Item C06BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date:_S)KI)i�115 1015 Division: E ---EW]oyce Services
Bulk Item: Yes X No
Department: Human Resources
Staff Contact Person/Phone #: Pam Pumar X4459
AGENDA ITS WORDING: Approval of contract with Richard L. Dolsey, PHC, Inc. dba
Physician's Health Center, Inc. to provide employment physical services.
ITS BACKGROUND- The County advertised a Request for Proposals for employee physical
services (which also included drug screening) in December, 2010. The County received two bids from
the lower keys and one bid from the Middle Keys and contracted with these physicians in April, 2011.
No bids were received from the Upper Keys.
On July, 2011, the County entered into an agreement with Dr. Deacyle to perform the screenings in the
upper keys. Dr. Deagle retired November 30, 2012.
It has been extremely difficult to rind a doctor in the upper keys to enter into an agreement with the
County to perform the required services. This contract will allow for employees and applicants to go
for the required screenings in the upper keys instead of traveling to the middle or lower keys to obtain
these services,
PREVIOUS RELEVANT BOCC ACTION:
CONTRACT/AGREERIENT CHANGES:
STAFF RECOMME, NDATIONS: Approval
TOTAL COST:_gnpM& $750.00yr INDIRECT COST: BUDGETED- Yes
DIFFERENTIAL OF LOCAL PREFERENCE:
COST TO COUNTY: -Approx.-j79.-0r SOURCOF FUNDS: Ad Valorem
REVENUE PRODUCING: Yes N) A AMOUNT PER MONTH Year
APPROVED BY: County Arty � MB/Purchasinl Risk Management
DOCUMENTATION- Included X Not Required —
DISPOSITION: AGENDA ITEM #
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
CONTRACT SUMMARY
Contract with: Richard L. Dolsey, PUC, Contract #
.........
Effective Date: June 10, 015
........................................
.........
Expiration Date:
Contract Purpose/Description:
To enter into a contract with Richard L. Dolsey, PHC, Inca dba Physician's Health
Center, Inc. to provide employment physical services.
Contract Manager: Pram Purnar 445 Human Resources
...........
(Name) (Ext.), (Depart ment/Stop )
for BOCC mectinn on June 10, 2015 Agenda Deadline: May , ` 015
CONTRACT COSTS
Total Dollar Value of Contract: Apron Current Year Portion:
750.00 °, r.
.
Budgeted? YesZ No Account Codes: 001-0 5 0-510- 1 .............. ..
Grant: $ ---------------- -
County Match: � f
-------u k--------
ADDITIONAL, COSTS
Estimated Ongoing Costs: _/yr For:
(Not included in dollar value above) (cg, maintenance, utilities, janitorial, salaries, etc.)
CONTRACT REVIEW
Changes Date Out
at I Needed Jeviewer
Division Director `�- Yes[] No
r �
Risk Management r Yes❑ NoE'] i II SI S
O.M.B./Purchasing 5 a�I !� Yes❑ No[ 1� � <
County Attorney 5'22•10tSYes❑ No[w S• Zz• Zc� I
Comments:
PHYSICALAGREEMENT
EMPLOYMENT 1
TABLE OF CONTENTS
SECTION ONE - Scope of Services
SECTION - County Forms and Insurance Forms
ATTACHMENTS:
A. Post -offer and Fit for Duty Physical Forms (4 pages)
t CBOT Physical (9 pages)
C. Respirator Physical "Part 1" (6 pages)
Respirator Physical "Part It" (3 pages)
MONROE COUNTY
CONTRACT FOR
EMPLOYMENT PHYSICAL SERVICES
THIS AGREEMENT ("Agreement") is made and entered into this — day of , by
MONROE COUNTY ("COUNTY"), a political subdivision of the State of Florida, whose address
is 1100 Simonton Street, Key West, Florida 33040 and Richard L. Dols r PRO Inca ribs
("CONTRACTOR"), whose address is at 1448 N. Krome Ave,
Suite 101, Florida City, FIL 33034.
Section 1. SCOPE OF SERVICES
CONTRACTOR shall do, perform and carry out in a professional and proper manner certain
duties as described in the Scope of Services — Section One — which is attached hereto and
made a part of this agreement.
CONTRACTOR shall provide the scope of services in Section One for COUNTY.
CONTRACTOR warrants that it is authorized by law to engage in the performance of the
activities herein described, subject to the terms and conditions set forth in these Agreement
documents. The CONTRACTOR shall at all times exercise independent, professional judgment
and shall assume professional responsibility for the services to be provided, Contractor shall
provide services using the following standards, as a minimum requirement:
A. The CONTRACTOR shall maintain adequate staffing levels to provide the
services required under the Agreement.
B. The contractor is responsible for obtaining proper releases from the
employee or prospective employee in order to discuss the results with
Monroe County BOCC.
C. The contractor will provide the required services at the location of'.
1448 N. Krome Ave. Suite 101
Florida City, FL 33034
Phone: 305-245-0222
Fax: 305-246-3700
D. All urine screens will conform with the standard chain of custody protocols
mandated by state and federal regulations.
E. The Contractor will have an employee designated as coordinator or
facilitator to assist in the communications with the Monroe County BOCC's
primary contact personnel.
F. Appointments will be available throughout the business hours of the facility:
Monday — Friday 8:30 a.m. — 5:30 p.m. Walk-ins will also be accepted it
an appointment cannot be reasonably scheduled.
A. The facility will be available 24 hours a day, 7 days a week for post
accident, random and reasonable suspicion alcohol and drug
screening.
® The Human Resources office will contact PHC after Hours Service.
• The authorized Human Resources representative or the authorized
supervisor shall complete the appropriate forms either the same
business day (or by the next business day if the test is after
normal working hours) in order for the physician to perform the
required test.
• After normal working hours the employee will be tested at a
location determined at the time of the call.
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H. Appointments will be seen by the contractor in a reasonable and timely
fashion.
1. The Contractor will provide the County with at least a 24 — 48 hour
turnaround time for the receipt of any drug and/or physical results.
J. The Medical Review Officer will be available for contact by the Monroe
County BOCC or its employees to answer questions about the effect of
prescribed drugs. Part of the requirements set forth by the State of Florida
drug free workplace policy, which Monroe County has adopted, and the
Department of Transportation, the County must have a qualified Medical
Review Officer "MRO" perform drug screening services. The MRO receives
lab reports from the laboratory (as governed by regulations); Reviews lab
reports for integrity, authenticity, false negatives, and false positives, interprets
lab results, including verification of lab positives, reports lab reports to the
employer (as defined by rules and regulations).
K. The personnel shall not be employees of or have any contractual relationship
with the County. To the extent that Contractor uses subcontractors or
independent contractors, this Agreement specifically requires that
subcontractors and independent contractors shall not be an employee of or
have any contractual relationship with County.
L. All personnel engaged in performing services under this Agreement shall be fully
qualified, and, if required, to be authorized or permitted under State and local law
to perform such services.
Section 2. QUALIFICATIONS NECESSARY OF CONTRACTOR
The CONTRACTOR must certify at least annually that all staff members, independent
contractors, subcontracted work, if any, all service providers it uses, engages or manages,
comply with Health Insurance Portability and Accountability Act (HIPAA) privacy and
security rules.
Physical examinations will be conducted by, or under the direct supervision, of a
physician or medical doctor currently licensed and practicing general medicine in the
State of Florida. The examining physician may employ assistants properly licensed and
trained, as necessary, to perform laboratory tests and/or assist in all phases of the
examination.
Section 3. COUNTY'S RESPONSIBILITIES
3.1 Provide all best available information as to the COUNTY'S requirements for the
Scope of Services described in Section One to this Agreement.
3.2 Designate in writing a person with authority to act on the COUNTY'S behalf on all matters
concerning said services.
Section 4. TERM OF AGREEMENT
4.1 The term of this contract will be for one (1) year beginning June 10, 2015 and shall
automatically renew for successive one year terms unless and until either party gives the
other notice of cancellations in accordance with the terms set forth in Section 7.
Section 5. COMPENSATION
Compensation to CONTRACTOR is outlined in the Scope of Services — Section One.
Section 6. PAYMENT TO CONTRACTOR
6.1 Payment will be made according to the Florida Local Government Prompt Payment Act.
Any request for payment must be in a form satisfactory to the Clerk of Courts for Monroe
County (Clerk). The request must describe in detail the services performed and the
payment amount requested. The CONTRACTOR must submit invoices to the
appropriate offices marked Human Resources. The respective office supervisor and the
Administrator of Human Resources, who will review the request, note his/her approval
on the request and forward it to the Clerk for payment.
6.2 Continuation of this Agreement is contingent upon annual appropriation by Monroe
County Board of County Commissioners.
Section 7. CONTRACT TERMINATION
Either party may terminate this Agreement because of the failure of the other party to perform its
obligations under the Agreement. Either party may terminate this Agreement without cause
upon sixty (60) days' notice to the other party in accordance with Section 9 of this Agreement.
The County shall pay CONTRACTOR for all work performed through the date of termination.
