunjllnctic— ,n Il the d S%) i
Respirator physical. ;1Il Fircti I t , °
IIIEARINCr',k DIOCRA.VI
STRESS TEST (SEE
ATTACHMENT "E" for
explanation of services to
be Performed by
t„oystctan)
C'I ILIIC',vL
PANEL C'till'
Clic
d.IPIC)S
(C'Fl0Lr--S rER0L)
Ulp
1.1.0 ti� ITH Nif(.'fZO
altld MOO yees `vho use a resp r for will
have a S irometr when hired.
Normally (lone in onjcttletton -
appropriate I th the
p lySical. `lay he reycfested
sc aratcl h ,ti�unruc County 130CC Normally dune to Conjunction with
new hire: Firefighter physical. the
Perfonnecl thereafter for firefighters as
neeciccl.
rests Glucoac (sugttt•), leidneys, lider ( I
tuhe uFblcuicd drown).
Fireti'=hter Physical
rest to see irAlletnic; it"Illy infections
within the holy; ifdehydrtttecd (test
11•0111 l (.)ftile tubes Ofbloo(I draosn).
Firefighter d'Ilv�;ieal
Tests ,rued cholesterol and bard
cholesterol ( one uf'thc tuhes uf'bloo(1
drawn)
r` ircti.�llt"Pll :sited
Normally clone in conjunction cvitl� 1" the
®h physical
Normally clone in conjunction with the
FireC 8hter Physical
S- `tl ). I )U
N:'.1
-IU.0o
` 4o.oU
N;. A
sIo.f)f)
.\
• The Contractor shall retain all records
Years after the termination of this contract.
Pertaining to this contract for a period of four (t)
• The County, the Clerk, the State Auditor General, and a
to Contractor's books, records, and documents re
to inspection or audit,rein gents thereof shall have access
business. 9 normal business hours,
by this contract for the
, at the Contractor's Purposes
Place(s) of
16
SECTION TWO: COUNTY FORMS AND INSURANCE FORM.1
1
SWORN STATEMENT UNDER ORDINANCE NO. olo.1991
MONROE COUNTY, FLORIDA
ETHICS CLAUSE
"KEY WEST URGENT CARE INC."
(Company)
...warrants that he/it has not employed, retained or otherwise had a
former County officer or employee in violation of Section 2 of Ordinance
County officer or employee in violation of Section 3 of Ordinanceact on his/her behalf any
violation of this provision the County may, in its discretion terminate No 010-1990 or any
liability and may also, n its discretion, deduct from No. 010-1990. For breach or
otherwise recover, the full amount et any fee, commission, tr n this Agreement without
the Agreement purchase price, or
paid to the former County officer or employee." percentage,
gift, or consideration
STATE OF:
r� l(rL
LC
.���,,
(Signature)
Date:
COUNTY OF:
Subscribed and sworn to (or affirmed) before me on
(date) by
`f (name of aff►ant).
personally known to or has produced
(type of identification) as identification.
He��IS
0
NOTARY PUBLI(!_�_
h • Vie*., 1 1 ,!F!,,1 L ?l' :!.4R
,ly Commission Expires: -•`� ' _''G-,11o'irY P,hlc • I13 ;r r
[tp r,I 11r 17 r`
y r'•'� I' ) nmms3b)n r 110 111'
3 VIN rN,l qh kilrk)n;U Nrf.-jty I
'IT
1, -a—CA at e t:Z my oath, and under pane ty ®f er the city of
jury, depose ands ' according to law on
y that
1. ! am—
aa` /k
Prop sal for the projed escribed in the Re of the firm of
''h 5,°c.c,1 s
Request for Proposals odder making the
Pro s with full authority to do so; and that I executed the said
2, The prices in this bid have been arrived at independent)
consultation, communication or agreement for the purpose of restrict'
competition, as to an Y without collusion,
any competitor; Y matter relating to such prices with any other bidder or with
3. Unless otherwise required by law, the prices which have
have not been knowingly disclosed by the bidder and will not k
be
disclosed by the bidder prior to bid opening, direc been quoted in this bid
bidder or to any competitor; and tlY or indirectly® ®� any ®that
4• No attempt has been made or will be made by the bidder
person, partnership or corporation to submit, or not to submit, a bid f®rY other
of restricting competition; and
5, the purpose
The statements contained in this affidavit are true and correct
knowledge that Monroe County relies upon the truth of the statements contained in
this affidavit in awarding contracts for said project. a and made with full
(Signature)
STATE OF: Da
COUNTY OF:
Subscribed and sworn to (or affirmed) before me on
(date) by
(name Of afliant)
personally known to me or has produced
(type of identification) as identification.
He/ -
She. is
A(r�
NOTARY PUBLIC
141y Commission Ex P ire
`� • ..lAWLK L GI+C ' .-it 71C •°( F'Or,
i4y(`r� �l5(0 21
'�ilrnes91,7n 9
1 r7•. � ,
U ` - REE NY® RK WaIU is ® nD 6
The undersigned vendor in accordance with Florid 1
that: a Statutes Section 287.087 hereby certifies
(Name of Business) KEY WEST URGENT CARE INC.
1 • Publishes a statement notifying employees that the unlawful man
dispensing, possession, or use of a controlled substance is Prohibited and specifying the actions that will be taken against employees manufin the acture, distribution,
ace
Prohibition. ployees foee i lations®of such
2. Informs employees about the dangers of drug abuse in the
Policy of maintaining a drug -free workplace, any available drug counseling,
and employee assistance programs, and the penalties
workplace, the business,
employees for drug abuse violations. p es that may beimposedupon
3• Gives each employee engaged in providing the commodities or
are under bid a copy of the statement specified in subsection (1).
4• In the statement specified in subsection , contractual services that
Of working on the commodities or contractual services that are under
( ), notifies the employees that, as a condition
will abide by the terms of the statement and will notify the employer
or plea of guilty or nolo contendere to, any violation of Chapter bid, the employee
of any controlled substance law of the United States or y of any conviction of,
occurring in the workplace no later than five (5) days 893 (Florida Statutes) or
5• Imposes a sanction on, or require the satisfactory any state, for a violation
assistance or rehabilitation program of such s y after such conviction.
any employee who it so convected.
available in the'cemployee°s comipation in a rmuni ug abuse or
6• Makes a good faith effort to continue to maintain a drug -free y'
implementation of this section.
9 ee workplace through
the person authorized to sign the statement, I certify that this firm
above requirements, rm complies fully with the
(Signature) j
Da te:
STATE OF:
COUNTY OF:
Subscribed and sworn to (or affirmed) before me on
1/ (date) by
(name of affiant). He/She is personally known
to me or has produced
(type of, identification) as identification.
ANOT
Nly Commission Expl eY PUBLIC
4'JFIA L. 0PAA g
irr�t17,y P PIiC F°rrl
17
S'• !�✓7.� Y pir?."+•,r21 )I'
PUBLIC EdWITY CRIME S"rxrolE,NT
"°A person or affiliate who has been placed on the convicted vendor list
public entity crime may nc�t ;1lbniit a bid on a contract to provide an
y goods or Public entity, may not submit a bid on a contract with a Public following a conviction for
of a public building or public P c entity for he construction eor repces to a
ofay p work, may not submit bids on leases of real property to Public
entity, may not be awarded or perform work as a contractor, supplier, s
CONTRACTOR under a contract with an p Irc
Public entity in excess of the threshold amount provided in Section subcontractor, or
Y Public entity, and may not transact business with any
CATEGORY TWO for a period of 36 months from the date of being
Florida Statutes, for
vendor list." g placed on the convicted
I have read the above and state that neither KEY WEST URGENT
CARE INC. (Contractor's
name) nor any Affiliate has been placed on the convicted vendor list within th
e last 36 months.
( ignature) s
Date:
STATE OF: —
COUNTY OF:
Subscribed and sworn to (or affirmed) before me on
(date) by'o r-- 1L� % °j
(name of affiant).
H
or has produced Cl he is personally known to me
identification) as identification. (type of
NOTARY PUBLIC
"y Commission Expires:
e."
• �1 J
PANIELAL PUMAR
•. s
Nallry Public • it )le of Flnrida
_
,�. '
°Ay Colnarisslon Eep ms N:`v 21, ?011
Boreed rhrrnnjh Nm-onal `Inl uy a,sn
10
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
Provided by the Contractor or any of i s Subcontractor(s) in any
tier, occasioned by negligencep errors, or other wrong 0 0
losses, damages, and expenses (including attorney's fees) which arise out f, in connection
With, or by reason of services
t Subcontractors in any tier, their employees, or agents, wrongful
act Of Omission of the Contractor or its
In the event the completion of the r®� (to include the work of others) is delayed or
suspended as a result of the Contractor's failure to Purchase or maintain he required insurance,
the Contractor shall indemnify the County from
such delay. t
The first ten dollars any and all increased expenses resulting from
Provided For above. ($10'00) Of remuneration paid t® the Contractor is for the indemnificatio
yn
The extent of liability is in no way limited to, reduced, or lessened b
contained elsewhere within this agreement. y the insurance requirements
21
WORKERS' COMPENSATION
INSURANCE REQUIREMENTS
FOR
EMPLOYMENT PHYSlCr4p9Bg7;rJ-x
BETWEEN ,7%J
MONROE COUNTY, FLORIDA
AND
JOHN R * VAN TUYL, M.D.
KEY WEST URGENT CARE, INC.
Prior to the commencement of work governed by this contract the Contractor shall obtain
Workers' Compensation Insurance with limits sufficient to respond
statutes. pond to the applicable state
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 Diseasepolicy limits
$100-000 Bodily Injury by Disease: each employee
Coverage shall be maintained throughout the entire term of the contract.
Coverage shall be Provided by a company or companies authorized to transact business in the
state of Florida.
If the Contractor has been approved by the Florida's Department of Labor, as an authorized
self -insurer, the County shall recognize and honor the Contractor's status. The Contractor may
be required to submit a Letter Of Authorization issued by the Department of Labor and a
Certificate of Insurance, providing details on the Contractor's Excess Insurance Program.
If the Contractor participates in a self-insurance fund, a Certificate of Insurance will be required.
In addition, the Contractor may be required to submit updated financial statements from the fun
upon request from the County. d
GENERAL LIABILITY
INSURANCE REQUIREMENTS
FOR
EMPLOYMENT PHYSICAL SERVICES
BETWEEN
MONROE COUNTY, FLORIDA
AND
JOHN R. VAN TUYL, M.D.
KEY WEST URGENT CARE, INC.
Prior to the commencement of work governed by this contract, the Contractor shall obtain
General Liability Insurance. Coverage shall be maintained throughout the life of the contract and
include, as a minimum:
• Premises Operations
• Products and Completed Operations
• Blanket Contractual Liability
• Personal Injury Liability
• Professional Liability
• Expanded Definition of Property Damage
The minimum limits acceptable shall be:
19r -r0 Combined Single
If split limits are provided, the minimum limits acceptable shall be:
200,000
0� 00o per Occurrence
,$— 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.
INSURANCE REQUIREMENTS
Compensation
General Liability, including $ 30_ p®ppp
Premises Operation ®Combined Single Limit
Products and Completed Operations
Blanket Contractual Liability
Personal Injury Liability
Expanded Definition of Property Damage
Professional Liability
Including errors and omissions $250,000 per Occurrence and
$750,000 Aggregate
The Monroe County Board of County Commissioners shall be named as Additional
insured on general liability policy.
:A a•1r Ir°AF•NrA
4MVILUCAL RECORD .'1'.t';-�-, ikFr.;
REPORT OF MEDICAL HISTORY
grnld{, rJn 3 or q Ic JI Jr1 P
ncd ca y con r. amial use on an
.4 ft. r .J st 'T W'+ nlJt be ro easRd to U I'll lull, pflPSgn9
Iy I:FP7; P.r;A (4Lry y' ',IIskH
E Position
,tire .In.1 .'Yt°r0 e5 Ft.8 P,1: °•d'he P AI'I11 r'r' '
rLU a IF^,®^E
I
'� ,Er'P k:e,8S4PlAfr•rj' __ _-_.___•.—..L. ._ r _�__--�_. ___�_ __.R..-_.. _..__. _._._ _ _.._-_-._ .- -- _.