Section 8. CONTRACTOR'S ACCEPTANCE OF CONDITIONS
As CONTRACTOR hereby agrees that he has carefully examined the RFP, his response,
and this Agreement and has made a determination that he/she has the personnel,
equipment, and other requirements suitable to perform this work and assumes full
responsibility therefore. The provisions of the Agreement shall control any inconsistent
provisions contained in the specifications. All specifications have been read and
carefully considered by CONTRACTOR, who understands the same and agrees to their
sufficiency for the work to be done. Under no circumstances, conditions, or situations
shall this Agreement be more strongly construed against COUNTY than against
CONTRACTOR.
B. Any ambiguity or uncertainty in the specifications shall be interpreted and construed by
COUNTY, and its decision shall be final and binding upon all parties.
C. The passing, approval, and/or acceptance by COUNTY of any of the services furnished
by CONTRACTOR shall not operate as a waiver by COUNTY of strict compliance with
the terms of this Agreement, and specifications covering the services.
D4 CONTRACTOR agrees that County Administrator or his designated representatives may
visit CONTRACTOR'S facility (ies) periodically to conduct random evaluations of
services during CONTRACTOR'S normal business hours.
E. CONTRACTOR has, and shall maintain throughout the term of this Agreement,
appropriate licenses and approvals required to conduct its business, and that it will at all
times conduct its business activities in a reputable manner. Proof of such licenses and
approvals shall be submitted to COUNTY upon request.
F. Pursuant to Florida Statute §119.0701, Contractor and its subcontractors shall comply
with all public records laws of the State of Florida, specifically to:
i. Keep and maintain public records that ordinarily and necessarily would be
required by Monroe County in the performance of this Agreement.
it. Provide the public with access to public records on the same terms and
conditions that Monroe County would provide the records and at a cost
that does not exceed the cost provided in Florida Statutes, Chapter 119
or as otherwise provided by law.
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iii. Ensure that public records that are exempt or confidential and exempt
from public records disclosure requirements are not disclosed except as
authorized by law.
iv. Meet all requirements for retaining public records and transfer, at no cost,
to Monroe County all public records in possession of the contractor upon
termination of this Agreement and destroy any duplicate public records
that are exempt or confidential and exempt from public records disclosure
requirements. All records stored electronically must be provided to
Monroe County in a format that is compatible with the information
technology systems of Monroe County.
Section 9. NOTICES
Any notice required or permitted under this agreement shall be in writing and hand delivered or
mailed, postage prepaid, to the other party by certified mail, returned receipt requested, to the
following:
To the COUNTY: Human Resources Administrator
1100 Simonton Street, Suite 2-268
Key West, Florida 33040
To the CONTRACTOR: Richard L. Dolsey, PHC, Inc. doe
Physician's Health Center
1448 N. Krome Ave., #101
Florida City, FL 33034
Section 10. RECORDS
CONTRACTOR shall maintain all books, records, and documents directly pertinent to
performance under this Agreement in accordance with generally accepted accounting principles
consistently applied. Each party to this Agreement or their authorized representatives shall
have reasonable and timely access to such records of each other party to this Agreement for
public records purposes during the term of the agreement and for four years following the
termination of this Agreement. It an auditor employed by the COUNTY or Clerk determines that
monies paid to CONTRACTOR pursuant to this Agreement were spent for purposes not
authorized by this Agreement, the CONTRACTOR shall repay the monies together with interest
calculated pursuant to Section 55.03 of the Florida Statutes, running from the date the monies
were paid to CONTRACTOR.
Section1l. EMPLOYEES SUBJECT TO COUNTY ORDINANCE NOS. 010 AND 020-1990
The CONTRACTOR warrants that it has not employed, retained or otherwise had act on its
behalf any former County officer or employee subject to the prohibition of Section 2 of
Ordinance No. 010-1990 or any County officer or employee in violation of Section 3 of
Ordinance No. 020-1990. For breach or violation of this provision the COUNTY may, in its
discretion, terminate this agreement without liability and may also, in its discretion, deduct from
the agreement or purchase price, or otherwise recover the full amount of any fee, commission,
I
percentage, gift, or consideration paid to the former County officer or employee.
Section 12. CONVICTED VENDOR
A person or affiliate who has been placed on the convicted vendor list following a conviction for
public entity crime may not submit a bid on an Agreement with a public entity for the
construction or repair of a public building or public work, may not perform work as a
CONTRACTOR, supplier, subcontractor, or CONTRACTOR under Agreement with any public
entity, and may not transact business with any public entity in excess of the threshold amount
provided in Section 287.017 of the Florida Statutes, for the Category Two for a period of 36
months from the date of being placed on the convicted vendor list.
Section 13. GOVERNING LAW, VENUE, INTERPRETATION, COSTS AND FEES
This Agreement shall be governed by and construed in accordance with the laws of the State of
Florida applicable to Agreements made and to be performed entirely in the State.
In the event that any cause of action or administrative proceeding is instituted for the
enforcement or interpretation of this Agreement, the COUNTY and CONTRACTOR agree that
venue shall lie in the appropriate court or before the appropriate administrative body in Monroe
County, Florida.
Section 14. SEVERABILITY
If any term, covenant, condition or provision of this Agreement (or the application thereof to any
circumstance or person) shall be declared invalid or unenforceable to any extent by a court of
competent jurisdiction, the remaining terms, covenants, conditions and provisions of this
Agreement, shall not be affected thereby; and each remaining term, covenant, condition and
provision of this Agreement shall be valid and shall be enforceable to the fullest extent permitted
by law unless the enforcement of the remaining terms, covenants, conditions and provisions of
this Agreement would prevent the accomplishment of the original intent of this Agreement. The
COUNTY and CONTRACTOR agree to reform the Agreement to replace any stricken provision
with a valid provision that comes as close as possible to the intent of the stricken provision.
Section 15. ATTORNEY'S FEES AND COSTS
The COUNTY and CONTRACTOR agree that in the event any cause of action or administrative
proceeding is initiated or defended by any party relative to the enforcement or interpretation of
this Agreement, the prevailing party shall be entitled to reasonable attorney's fees, and court
costs, as an award against the non -prevailing party. Mediation proceedings initiated and
conducted pursuant to this Agreement shall be in accordance with the Florida Rules of Civil
Procedure and usual and customary procedures required by the Circuit Court of Monroe
County.
Section 16. BINDING EFFECT
The terms, covenants, conditions, and provisions of this Agreement shall bind and inure to the
benefit of the COUNTY and CONTRACTOR and their respective legal representatives,
successors, and assigns.
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Section 17. AUTHORITY
Each party represents and warrants to the other that the execution, delivery and performance of
this Agreement have been duly authorized by all necessary County and corporate action, as
required by law.
Section 18. ADJUDICATION OF DISPUTES OR DISAGREEMENTS
COUNTY and CONTRACTOR agree that all disputes and disagreements shall be attempted to
be resolved by meet and confer sessions between representatives of each of the parties. If the
issue or issues are still not resolved to the satisfaction of the parties, then any party shall have
the right to seek such relief or remedy as may be provided by this Agreement or by Florida law.
This Agreement shall not be subject to arbitration.
Section 19. COOPERATION
In the event any administrative or legal proceeding is instituted against either party relating to
the formation, execution, performance, or breach of this Agreement, COUNTY and
CONTRACTOR agree to participate, to the extent required by the other party, in all
proceedings, hearings, processes, meetings, and other activities related to the substance of this
Agreement or provision of the services under this Agreement. COUNTY and CONTRACTOR
specifically agree that no party to this Agreement shall be required to enter into any arbitration
proceedings related to this Agreement.
Section 20, NONDISCRIMINATION
COUNTY and CONTRACTOR agree that there will be no discrimination against any person,
and it is expressly understood that upon a determination by a court of competent jurisdiction that
discrimination has occurred, this Agreement automatically terminates without any further action
on the part of any party, effective the date of the court order. The parties agree to comply with
all Federal and Florida statutes, and all local ordinances, as applicable, relating to
nondiscrimination. These include but are not limited to: 1) Title All of the Civil Rights Act of
1964 (PL 88-352) which prohibits discrimination in employment on the basis of race, color,
national origin; 2) Title IX of the Education Amendment of 1972, as amended (20 USC as. 1681-
1683, and 1685-1686), which prohibits discrimination on the basis of sex; 3) Section 504 of the
Rehabilitation Act of 1973, as amended (20 USC a. 794), which prohibits discrimination on the
basis of handicaps: 4) The Age Discrimination Act of 1975, as amended (42 USC as. 6101-
6107) which prohibits discrimination on the basis of age; 5) The Drug Abuse Office and
Treatment Act of 1972 (PL 29-255), as amended, relating to nondiscrimination on the basis of
drug abuse; 6) The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and
Rehabilitation Act of 1970 (PL 91-616), as amended, relating to nondiscrimination on the basis
of alcohol abuse or alcoholism; 7) The Public Health Service Act of 1912, as. 523 and 527 (42
USC as. 690dd-3 and 290ee-3) as amended, relating to confidentiality of alcohol and drug
abuse patient records; 8) Title gill of the Civil Rights Act of 1968 (42 US C as. 3601 at seq.), as
amended, relating to nondiscrimination in the sale, rental or financing of housing; 9) The
Americans with Disabilities Act of 1990 (42 DISC a. 1201), as may be amended from time to
time, relating to nondiscrimination on the basis of disability; 10) Monroe County Code Chapter
13, Article VI, which prohibits discrimination on the basis of race, color, sex, religion, national
origin, ancestry, sexual orientation, gender identity or expression, familial status or age; and 11)
any other nondiscrimination provisions in any Federal or state statutes which may apply to the
parties to, or the subject matter of, this Agreement.
h
Section 21. COVENANT OF NO INTEREST
COUNTY and CONTRACTOR covenant that neither presently has any interest, and shall not
acquire any interest, which would conflict in any manner or degree with its performance under
this Agreement, and that only interest of each is to perform and receive benefits as recited in
this Agreement.