7 ,rAtFPdFNr I F PA —VIP a; rRE';ENr -sEALrM tPlq bst L'p.A rir'PJS I: I, rINEA1IL/ .NFU d srd LlJn„ Je
,h VrIE'.;F'7I {EAL 'Fj - ... - - __----._ N.n,t•t r7 r n:r rI,nPEN'_ME17+:aP�r,,y
Ij .1Er,,;•,A71v�t{ PJFE17M
-- _-
C,ALLE;s.ilE;iy,n•/„Je
L
RlriHi HANLEO
PAs F URREN P F,IEDICAL HISTORY LEFP-fANCEO
CMEI;K EACH 11E!A — Cr7N'r
YES NO MNOW CHEF_ K EACH I rE PA --
_ '/ ES P70 l71. Pd r
Nr,,rtph :hl e.•nl feat'.vrtie Iny,inal y, _ 14OW CHECK LACrl iTF.m yESTi0 � Cr?N'r
•.velh t,orreuP,)7,3-•h.rtrrss "P brr.nh _ - - --'-- �_- ___ I Y-- KNq'N
_. 'hn ur prrNteae-----•--_ J+n�. n, nl •,r 'Pher �1N )rrnrv•, — -
7'YlPrrrrlli,tr9.Ir ay.td Nr rR •»91
_ __L-tt )1 ® Trill ,r t•,r '-j`--- - _�
Lu•,od �n tpulwn.,, ,vhrn a _ re dnhd 7f 'Inui h.�r,11M ---
.:nrrgPlrQ •'olpll uwn )r
le
F *rnv'rr NrrJlnrJ Itlrr.npay„s :7 j-_ -- _
Il r°Ist.11 n. < i '� , h rr t )w 1 , —� ` -- - _ _ pe'e rnrnr rn[M p.un n In• -_ —
i 7 b r od pr r4•.•Irr C•tr.lr tI,
_—__.-__ i �__ ':r.unps �n ynr.,r •njs --._.,m_ �_ _
.nc Ir �et•nlnpl or pl.Mis �i-- ---_. -® _ ��'ra[4' ,)r t,+:knl 6r•.-y, •—_. 7trnpw,uh rg - F r,l trq.,hl®
i4Tj,'wrr .11 r Iry r•se1 u
ble
v a
s.t/ c ;re pr. n•s» Inrtrt rIP- hors Injwy tr—
Fya srt,;rr' 78f _' - .LIIIP1,1,1ln vr._rCPe u
/ /rrfl v.ir.n .j lll9b,rrs p it d•y9 9 •o r. .... j r/, nf,rp -
.Ifw veto n n nyW +®-�`-
°'/'• 9/ 1 h _•_ __- P.IIP°hr.e )P Prp Af,l 9 r r Frslrrp 4•/ .tr 4rr7 N• _ _ _
r.lr,rrl IrPJ -- �.- Tom•• I ___�._.. t: DI, 1, !'n. tr,t 11 Nr tr1i-rts lm_ ';1 rl Prr ..I �• 1 IIr :Men rprr9 ___—
... `... �A,1•. •+tn riw ,,: ) -- -_ - _ Fr rq"rrt Ira ,htr tlrrp.r 0 -®
'.Y r sr I hr u•r nr r,9r 6 v � - I -�-- :n la rn Hlr rnnn--
._— r®'rt - r.';hin
,_..h. :H�_- I. rt7 P r•r.r .: r• ®—_
a,h^ ern Ila: L•r rr_ ... .__ _- ---- N__ +- -_• .6 r n„r ,Ir .vlI -___.� -I�r Ir •rrrtr,e
-... rn _..-_ _�._.,.. __�. —_ ..reel, _._ ` 7 Vrrv• I: u r d'r, .P Ir'y b.lr •_...�-_�'-__}'.. .. .
•rr9 _i-.-...:-___..:.___ •e�11 .n �n.li lvtar I'--.L—_..-m _ .�'rn—�Dt�l rr.: )r9r. ,teat I { .__ L. ...Y.
rN n L
or
It `r rN'1'annf ;r p.hrhd In•11 n L _ �.,..� �dr»rl tP+r.l v=Ih blPr __..._-�_'.._h _
rr tlr.
t rr Iv., Irl• .. ._ r®_ 1•_- _III r,7 tti r p r 1 • F - _•• 4 t ,
,
'r+Ir r"7 tt - r r1„®v Sl�lrr rrl 1,n p,.A-i----. �__ .�_ • rlrY I�rr ref lln IPrr,pr ._ .. j.. r._ ._
.)r,. ,r...nl ,•ar ,'••rl 'r t. _ ` _- � ,� �;.ee ar 1 r are' n n r - — -' 6 -'1_- } • :-. -' - - .y - .. _. .. __ - - - •_- .
r"hr r u h rrI ,'it t "' •I'ir hI•or Pal lie l•rt- I - �L --- r ,t ,r.tl gar r . In.,, .a r _
"F 1 u A
• .r r I r ,IP P'r ,7 .r rl tr r .` - 1 __ .- ._.-. __ e•'^ ,r It ,1 r. •,7hr P � r _ _ _ _. P-
r .r
7 4a.,e J.r � _ �- '- ♦ { .. ._Itr g u r r B rr"r P � I
'-e ry r+ rr r r'•r.B• r r r t .. 'Ir l r• r d rr ,t
N.. f t
Irt r - --" - - I• 1 'rr t t •Pun , 7r - i ,'
,
r ' •! 1, 'h r r 1 t , r r _ .» r - r._ ... ' '.r�l :..., IP , r ;r u' -t- - .- •- -
°Fti taU I lt',N r n
1A �E ';F .t'ir'r'.lV"41F.t q�e lA rF 'lF',t';i t9.9 r.9 ti117
r.411a•1 Il.r I lor,alr 91sa• l._ -�
N.NANt
':_r b _8®'n n•Pre le,,a(p P8°P!n ._r_.'..N/ �.. —_ N/A N / A v
:IIErY EAI:•11fC1 I /A
f)rpL1lN ,N lLA°eK ;FAa:E rq fhl- — %I'IAN---__--
I;rFArl N BY IrE°.1 V ,•.IPER -
1! •Pave fora t: Rrrn ral�, .._®__ --._ _ ,fS Ptl) -_.. .._._ _ __—. -_. _�,� ..__ _.__---___.
1 a,J or"PIrtmeet nr un abl
SY In 3GP.:UB CPr e'rq nl: Y bRe IIn • to nrlJ s ;b „e
1
b-',InyllwllY to ':h,Ime: Jig. fie gB. U°rl,Rt, rP�
b l,'abdllp Bo pPllrarn I:e19yn n+e:lu.11g. _
r Irablt,lY Bn a4!tens r,, ®�_®
®1 lalhPl 1_ M�If.40 fRRyU ng are Yes. .;, rCegnr s. a
9 1 '1.IVP fn„ eyw Pepl Ife IP ReI 11t(R ,nenfet r, rrlllll:rt__® 6.vrPn, where, anll yy,1P ,!P/a,iY.l f'/ ra's Sdaa,'e/p �_-
1 A Rv v ynn evew Peron I:Rn.rW hM maneartes/ !d,ve edereds.I f%/ paa, ;bee faason and
9 5 Hsv4 you h,n1, nr 1`JVR yn,l teen .blvovd Bo h ldd Yes, ,do rchbe end ,live a,P et wh.ch ncr n 8vR• vo'P nperehnn
u evi I
I rl , . yla°I a/Pr PPPn J (:,1llgnl In .In B CdIPM1/Y PrhPn, where, wh Y Ype nl hn4l.t. vli it —"
1 / An Sy fYl.f Y. 4nd ,tern/ n/,for'Pnr erd �nmryPlt! Rd,freeg
17 r9ave fner coa'g,.atfr! nr Peen URa1ad by r, nlr. g, {A,ysnaRro. !'R.11Prg,
f r nIPR/ pe Ir t'e" 'Ji 'atlhm IhR past 5 pR"I fn/ nlhar Ihan mmnr
dlrtival I a fit pee, /roe r. crnplete ,n/,fuss n/ lrctnr hn plat ctmr, an,!
JPIeJs I
I I]-1,lyifrollou evnf br»n nterlm fat mu try ganlrn hee augR cl
61eY grcaa men PRl, nr ether rP,Igong! ldl bas, V, v ,ja/e errJ reason for
tr•ecP,on / 4_
P ,l ''favP YOU evw bran ,1egCM Je ���'�•—
phystr,al. mental. or nlPer reason ' ir,ytl mlPB ary sernce bec.I of
'We of J,schenle, .yherher henoraD/1e0 yes, -I /eke, Meson Ord
v, I/IP•'e is or un4Wtab�ll/y t • ohier than honorabte, %ot
1n�HJVRf Ula RYM enrel'IINi, y thrwn p
Fenq,n9.
.ehafea 'n PyoNe'l by "I., nel ev4hfv,1 ,F4aCIL rtP yes, IvecIVY
n,Y :vh,v/ emelf. rnl, wP,.. whY I
Z. a'I4ve you nve/ bean ,1lagno4f°e8 .,,In a'Perron, 'Y°e type, where 4nJhnw ./„lgnosr,f/ J'J,gabWly7 /Il pee,
:) �aST Air i°.1NI MIA71f'N; RcCEt°dEU ___ --------- --- - -' —_---
r vn r 7T7.l ' wa rP'.,Pwar _. _ - - - - _ •- - - -- --
I'e nr Pgoletq In 11 maamn I,
nr •„nog merhr.ne•1 ehov0 to hen,sh IPe linvernment a •F mPl Y me an ._
In levgl.en,l Ir If Ials"Irallon .11 mlorm,Ihnn ,;n ,J 6 0OP tr Irgrr t •II II q Ina' p'4 rr mh. � Fegj Tm
nverrvr and Ir,rmt,g tN.nyh,Pblel my era,''°: ad Ewror, Ine +r Y Iv°v e'Je vn-IT'n il,• f I e, or tnl e'^-^
Fa rYlrEp IJR t IIIN rE0 NA+,tE rJF EV A by IinR ar,1.nf ,IrpP 4onln•M9 6:Ng n1 Plltre9g,nr) my .IFpIIP.JIIrn I r Irisg, , n4ptlalf,
MINEF :16 4 mplofn'entrr service 1
�Ir:NA rIJRE
�. l CA rE—
u -'A DOCTOR OR NURSklm
E, OR IF MAILED MARK O BE io.or'pbt,OPENED BY .MEDICAL OFFICER ONLY
,,tel4 lsvl anygrc!=I/oENVELOPE"T,,v/.ne,Jr°elthArl't Pt 'F ''I.LIEItr VENT pA rA !'hpP",An 4'`4df ,°•
.sfnry 'h'erne4 ,rpn rant, arld re°rnl eny s n,/„_. fn nPnv nn ut ,•n W.'o ln;were ,.T •rPrnf l lhrrlr h P a w; 9 are („"1 'qs !Pre. I 6, en ,n4y
MEDICAL RECORD
1 I AST •,ASIE • FIPS-PIA'dE '.1
�1 r•ri,1E aCC�ESS ,l.u.iJw ,rmrf vNFp, • 4y v r,.n .trYN.D�'t1 jiP ^,a) ®—j":
'i - TE =;F I]IRTH
v "I.—C '.P tlni TH
I:w AGENCY
REPORT OF MEDICAL EXAMINATION
2 CENT F QA Tb'rPd .......- 1
_ L position
T I °amw drkd retn•s „t • - nP F I) ---• `-` - -____
CA-E :F
I
AejE 9 '.EA 9 RELA 1e]N:HI1111! 1: 1 1JTX.;T
FEMALE MALE
If PACE
' Jte•II TE BLAe;K 'V6IERICAN INGAW HISP�APnC ofANIC a,^eiAN,nA
I:ti '"RGrVd1264fl .N UtdIT 4LASItA PWT aE I'h11 CIFIC
13 TOTAL (EARS 3.VERtIPAE 9ER'd14--
1 MILITARY C I:IyILIAN—
E1AMIf1E1, aPJO Af7CRE.^•S 15 RATTN3OR SPECIALTY OF AMINER
IN PURPOSE I7F EfAMIfJATICN
'A; I :heck + 17. C
.reh,Pemn.lpryn�Pe,.Jumn unfer'fJE'r/nole6nkrnleJ)
A HEAD, FAr;E. NECK APdO SCALP
8 EARS • GENERAL 11NTERNAL CANALS)
;.:udlMry xv,lyunrlernPms 79 nrw/ M)
C OPUMS IPur/rrrelkn)
D t1usE
E SINUSES
F UOUTH ANO ThFt3A T
G EYES GENERAL, V•msl n•" ymd .hu'an ,n•, .r �wrrt, ;e ,9, n•d 0)
H ';PTHAL.MOSC,-PIC
I PUPILS (E-lullllymldmocam)
1 ';CUL.AR MI)TIUT-/IA•„ax1,rPHd ,},)r,1JI@P 17K)6PlIfMfl n Nt y • tnlymus)
K. ll,rlGS ANO CHESt
L HEARTI Tf nrsP. ,l: e, rhphm, bnurwle)
_ M 4aSCULAq S Y�TEM (Y,utr;rAu, nPr..)
-_— �N ABOr_AAENANO'.ISr;EpAJOn-PlnJnhrm Ip
NOTES 1Lbxnl,e#uberry ItnornMlrly.n'k'InM Er1lnrLkDrnr- nr.lom.°.....>.._'._'.-
1 :; - tech ,luny !n .IPPrrPrysla r nlIJrM e„ JPF •NE° Atilt rn e,'ualaJ )
O PROSTATE (QVMJ0, r01074:411y neli'•atP•1)
P TESTICULAR -----_
.R END®CRIPIESYSTEM
4 r;.0 SYSTEM
T UPPER EXTREMITIES (SPrenyPPt, nnryeMnrPKnJ
U. FEE7
V WINEREXTREMITIESIE+,LePIt061)IylsargPh.rnnlyerdrPa,li;n)
W SPIPl !. OTHER MUSCULOSKELETAL
R ICEN T iFYING BODY MARKS SCARS, TA. tTrJOS
�-AC
1MPHATICSLOGI ',PHIATpICIgPy(,J,,nnyP,,nnMly,lebulfk:n)
—h rmment I:',nhnuu n "I"-andu:®,nld.rbnao AF+rltJn,kK%.Iry)
IH CEPDTAL,N'a'ualyu„t�.fp y,rlc4..y,�n,nnn.Dny;tys.,DPx,:a.yMbwnumbxrn,0u;cwr.arnYrwnrP�lA)
f• .f; _ZT'•y ^`+t.,rW , '•. n- M {..(. ,r.-'---_.®.T—EwAp M3 AND orfil ".':w,A4 C$N TAL
CEFECT ANO CISEASES
71 ..en Y tr Tr-�
.• ,u na
R - "
7 0 S d P
13 1.6 I S I q E
J nl I!i I T F
r
-- _ 19 TEST RESULTS �Copdas of r!yUIP! .lr@ preferred a9 ,Mac fhmenlyl
A .n�yALr;1': I FFi: F07-,mA'dlry
i:He "I q r t:a Pp IF:Der, L.Pr' nl nao,; IN 7n.7 '•tii.,T)
tp, NIA
r: '; • { HII, S ENr'o,}�� . • ea ly „J ,at i U EK'3
e ,l e•.,.d•I +E Ol! O �•r^E shO l:P:I p FACT a q ;EST.
- - -
IIJ
•1 '•W -31 id
l I.A
iTAfdUAAD FQn51 Ad 1?•
•' •4,,ta•1 Pr ;I .MAI. n1.17 61 rN I
EN SANDOTHERFIN
23
BL' 0
f7L
N BL -4..r) PRESS(. RT
ll�PE
-i FNIPEPA-,RE
(drm. �EIPEF
. _ q
3, 1,,1, IE-:B:-,
T-LEF
S q I PULL E
t
BENT
rot.; �F; J.' �'E I I Y7 'Z7 -TAF, E I F -ggy ra-
11-AS AFTER C,ERCI�E
A C R rlj
'0 REF14 . ... .... ....
AR ro
--EAR 11SI.-II4
zx
I I` IE —rERlPll6T1-A—',,l'
BY To
El a EXO
III
------
R H L H P111 I sm ulv PRI;'M.--cotiv
-Mi�--XA rl—r-N
31 —ir,
v-'L'A r'
—
Pr.
1-1 CT Pa
33
LEFT
14 C -P �E R I NEWI rl- -tr
JS FIEW 'JF
-""3HT
r')ll ."Wd W r"'R
'I'vj '(-.%qREc rEE)
34 %IGHT'
LEFT
Ands#;Lm) �':CZARE,ZrEo
A 37 REQ LENS
is EARIfIG
TEST It', A-1-17 IA. TI-1—
�TE
� W TEPJ!;l :)N
jLA
alA "'T" _A IISION�,
40 Rlr-,HT
Rl(-,Hr qjV 15sv
Aijr;l.: EMIR LEFT -7A
I Y- x ir,11C�1011 7,:-
,!I p7m 1"C!1:111 M. Sol and
.IS "SO Wa -00 'CCQ 3100 'C'30
-'% il-2 0.24 IC48 : '"m swoo
'296
LE FT iV,,V 155V
4D)a V-14 01192
1 3HI
A
115
LEFT
,-')At,iDSI(-,tIIFICAtJTCRItIT'ERVALHST(-'PV
kA 0' CF —CEFF1'M--
,lN5 FIATHER ',PEO ALI:; r EXAPAINA r,::44s ItICI--'ArED, yj
-15A PHI 31CAL PROF LE
4A F
L T 7
A
In accordance with attached Job
AJAL-FEC LI •�AL F desil
-pt [on
','J CEFECT'; 8 r I
E
--IAPI - T
13 r�-EB R --p""E6 ',711E 1
JJE
IJE
:i rANOA NO F, R
Medical Examination Report n... -m—i rn4,,
FOR COMMERCIAL DRIVER FITNESS DETERMINATION
lill. is Driver completes this section.
Divers Name (Last. First Meddle)
Social Security No. Birthdate r Age Sex L-j New Certification
M Data C! Evam
Address 0 Recertification
F:City. State. ZPo CodeWF
®Follow
Work 'Drive, LicenseHome To ( DA c Issup
------------
'Ps No Driver completes this section, but medical examiner is encouraged to discuss with driver O'hor
aTM, d'"S. or 1, urvn!*,e foist 5 yeers7 Yes No Yes No
"Pat! Nat" tmunrs disoda-s or l;InesspS Lung disease ernOmma, asn,,a, charic b-mr-cNtis 11 -1 0 Filming. i:*zvn-Ks
�zePrfea,sy Kidriov disease, dialysis E
Liver disease
EW -*Sorjos or Fmv;)!Md visori (excep! cormcv,❑ Digestive Problems sk I&-:1 S-V—(l
t""P" 'Oss 0'!�earinq or balance 01atielas or 6'e"Ied blood super controtio F1 c-r pRrRtvps
• heq '%, oph_r Ca'J;0vas'zUJa1 VX�tion C: der _d bv. ❑ El
0 - n a"aL
nvdicat-n C El Somal mrury 0, 6sn.15.
I r j E] "elirl %rop-ristiin Ll Ecironc iovv, ," va,anzvla� l
-,Oh NOM Pressure ENqrvus orys,e LJ ❑ P0gU ar, Y-pant aa
PSYchefr
oj jpcsorprs_V-'5r'Ja1 dnease "-dication Niroo,--
U-.
D L-0 s Or, or alf@r--d consclousnpss
":Or any YES anSWP-®. indicate onset date, diagnosis,
MediCatio treating phys clan s name and address. and any current �r!,iit,
'!s) used regularly or recently. limitation. List all rneftafinnS (;ncltjd,no n- vim
I certifv that the above information Is complete and true. I understand that inaccurate, false or missing information maY invalidate the ex,3minatinn and MY klari,ra(
Eltamirters Cetl!lcate
DrIver's Signature
Date
Medical Examiner's Comments on Health History (The medical examiner must review and discuss with the driver anv *vas" answers and r.f-,*Pnt!al haa
medications including Over-thp-counter medications. while driving. This discussion must be documented below) rd-
rD
LL
� >r
vvtculcaf examiner completes Section 3 through-
7) Narita; La,, Fiat
standard: At least 20140 acu
3. • ity (Snellen) In each eye with or without correction. At least 70°
each eye. The use of corrective lenses should be noted on the Medical Examiner°s Certificateerfpheral in horizontal meridian mPasurnd in
INSTRUCTIONS: Whon other than the arrolren Chart ie used.
nf°O wit°° 20 ac numPraivr and the cma!'ecf 4r- read at cno feet as denominatn_f► in $rrogen comparaNlP valupc. In ror_ordmp dlclance vic,M, uco � 1 tact at mm,m l an hat°>aUarh' cvoaN Contact I®need, Or intends ►^ de cp µchirp If the aptirfrant wears corrertiyP tense, these should t- wCrn whOn ' C^ t rcrl +a .err. °Z ac a
d^ivrno. Stefimprif evidpnCp Oa On d foloranco and adavfarion fO their us' must ,, vrcrlaJ aCUa`Y rc hr°nry fnc9n,y ra .r,® �•- ya -
Numerical readings must be provided. tip 0�61"Ouc Ai'fonocuffir drfvere arrr nor nupfl®fa,d
- - Applicant can reCounlze and disiinoulsh among 9rafr.r rnmtrmi
ACUITY • UNCORRECTED J1 CORRECTED HOR20NTA_ L_ FIELD OF VIStON signals and devices showinq standard rod qro®n_ ;%n %r
_RI®h+ Ft- = 2�' n+ 1 Rlqht Eve _ - ___ -- color-1
d amhP�
_ 1 2•__
LWI Etio -� 20® l fit'' _—ILo- - - "—' Avellcan! moots visual arully rejuiromor.! only' whom Wo,,rl rJn
Rn®h -vos 2n i 2nr -- -� 11 COrrectivp Lenses
C^mhl®+P noyt line only d vision tectina is done by an ol,hthaimoln rct nr o n ti+onrx urar vis°rin: !=l vPs i No
q __ Dt_metrist
Capp f -
O E*a—riahon Name Of OphthalmOlogist Or 001nmetrist (print) Tel- NO.
Lirpnsp No 5tatp of IS——
slp G�naa,rP
4. c Standard: a) Must first perceive forced whispered voice > 5 ft.. with or without hearing aid, or b) average hearinq loss in fionPr Par • an dct
I j Check. if hearing aid used for tests. ❑ Check if hearin aid m it to
INSTRUCTIONS: rO cnnvorf audiometric fact resul c g qU` ed .. meet standard.
tocfed and divide by ? t from ISO fo ANSi. - f4 dB from ISn for 500 Hz. -!0 dP fcr f, 000 Hz. -8 5 dP fir 2. On(1 Ns T
Numerical readings must be 0atinp7a a�� 96.®
_ recorded.
a' Record d+stat"re `rem individual at which, PW0ht Ear
`"trod WHS[Mrpd vo°r;o can first tw lloarrJ. Left ESP I
— l_ ept I 6Fppt
BUM PRESSURE / PULSE RATE
91nod cyctnliry �lactnliC
I'roceurp
[,river quai'find if, tdr'on
_p'llcP r=;fta_ ' L;aJ'Jtar ' l IRP3ul7r1
Oorrrd Cltica 0,9a
P ON Ear ; Lnf+ Ear
bt 1f audirxnoPerie usM. rpoOrd hearing loss l 9nQ Hz I tn_nn yZ. 2n^9 yZ ' Son ►i''tr�n u__
i dwbel5. lacc to'INSI Z?d z;_ I
AVPrO®' I • tivorago
Numerical readings must be recorded. Medical examiner should take at least two rpadl
Readingngs
Category I Expiration Date - —
10 confirm' PP.
--
tdr�tSoron_oo
5tape t
t year
_
Recertl ticatiorl
i
t Yoir if -. t.Tn on s
---
1
B
1
f,*1P-hrna rO rt°r9rat® rnv '} rTn>t r,l; .a
i
' te;n_1;o'1C�l1 tp®
� _� —
_ StagP 2
Ondtimp Co..ifirato 1nr
i tdt-1S0'ot_oo
- -
�' lAnrt t!t
- -- --_-- ---
_ �._
1 Stage 3
7 rnnn+hs,
+ .`. _.— __—m_ __ _.__—__
E mOrtlts from date of Piram
�_1 year from rt,9a of nYJm .B
ii . tdn•on
R m+nn+hc .f . a..+,n.yt
Numerical readings must be recorded.
I lrinalysm IS ►?qU+red PrntPln, blond or Sllgar 9n the ur'ne ma bP an 'indication for further testing to
rUl® nUt any UndPHyrnq medical problem. Y
O!hPr oclrnq fC'ncrrihc. an,+rpCnrdi FL.1114Ecc CIt j _ E a_N
ffm=n M— Height: -- — (in.) Weight:
The presence of a Certain conditton may not necessarily diSqual;fV a Oki P4nw- Lgst
f a condition dr-%Ps not di-rqualitVl driver. particularly if the condition iS Ciontrinfladadequately
t01'e-Itmi?nt E'en i F
!hp n0cP4ZS;3n,'5tj?DS to driver. the
as iq not 4g?iV tr, %p.Frr, condition
correct thin medic -if examiner may cons deterring the drive, tamw)-arifV A', s?n or iq rAr
Chlac� YES if there? are any abnormal;tieS. CheO soon as POSS'ble Particularly if the condition, if nPolected. If rlrtvp-
'he driver's abil,tv to operate a CO"imercial Moto NO if the body syst could result 1-1 Mora, zPrinjq to I'Vel
emis normal. Discuss any YES anSwp rrfr0'1' r4
able item number before each corn in the spicp holnw. And Tnj!,:.!tp w
colnvenS-Wed for r vehicle safe Enter apPlic. rs in detaq
�-7-5!raC!1017s fV jhP "edical EiraMiner for Cluidanc, ment. 11 ^F0;3n,r d—za;!Irp V,C3#z0"q rj�ln L,:%&
BODY SYSTEM CHECK FOR:
: YES WO
BODY SYSTEM CHECK
FOR:
of dtu?'abure 1 117
I il4o
Pur""WY Ocwalitv. ra"ion flat., a-ry""atiin.
rn,�lflqv ocular rnu!cla rnbalance. ey'-Y.-ifiar mrwornpnt. r 'Syearn Ab-:wnal pule
altopp`falmns Ark atgul - r, �. ;,Ij
"e*;nW-3?hV
019UT-Ma. macular doppnorg"n and -lfor tn.,
if .3mropri-ita. - 19- Warnins
r, qr-A-3 0 f-vanic marnb-a-le. tXdUslon of ey.fwnai canal. 110. Etr li*m Lim, Lo t
.3 1 '"Irlalred Drivpr 'f 'PT irm. -,a,
VIV -1^d T16rlo j , - I-P. d-ITrwll.K ;31
1 t- E I clijNkin
swalt-A-l" "N likely !�' in""' Willi bT-3lf`l1-!0 or
I "ra svundq Pnl:3-0ad hParl Vacvlmak-r
P,vatabio rf&41-9.3!nr
Luiis ;ind Abnnrrnal chest waif a"nqf -on. ablo"31 ha _
ralp- ab"Orr"'If b-0, -iunds i1cludina wh"ZaS 0,
afV-nl;i.rale5 Irnm,radrp
ciflanosis
Abimr-,11 hndt,7 C -1 phycPral ova - 'MY -00- furlhar
'an"'J sjcp' -35 Pul 'ari 'esq andnr fir - 4V Cq chart
'COMMENTS:
--
Note CL Spa In"' '"iffeati" statusstatushere. JiC4l EX Mi-- r!o, guidance.
Omndarj-, 1-1 d'11 C-Q 391 41.