Section 22. CODE OF ETHICS
COUNTY agrees that officers and employees of the COUNTY recognize and will be required to
comply with the standards of conduct for public officers and employees as delineated in Section
112.313, Florida Statutes, regarding, but not limited to, solicitation or acceptance of gifts-, doing
business with one's agency; unauthorized compensation-, misuse of public position, conflicting
employment or contractual relationship; and disclosure or use of certain information.
Section 23. NO SOLICITATION/PAYINENT
The COUNTY and CONTRACTOR warrant that, in respect to itself, it has neither employed nor
retained any company or person, other than a bona fide employee working solely for it, to solicit
or secure this Agreement and that it has not paid or agreed to pay any person, company,
corporation, individual, or firm, other than a bona fide employee working solely for it, any fee,
commission, percentage, gift, or other consideration contingent upon or resulting from the award
or making of this Agreement. For the breach or violation of the provision, the CONTRACTOR
agrees that the COUNTY shall have the right to terminate this Agreement without liability and, at
its discretion, to offset from monies owed, or otherwise recover, the full amount of such fee,
commission, percentage, gift, or consideration.
Section 24. PUBLIC ACCESS
The COUNTY and CONTRACTOR shall allow and permit reasonable access to, and inspection
of, all documents, papers, letters or other materials in its possession or under its control subject
to the provisions of Chapter 119, Florida Statutes, and made or received by the COUNTY and
CONTRACTOR in conjunction with this Agreement', and the COUNTY shall have the right to
unilaterally cancel this Agreement upon violation of this provision by CONTRACTOR.
Section 25. NON -WAIVER OF IMMUNITY
Notwithstanding the provisions of Sec. 768.28, Florida Statutes, the participation of the
COUNTY and the CONTRACTOR in this Agreement and the acquisition of any commercial
liability insurance coverage, self-insurance coverage, or local government liability insurance
pool coverage shall not be deemed a waiver of immunity to the extent of liability coverage, nor
shall any Agreement entered into by the COUNTY be required to contain any provision for
waiver.
Section 26. PRIVILEGES AND IMMUNITIES
All of the privileges and immunities from liability, exemptions from laws, ordinances, and rules
and pensions and relief, disability, workers' compensation, and other benefits which apply to the
activity of officers, agents, or employees of any public agents or employees of the COUNTY,
when performing their respective functions under this Agreement within the territorial limits of
the COUNTY shall apply to the same degree and extent to the performance of such functions
and duties of such officers, agents, volunteers, or employees outside the territorial limits of the
COUNTY.
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Section 27. LEGAL OBLIGATIONS AND RESPONSIBILITIES
Non -Delegation of Constitutional or Statutory Duties. This Agreement is not intended to, nor
shall it be construed as, relieving any participating entity from any obligation or responsibility
imposed upon the entity by law except to the extent of actual and timely performance thereof by
any participating entity, in which case the performance may be offered in satisfaction of the
obligation or responsibility. Further, this Agreement is not intended to, nor shall it be construed
as, authorizing the delegation of the constitutional or statutory duties of the COUNTY, except to
the extent permitted by the Florida constitution, state statute, and case law.
Section 28. NON -RELIANCE BY NON-PARTIES
No person or entity shall be entitled to rely upon the terms, or any of them, of this Agreement to
enforce or attempt to enforce any third -party claim or entitlement to or benefit of any service or
program contemplated hereunder, and the COUNTY and the CONTRACTOR agree that neither
the COUNTY nor the CONTRACTOR or any agent, officer, or employee of either shall have the
authority to inform, counsel, or otherwise indicate that any particular individual or group of
individuals, entity or entities, have entitlements or benefits under this Agreement separate and
apart, inferior to, or superior to the community in general or for the purposes contemplated in
this Agreement.
Section 29. ATTESTATIONS
CONTRACTOR agrees to execute such documents as the COUNTY may reasonably require,
including, but not being limited to, a Public Entity Crime Statement, an Ethics Statement, and a
Drug -Free Workplace Statement, Lobbying and Conflict of Interest Clause, and Non -Collusion
Agreement,
Section 30. NO PERSONAL LIABILITY
No covenant or agreement contained herein shall be deemed to be a covenant or agreement of
any member, officer, agent or employee of Monroe County in his or her individual capacity, and
no member, officer, agent or employee of Monroe County shall be liable personally on this
Agreement or be subject to any personal liability or accountability by reason of the execution of
this Agreement.
Section 31. EXECUTION IN COUNTERPARTS
This Agreement may be executed in any number of counterparts, each of which shall be
regarded as an original, all of which taken together shall constitute one and the same instrument
and any of the parties hereto may execute this Agreement by signing any such counterpart.
Section 32. SECTION HEADINGS
Section headings have been inserted in this Agreement as a matter of convenience of reference
only, and it is agreed that such section headings are not a part of this Agreement and will not be
used in the interpretation of any provision of this Agreement.
Section 33. INSURANCE POLICIES
33.1 General Insurance Requirements for Other Contractors and Subcontractors.
As a pre -requisite of the work governed, the CONTRACTOR shall obtain, at his/her own
expense, insurance as specified in any attached schedules, which are made part of this
9
contract. The CONTRACTOR will ensure that the insurance obtained will extend protection to
all Subcontractors engaged by the CONTRACTOR. As an alternative, the CONTRACTOR may
require all Subcontractors to obtain insurance consistent with the attached schedules; however
CONTRACTOR is solely responsible to ensure that said insurance is obtained and shall submit
proof of insurance to COUNTY. Failure to provide proof of insurance shall be grounds for
termination of this Agreement.
The CONTRACTOR will not be permitted to commence work governed by this contract until
satisfactory evidence of the required insurance has been furnished to the COUNTY as specified
below, Delays in the commencement of work, resulting from the failure of the CONTRACTOR
to provide satisfactory evidence of the required insurance, shall not extend deadlines specified
in this contract and any penalties and failure to perform assessments shall be imposed as if the
work commenced on the specified date and time, except for the CONTRACTOR's failure to
provide satisfactory evidence.
The CONTRACTOR shall maintain the required insurance throughout the entire term of this
contract and any extensions specified in the attached schedules. Failure to comply with this
provision may result in the immediate suspension of all work until the required insurance has
been reinstated or replaced and/or termination of this Agreement and for damages to the
COUNTY. Delays in the completion of work resulting from the failure of the CONTRACTOR to
maintain the required insurance shall not extend deadlines specified in this contract and any
penalties and failure to perform assessments shall be imposed as if the work had not been
suspended, except for the CONTRACTOR's failure to maintain the required insurance.
The CONTRACTOR shall provide, to the COUNTY, as satisfactory evidence of the required
insurance, either:
• Certificate of Insurance
or
• A Certified copy of the actual insurance policy.
The County, at its sole option, has the right to request a certified copy of any or all insurance
policies required by this contract.
All insurance policies must specify that they are not subject to cancellation, non -renewal,
material change, or reduction in coverage unless a minimum of thirty (30) days prior notification
is given to the County by the insurer.
The acceptance and/or approval of the Contractor's insurance shall not be construed as
relieving the Contractor from any liability or obligation assumed under this contract or imposed
by law,
The Monroe County Board of County Commissioners, its employees and officials will be
included as "Additional Insured" on general liability policies.
33.2 General Liability Insurance Requirements For Contract Between County And
Contractor
Prior to the commencement of work governed by this contract, the CONTRACTOR shall obtain
General Liability Insurance. Coverage shall be maintained throughout the life of the contract
and include, as a minimum-
• Premises Operations
• Bodily Injury Liability
• Expanded Definition of Property Damage
H
The minimum limits acceptable shall be-
$300,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$200,000 per Person
$300,000 per Occurrence
$ 50,000 Property Damage
An Occurrence Form policy is preferred, If coverage is provided on a Claims Made policy, its
provisions should include coverage for claims filed on or after the effective date of this contract.
In addition, the period for which claims may be reported should extend for a minimum of twelve
(12) months following the acceptance of work by the County.
The Monroe County Board of County Commissioners shall be named as Additional Insured on
all policies issued to satisfy the above requirements.
33.3 Workers' Compensation Insurance Requirements
Prior to commencement of work governed by this contract, the CONTRACTOR shall obtain
Workers' Compensation Insurance with limits sufficient to respond to the applicable state
statutes.
In addition, the CONTRACTOR shall obtain Employers' Liability Insurance with limits of not less
than:
$100,000 Bodily Injury by Accident
$500,000 Bodily Injury by Disease, policy limits
$100,000 Bodily Injury by Disease, each employee
Coverage shall be maintained throughout the entire term of the contract.
Coverage shall be provided by a company or companies authorized to transact business in the
state of Florida.
33.4 Professional Liability Requirements
Recognizing that the work governed by this contract involves the furnishing of advice or services
of a professional nature, the Contractor shall purchase and maintain, throughout the life of the
contract, Professional Liability Insurance which will respond to damages resulting from any
claim arising out of the performance of professional services or any error or omission of the
Contractor arising out of work governed by this contract.