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n or medic-l!inn). Medical Examiner'- Sign:1,um
W. Up on M-Jic-31 Examiners Name
if maple ttanda►ds. coin®fete a Medical Examiner's T0100honp Nnmm
aFe81; stated in 49CFR 391JUNU'Zt
C-irl, - j rarlibrifa
r
MUST HE LEfulKE
MEDICAL ErAIMPSFP-S CEWfTIF.CATE
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MEDICAL EXAMINER'S CERTIFICATE
49 GFR 391.41 Physical Qualifications for Drivers
THE DRIVER'S ROLE
PpSMnsib-111as, work schedules. Dhvisical and emotional demands. and lifestyles among commarr-ial drivers vary by It•® Noe Of driving 1 Naf "Pv do Somp n- -hn mg," `VCac r- 'nvarc ,^ °drip hp
iol'7imng cum around o• slier! rel8v (diners return to their home base each et-e-ning):lOnq relay (drtvprs drive 9.11 hours and ihen have at i®act a tn.hru. (:ia+!ufv
(cross eour+'•v drivers), and team drivers (dnvprs shared file driving by alternating their 5-hour driving periods and 5-hour rest Dariods.)
The fellowinq factors may by involved in a driver's DerfgrmancP of duties: abrupt s&-dulp changes and rolatinq work schedu'as, which may resull in l•rpcular e'aav Dar -erns and a va. hp0:•..,,.,o
a hip in a fa'iqupd c®n,gtton: long hours: extended time away from family and friends, which may resuft in lack of soC+al suDDort: Pam p•ckuD art! de'hrory echadulpc. w+'+e ,rpqu'gr d wn'k roe'
and Parnq vaitarns, advemp road. wealhpr and traffic conditions. which may cause delays and lead 10 hurriedly loading or unloading Pam() in o•der to rn-nlspnCata -tine, il•a Intl an" pcv
condi tons such as evicesq". vibration, noise, and "comes in temperature. Transportina passengers or hazardous materials may add to the rlpmer,ds tin!'- rniPrr,gl rt•,-er
Tae.o may bP duties in addition to IhP dnvinq task rnr which a driver is resoonsible end needs to be fit. Some of tt+pse tpsponsib,lifies arp r_nuohno and un^^uC"n4 --ai'p (';) 'rO-n'tin tray
Ioadmq and unload -no irallpr(s) (sometimes a driver may li`1 a heavy load or unload as much as 50.000 lbs. of freight 81tpr sitfinq'nr a long oe^ o► lima wi-'+nu} env 4t.ptrti.n7
01- oDnra'Pn0 condition of tractor aryl/or Iraifm(s) before, during, and after defivary of cargo: fiffing, installing, and re-movinq heavy PrP chains: and, h1l" o haaw Nrrgu'•ns Io rCrvpr Cr•.,c •.a,,p c
T''et°CV0 •asks dani4nd aglhty, the ability to bend and sloop. the ability to maintain a crouehinq position 10 inspect f'-e undem,de 0' clip Vph-tile f*er upr• pn}pr r.c gn j pY,••r.r • •ha rah a^d ,+•n
ab. ,'v t� climb ladders on }ha tractor andJor trailar(s).
Cr inO' adi'iio p.�a'd® vPr muel have ihP perceptual skills to monitor a sompthnas complex driving situation, the judgment skills to make quick, deeivnns, vegan na,":wrv. ans •hp mgr.t+'J'�° vn c6•"c e„
rr-q wheel eh' gears using a manual transmission. and maneuver a vehicle in crowded areas. -
§391.41 PHYSICAL OUALMCATiONS FOR DRIVERS
(a) A parson shall not drive a commercial motor vehicle
unless he is physicalxy qualified 10 do so and, except as
provided in 6391.57. has on his person the original, or a
r' M-crach-c copy, o' a medical examiner's cer115cate that he
,s o'*yslcal°v qualified to drive a Commercial molar vehicle.
tbl A Damon is physicalfv QualfFed to drive a motor vehicle
' 'hat Derson:
(' l Has no toes of a (lot, a lag, a hand, or an arm, or
has been orantad a Skill Performance Evalua!'on (SPE)
Cer*',cate (*_)—ar'v Limb Waiver program) pursuant to
$391 49•
(2) Has no impairment of: (i) A hand Or finger which
tnteeares with prehension or power grasping: or (it) An arm,
foot, or In which inter -ergs with the abi'ify to perform normal
tasks as"Wed wi!h op Prating a commercial motor vehicle:
or env other significan! I•mb defect or limitation which
mlar'P-es wi!h the ability to Der-orm normal tasks associated
W14 oc—at nq a corn-eirci3l motor vehicle: or has been
Ora -lad a ScE Ca•4-Cate Dursuant to §391 ao.
121 Has no established medical history or clinical
diaonosis Cl C,abales -el Ws currpn'ry requiring insulin for
con!•cl.
let Has no current cfn,cal diao_ nosis of mvccardlal
i^'?rct-on, angina Dar_!-jns. coronary. msu" iciency. thrombosis.
O• any other cardiovascular disease of a variety known to be
acco,riranind by svncove, dvsCnea. co^aDse. or congestive
rpndtac `?tr,rp
(51 Has no evabfist•ed mmlical history or clinical
diaonxrs Ot a resolmlory dysfunction Iikalv to interfare WWI
his abi'•N to cor•'•cr and drive a commercial motor vphicle
safely
(5) Has no cunt clinical diggno". of Mph blood
prsssuro'ikely to in!er"ero with his ab"i'y TO Overate a
Cnm!nprrial motor vee.,clp cafply
(n Has no pslablished medical history or clinical
diagnosis of rheumatic, arthritic. orlhoDadic, muscular,
neuromuscular, or vascular disease which IMerferps with his
Wilily to control and ooerate a commercial motor vehicle
saf9ty.
(e) Has no established medical history or clinical
diagnosis of epilepsy or any other condition which is nkely to
cause loss of consciousness or env loss of shifty to Control a
commercial motor vehicle;
(9) Has no marital, nervous, organic, or functional
disease or psychiatric disorder I(kely to Interfere w'!h his
ability to drive a commercial motor vehicle safely;
(101 Has distant visual acuity of at least 20/40
(Snelleri) in each eve without corrective lenses Or visual
acuity separately corrected to MAO (Snel on) or better with
corrective lenses, distant birocular acuity of at least 2n'40
(Snellen) In beth eyes with or without coractive tenses, yield
of vision of at least 70 degrees in the horizontal ma_ ridian in
each eye, and the ability to recogn)ze the colors et traffic
Signals and devices showing standard red, green, and
amber;
01) Fv-st perceives a forced whispered voice in The
better ear not less than 5 feet with or wi'houl tha use of a
hearinq aid, or, if tested by use of an audiomet-ic device.
does not have an average "arnq loss in 1hp better Par
greater tt+7n 40 decibels a1 500 Hz. 1.000 Hz and 2 OM Hz
with or without a haarina device when the audiomatric device
is calibrated to American National Standard fformeriv ASA
Standard) Z24,5-1951:
(12) (1) Does not use a conlrollad substance idPntfied
In 21 CF9 1309.11 Schedule I, an amvhatamine, a narcotic,
or any other habit-forming drug. (ii) Exception: A driver may
use such a substance or druc, 9 the substance or dnig is
prescribed by a licensed medical Drac!�Boner who (A) Is
far"Nar with the driv(sr's medical history and assigned duNns,
end (9) Has aCh'ised !'°P drivar ."a' the rratrr!7ad e�Jhc1A^-a
or drug Ae not adversety 8"nrt »,a d.fvere it, -v •„ cg'n,y
Oparalp a commarrlal mO-T• w�irlp, and
07) Has r9 rurrard rl,r.,ral r!•ar- a'rch^°ern
Federal Motor Carrier Safety Regulations
-Advisory CrfteHe
Loss of Limb:
5391.41(b)(1)
A Person is physically qualified to drive a commercial motor
vehecBe if that person.
Has no loss of a foot leg, hand or an arm, or has been
granted a 8ki11 Performance Evaluation (SPEi Cerfgcate
Pursuant to Section 3gt.dg,
General information 4111
The purpose of this examination Is to determine a driver's
Physical ouallheat on to olae'ate a eommorclal motor vehicle ((-MVl in nite�tate commerce according 10 the motor
efhicle in
rnwl p 7g1 -tt-eo Therefore. the medical examiner must be
odgeaNe n 'hegtt requirements and N
guidelines dev!oped
by the F44CSA to assist the medical examiner in making the
oualificatietn dererminaflon The medical examiner should be
`amiUar wish the dnVor's responsibilities and work environment
and is mf9rred to the section on -the form, The Drhrer's Role.
In addition to reviewing the Health History section with the
driver and cpnducbng the physical examination, the medical Lhttb impairment:
examner should discuss common prescriptions and over-
the-counter mediCabpns relative to the side eff!+cts and hazards of A person Is Physi, ally qualified to drive a commercial motor
those medlcatipns while driving Educate the driver to read Vehicle r that person:
warring labels on all medications History of certain conditions Has no impairment of fat 4 hand or finger which interferes
may be cause for rejection. Particularly it required by regulation. with nehensi0n Or grasping. " or 00 An arm, fool, or le
Of may indicate the need for additional laboratory tests or more p h the
i
which interferes with the ability to perform normal tasks
stringent examination perhaps by a medical specialist. These associated with operating a commercial motor vehicle: or (fill
decisions are usually made by the medical examiner in light of Any othersignifiicant limb defect orAmilation Which interferes
the driver S job responsibilities. work schedule and potential for Witt? the ability to perform normal tasks associated with
the conditions to render the driver unsa►e 0perati'tg a commercial motor ►t+hicle: or (iv) Has been
Medic.,al conditions should be recorded even if they are not granted a Skill Performance Evaluation SP
cause 'Or denial, and they should be discussed with the driver to Pursuant to Section 391.44. (SPE) Certificate
enc®urage appropriate remedial Care. This advice is especially A Person who suffers loss of a loot, leg, hand or arm or
needed when a condition, If neglected, could develop In!o a whose limb impairment in any wa_v interferes with the safe
serious illneSs that could affect driving, performance of normal tasks associated with
It the medical examiner determines that the driver is fu to commercial motor vehicle Is subject to the operating a
dew? and is also able to Perform non -driving responsibilities as Evaluation Certification P Still Performance
may be required, the rogram pursuant to section 391.4 _ 'fledical examiner signs the medical assuming the person is otherwise OuaPified.
eQrt+f ,ate which the driver must carry with histher license The With the advancement of technology, medical aids and
certificate must be dated Under current regulations. the equipment M01111fiiCations have been devel
d to
certHicatP Is valid for rM years, unless the driver has a Compensate for certain disabilities. The SPE Certific
medical condition that does not Prohibit dNving but does Program (°ormerly the Limb Waiver P at'inn
require more frequent monitofing. In such situations, than to allow persons with the loss of a foot
was designed
medical certificate should be issued for a shorter le f functional i Oot or limb or with
meth p, pimp impairment to qualify under the Federal Motor
Thy PMSKAI nY7minahon ShCUId be done Carefully and at least Carrier Safety Regulations
as cOT tale as Is indicated b the attached form. (FMCns w is the enable
prosthetic
c Y Contact the devices or equipment modifications which enable them to
fvfCSA at i2Q21 366-1i qo for further information (a vision safely, operate a commercial motor vehicle. Since there are
exemption, ouafifying drivers under 49 CcR 391.E4. etc.). no medical aids equivalent to the
certain risks are still present, and thus elst�ionsor lmav be
Intefpretatlon of Medical Standards included on individual SPE certificates when a State L7iroct�tr
Since the issuansy of the regulations lot physical qualifications for the Of commercial drivers. the Federal Mot FMCSh determines they ate necessary to be
Ad-ninis!ratson Fgii or Carrier Consistent with safety and public interest
( CSA) ties published Ir9Commendations called if the driver is found otherwise medical
AdyiSCrV Criteria *p help medical examiners in determining whother a driver moots the q (397.47 medically qualified
Physical qualifications commercial fro (3) throng f13t)• the medical examiner must check
driving Thpga ri Cpmmen- h ysi have f on tits certificate that the driver is Qualified
Provide Inti+r•ttatyJrt 1p m. been condensed to fJ accompanied by a SPE certificate. The driver and the only it
relevant to the Mimi ation examiners that (1) B5 directN employing motor carrier are subject to appropriate
included in th Physical examination and (2) is not already the driver penally if
e fnfOdiCal examRtatlon form operates a motor vehicle in interstate or breigr.
►ogula!ion Is rIn• The specific commerce without a current SPE ce f p ed in italics and its reference by section Is physical di fti irate for higher
hiohllghtart sablbtV,
Diabetes
§391.41(b)(3)
A parson is phVClralIV GUahf+o.1 to •;rive a rr n rierrlal ^Y •r-
vehicle if that pe'�r)n
Has n0 PstablishPd mwfical hlston• Or C4nv.,o/ draprns,g
diabPtes melfirus currPnfly requ:nn0 vnsul•n 'or
Diabetes melli!Us IS a dscoace which, on nrrac,rr, ran result in a Boss of COnCCinUSnoSS or c!isn..ervp�,rr In tine ar r
space. individuals who requr-a insulin ?C.' Cri .rnl kayo
Conditions which can get out Cf n^?m
much or too tittle insulin, or C. I bV ha U, of Inn
food Intake rn! rrncvctanr wi h
In -
the insulin dosage IncapaC'latinn may C'r'rUP frP,T Syr^C•rTe
0 01 hyperglycemic or glyrom ro r
semiconS ns^ hiaL iC , Insulin
idh-ri,; ec
CIOUSn_^�. diabetic Cr•na or InSUlir+ chrr6;
Ttle administration of insulin is, w+thin itsoii, a rr .iPi'raiad Process reouinnq PeCinsulin, syringe needle. alrphnl 9pr^q®
and a sterile hnlqun FaCors rplaybd
It, ksnq_hauI
cornmerelal motor veh ICIe opePalir.ns SUCK ac Wlalio. I?ck r' SI?e
p. Poor diet, emotional CCnVions, slrasc, aril
concomitant illness. Cempnund the dangers the c!'rSd ties
conSlsten`,ly hold that a dra "11C whn uces Inn JIrn Or).
does not moat the min,m,Jm phvs,ral r
FMCSRs_ Muirn roc r' ha
HYPOgNceinic drugs. takon nragy. are SCTo'I nPs
Prescribed for diabetic Irdividua i5 10 helpbode•irlv�I,i•a nai r• It
Y prOdurbOn of insulin It T'te condition can bo ccn'-n11-
be qualified e' oral maderapTn and diet. then an Individual *say
ed ursder tho present rule CMV drsvom Whr r;,, nr•
meet the Federal diabev?s stardard nay call 0,21 -17011
tar an application for a d•abet®s eirom0cr
(S" Conference Rohr! on Diabolic Ussnrdorc and
Vehicle eDriversrcial AI.
rs and In^>ul,r.Ucrrq dc^s^terrval fur•-r
h'tpl/www fnrca dC9.gCWrulosroq :'r",odrepn.te' •Tl
CardIO"sculer Condition
§391.41(bN4)
A person is physically qualified to drive a commercial motor vehicle If that person: L
Has no currant C'rn'cat diagr p$rs Co r"1^►-a►dialanoina
other ca.dr errs. trr[)na1, ,nsu'"an�, 'hrcr'tvlsls or a"Y
RCCe!m Adbt, -tar disease of a varlPY' 4npiwf' •p bo
Dfailu i by __ - , dog rsa ri
Cardiac O a, CO aDSa n• Cnn2ar..�,o
lailUrP_
Tho Yerm -has no currar! Clinical divigr+n5r5 C, Is
Sv->fically designed to encc-npacs a ci• , r
i1) a Current ra ca drap^^srS pv
rdiovavUlar rprdl°inn, or f21 a carr,n:acri�iar Condition which has art'UpV Slabifirad rogaMlagS rt tin •i nn limit. Tho term-bnntgn ),, bo'trrCmpanir- j aV is ';atircv!
include a clinical diagnosis of a cardiovascular disease (1)
which is acmriparied by svmptoms of syncr� dvspnea,
collapse Of cortgesttve cardiac Failure. and/or (1) which is
KeIv to cause synrnpe. dyspnea. cnllav%e or r_ongashve
cardiac failure It is the intprtt of the FMCSRs !o render unqualified. a
driver fvho has a current cardiovascular diseacp which is
arcompanied b•; and,°or likely to cause symptoms or syncope.
dyspnea. cNiaose. or ronaeettvp rardiar failure However,
the subtectivp derision of whether 'he nature and seventy Of
an indWual•s condition will likely cause symptoms of
cardiovascular insu"iciencv is on an individual basis and
qualification rests with the mpdiral examiner and the motor
carrier in *hose cases whp►p there is an occurrence of
cardiovascular insut°icienry (mvnrardfal Infarction.
thrombosis. etc 1, it Is suoaected before a driver is certified
that he or she have a normal rpstinq and stress
elertr—ardiog►am (ECG), no residual Complications and no
Phvstr_al limitations, and is takinq no mediration likely to
Interfere with safe dnviN
Coronary a-+ery bypass surgery and pacemaker
implantation arp rerwdial procedures and thus, not
unquahl'inq. Implantable cardfoverter dp5briliatom are
disqualilvino due to risk of syncope Coumadin is a medical
t,eatment which car improve the heal"[ and safety of 'he
driver and should not. by its use, medically disqualify the
commercial driver The emphasis should be on the
underlying medical conditionfs) which require treatment and
the general health of 'he driver The FMCSA should be
contacted at (202) 366-1790 for additional recommendations
rpgardtnq'he physical qualification of drivers on cournadin
(See Cardiovascular Advisory Panel Guidelines for 'he
Medical examtnation of Commercial Motor Vehicle Drivers at:
http f:'www'm:ad•dot•3ov'rUle;reQSr_mk''d►Vp_9rts_html
Respiratory Dysfunction
§39 7411AN51
4 person is Phvsiratly qual;fied to drive a commercial motor
Vehicle it that person
'gas no esratwrshed medical h,:,rCn. Or ctrrical diagnosis of a
resl•'ralc'n' dysfunrlion likely to Interfere with abnrtty to control
and drove a ccrr+rneroal motor vehicle safety
Sincp a driver must by ale•t at all times, anv change in his
Or her men!aI state is in direct conflict with highway safety.
Even thin sllahtpst Impairment in respira!ory function under
emergen y conditions (when greater oxvaen suDDIV Is
necessary for rip''nrriat-ir el may be datrlmental t0 safe
dr'vinq
Therp arp many conditions that interfere with oxygen
exchanae and may result in incapacitation, mr_ludinq
ernphv,Pma chronic asthma, r_arcinoma, tuberculosis,
chronic brnrichihs and steep apnea It the medical examiner
dimes•% a resoura•nry dys'uncbOn, that in any way Is likely to
mte,4are wMh •ha driver's ability to Satz
V Control and drive a
r_nr+'sprrlai mr.•^r vehicle. +ter driver must he referred to a
sr%pcfalvst f^r tur•her evaluation and therapy. Anticoaoulahon
"oPr(DV'�• d�D yp,n °h•.^.nMSic 3njnr DUIm'n9N
thremboembf►6sm is not unquaedyinq once optimum dose is
achieved. provided lower extremity venous examinations
remain normal and the treating physician gives a favnrablp
recommendation.
(See Conference on Pulmonary/Respiratory Disorders and
Commercial Drivers at
http',*"-fmcsa.dot.govtrglesreosrmedreports.htm )
Nyp~slon
§391.41(b)(6)
A person is physically qualified to drive a commercial motor
vehicle if thatperson.
Has no current clinical diagnosis Of high blood prec,ure, ►okpry
safety.
lO interfere with ability to operate a commerr_ral motor vehicle
Hypertension alone is unlikely to cause sudden collapse;
however, the likelihood increases when target organ damage,
particularly cerebral vascular disease, is present. This
regulatory criteria is based on FMCSA's Cardiovascular
Advisory Guidelines for the Examination of CMV Drivers.
which used the Sixth Report of the Joint National Committee
on Detection, Evaluation, and Treatment of Hiatt elo•_•d
Pressure (1997).
Stage 1 hypertension corresponds to a systntic BP of
140159 mmHg and/or a diastolic BP of 90-69 mmHg. The
driver with a BP in this range is at low risk for hypertension.
related acute incapacitation and may be medically certified to
drive for a one-year period. Certification examinations should
be done annually thereafter and should be at or less than
141)/90. If less than 160!1()0. certification may be extended
one time for 3 months.
A blood pressure of 160-179 syefolic and/or 1Q0.1o9
diastolic is considered Stage 2 hypertension. and the driver is
not necessarily unqualified during evaluation and institution of
treatment. The driver is aiven a one time certification of three
months to reduce his or her blood pressure to less than or
equal to 140/90. A blood pressure in this range is an
absolute indication for anti -hypertensive drug therat'v.
Provided treatment is well tolerated and The driver
demonstrates a Ba value of 140190 or less. he or she may be
certified for one year from date of the initial exam. The driver
is certified annually thereafter.
A blood pressure at or greater than 160 (systolic) and 110
(diastolic) is considered Stage 3, high risk for an acute BP -
related event, The diner may not be qualified, even
temporarily, until redur_ed to 140/90 or less and treatment is
well tolerated. The driver may be certified for 6 months and
biannually (every 6 months) thereafter it at recheck BP is
140190 or less.
Annual recertification is recommended if the medical
examiner does not know the severity of hyDetension prior to
treatment.
An elevated blood pressure findinq Should be confirmed
by at least two subsequent measurements on different days.
Treatment includes nonpharmacologic- and Pharriacologic
modalities as well as counselinq to reduce other risk factors.
Most anti!yypertencive med icationc also have side effects thin
importance of which mutt be lur!,iPd nn an injrvj!Ual',a.;:
individuals mint be alprtad to thin hazard, o° thacp
MediCations while drivirrj Slrfp pHarts of c_•^1rwlpnra nr
WricoDe are vartiruiariv undpsr-ahfa In ror•irnpraa, r!•i>cr-
Sacnndary hypertension is hated on hp ah try c"ages
Evaluation is warranted it patipnt is pprcictantiv hvra--i":a
On maximal or npar•'rlarimal d^epc no 22-3 rharma-^'- jir
aqents. SC'ne causes r' saconftary hvoer•p•^cen, rngY ••o
amenable to suratral Intprvpn'tnn ^r criprir.r rha•^
disease
(See Cardiovascular Advicniv Panel ruide6nas for •' a
Medical Examination o' rn nmpraai Mn•n• ,e h'cie "-i•,•••pm no
httD ', WwW'mrca.dnr UOV,'ruia,reac'madrer nr•c * • .,
Rheumatic, Arthritic. Orthopaedic, Muscular,
NeUMMUScular or Vascular Dlsease
§391,41(b)(7)
A person is physically qua16r•d on dnvp a r^rn•' o,rrfgl ^s^ ^•
vehicle if that person.
Has no esratlishad medical husion, cr c,,niaal d ar�nncic c'
rheumatic, arthreir_. Cr!'' +ped,r rrucru'Ar npur,' ^ucn�Cp• r•,
Vascular disnase µhirh rn°e1ere, w.n• abi/r•t •^ i r•»'•^" �.•,�
operate a commercial ntn'nr twhrcra cafpiv
Certain di,pase, an, known to have aruor aric,rjpc ,,•
transient muscle weaknpss• Eno, r'iu:rular con-d'1a•,^n
(ataria). abnormal sensations iparpc•hpciaj. darreacad
muscular t^rip (hvpoto•tfa) visual dis'ur•9anrpc and D:in
which may be suddenly incaparita•inq With eqr h •art,... ,0
ePis de. these symptom, maV bprn'np mnrp ornnounred
and remain for longer pert^ds of time 0-her dicpacpc ova
more insidious onsets and, display cvmpint'i, ni ^'iucrjp
wasting latrophyl. Swellina and para,!hn,ta whBrh rnai, nr•
suddenly incapacitate a Person but may rpc'rirt his%,p,
movements and eventuanv mtprfnre wi'h thin abillb 10 ,afrty
operate a motor vphirle. In many instance; ihpcp dicpacpc
are deapnerative in nature or mar rp,uN
the invnlved area.
Once the individual has been dinnnsnd ac havi•rj a
rheumatic, arthritic. orthoredir. muscular, neurnmucrular or
Vascular disea-e. f►ipn he she has an ac•ablichpd hoc•rr+ r,i
that disease. The Physician, whpn e.ar•,inino an individuar
should ronsidpr •he °ollowinq fit •tin nature and cpyar ; rf
the individual's condition (such as sencrry lncc or I^-c of
strength!: (2) thin degree Of limt'a'icn rra;pnt (,Uch ac ra77p
of motion). (3) the likelihood of rrnq•aePivn brfl•ar(not
always present attbally but may rn;mitast,•cplf nvpr •:•-ip' ant_+
y
(4'1 the li4alihood or ,uddpn fnsaracoq•rnn It cnvprc
turlrllonal ImM7irment pHOizir. the drwpr dr)p, )T' quaI,L,. in
rases where more frpgupnt --n0ortr!3 is raouirpd a
rertificatp f^r a shorter time ppnrvj maV bin tc ;upd
(See Continence on NPurn:e jv:al D,,^•darc and r^ n,.,p• ,al
Drivers at
http_'/www.°r'lrca rtn• q^vrrulp,rpa; mpdrppn.o; h•..,,
Epilepsy
§391.41(bXB)
A person it D`tvetrallV QUah'itid In drivp a
vPhlrtP It that Elprsnn
Nay no pelahliehPd mPd/npl hrslory or Clinical diapnOsis of
rPPSt' or any Cher Crr dtlilr. wh ch is ►i4Ply to cause loss
vehicle
islrerIe rcu`npcc or pnv k cs Of abd1ty to cc^furl a Tutor
vehvC►p
Ep•leDcv i, a rhrnnir funrhntal disease Characterized by
sP17UWs n• Pplendps that xr_ur without wamin®. resul!ing in lonc O' vn1uf%tary control which flay lead to Boss Of
rnncryrnJcness aril or ePl7urpe Thpre'OrP, the following
dnvprc cannot by qual+herd (t I a driver who has a medical
history e! erlernv. f2l a drrrer who has a Current clinical
diagnopr Of Pr"'rsv. or 13) a driver who Is taking arfisei7Urp
mad,cat,on
If an In'fVduaf has had a su'idpn PC'inOde of a
rrnPpdPrt,C set.•IJrp or IocC of CotlsCioUsnecs Of Unknown
Call —which did nr+t require antlseleure medication, the
decicnn an •o w%P!hpr that DprsOnc Cond-Son w•it likely
CaUCP Inss of consciousness or loss of abuity to Control a
mcfor vehicle Is °Wade nn an individual basic by !hP medical
P•amrnpr In consultation with the treating physician. Before
rartltitatiCen rs cvnnidpred, it „ suggested that a 5 month
wa'!Ing ppr'lod Piapse.front the tireio Of the Pp sOdP. FollOwing
•he waihnq ['Pr+od. It Is suMe,ted that the individual have a
r_omriate nPuroingical eTar+inahon. If the results of the
Piraminatl,in are nPoativP and antlseizure medication is rot
required. °hpn the driver may be qualified
In 111-P +ndiirdual caspc where a driver has a seizure or
an Prisrvie of lon, of ron,rinusnpss that resuffed frnrn a
known mPr+ioat condition (e q . drug rpartion, high
tPmpPrahJra acute InfPrtiovs di" --asp. dahvdrahon or acute
metabolic dwPurbanCP). certification should be deferred until
'he driver has fully recovered from that condition and has no
evist+nq rpvedual eor-rllcationc. and not tak;ng anticalzure
mpd+rat,nn
nrtvPrr- with a t`°,fn'v Of eOPMyfspizurps off antisei7ure
mPd,rat•nn And ,pi7urp-frpp for to Vpam may be qualised to
drwp a CM'c' to 'ntamtatP Crmmprc-e IntPrstatp driver, with a
h,etory Of a cinglp unprovoked splzure may be qualified to
drive a 17M111 In in -mute c^r^mprce d seizure -free and oft
ar'ICPt7lirp rnpol:atton in• a vpar rm.-nod or morn.