The minimum limits of liability shall be:
$250,000 per occurrence and $750,000 aggregate
Section 34. INDEMNIFICATION
The CONTRACTOR does hereby consent and agree to indemnify and hold harmless the
COUNTY, its Mayor, the Board of County Commissioners, appointed Boards and Commissions,
Officers, and the Employees, and any other agents, individually and collectively, from all fines,
suits, claims, demands, actions, costs, obligations, attorney's fees, or liability of any kind arising
out of the sole negligent actions of the CONTRACTOR or substantial and unnecessary delay
caused by the willful nonperformance of the CONTRACTOR and shall be solely responsible and
answerable for any and all accidents or injuries to persons or property arising out of its
performance of this contract. The amount and type of insurance coverage requirements set
forth hereunder shall in no way be construed as limiting the scope of indemnity set forth in this
paragraph. Further the CONTRACTOR agrees to defend and pay all legal costs attendant to
acts attributable to the sole negligent act of the CONTRACTOR.
At all times and for all purposes hereunder, the CONTRACTOR is an independent contractor
and not an employee of the Board of County Commissioners, No statement contained in this
agreement shall be construed so as to find the CONTRACTOR or any of his/her employees,
contractors, servants or agents to be employees of the Board of County Commissioners for
Monroe County. As an independent contractor the CONTRACTOR shall provide independent,
professional judgment and comply with all federal, state, and local statutes, ordinances, rules
and regulations applicable to the services to be provided.
The CONTRACTOR shall be responsible for the completeness and accuracy of its work, plan,
supporting data, and other documents prepared or compiled under its obligation for this project,
and shall correct at its expense all significant errors or omissions therein which may be
disclosed. The cost of the work necessary to correct those errors attributable to the
CONTRACTOR and any damage incurred by the COUNTY as a result of additional costs
caused by such errors shall be chargeable to the CONTRACTOR. This provision shall not apply
to any maps, official records, contracts, or other data that may be provided by the COUNTY or
other public or semi-public agencies.
The CONTRACTOR agrees that no charges or claims for damages shall be made by it
for any delays or hindrances attributable to the COUNTY during the progress of any
portion of the services specified in this contract. Such delays or hindrances, if any, shall
be compensated for by the COUNTY by an extension of time for a reasonable period for
the CONTRACTOR to complete the work schedule. Such an agreement shall be made
between the parties.
17
IN WITNESS WHEREOF, the parties hereto have caused these presents to be executed on the
- day of
Attest', AMY HEAVILIN CLERK
By
Deputy Clerk
(CORPORAT E SEAL)
ATTEST'
Print name i I
1,
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA
M
Mayor/Chairman
Richard L, Dolsey, RISC, Inc, dba
Physician's Health Center
by
SECTION ONE
SCOPE OF SERVICES
EMPLOYMENT PHYSICAL SERVICES
The scope of services to be provided on an as needed basis by the Provider and may
include, but not be limited to, the following. The forms to be reviewed and completed by the
Contractor are attached to this agreement (Attachments A - C).
All results will include:
• Written interpretation of test results in common terms and written explanation of the
significance of each abnormality or written explanation of those results which are
outside the normal range.
• Examining physician's written recommendation concerning future action on any
condition considered outside the normal range.
• Written recommendation of specific reasonable accommodations in accordance with
the AIA.
SERVICE
FEE
DRUG SCREEN:
When requested, a drug screen will
(Collection, Lab, MRO
be performed by the physician's
review)10 panel State
tech and will be either scheduled or
$40.00
Requirement
done on a walk-in basis
_
After hours drug testing for post-
$I75 plus
accident, random, and
cost of un-
reasonable suspicion drug
site
screening.
services.
(which is
the cost of
test being
erformed)
DRUG SCREEN:
When requested, a drag screen will
(Collection, Lab, MRO
be performed by the physician's
review) 5 panel
tech and will be either scheduled or
$40.00
Department of
done on a walk-in basis.
Transportation
Requirement
After hours drug testing for a
$175.00
moving violation or an accident
plus cost
where a fatality occurs.
of on -site
services
(which is
cost of test
being
_ -
The MRO receives lab reports from
erforme_d)
$5.00 y
Medical Review Officer
(MRO) REVIEW
the Iaboratory (as governed by
relations); Reviews lab reports for
14
integrity, authenticity, false
negatives, and false positives;
interprets lab results, including
verification of lab positives; reports
lab reports to the employer (as
..................................................................................................................................................
defined by rules and re�11.ulations)-
.................................................... . .................................................................. . .............................................
.......................... ..............
BLOOD ALCOHOL
When requested, Blood Alcohol
(Collection, Lab, 1
x Screens will be performed by the
review)
physician's tech& and will be either
$35.00
scheduled or done on a walk-in
..................................................................................................................................................
basis.
.................................................................................................................................................................................................................
................................................................................
After hours testing for post -accident,
r $175,00 plus
random and reasonable suspicion
cost of on -site
alcohol screen.
r services
(which is cost I
of test bein-
..................................................................................................................................................
BREATH ALCOHOL
................................................................................................................................................................................................................
When requested, may be used for
................................................... ....................
screening. If breath alcohol screen is
$35.00
positive, a blood screen will be
�erformed.
After hours testing for post -accident,
$175.00 plus
random, and reasonable suspicion
cost of on -site
alcohol screening. If breath alcohol
services
screen is positive, a blood screen will
which is cost
(
be performed at the rate designated
of test being
above,
............ ...............................................................................................................................................................................................................
performed)
... .... ........................................................................
PPD- TB screen
When requested, a PPD-.TB screen will
be scheduled and performed by the
$25.00
physician's tech. during the facility's
I'M
normal business hours.
............. ...............................................................................................................................................................................................................
..............................................................................
HEPATITIS A
When requested, a Hepatitis A
$82.00
inoculation will be scheduled and
performed by the physician's tech.
during the facility's normal business
.............................................................................................................
hours.
.............................................................................................................................................................
............................................................
HEPATITIS B
When requested, as Hepatitis B
I inoculation(s) will be scheduled and
$72.00 x 3
performed by the physician's tech.
I during the facility's normal business
$40.00 Titer
hours.
TYPHOID
t When requested, as Typhoid inoculation
................
will be scheduled and performed by the
$56.00
physician's tech. during the facility's
normal business hours,
....................... .................. ...........
�TETANIJS
.................................... ................. ................................................................................
When requested, a Tetanus inoculation
................................................................................
$20.00
will be scheduled and performed by the
physician's tech. during the facility's
normal business hours.
15
DIPHTHERIA
When requested, a Diphtheria
inoculation will be scheduled and
$2T00
performed by the physician's tech,
during the facility's normal business
hours,
quested, a DOT physical will
EELI
be haled and performed by the
$45.00
"B" to be completed by
physician during the facility's normal
employee and physician)
business hours. Includes exam and
physician review of employee health
history and job description.
The DOT physical is initially
performed in conjunction with a post -
offer physical. Thereafter, only a DOT
physical is performed by the physician,
Physician may also perform a urine
drug screen if requested separately by
Monroe gaunt r BOCC,
POST -OFFER
-
When requested, a post -offer physical
PHYSICAL:
will be scheduled and performed by the
(SEE ATTACHMENT
physician during the facility's normal
$5000
"A" to be completed by
business hours. Includes exam and
employee and physician)
physician review of employee health
history and job description.
Physician may also perform a urine
drug screen if requested separately by
Monroe County BOCC.
FITNESS FOR DUTY
When requested, a Fitness for Duty
PHYSICAL (SEE
Physical may be requested at any time
ATTACHMENT "A" to be
by the employer in the employee's
$100.00
completed by employee
respective area of work, The exam will
and physician)
be scheduled during the facility's
normal business hours. Includes
physician review of employee health
history, exam, review of job duties and
medical records if necessary.
Physician may also perform a urine
drug screen if requested separately by
Monroe County BOCC.
RESPIRATOR
When requested, a Respirator physical
PHYSICAL (SEE
will be scheduled and performed by the
ATTACHMENTS "C"
physician during the facility's normal
$45.00 for
PART I & IT to be
business hours. Includes exam and
physical
completed by employee
physician review of employee health
clearance to
and physician)
history and job description.
wear
Physician may also perform a urine
respirator.
drug screen if requested separately by
Monroe County BOCC.
16
Also required: Chest X-ray and
SpIrtaneirrv.
CHEST X RAY
Chest X Ray is normally done in
conjunction with the Respirator
$40.00
physical if there is an issue with the
a irometr results.
SPIROMETRY
Normally done in conjunction with tbe
T_
Respirator physical. All employees
who use a respirator will have a
$30.00
1 . irornetr when hired.
Normally done in conjunction with the
HEARING/AUDIOGRAM
appropriate physical. May be
$20.00
requested separately by Monroe
County Id
CHEMICAL
Tests Glucose (sugar), kidneys, liver (1
$20.00
PANEUCMP
tube of blood drawn).
CBC2
Test to see if Anemic; if any infections
$20.00
within the body-, if dehydrated (test
frorn I of the tubes of blood drawn).
UA DIP
Normally done in conjunction with the
$15.00
D ph sical.