i ePe t'onspranrP On 4IPU'N�glral Cicorderq and vel
me COmt
Dmprc aP a.
h"L` "*%%Nv }mesa doe gcv'rtilpsragc'mpdrppnrte.li")
Mental olsordem
§391.41(bug)
A harsnf >s vh"Ir_alty gflal°f'ed to drove a co-rfprcial mo!or
ire C'p t hat rocs;
ti-is no mensal n0s-vus. crparrr or runrryM3t &gppsp Or
`ZVCh13•'Ir d-C-der 1,6P1Y to I°1lp'ferP ;4,11 ph,/.h. I^ drrve a
I—frr imhirlP cafpl
Fr/n>rynal nr nd•tfntm—t rmblpmc r_nntri,,gAe dirertfy to an
iltdividual's Ievel of menr_ry reasoning. atterhnn. and
judgment. These emblems often underlie Dttvsical fftnordptc_
A variety of functional disorders Can Cause drowcinpcs.
dizziness. confusion, weakness or paralysis that may lead to
incoordination. inattantto•t, logs of funrf•onal control and
susceptibility 10 accidents while driving. Physical taNave.
headache. Impaired coordination, recurring pltvciCal ailments
and ehronle'nattgln® pain may be present to such a dearp,
that certiticatiori tOr commercial driving is inadvisable•
Somatic and psychosomatic COmDlaints should be th^rOughlV
elraminad when det"m°mtng an individual-s overall fitnpcc to
drive. Disorders of a ppriOdicanv incapacitating nature. eyPn
in the early stages of dpvelnpmpnt. may warrant
disqualification.
Many bus and truck drivers have documented that
`nervous trouble' related to neurotic, personafitV, Pmnlinnal e' adjustment problems is responsible for a sionificant frac"on
of their preventable accidents. The deorpe io which an
individual is able to appreciate. evaluate and adeouately
respond to environmental strain and emotional stress iS
critical when assessing an individual°s mental alprtnecs and
ftevibufty to Cope with the stresses of commercial motor
vehicle driving_
When examininq the driver. it should by kept in mind that
individuals who Ifve under chronic emotional upsets may have deeply in']rain®d maladaptive o► erratic beha47or .
Patterns. Ercessrwly antagonistic. instinctive, ImDulciyP.
openly aggressive. paranoid or severely dppressed bphav
greatly interfere with the driOr
vers abifity to drive safely Thoor
Individuals who are highly eusqp
CeDtiblp to frpg9Jent states Of
emotional instability (sChlzophrprn a. affect- psyr_hoses,
Paranoia. anrmty or depressive neuroses may warrant
disqualfication. Careful consideration should be given to the
side effects and interactions Of medications in the overall
qualification determination. Sep Psychiatric ConfemrCe
Report for specific reCommendations on the use of
medica!ionc and potential hazards for driving.
(See Corfere'me on Psychiatric Disorders anti Cnrn'nerrial
Drivers at.
h'ta:"www-fmcsa.dot-qw,°rulesregsimedrernrts htmt
Vision
§391-41(b)(10)
A person is physically qualified to drive a rommercial ►nOtnr
Vehicle if that person;
Has dicranr visual aCA, Of at least 2000 (SnPI►pn) in Parh
eve wi.fh or wf.,I?oul correctivP lenses Or visual acuifl,
se@aralply corrected ro 20140 (SnP/lent O't-ffor I ..rh
cvrrp0n'P fenses. disranr brnc-ular,?cuity of ar !east 20'4D
(Snef/en! in both eves with or nohnul Cc7pClrVe /?rite•: hold
or vision cr al /Past .' 0 dPgrpPs in 'he hcriZontal rnpr-'Jtar• in
each eta, and Mp at>:ri°i' re recognize 14p ro/e'S of ►raffr
s/prid dpviCv S show,- a
The As!7nrj'rd rnr{ C nnn ar±a ran-
rm "abll•ty toto Pet !,g^qn the rn° re- n'P. .rtn
tea file root Wiper; 1 ran rvcoq-'p and .t,..•. IJ.eh ar^^n7
Ig a n anti day,rce a
green, and amber a c nw ng e.,n 1a.d rr
, nr a
pion
tough hhe nr ehn mAV ''ay. en
°nr tvrn r'rn'n.
pprrerann dpficiercy 1/ r-pr•a,n rot...
adnr'nicterpd. tcu'h ac lch,ha A; rev-nr'•nn tPe.e a•P
and dot+ �. el7dn,e.r°,.nw•a /a,
Jb UI f. Indl'Igc are dI^.rnvr Pad. a,zicons.,, t•p.• •P -• +
4onal red. preen. and amber May t+n rrnrl^Vp,g •., .an•pr.-.,
dnwr'c abI',ty °n •prngr•7P thpnp rnl,-
Co-far, Ipncpe arp pprm,n^rNn
d 'horn r. CIJ�•r,nn•
evidence tP -hat the d••ver tiac ^ a Go'-P-nre ar-i .c
for adap 'ed to
n t dcParrP visuall them
UcP +Ice nt a rrr'ar• IPr;
aru•ty and anmhpr lane .n •an r•ar• n.;p It:- ear vinion Is not arrarta-, blp. n• lnlr^rr,r.r ter.cpc
a---:-pr ablpfn •hp dnving of CTr—prr•'1 r r•n. yea,^lee
If an Individual mPpfn the C^fpr+n by ran Ucp o+contact IPnCPC. Phe fnllnw,ng etalernnm chart aL'CP �• n•, sap
Medical Evam,nprc Cartv',^ate '1;IJal.+Pre
rorrertrve IPn,ps' - wnar•^Z
CPA!' dnvpr, who do rnt moot tNo F
Pdnrai'.I:,nn d
may call (%•n21 an ar •�n ' d
P—fiction a P 'ea•I n •n• a •.
{Sep visual Dic(•rdPrq and Cr mrnnrryat bite /www fmr sad O"V rIJ°PcrPo:°mP+.PI n.._ • .
Hearing
§391.41(bi(11)
A pemen In rhvciralIv OIJaW,art •,.
vehICIP if that ppr,n'1 "' a • r r-;•,I
Frrcf Pop -pivpc a +rr*,pd wh,gwred tr,rp fr. °hn hr•tn• pa. ,,P
rn? lPCs Man S /Per IV-, r• w,lhnUt .o p uep c' hny.•ry a d
or if tPSPprI hi, Use of an aUd,^ nP+rrr dU..rp d ne 7-I �,tn
a"P vPragP hparng rocs In i•,P g"r'aPn• wean a� de-ifv=lc pt S!1!) Nz. i.Mln r.r.
heart+® Aid when Me . an 1 ^ (1M 0J, N•.+h c' W^ •V' .v
aurf•r.n.P•rr'10-co ,c raP•ar,vp,1 ,
1 Sjrran lip•rr+n?I C+aria rrf rr.,r..,P rh 4,"4 Cbr.j., •r+..'.
. 5-
$Inrp the pfpsrr$'Ptd :ta^•ta'*; Urdpr °ha rear-rq: e a
t7 n• oft thearran nda•de Aeenr,a,.nn tA'J �I, n may hP nnrc:ra•v
aud'^mp^nr rPc9;f'c Prnrry ilia IC
Evarlna%on Pa'd lne4rl.r..rnc are • ,rlvJ toil r f taP rep + at
rc•i firm
It an IndMdua! map:: 'ho r..•Prl? P": uc•nrJ a •. n;tr•.. -,
the driver mtJ=! wear " at hpar',q aid and havp I• •^ rrr a..^n
at all —5 w1..IP rdrrf•no Olen_ rap rrr.,rer r.elct I- n
p_ .c C "on O• a warp rnwer C,,vrre IT, 'ap aearn
For flit? wh.erarod ynire fee, "'p I^rt%-d°°a: Chro r f'ae ntat•ooed at leant 5 feet 'rr,vl'hp
Pctng rtLeir b . h wl+erae p,a.n.npr 7hP ._.• P- ear raper' c.r 7
e.am"t wtrspers words or random numbers such as 66.
1R. 23 etc The examiner should not use only sibilants (s-
sounding matenalsl The opposite ear should be tested in
the same manner If the individual fails the whispered voice
test, the audiometric test sheul^ be administered.
I' an Indrvldual meets the criteria by the use of a hearing
aid. the foilowinq statement must appear on the Medical
Firaminer's Cer!lhcate-Oual!ned only when wearing a
hearinq aid'
I4Pe kParinq Disorders and Commercial Motor Vehicle
Drivers ai
h^p www'mrsa.dot gov.'r°.ilesregsmedrepor's.html
Drug Use
4391.41(b)(121
4 person is phys,cally ouali'ied to drive a commercial motor
ve~lcle "that person
L'oes not uce a controlled substance idenflfied in 21 CF9
13C'9 ii Schedule I an amphelar*ine, a narcotic, or any
ether !nab+' -forming, drug Ercep'%on. A driver may use such
a substance or druo, it !tie substance or drug rs prescnbrsd
by a licensed medcal practitioner vitro rs tamilear wish the
dmter's medical hiefory and ass,gned dupes, and has
adt reed the driver that the prescribed substance or druo t777/ no! advers!+ly eMecP the drivpr'c abrlkl . to safely operate a
co,"merca' -&Or vehicle,
This e=cection does not apply to methadone. The intent
of the medical cerMicatio,n process is to medically evaluate a
driver to ensure that the driver has no medical condition
which rVerferes with the safe performance of driving tasks on
3 public road 1' a driver uses a Schedule I drug or ether
substan-e. an arnphelamine, a narcotic, or any other habit-
forming dnjq. it may be cause for the driver to be found
medically urqualihed. Motor carriers are encouraged to
obtatn a oract'ioner's written statement about !he'effects on
'ransmrtatr_n safetIV Of the use of a particular drug.
A test 'or controlled substances is not required as part of
this biennial certification process. The FMCSA or the drivers
employer Should be contacted directly for information on
controlled substances and alcohol testing
the e%+CS95 under Fart 292 of
The term -Uses- is designed to encompass instances of
prohibited d!ug use determined by a physician throuoh
ectabIv;hed medical means. This may or may not involve
t"'dV fiu,d testing It b,dy quid testing takes place, positive
test results shcuid be confirmed by a second test of greater
;WPICIN The term 'habit-forming- is Intended to include
a^y dr`,ig -.r med•cat!on generally recognized as capable of
ber-m,nq habitual, and which may impair the user's ability to
operate a commercial motor vehicle safely
The driver Is medically unquali'ted for the duration of "tin
pr`hb't 'ed dnmisl vise and until a second examination sh the driver is free from the prohibited drug(sl use. ows
QecerVication may involve a substance abuse evaluation, the
S.1cceSS'JI rnrnpae•ipt+ of a drug rehablG°alien program, and a
negative drug test result. Additionalf . given that the
certification period is normally two years, the examiner has
the option to cer y for a period of less than 2 years if this
examiner determines more frequent monitoring is required,
(See Conference on Neurological Disorders and Commercial
Drivers and Conference on Psychiatric Disorders and
Commercial Drivers at:
htb'-'/www fmcsa.doi.gov/rulesregs/medre0orts.htm)
Aleohottsm
5391.41(b)(13)
A person is physically quaCfied to drive a commercial motor
vehicle if that person -
Has no current clinical diagnosis of alcoholism.
The term 'current clinical diagnosis offs specifically
designed to encommpacs a current alcoholic illness or those
Instances where the individual's physical condition has not
fully Stabilized, regardless of the time element, if an
individual shows signs of having an alcohol -use problem, he
or she should be referred to a specialist. After counset;mg
and/or treatment, he or she may be considered for
certification.
t'v J J" LL9Q84tSr'_!4'rc re+- :w,.•,u; .,,;.
wv�l ,� - " . r•wo eaY4. mow-, . n....,w_ - ry • e-•.r V,>.