URINE TESTING FOR
When requested, a nicotine test will be
$10.00
NICOTINE USE
performed by the physician's tech. and
will be either scheduled or done on a
walk-in basis
17
SECTION TWO: COUNTY FORMS AND INSURANCE FORMS
LOBBYING AND CONFLICT OF INTEREST CLAUSE
SWORN STATEMENT UNDER ORDINANCE NO. 010-1990
MONROE COUNTY, FLORIDA
ETHICS CLAUSE
"RICHARD L. DOLSEY PHC Inc. doe
PHYSICIANS HEALTH CENTER"
"Company)
k
—warrants that he/it has not employed, retained or otherwise had act on his/her behalf any
former County officer oi
r employee n violation of Section 2 of Ordinance No, 010-1990 or any
County officer or employee in violation of Section 3 of Ord�nance No, 010-1990, For breach or
violation of this provision the County may, in its discretion, terminate this Agreement without
liability and may also, in its discretion, deduct from the Agreement or purchase price, or
otherwise recover, the full amount of any fee, commission, percentage, gift, or consideration
paid to the former County officer or employee."
STATE OF, Flo r t de",
COUNTY OF: i —baffl--
Subscribed and sworn to (or affirmed) before me on
11
/I
0e 1 0 - -1
(date) byy me of affiant). He/She is
pe sonally
(type of identification) as identific@t'on,
0.0 ......
VAS E VELUNZA
re or Florida
c So
V 015 6
T
0 r diary Pu NO I ARY PUBLICJ
Notary publIc St ote or Florida
y Cr.rnm ExpffeS NOV 17, 2015
'P
4731
n EE I
rcrnrrussion EE 147316
My Commission Expires:
E
NON -COLLUSION AFFIDAVIT
it ke vi�n J 11 of the city of 161 rn I according to law on
my oath, and under 'enalty of perjury, depose and say that
1, lam— 1116e of the firm of
LnIthe bidder making the
c _r
proposal fort project described in the Request for proposals for
a
and that I executed the said
proposal with full authority to do so;
2, The prices in this bid have been arrived at independently without collusion,
consultation, communication or agreement for the purpose of restricting
competition, as to any matter relating to such prices with any other bidder or with
any competitor;
3, Unless otherwise required by law, the prices which have been quoted in this bid
have not been knowingly disclosed by the bidder and will not knowingly be
disclosed by the bidder prior to bid opening, directly or indirectly, 4. to any other
bidder or to any competitor-, and
4, No attempt has been made or will be made by the bidder to induce any other
person, partnership or corporation to submit, or not to submit, a bid for the purpose
of restricting competitio', and
5he statements contained in this affidavit are 'true and correct, and made with full
knowledge that IMonme County relies upon the truth of the statements contained in
this affidavit in awarding contracts for said project,
(Sig Wre'
Date, e �2
STAT E OF: _—EL01 ri —de-L
COUNTY OF, I �"l I dw)1, - bne fe-
111111111
ubscrib d and sworn to (or affirmed) before me on
(date) by ke v, ifi I Rt SC_ (name of affiant), He/She is
per r illy l rl n to mor has produced
(type of identification) as identification.
"011M,
E, VIELUNZA
5o
S� Fio;�Odla5
W'C
Notary Public Sr;ile of Ficuida
V 7
E-Agires Nov 17 2015
ri
IV Cr wn
M
S sutit C 316
EE 47 , EE 147316
M
NOTARY P&BR
My Commission Expires: I /I _/�
DRUG -FREE WORKPLACE FORM
The undersigned vendor in accordance with Florida Statutes Section 287,087 here. by certifies
that', RICHARD L. DOLSEY PFIC INC. dba PHYSICIANS HEALTH CENTER
,Name of Business)
1, Publishes a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession, or use of a controlled substance is prohibited in the Wor place
and specifying the actions that will be taken against employees for violations of such
prohibition, sl
2, Informs employees about the dangers of drug abuse in 'the workplace, the cosines
policy of maintaining a drug -free workplace, any available drug counseling, rehabilitation,
and employ ee assistance programs, and the penalties that may be imposed upon
employees for drug abuse violations,
3, Gives each employee engaged in providing the commodities or contractual services that
are Linder bid a copy of the statement specified in subsection (1),
4, In the statement specified in subsection (1), notifies the employees that, as a condition
of work Ing on the commodities or contractual services that are under bid, the employee
will @bNe by the terms of the statement and will notify the employer of any conviction of,
or plea of guilty or nolo contenders to, any violation of Chapter 893 (Florida Statutes) or
of any controlled Substance 'law of the United States or any state, for a violation
occurring in the workplace no later than five (5) days after such conviction.
5: Imposes a sanction on, or require the satisfactory participation in a drug abuse
assistance or rehabilitation program if such is available in the employee's community, or
any employee who is so convicted.
6. Makes a good faith effort to continue to maintain a drug -free workplace through
implementation of this section.
As the person authorized to sign the statement, I certify that this firm complies fully with the
above requirements.
E
STATE F OF: �V- -d
COUNTY OR M ir —IX6
Subscribed and sworn to or affirmed) before me on —5kJ—/-5—rebate) by
ke V jr (name of affliant). He/She is
to me or has produced
as i "VS E ill
V
IS E VVEELUUN
NOlary hbfic s State ZZoAAf
Ffaf;d
11V COMM EXMre,r4QVI7,201a55
MMir,
147 "MMI's P- ff EF 147316
(type of identification) as identification.
NOTARY PUB
My Commission Exp'res, _
E
PUBLIC ENTITY CRIME STATEMENT
"A person or affiliate who has been placed on the convicted vendor list following a conviction for
a a
Public entity crime may not submit a bid on a contract to provide any goods or service to
a public entity for the construction or repair
public entity, may not submiL a bid on a contrt acwitth @ property to public
Of a Public building or public work, may not submit bids on leases of re I
entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or
CONTRACTOR under a contract with any public entity, and may not transact business with any
public entity in excess of the threshold amount provided in Section 287,017, Florida Statutes, for
CATEGORY TWO for a period of 36 months from the date of being placed on the convicted
vendor list,"
I have read the above and state that neither RICHARD L. DOLSEY� PHC. INC. dba
PHYSICIANS HEALTH CENTER (Contractor's name) nor any Affiliate has been placed on the
convicted vendor list within the last 36 months.
E
D$
ST ATE OF' I I v rief 6-
COUNTY OF:
Subscribed and sworn to (or affirmed) before me on $5
(dateby name of affian-0. He/She personally kno to 'n me
)
or has produced (type of
identification) as identification
IVIS E VELUNZA
"A"t Notary Public • State of Florida
My Comm Expires Nov 17.2015015
1,1r rcV Commission # EE 147316
16
----���NOTARY 'PUBL
My Commission ExpiresI 1—/1,1s,
MONROE COUNTY, FLORIDA
RISK MANAGEMENT
POLICY AND PROCEDURES
CONTRACT ADMINISTRATION MANUAL
Indemnification and Hold Harmless
For
Other Contractors and Subcontractors
The Contractor covenants and agrees to indemnify and hold harmless Monroe County Board of
County Commissioners from any and all claims for bodily injury (including death), personal
injury, and property damage (including property owned by Monroe County) and any other
losses, damages, and expenses (including attorneys fees) which arise out of, in connection
with, or by reason of services provided by the Contractor or any of its Subcontractor(s) in any
tier, occasioned by negligence, errors, or other wrongful act of omission of the Contractor or its
Subcontractors in any tier, their employees, or agents.
In the event the completion of the project (to include the work of others) is delayed or
suspended as a result of the Contractor's failure to purchase or maintain the required insurance,
the Contractor shall indemnify the County from any and all increased expenses resulting from
such delay.
The first ten dollars ($10.00) of remuneration paid to the Contractor is for the indemnification
provided for above.
The extent of liability is in no way limited to, reduced, or lessened by the insurance requirements
contained elsewhere within this agreement.
1) 1
WORKERS'COMPENSATION
INSURANCE REQUIREMENTS
FOR
EMPLOYMENT PHYSICAL SERVICES
BETWEEN
MONROE COUNTY, FLORIDA
AND
RICHARD L. DOLSEY, PHC, INC. d1ba PHYSICIANS HEALTH CENTER
Prior to the commencement of work governed by this contract, the Contractor shall obtain
Workers' Compensation Insurance with limits sufficient to respond to the applicable state
statutes.
In addition, the Contractor shall obtain Employers' Liability Insurance with limits of not less than:
$100,000 Bodily Injury by Accident
$500,000 Bodily Injury by Disease, policy limits
$100,000 Bodily Injury by Disease, each employee
Coverage shall be maintained throughout the entire term of the contract.
Coverage shall be provided by a company or companies authorized to transact business in the
state of Florida,
If the Contractor has been approved by the Florida's Department of Labor, as an authorized
self -insurer, the County shall recognize and honor the Contractor's status, The Contractor may
be required to submit a Letter of Authorization issued by the Department of Labor and a
Certificate of Insurance, providing details on the Contractor's Excess Insurance Program.
If the Contractor participates in a self-insurance fund, a Certificate of Insurance will be required.
In addition, the Contractor may be required to submit updated financial statements from the fund
upon request from the County.
23
GENERAL LIABILITY
INSURANCE REQUIREMENTS
FOR
EMPLOYMENT PHYSICAL SERVICES
BETWEEN
MONROE COUNTY, FLORIDA
AND
RICHARD L. DOLSEY, PHA, INC. dba PHYSICIANS HEALTH CENTER
Prior to the commencement of work governed by this contract, the Contractor shall obtain
General Liability Insurance. Coverage shall be maintained throughout the life of the contract and
include, as a minimum:
• Premises Operations
• Products and Completed Operations
• Blanket Contractual Liability
• Personal Injury Liability
• Professional Liability
® Expanded Definition of Property Damage
The minimum limits acceptable shall be:
J3QQ,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
200,000 _ per Person
300,000 per Occurrence
50�000 Property Damage
An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy, its
provisions should include coverage for claims filed on or after the effective data of this contra
In addition, the period for which claims may be reported should extend for a minimum of twelve
(12) months following the acceptance of work by the County.
The Monroe County Board of County Commissioners shall be named as Additional Insured on
all policies issued to satisfy the above requirements.
24
INSURANCE REQUIREMENTS
Worker's Compensation $100 00 Bodily Injury by Ace.
,0
$500,.000 Bodily Inj. by Disease, policy Irate
$_100,000 Bodily Inj. by Disease, each emp.
General Liability, including $ 300 000 Combined Single Limit
Premises Operation
Products and Completed Operations
Blanket Contractual Liability
Personal Injury Liability
Expanded Definition of Property Damage
Professional Liability $250,000 per Occurrence and
Including errors and omissions $750,000 Aggregate
The Monroe County Board of County Commissioners shall be named as Additional
insured on general liability policy.
25
,#VtV 0 N Ctd
NO OF ATTACHED SHEETS
MEDICAL RECORD
NOTE: This hildhornation Is for official and pri
1 NAME OF PATIENT (Last, first middle)
REPORT OF MEDICAL HISTORY
lCbEhITIFiC�TIi��t NUMBER � DE
4a. HOME STREET ADDRESS (Street or RFD, City or Town. State and ZIP Cape,' 15 [!XAMINING FACILITY
in
7 STATEMENT OF PATIENT'S PRESENT HEALTH AND MEDICATIONS CURRENTLY USED (Use additional pages if necessary)
a PRESENT HEALTH GULAR OR INTERM
a, ALLERGIES (include insect bilesinfings and common foods)
Household contact with anyone
with tuberculosis
Tuberculosis or positive TIE test
Blood in sputum or when coughing
Excessive bleeding offer Injury or
dental work
Suicide attempt or plans
Sleepwalking
Wear corrective lenses
Eye surgery to correct vision
Lack vision In either eye
—1
R Wear a hearing aid
a
Stutter or stammer
Wear a brace or back support
v
Swed at fever
'or
Rheumatic fever
Swollen or painful Pines
Frequent or severe headaches
Cosmetic or fainting spells
Eye trouble
Hearing loss
Recurrent ear Infections
Chronic or frequent colds
Severe tooth or gum trouble
Sinusitis
Hey fever or Allergic mindis
Head injury
Asthma
PON 7540-00-181-8368
Previous edition not usable
9 ARE YOU (Check one)
[—] RIGHT HANDED
10. PAST/CURRENT MEDICAL HISTORY
YES NO DON7 CH D
KNOW KNOONTW
Shortness tat breath
Paid or pressure to cites!
Chronic ugh
Palpitation or pounding
Dead trouble
High or low blood pressure
Cramps in your lags
Frequent ind gest on
Stomach. liver or intestinal trouble
Gall bladder trout a or gallstones
Jaundice or hepatitis
Broken bones
Adverse react on to medication
Skin diseases
Turner, growth. cyst. cancer
Hernia
Romantic us or rectal disease
Frequent or painful ur-nation
Bed wetting since age 12
Kidney stone or blood in urine
Sugar or album -n in urine
Sexually transmitted diseases
Recent gain or loss of weight
Going it sorder (anorexia bulimia,
etc,)
Arthritis. Rheumatism, or Bursitis
Thyroid trouble or go ter
Doh rT
,CHECK EACH ITEM YES NO KNOW C
Bone, joint or other deformity
Loss of finger or toe
.10 . are"
Painful or "trick" shoulder or elbow
Recurrent back pain or any back
injury
"Trick" or locked knee
Foot trouble
Nerve Injury
Epilepsy or seizure
Car, train, sea or air sickness
Frequent trouble sleeping
Depression or excessive worry
Loss of memory or amnesia
Nervous trouble of any sort
Periods of unconsciousness
Parenhaftiling with diabetes, cancer,
stroke or heart disease
X-ray or other radiation therapy
Chemotherapy
Asbestos or toxic chemical exposure
Plate, pin or rod in any bone
Been told to cut down or criticized
a her
for alcohol use
re " use Used illegal substances
used lobs
STANDARD FORM 93 (REV 6.96)
Prescribed by ICMRIGSA
POOR (41 CFR) 201-9,202.1
11 FEMALES ONLY
CHECK EACH ITEM YES I No I SORT I DATECIF LAST MENSTRUAL JDATE OF LAST PAP SMEAR JDATE OF LAST MAPAMOGMM I KNOW PERIOD
Treated for a female disorder
Change in menstrual pattern
CHECK EACH ITEM IF "YES" EXPLAIN IN BLANK SPACE TO RIGHT LIST EXPLANATION BY ITEM NUMBER
ITEM
12. Have you been refused employment or been unable to he d a job or
stay in slowed because of
a. Sensitivity to chemicals dust sunlight, etc
b. Inability to Mariann certain motions.
c. Inability to assume certain positions,
d. Other medical reasons fifyies, give reasons)
13. Have you ever been treated for a mental send lion? {!ties. specify
when, where, and give details.)
14, Have you ever been denied life insurance? (!foes. state reason and
give details.)
15, Have you had, or have you been advised to have. any operation
iffives, describe and give age at which occurred)
16. Have you ever been a patient in any type of hospital? (if yes, specify
when, where, why, and name of doctor and complete address of hospital.}
17. Have you consulted or been treated by clinics phys crone headers or
other practitioners within the past 5 years for other than minor illnesses?
'a g
Afyes, give complete address of doctor. hospital, clinic and details.)
it
18. Have you ever been rejected for military service because of physical
,Joe re
mental, or other reasons? (it yes, give date and reason for raj
19. Have you ever been discharged from military service because of
physical, mental, or other reasons? Rfyerc give dale. reason, and type
of discharge, whether honorable, other than honorable for unfitness or
unsuitability.}
20. Have you ever received is there pending or have you ever sop -ad to,
pension or compensation for existing A saffility? fifyies, specify what triad.
granted by whom, and what amount, when, why)
21. Have you ever been arrested or convicted of a crime, other than
minor traffic violations, (If yes, provide details.)
22. Have you ever been diagnosed with a hearing disability? (If yes, give
type, where, and how diagnosed it
23. LIST ALL IMMUNIZA—iIONS RECEIVED
I car* that I have reviewed the foregoing Information supplied by me and that it is true and complete to the best of any knowledge I authorize any of the doctors, hospitals or
dinks mentioned above to tarnish the Government a complete transcript of my medical record for purposes of processing my application for this employment or service 1
understand that falsification of information on Government forms is punishable by fine andlor imprisonment
Wa, TYPED OR PRINTED NAME OF EXAMINEE 124b SIGNATURE
No
NOTE: HAND TO THE DOCTOR OR NURSE, OR IF MAILED MARK ENVELOPE "TO BE OPENED BY MEDICAL OFFICER ONLY.
25. PHYSICIAN'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA (Physician shall comment on all posilive answers in items 7 through 11 Physician may
develop by interview any additional medical history deemed important and record any significant findings here)
Sea TYPED OR PRINTED NAME OF PHYSICIAN OR EXAMINER 126b SIGNATURE 126c, DATE
STANDARD FORM 93 (REV 6.96) BACK
MEDICAL RECORD REPORT OF MEDICAL 'EXAMINATION DAT E OF EXAM
T _ 10 NAME 1 J'n
:iLA:ST NAME - FIRST NAME - MIDDLE NAME� 2. IDENTIFICATION NUMBER Position
back a. happe am, .let, trad zip Cood S.
EME G
4 HOW! E ADDRESS Paundpor amad or RFD, edry or Man, Abatis are Zip Code) 5. EMERGE NOT CONTACT (Name and address oficonoic!)
S. RATE OF BIRTH
10. PLACE OF BIRTH
12s, AGENCY
AGE & sox
So X FEMAI E M
Ed 111. RACE
I C 41
WHITE M 13LACK
*12b, ORGANIZATION UNIT
(Check oach som ki appmeaddis comma, enter WE, year ongas2led,
A. MEAD, FACE, NECK AND SCALP
B. EARS - GENERAL (INTERNAL CANALS)
Madero, twWrl underhanad 39 and 44)
C DRUMS aPoodrarlarm
ro —ROSE
I'NU S�S M TH AND THE, AT
ON I
VdMAX
EYE _ ilu I va I anty arulmilar pan und-4. r-ru 20, 19, 8,,ol j 6)
II GPTNAUMOSCOPIC
I AD ILE OF reactIon Ad drod, orn
P C C LAR EITYN18—�,'Wopa� ard"I's "yongeres
.5 MOT'L BE mon lhcv��
G AND
E ON _ T
U
K
LUN
L HEART frannel, do. wask., proarea
so
rM KASCULAR SYSTEM (Ida :Ye to)
A VN:A5.ra'EN �XNO 111SCIR
to '11. ndyouramordy it
eis
4Qt a! S"J.'andappardabour bpdraw�
I.