["'oil'11++b9t-I'aI'lAt"At AL
ii.es
r
Uorumin
I11 the alisp loyrr. ®Iltie\t'I� It++Ilit':lIt:114 on IP11.1 lit elllt".t1t+11 td I11'+t'e 11t+71 e t it I'.Irt ,, d6+ Ile t rt°e. lUrt' .! I
1e.1I11BILltli Il.
1 u the vnaployer: t '.an tt:u rv.a,l' 6Iv,,, k „Ilt ):..... 1 nt dig ,al
a t+urrnll'loll•r num ,1lltlev etlu In,lpt.4e\i'r 11114e1ut°4tlt Tlllellrt' tlllriPlte nn
J 1 e'4 J ®•,I D
et+Ilt.t•piBt'llt1111t+U, It+Ir1•IllltellIIinurettitldt'PltI,,laty,yltlart'InItIf,s'rtirtiuh!'rti4/1p'1111111,11rsl1irAat+Pet+blt•6v'61+ur�1114eVt•
rnl.al wtlrkul}; htnll�, t+p•.It.a lima+•nld hl.lt 1' th.lt 1.4
9Bul etnarl'nlloh+yl•rmutit ll II etnl hll%v tit,Il,h%4+ror't,'nll the4,lutklu'nnaarl'ttDthe
! lul 1 tit)w Btv he••Illh tart' lore lli'"'(111al e\ hll \.III rt,% It'ev It
(l•l+'.aw hnrlt), - 1+Illftlrnl.atum nnitit ht' hrilelllt•ll by 1'tory i°rnhlttmt+r c\hi) ha4la'i+n �e'II•I tt'd tat utie•eany tvlt9'tll rt•4 ,Inrtttr
Varese: _®--
A n't' (to ne4mgt d e'!'®--.-
Heights __`_ ll•e•t ® iax haw Weight:
Phone numberwhel;e you can be reached by the health
care person who revlew9 this Ono lude ,an+a lodte);_- ._ -
fhe best time to call you at this number.
11.r.9 your employer told you how to contact the health care
Vernon who will review this (l htet k t nv): u Yes ❑ No
Job Citle:
liar k one) 'J ifalt+ •J Fvtnale Date:
Check the type of nespiratorYou will use (ylttl tan l htr k
1111)aa! (hdn ono, l'tJtt'te()ry);
J. IJ N, R, or P &spindble nwpirator (filtvr-matik,
non-ttartridge type (,Illy),
d, IJ Other type (fear t+x,ansple, half- tar full-fate+pit+l t+
type, pt)wvrt'd-air purifyin}�, tiupplie+d-air, St'If ctant eint•f.
hn°dthing apparatus).
] lave you worn a respirator. ',1't�l ;J No
If "yvf;, ' w ha t typl+(ti); —
Part, it - --- -- - ----- -
I — • hon 21A,Iandat(rry)
Qt11,4ti(,its I thmu};l1 9 ht+l(tw must bt•
attSWen'd h
(1111'.aw t. het k "ye s" or "tit)"). y t'y"S' Vmrlll )ow who
has Ex•e+n SFltet led to
uw anY t ' y F*t' of rt'cpiratelr
1- "0 you lunvntly .9moke tobacco, or have
you Smoked tobacco In the last month?
2 1'14ve you ever had any of the following
.......•..
conditions?
.t. 9wisunw (fits):.......
h. l,iaht•tts (sugar dlst+taSe)• ...................................................................................
Yew
J ail)
t'. ;Vll•r 4. real tions that interft+rt! with hrrathing: .......................
••" • ••' J Ylw
°'•"'°'
J MID
ll. C'Itltltitrt> pK+jj (fear t)f t lot4w, -
d lei ,I
l alt 1•ti); .....................................
...................................
...... ••••� J Yt°ti
t' I'I,+llhlt+'+till+llln}l it
.........................................
I. Have you ever had . ..........
'
.any of the following pulmo•• ry or lung s
•a• \•,I•t°titl+tiLS: n'arY R ptihlems.
..................... .......................
`r
............ .
'. •ltithplla:.........
.•.......... ........
t t lln `t111 hntnt Ili(1.4:
. ............. .
.....
11
.. ..
........... _
t',
`
J .VI6
++ l+lll'1t I11 t : Illel:
... ...
t I lllk•„ lilt'•.1.4' .. .. ...
.. .. J'tIs
1 Nil)
J
J �1
J Nil
it �'nt'lult� tlll'r.l`t (e1�lL11wa'el'uny,): ••
t
P. � li i9t!t,119t t'f'
1 I•'1 tl'll I li`O•
J 1r4
J \.ID
111e e'ie •,t ulrurll.e r''url a ,it
l 1lse d19� P '811+t, I'rl l°it'llt th,tl ,. 'll 11' t'. ,•tl It I'I !Ik •'ll
a
J
-�(e
J e l ♦
J ``. 1 1
`l. if you'e•e u•aed a realiiratur, have you ever had Ann of the I1ifollowing proble,tty?
'ei r uwd it ri-rinittir y;i, tit i Itae•slll,n 4)
i. Fv irnt..itimu.. ..
I, '-km ,illvey;u•ti or r.i.h,•e
1 l i•Iit nil 4ei',iklh ed t,r 1, it
t't1,cr Iir.I,It-o, th,It ntl'rh•ri, s\ Ith a, nr ri °pvr,,ttrr a i'
t ,.-x icru9 9
.:.*3 %tvv q -rot
{. "0 VIM clirn°rltly ha`r ,I11y t)f the ff)lI1)w'119 ';y1111,t1)P11!I "f plelnlon.lry orltlnK illnetia'
•,. `,Itl'rtnl'°S I+I hrl°,alb: ....
h. • lit rota"W oI hrv,ilh 4e ht'B1 4a ,111,1i1y; I,B°t uP1 It'`1°I y;r'ntllit] or 4Y,Blletnp; 1IF, ,a °Ily;Ill hill t'r Irtt IIIIe J `r 1•ti
;horuiosso l,re'.ilhaelit `nee,eIIt"T,t,Itlit AIit-rl,l•itl,It, it,titorllnl,uyp,it%,I'I)It-%I,I ;rnunll;
ll. 11.141° tU',lltl, I' or I,r+°,Bth t•;11e°I) 6\.Ilkin), .It 1l)lrr t,4e Il l,.Bl i" lill Il°\1°l y;n,UlAl:. ' -j °I I'`
a'. 'Ahtirwe'sti,,I hrt'•alh aehl"n w,e.holy;t,r tln-,%inp;
J're
I. `,hurtni.al,I hre',Ith lh.It inti'rfrrlw 4,IIh ynurp,h: .......•
ti
c.'iluy;hang that pnidut 1•ti I,hlegn1 ithit k %putuln): th. '. J Yt v t'.ltu �hntp; 4v..a • ..... ................ .... ..................... • w ylau e•,irl1• lit the morning: ... .............. that 1 v
1. Coughing at ix t U174 ls°tly eien you tin- 4•Bnle tt4V n: .............. Ys
•......
I. Coughing up bhx,J in this last month , Yt•er
k. tt'hir•sing: ...............................
I. "I)t'..iinF; that into'rf1 nw 4e Ith y`a,urjeih
................................................................................................ .........1 Yt+s
m. Chest pain 4ehl•n yllu bn'athr sAmply:
n. Any i ttlwr by t ms tllat...........................................................................................
rnpt , you think may he re°Lite'd to lung J Ye•q
YI •+t
S. Have you ever had any lif the follow iulg "WiovAtwular or heart problem?
,r, FIi°ii.t att.il•k:....................................................
h. Stnike
.............................
...............................
] Ytw
d. Ffngiearfail..`..:........ .........................................................................................................................
e^. Swelling in your lep� or fe•e't (nett t•ausl'l1 by w,alkin................................................................................... �:] Yt•g
f. F{t°art arrh thmia he �:
:Iy ( +:art t,t°at1nF u•r..}►talarly):..................................................... Ytw
!;• High hlexrtl F,ra'4,tiuta1:.........................................................,........,..............,.............................
........................................................................ J Y1•Y
Any oth..r hart problem that you've. K4,n told jjx)ut:............ I'1 Yew
h.
............................
6. E lave you ever had any of the following carrdiovascul r or heart symptomar?
a. Fntiluent pain or tighten .,q in your t hest:
b. Pain t1 )htntws i.......................................... ........... r tig n your t 1". t during 1-1 Ytis
F, physit•al al tivity. ..,....
a•. Pain 1,r tiyh:....................................
trims in your t hest that interfems with o) -� Yew
pu.•:t two Years, have you rle) ° ....'..'t: Y1w
tila tl your heartakr rn o ........
t•. Heartburn or indiyp.-ition that is not r0att°ll to t°,atin • pF $ r Inititiin}; a !,a•at:...........
Any lltl%-r symptoms that J Ytw
P you think may he• Mated toha•artt)rt irtulatiun pm hle'ens:......................
.........'J Yi•.'+
'• Du you currently take medication for any of the following problems?
,a. Flnaathing or lung. prr,hlenls:............
h. Heart trouble: .................... ................,.................................,............................................................................................
..
• Yt•�
....I ............. ..................................
.'J Y1•s
t �t•Islinw (ittti):....... ................... ... ...1 Y"i•ti
............. I .......... '_1 Y is
J °a1t
J \e l )
%
J �a r
JN
J \: o
J No
'J No
-1 No
'J No
Ne it
13 No
V No
`7 No
U No
rJ No
J No
U No
Q No
1, No
V No
Q No
J No
U No
rJ No
J No
J No
)
J No
J No)
li k--tte 3
'A A ilat DM I '.ip+,tryq r't?1
tt. Would o ou like to talk to the ht'alth tarp prlDles%ional tvho 1vill renew thi.4 tlue.tionnaim .111out V ,tlr
IIL+tnrr+,lllll B4'ILII%(I,11119.1arv:
i lUt°titII111.r III tt1 I J lte'II IW II111,1 1"4° II1�N1'I'I°tl 11P 1'\P
I )r r\ f'tt11 °Illti ty' '.\ 11i1 1141%'11° ."i 'e'I11 ti'tl III W,4- I'Itll,'r .l I.1ll I,1t • I`16°t t' rl'v 11l r.Itf'P
J 'A'If, t.lILL IIh'tl 1,mitlllllt; 1 EI t •,Ir°Itllti t1(
I I i 1). f l Ir rlttjilt l\I'rti \\ ht l h,ld t t
he°,vl tit°6v il o tow 14 11,'r tt JIV% III n �Iitrtato, m,
,uLtisvl'nnl; th1'W'tlu,'.tit,l,.ti Lti \IJuntarv. ta
IU. F Lave you ever lost vision in either eye (temporarily orpenn+silently):
..........................
11. Do you currently have any of the following vision PADblerns?
a. 1Vt'ar t I tlltat t INf1.tit •ti:.
.................
h..................................................
6V,'ttr l;la�,',°s: J YIN 4
'J No
.............................. .
I . Color blind: ...... J Ytw
.....................................
J Nt t
......................°.............. °Other ta 11r vltiitti pn t1 ....
1J Yt-4
rJ t11eD
IJ Yt'S
.] No
12 Flave you ever had an injury to
yurtr ears, including a broken ear tfrum
..............•.•.••.•••.•.
13. Do you currently have any of the following hearing pmblerny?
LI. Difficulty he,Iring:............................. .
b. M,ar a he tring pill rJ YvS
1:1 No
C. Any oth.....................................................
t,r he firing or t'a.
r rroblem rJ YvS
..........................
(, 'No
14° F lave you ever had a back injury. ..............................................
............... Q Yes
U No
15. Do you currently have any of the following musculoskeletd problems?
a. LV't'alule"s in .any of yt tut .arms, hands, leps, or
feet:h.
..............
.....................................
IYk•SHak ptein:J
..................
No
DifficultyU
full moving your a •°••••..... -} Yi'4
Y rnLs anti Il°I�:...........
iJ NO
t . Pain or 4tlfflltS+3 when you tt'ael fi,nvard or hat kward at t J Yes
he waist :..................
rJ No
+•. 1?1I'fit ult full ,
Y y mudZnM, Y'tur h<wd up or tluwn;................................. J Yes
.] No
E. Difficulty full movie our Y head aide to ~ilia.
'J No
I� y' elfin}; at your kne't�s:................ .....
Difficult ht° J Yk-5
U No
................................
...............................
h. Dlffitulty vluatting to the ground: ..,.. .....'] Ye s
:1 tNCD
J Ye'S
i. C inibing a Ilight of st+au+i or a l iddi�r t orryln}; mory' than 25 1119
J No
.:...........