9. RELATIONSHIP OF CONTACT
1 AMERIT AN INDIAN! HISPANIC F--j � JaPttaC rj joblANIPAt"Illoo
ALASKA NATIVE RHITS
13, TOTAL YEARS GOVERNMENT SERVICE
MILITARY b. CIVILIAN
I S. RATING OR SPECIALTY OF EXAMINER
16, PURPOSE OF EXAMINATION
ATION
(Chisoll each Item inappropidaidwaturrin, anferNE'Anorevatua
0 PROSTATE (Near 40 or Alhocially reelected)
A TESTICULAR
R ENDOGRINESYSTE-10
S. G-U SYSTEM
T. UPPER EXTREMITIES OdnotgM, tainge Alinsithoo
U, FEET
A LONVER, EXTREMITIES tExceas deal (Sticingth, onage of
W. SPINE, OTHER MUSCULOSKELETAL
A IDENTIFYING BODY MARKS, SCARS, TATTOOS
Y SKIN, LYMPHATICS
Z NEUROLOGIC (Equildhfurn tests under Jam 4 1)
AA PSYCHIATRICIS R-dy any persormaly dowebtad
and use ankfalonal Senate
18, DENTAL shown in camestes, share of below number of upper and Near loeft) REMARKS AND ADDITIOIItail. DENTAL
to Jplan x Replaced 7,-71—T DEFECTS AND DISEASES
in F,xed
'able 1-- 1 2 3 Panel
37, Or New
-4414 Town finue, T by
a
x A x X A L
R L
1 1 2 3 4 5 5 7 8 9 10 11 112 13 14 15 18 E
G 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 F
H T
T
1% TEST RESULTS (Copies of results are preferred as attachments)
A.URINALYSIS (1) SPECIFIC GRAVITY 8 CHEST X-RAY OR PRO (Place. drim. Not n-anaterand month
(2) URINE ALBUMIN N) MICROSCOPIC
(3) URINE SUGAR
C SYPHILIS SEROLOGY ISpecid, licst us D, EKG E BLOOD ND RH TYPE AF OTHER TESTS
XOTy
and Tanaka) FACTOR
88-126
'An Agned unad; Ped arm Pro, AYiSAjoR. bin 91
STANDARD FORM 88 (Rev 10-94) {SG)
Prescribed by GSAACMR FIONA (41 CFFU 201.9 202-1
DENTIFICATION NUMBER NO OF SHEETS ATTACHEE
MEASUREMENT; AND OTHER FINDINGS
20, HEIGHT 21 WRIGHT
22. COLOR HAIR 23 OR EYES N. BUILD
TEMPERATURE
26 BLOOD PRESSURE (Affn at heart leved)
27 PULSE (Ann at heaft level)
HIS B. RECUMBENT C. 5 01 2
D. AFTER EXERCISE E, 2 MI MS AFTER
Ul non) 1
ON
30 NEAR VISICN
OR
CORR TO BY
on
CISRR- TO BY
lance)
---------- --------- -----
ESO SAO
ON. LML PRISM DIV
PRISM COUP, PC PC
CT
32 ACCOMMODA71ON
33, COLOR VISION (Test used andmicia
3 ECTED
RIGHT LEFT
TED
35. FIELD OF VISION
36,MIGHT VO-ON (Test used and wore)
3 TRACCULAR TENSION
RIGHT LEFT
Rf aliT LEFT
39 HEARING
40. AUDIOMETER
41 PSYCHOLOGICAL AND PSYCHOMOTOR (Goo used and sciase
RIGHT GeV ;IGEV
,15 2913 Sea 1000 2000 3000 40Ia0 6OW
8000
256 512 l 1024 2048 2898 40 6 6144
8192
LEFT WAF N55V
GI I
LEFT
42 NOTES (CcolftealoAND SIGNIF-CANT OR NTERVAL HISTORY
(Use addiflonal Amea; if nocessafy)
43 SUMMARY OF DEFECTS AND DIAGNOSES (Lot dboinses With, Juirrinumberal
44 RECOMMENDATIONS r PURTHER SPECIALIST EXAMINATIONS INDICATED (Specify) 45A. PHYSICAL PROFILE
P E 1 S
46 EXAMINEE (Check)
Ai. E] IS QUALIFIED FOR In accordance with attached job 4- 5 S PH Y S I C A-L CA TEARY
A 8 C E
48 TYPED OR PRINTED NAME OF PHYSICIAN S:GNA7,j-RE
49 TYPED OR PRIM IED NAME OF PHYSICIAN S GNATURE
50 TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN VadIcapiwim-h) S-ONATURE
51 TYPED OR PRINTED NAME OF
01,11GER OR APPROVING AUTHOIS I S ONATURE
STANDARD FORM 88 IRev io-94) BACK
Medical Examination Report
FOR CIAO, DRIVER FITNESS DETERMINATION
X ¥ WY uxv
649-F 6 45)
...............
01
111 r e vrr �vr r per
err triver completes this section
... .............. ........ ......................................................................................................
riverxs Name (Last, Fiat„ Middle) Social Security No. Birthdate t Age ,Sex t New Certification Gate of Exam
IS } Decertification
' D ' Y F I Follow-up
.............. x...,x,xxx,xxxxxxxx ..............................................x.. .................
x ........ ............ .. ........ .......................
Address „City, State, Zip Code f ork Tel: Driver License No, I License Class H State of Issue
A
'Home Tel; { } S D i
Other
r� HEALTH HISTORY
y illness or injury in the last 5 years?
Headfivilm injuries, disorders or illnesses
Seizures, epilepsy
medication
Eye disorders or impaired vision (except conandure lenses)
Ear disorders, loss or hearing or balance
Heart disease or heart attack: other cardiovascular condition
med t6on
Heart surgery (valve replacemenVbypass, angioplasty,
pacemaker)
High blood pressure medication
Musculardisease
Shortness of breath
Yes No Yes No
Lung disease, emphysema, asthma, chronic bronchitis
Kidney disease, dialysis
Liver disease
Digestive problems
Diabetes or elevated blood sugar controlled by:
diet
pills
insulin
Nervous or psychiatric disorders, e.g., severe depression
medication
Loss of, or altered consciousness
Fainting, dizziness
Sleep disorders, pauses in breathing
while asleep, daytime sleepiness, loud
snoring
Stroke or paralysis
Missing or impaired hand, arm, foot, leg,
finger, toe
Spinal injury or disease
Chronic low back pain
Regular, frequent alcohol use `
Narcotic or habit forming drug use I
For any YES answer, indicate onset date, diagnosis, treating physician's name and address, and any current limitation. List all medications (including
over-the-counter medications) used regularly or recently.
1 certify that the above information is complete and true. I understand that inaccurate, false or missing information may invalidate the examination and ray
Medical Examiners Certificate.
Driver's Signature
Em
Medical Examiner's Comments on Health History (The medical examiner must review and discuss with the driver any "yes" answers and potential hazards of
medications, including over-the-counter medications, while driving, This discussion must be documented below,
TESTING (Medical Examiner completes Section 3 through 7) Namw Last, First, Middle,
EEMStandard, At least 20140 acuity (Snellem in each eye with or without correction. At least 70 degrees peripheral in horizontal meridian
measured in each eye. The use of corrective lenses should be noted on the Medical Examiner's Certificate,
INSTRUCTIONS: When other than the Snellen chart is used, give test results in Snellen-comparable values. In recording distance vision, use 20 feet as no al, Report visual acuity as a
ratio with 20 as numerator and the smallest type read at 20 feet as denominator, If the applicant wears corrective lenses, these should be worn while visual acuity is being tested. If the driver
habitually wears contact lenses, or intends to do so while driving, sufficient evidence of good tolerance and adaptation to their use must be obvious. Monocular drivers are not qualified.
Numerical readings must be provided.
ACUITY UNCORRECTED CORRECTED HORIZONTAL FIELD OF VISION
Applicant can recognize and distinguish among traffic control Yes
signals and devices showing standard red, green, and amber colors ? No
Right Eye 20/ 201 Right Eye Applicant meets visual acuity requirement only when wearing,
Left Eye 201 201 Left Eye Corrective Lenses
Both Eyes 201 201 Monocular Vision: Yes No
Complete next line only if vision testing is done by an opthalmologist or optometrist
Date of Examination Name of Ophthalmologist or Optometrist (print) ................ ........ . I —ic-e—n "Se— NE I a to A a sue Signature
[!]j1j= Standard; as Must first perceive forced whispered voice > 5 ft., with or without hearing aid, or b) average hearing loss in better ear < 40 xB
Check if hearing aid used for tests. Check if hearing aid required to meet standard.
INSTRUCTIONS: To convert audiometric test results from ISO to ANSI, -14 dB from ISO for 500Hz, AOM for 1,000 Hz, -8,5 dB for 2000 Hz, To average, add the readings for 3
frequencies tested and divide by 3.