I• Ily 6.tlit °r mtlti4 le Itr akt'It, t.tl I1rytbll'fn that lilt/'rtk'A'S tYlth lisle „•,,,,,,,,,,,,,,•••••••..•••••••.••.,•..•..•.•• J YvS
_
'J No
}; a rl•c1lir,lttrr:............... ...................... 1J yes
'J No
I fart 13
\nv t'f the follc,"tng yul°°ttlonv, .11Id Iitlit-rytat',tiolLti 11,I1listed, 111°ly Iv',ltith'd tothrtluc`titnnlalr,°,It t11,'tl1-A rl tIon tht' fit,.II
+ ,Bit' I1ry lfl'ti51try1,41 W hit t\ III rl•L It'\v the tltlt•1tlonlhlln'.
h
1. 111! your ptV,4ellt job, ,1r! Vdtu working -it high .,Itihltlev (over S,IIIN) feet)
or In ,lf place th it hay lower
111,11111+ tfmil.111111II1IIiI)fI
t'It:..........
l �P• I tl•t'r `•1I1BItll�1T1� '.\ 11t'!1 \I�IB P°I' %%orl mkl Lin, It It It) I....... .. t', •, \o
I 1 I{t.trdt home, ll.Iie 'I/
ti 14 ever beent°1vfD�.etl t,) h,8/,IAlllllq oolc't'tlty, 1t.1/.IRId)t1V
l
,Bir}1e1me , ht•199it.11a
°' ' '° I'i ♦ ItIIIU %. o'r •Ill't). I'r 11,IL1' ' , it t it111i' .PIG' 1,111, a II1,14 t It Itll I�,If.lr�.11
• Ia , lBe'llllt .tlr
Name
f 10,71cAddress
RESMICATOR USE
---PHYSICAL
lie
'7 C Sex
'relcphone
Occupation
Lungth of Employment
I agree to the release of this information for State anti Federal regulatory purposes to the
extent provided by applicable laws.
DATE
SIGR-ED--
E �IPLdj;E--R--❑ FullOW-up Medical Evaluation Physical
Required. (Positive response QLICS'tiun I
❑ Post -Offer Physical: %ledical EVaNatiun
Physical Required.
'a. l0'olale! y ou dike to talk to ttlu hr.,dtlr a ary E,n,t°r:::iun.11 who will n'vies
dais
.111-Mvers to this
elue•�ti„nn.airr .about v°nae
.................. `
• -1 ore,
'dl,l'titl6:lT,y dl) to,
d, III -It RV I11a4;+e',111ii0tfflil
E tie'If, 1'Itt.11l'e'tl I'n'.Ithln r , , �' v'ItIF II1`t °t! i♦ Ill) I'Jti 1-t'
I, IF I .If,ltU.ti (`j (j a°tl'Gt' e
6 l e'� tl , list' 1' I t lle'r �! I I l l l • I.II t' F ll'l t' h r"
[ I tiv:rti s'.1 IIII,l.ary, F I c, whv> Lat" hlr'
�� Fv�r l'I el III', e e
n',e'l,r tr(.I to util' I thl!r tyd�ts l• Iratr f Initur r
dU. f f.ave Pita ever lost vis ion in either eye (te•mpocarily oe ►e
l 1. Du YOU t•urnntly h.a`•e anV of the f°ullucvint; ti'isiun Fttibl@�' .................. ......... I= ���rO
.......
J• ��'°I°are'1ltt.11-tll'lr:Ew:........ '
Color blind:
tl. Ctht'r 0)o or Vtsmn Fn;hle ln: •.............................................................................................. ..................°] Y(�s
? Have )] 115 Q Not,1
you ever had An in' ...... ......� Y1°s Q Nu
fury to Your cars, iMludin5a bnaken e
13, Do you currently have any Ofthe foUOI-vin arinr°.................................... I ................. Q YI°s I] t11u
a• Diffit.vlty h,taa•dn � he�d3 probl@ms1
b. Wear a hearing aid: ...................°..............................................................
C. Any tither hearing or rear prtll9le............................................................................. .............................Q Y S ) No
14' Efave you ever had a back inj Q Y �s � Nu
15. Do you sunently have an �.......................................................................................................................rJ Yts
y of the followin Q NO
a. 6Veakness in any of your .t rnusculoskeletal prvblemsi'
b• Balk �. Mantis, legs, or fi�'t:.......,
C. Difficulty fully muvin9 yourarms an(i legs:.................................................................................................Q 1't�s Q No
tl. Pain or stilfnE"S$ r` hen you lean fu .............................................. Q Yes Q NO
r®nv,, a ur backwa ...................
e Dtfficvl full r l at the w
tY Y movin gist: ""Q Yes Q Nu
K Yuw brava up t'r clown; .....................
......................................
Lhaulty movi Q yes Q °Vu
Y- DltfiL„(ty fully np; your head sick.' to side:................................................................. .................
h. D l,rn�ling at yourktteE�s :............................. Q Yeas Q I%lu
lffi�ulty, ,quatting to thegmund:............................................ Q Yrs
Nu
!ng a tli t tl F. ........................ ..
t'S
a l dderr Ca I�IU
1• Any v�lher mus+:lee u rryinK inure than S If±s.:..................................Q Ya.'g Q IVo
r.skv.letal problem t ..,..pj......................................
that intt:rfen's with usin °"""°'°•••'� Y'-'s Q No
Put D g a n�piraWin ..........
yki 1-3 NO
Any of the following yuEstiuns, and other yulstions nl•t listEnt, may t+eP ad
tare pmfe s iunal who will n!o lew th:� yucstlonn.ain
det! to the tluc.stiUn(tiiar, at tiro d�nition of tbs. health
1. frr your present job, are you workin at him
th.rn na 8 altitudes (uverS,U!)t) f@�•t ur'
Rna! arnuunts of utV,en:.............
urutllt'rs ` that as low r
uaapta•@ h
ykS
y'mFGirns `e Ilen you're .... "' '
_ :••urkinK !antis-'r tht•w I•llndlt:t,rts:.....................................................................]
t work vjr.at home, have yvru ever be •..................
ie •fir ° ,fumes, or dust), urhati°e you curve in" kin to -utl w Solvents, h,az.ardous airfio
With h. z me t'hrrraiaal9
Lttnloau `hemicalsr.....,...
a. If rA. - wo NA. Ilk 12 11)
riecl with arty
() f t 111 "' L I t"I'Llis, oriintlerany ()f the conditilill.-j, li'j'j
... . .. .. ........ ......... ........ I .............. ... ... .. I .. ... .... . ..... .... ...
. ... .... ................... . .................... .. .... ...............
"it 111,16-nal): .......................... ...... ................... ....... ..... T 1201" HILIIII: ........ .. . ......
AILIIIIIIII.IIII: ................. . .. ...... .... .. . ... ............. ......... .... .... .... .... . .. .. ... .... ... ..
IS
. .................................. ................ . ....................... ... ............. ....... .............. . ......................... ............. . ..... .. ............
r t I-S.. . .%
I.
. ............................................ ...... .............. ...............................
....... ... . Y4
LA11, . ....... . ....
if."" 11 .
r ............ I .............................. ..
t l7i'se 1, " pq Is tims: ........... ............. ......... ....... ........ . . Yi-
- ---------
I. List any ZeconL�jobs onside bus'
""e"'Ies you have.
5. List Your previous Oc'-up'ttions:
6, Listyourruniet tan,,
Previous hobbies:
No
J
Sri)
NU
7. Have you been in the "I"Uyservioces?
. . .. .... .. . ...... .
$Vij're you L..XF415,�d 1, biolo&al or chLVVcjlJgenILs (Ifither in tr-uining-o-r- com - b - j - t): Yes rjVL,
19, 1 Uve You everworked on,, FLiiA%T team? yes
...........
9. OtherUlan "nedi"Nons for breithing Ind ....................................................... ytls NO
mentioned earlier in this questjonnAiim' 4m Y11mg problerim, he-txt tmuble, blood pressure, xnd
(inclujing O"Ll-thoe-counter ME'dications): ........ ou . b . jcmi . ng 1nY other medications frany M-Mon geizums
If"Y('s," name the medications if You krx)w them: ... ... ...............................................................................................
Q y"S Q No
It)- lVill you be tising any of -------------
HERA Filters: .......r .... the following items with YOUre ---
'Pirat
... . ..... . ...... .. ................................ o;s)?
C-11%stors (for exam le!, 1pas
I .................................................. .............................................................
c ......... ............................ YOS
,j Y.
.......3
I row oftenen are You k?'Tpeded to t,,.je the re4pir
.J. p A . -)I Ify (I I') n %L U #!): ato r
.......... Yes, 'j flus
I`- Erne' qTnt y rwN jjj� Illy. ..... ... ...
C. I I . ............................... .... ........... ............ ................................ ...... . ... .................. .....
r-1 `-" th"n 5 1'm) u M p-r ivo k . ............. :1 Yl -5
o-S thin 2114MI79 ........................... ......... ............ -:) Y, I
to I hours FN,r,fa ..... .................. -1 YLS
V: ................................. ............ I ............................................. ............................. ... ,
tl' .............................................. ............ .. ... ...... .
dy: .................... . ................................... ... .................... .......... I .......................... j �'-q No
. ..... — . ..... ....... I .. ... -1 Y'l
"�W-VIrA. vu NicilklAnx)
PlIring the perifuj YtItA an. lisinq the rv.,j,jrjtorf,,),
ro
jvr lit fir):. ' v(jtirtvi)lk* 1.1-fort
........ ...... ...... ....................... ...........
I' N Fl,ritil I %ltlnll}; tile' I,. i,r.j);t! .:III 11t:
t rk 06, rt jry 'It I I I I,;%% III -.- I".
YW(xk. 4:a r..).o.t..r...4.ft...i.t.ig...f.. r Iv...r.f.o...m...lir1j11, 1ke1'. .) fr
1. ................. ... ..I
,lilt t•s.
n......... ...VplSt till'..
ff It
ary sjttjn�;IT.aIJIM. Illil1q.
t%,11111! drillini, I -r jrI%,IlI1;,j trick 1)r bus ill
Ivrill
J 111Cdorato !t)j,i 1,.Ilx)tlt 13 * W4)rk ,r tromfi.-rrinji, 41 Lnink Iv%el; w,jIkIII,,
ll,ph;l 011
jr pushin;; .4 wIlt4,1b,lm,�v a I"', lipil or J4 it% 11
ttr
...... �] yos
'"l%v Lit"i tills rerivd I-Ist durin�., ......
Ex.impli-i of h,,,Ivy tvorkiry liftingi Ilt"ivvI(MLI(,I[x)Ijt3O ha-L mills.
ur 'illl:llkjvr working, on lo.,Liill k; sht)vf lbs') "mill th'! lloor to yl,LLr wart
up 'Ul 'Ilin�; staxidirij; While brit mph, t ;Ljir., �,*jth 4 Ile'lvv Ili atl �orvhippine, castilleys
13. Will you be wearing Mtft-tiveclothing -about A) 11,S).
using your re. .;pLutor -Ind/ore4tapment (other than the respimtc)zj When You,M
......................................................... . .
'rlbt? tills prutt-ail, p 1(qjlinF, d"K Uld/or vquipment*** ........... .......... Q yt s
14L 6V111 you be Working under hot 15. 1VO1 y®u be workinconditions (tempera
ture
ex ce"ding 77PF): ..................................................... Q Yes
...... Q yos
g under humid conditions:
17. Describe any special or h"-UdOus conditions you mi
(for e-'14mple, confined Spaces, life -threat s� Sht encounter when You're using your ms irator(s)
----------- gase . p
"" Pmv'de the following information, if You know it. for edt.h lox'c subs
"'V111112,1111 YOU'M ti.4ingyattrn'Spiratoris): Lance that you'll be "Po.qed to
\;anu? if tilt. (Int
Fstimatj`d m,jxImLjn 1"1P*611ro It-00 jvr shilt.
ra NO
IM
•i°i ttc�lrre•-�rrU I}�arldbi3aM!
Cur dtl+ to i of+•• lV 4Un' h r •,hilt:
e .l dl7l'ttl till'�ak.t
nJ to aru• tiuhst.dax•e: "-----•—
F•adnt,ltc J muximunt v\F4run' It?VVI p<-rtihiIb
Dur,ltion of t'el4•6urr. �X,r shaft:
Name of the then! t"xiesubstancm
Estimated maximum exposure IOWA I,r sha.
Durati(an Of exPSure per shift;
The na
me
of uthc'r to,
su6stanc�s that you'll be ex
POto while using your respirator
19. Describe any special r"Ponsibilit3es yoy'll h.tve while us ing Y®
Others (forrcample, mscve,seaurity);
respirators) that may affe"-t the safety .and well-being of
�tC!� trlet • ,IAU I`uc
PLHCr ro
lIOTV-UP
c� 1 ci rl
r�mp(uyee tilutrc:.-
Tub title•
Date of this fuUow-up:
ROAsons for follow-up
,e"ons:
rtpy of Wcomatendation •,Iven to ampj(jycr? °a y19
rr'� r;mmvnd.ajoilti ,,l'uut r111 'Ie,) Iq+ US<t i
Li,nitatic�rls- I ) tIV r�E,ir�te;r.
NoWd for follow-up rnedical evaluations -
Date li ne,k
Date;isen:
Q V
SPI
RAT
O
P"YSiCAR
USE
See Attached Job Description
NAME
_
1AGE
-
___
10-ME ADDRESS SEX �®
TELEPHONE OCCLIP"krro",
LENGTH OF EMPLOYMENT
aaareO to the release of 1/1 is information
jor State and Federal reg,
DATE UlatoryPurpasex
10-P ULVf ONARY E-VAINUNA 770M
C 4.r
I . I ;�
HEIGHT WEIGHT
2. HEART: ------
Murmers: Rate ------ � Rhythm
3. LUNGS: Enlargement
4. P'Ulrnonazy Function Within Normal Limits —® outside Normal Limits
PA CHEST X-R.A Y:
5. Within No Limits ____ Outside Normal Limits
RECO?v MItENDAT'IONS:
It is rn
at above _M ed�Latle`ntjs nnt
ator i
Y ®pinion that the above named Patient is
qualified to vy'arx Respirator in the perforru Is not
1 tonv c
Unce of his/ber dutic... --' medically