Numerical readings must be recorded. Right Ear Left Ear
a) Record distance from individual at which Right ear Left Ear N If audiometer is used, record hearing loss in 500 Hz 1000Hz 2000Hz 500 Hz 1000 Hz 20DO He
forced whispered voice can first be heard, % Feet % Feet decibels. (acc. to ANSI Z24,5-1951) Average: Average:
5, czmm���� Numerical readings must be recorded. Medical Examiner should take at least two readings to confirm Blo.
Blood Systolic Diastolic
q is
at _gory,
Expiration Date
Pressure
140-159190-99
Stage 1
1 year
Driver qualified if <140/90,
Pulse Rate- Regular Irregular
160-1791100-109
Stage 2
One-time certificate for 3 months.
F ecord pulse bate:
>1 80/110
Stage 3
6 months from date of exam if <140/90
SIMMEM
1 year if <1 40190,
One-time certificate for 3 months if
141-159/91-99.
1 year from date of exam if <140/90
6 months if < 140/90
[d- ZZMEMSEREE= Numerical readings must be recorded. SSP. GR. PROTEIN BLOOD SUGAR
URINE PECIMEN
Urinalysis is required. Protein, blood or sugar in the urine may be an indication for further testing to
rule out any underlying medical problem.
Other Testing (Describe and record)
F_K0MZ2NZ= Height: (in.) Weight: (lbs.) Name: Last, First, Middle,
The presence of a certain condition may not necessarily disqualify a driver, particularly if the condition is controlled adequately, is not likely to worsen or is readily amenable to treatment.
Even if a condition does not disqualify a driver, the medical examiner may consider deferring the driver temporarily. Also, the driver should be advised to take the necessary steps to correct
the condition as soon as possible particularly if the condition, if neglected, could result in more serious illness that might affect driving.
Check YES if there are any abrionnalities. Check NO if the body system is normal. Discuss any YES answers in detail in the space below, and indicate whetherit would affect the driver's
ability to operate a commercial motor vehicle safely. Enter applicable item number before each comment, If organic disease is present, note that it has been compensated for,
See Instructions to the Medical Examirwr for guidance.
BODY SYSTEM CHECK FOR: YES* NO
1. General Appearance Marked overweight, tremor, signs of alcoholism, problem
drinking, or drug abuse,
2. Eyes
Pupillary equality, reaction to light, accommodation, ocular
motility, ocular muscle imbalance, extraricular movement,
mrstagmus, exophthalmos, Ask about retinopathy, cataracts,
aphakia, glaucoma, macular degeneration and refer to a
specialist if appropriate,
3 Ears
Scarring of tympanic membrane, occlusion of external canal,
perforated eardrums.
4. Mouth and Throat
Irremediable deformities likely to interfere with breathing or
swallowing.
5. Heart
Murmurs, extra sounds, enlarged heart, pacemaker,
implantable defibrillator.
6, Lungs and chest,
Abnormal chest wall expansion, abnormal respiratory rate,
not including breast
abnormal breath sounds including wheezes or alveolar rates,
examination
impaired respiratory function, cyanosis. Abnormal findings on
physical exam may require further testing such as pulmonary
tests and/ or xray of chest.
*COMMENTS:
Note certification status here. See Instructions to the Medical Examiner for guidance.
Meets standards in 49 CFR 391,41 ; qualifies for 2 year certificate
Does not meet standards
Meets standards, but periodic monitoring required due to
Driver qualified only for: 3 months 6 months 1 year Other
Temporarily disqualified due to (condition or merficatiorff:
Return to medical examinees office for follow up on
BODY SYSTEM CHECK FOR:
7. Abdomen and Viscera Enlarged liver, enlarged spleen, masses, bruits,
hernia, significant abdominal wall muscle
weakness,
S. Vascular System
Abnormal pulse and amplitude, cadrod or
casual bruits, varicose veins.
9. Genfle-urinary System
Hermes,
10. Extremilies- Limb
Loss or impairment of leg, fool, toe, arm. hand,
impaired. Driver may
finger. Perceptible limp, deformities. atrophy,
be subject to SIDE
weakness, paralysis, clubbing, edema,
certificate of otherwise
hypotonia, Insufficicent grasp and prehension
qualified,
in upper limb to maintain steering wheel grip.
Insufficient mobility and strength in lower limb
to operate pedals properly.
11 Spine, other
Previous surgery, deformities, limitation of
musculoskeletal
motion. tenderness.
12. Neurological
Impaired equilibrium, coordination or speech
pattern; asymmetric deep tendon reflexes,
sensory or positional abnormalities, abrionnal
patellar and Babinki's reflexes, ataxia.
UNNEIM
Wearing corrective loose
Wearing hearing aid
Accompanied by a waiver/ exemption. Driver must present
exemption at time of certification,
Skill Perfonnance Evaluation (SPE) Certificate
Driving within an exempt intracity zone (See 49 CFR 391,62)
Qualified by operation of 49 DER 391.64
Medical Examinees signature
Medical Examiners name
Address
Telephone Number
If meats standards, complete a Medical Examiner's Certificate as stated in 49 CFR 391 .43(h). (Driver must carry certificate when operating a commercial vehicle,)
49 CFR 391.41 Physical Qualifications for Drivers
THE DRIVER'S ROLE
Responsibilities, work schedules, physical and emotional demands, and lifestyles among commercial drivers vary by the type of driving that they do. Some of main types of
drivers include the following: to around or short relay (drivers return to their home base each evening); long relay (drivers drive 9-11 hours and then have at least a 10-hour off -
duty period), straight through haul (cross country drivers); and team drivers (drivers share the driving by alternating their 5-hour driving periods and 5-hour rest periods.)
The following factors may be involved in a driver's performance of duties: abrupt schedule changes and totaling work schedules, which may result in irregular sleep patterns and
a driver beginning a trip in a fatigued condition; long hours; extended time away from family and friends, which may result in lack of social support- tight pickup and delivery
schedules, with irregularity in work-, rest, and eating patterns, adverse road, weather and traffic conditions, which may cause delays and lead to hurriedly loading or unloading
cargo in order to compensate for the lost time; and environmental conditions such as excessive vibration, noise, and extremes in temperature. Transporting passengers or hazardous
materials may add to the demands on the commercial driver.
There max be duties in addition to the driving task for which a driver is responsible and needs to be fit. Some of these responsibilities are: coupling and uncoupling trailer(s) from
the tractor, loading and unloading trailer(s) (sometimes a driver may lift a heavy load or unload as much as 50,000 lbs. of freight afler sitting for a long period offintre without any
stretching period); inspecting the operating condition of tractor and/or trailer(s) before, during and after delivery of cargo; lifting, installing, and removing heavy tire chains; and,
lifting heavy tarpaulins to cover open top trailers. The above tasks demand agility, the ability to bend and stoop, the ability to maintain a crouching position to inspect the underside
of the vehicle, frequent entering and exiting of the cab, and the ability to climb ladders on the tractor and/or trailer(s).
In addition, a driver must have the perceptual skills to monitor a sometimes complex driving situation, thejudgmentskills to make quick decisions, when necessary, and the
manipulative skills to control an oversize steering wheat, sing gears using a manual transmission, and maneuver a vehicle in crowded areas.
§391.41 PID'SICAL QUALIVICATIONS FOR
DRIVERS
(a) A person such not drive a commercial ranter vehicle
unless lie is physically qualified to do so and. except as
provided in §391.67, has on his person the original, or a
photographic copy, era medical examinees certificate that
lie is physically qualified it) drive a commercial motor
vehicle
(b) A person is physically qualified to drive a motor vehicle
ifthat person:
(1) Flats no loss ofa fact, a leg, a hand, or an arm, or has
been granted a Skill performance Evaluation (SPE)
Certificate (formerly Limb Waiver program) pursuant to
§391.49.
(2) 1 las no impairment or, (i) A hand or finger which
interferes %van prehension or power grasping-, or (it) An
arm, fool, or lcg %%-Inch interferes with the ability to perform
normal tasks associated with encoding as commercial motor
vehicle. or any other significant hour defect or limitation
which interferes with the ability to perform normal tasks
associated with operating a commercial motor vehicle; or
Naas been granted a SPF, Certificate pursuant it) §391.49.
(3) 1 las tit) established medical history or clinical diagnosis
ofifilanoes mellitus currently requiring insulin for control;
(4) l4as no current clinical diagnosis ofniyocardial
infaretion, angina fissions, coronary insufficiency,
thrombosis, or any other cardiovascular disease ol'a variety
known to be accompanied by syncope, dystaica, collapse.
or congestive cardiac failure.
(5) Has no established medical history or clinical diagnosis
of a respiratory dysfunction likely to interlere %van his
ability to control and drive a commercial motor vehicle
sureiv,
(6) 1 ho no current clinical diagnosis of high blood pressure
likely to interfere pith his ability to operate as commercial
motor vehicle safely.
(7) 1 las no established medical history or clinical diagnosis
oft-licumatic, arthritic, orthopedic, muscular.
11CUmmuscular. or vascular disease which interfaces with
his ability to control and operate a commercial motor
vehicle safely.
(8) Flas no established medical history or clinical diagnosis
of epilepsy or any other condition Much is likely to cause
loss of consciousness or any loss ol'abilily to control a
commercial motor vehicle;
(9) Has no mental, nervous, organic, or functional disease
or psychiatric disorder likely to inlerlere with his ability to
drive a commercial motor vehicle smelv-
(10) Has distant visual acuity ofat [cast 20/40 (Suellen) in
cacti eye without corrective lenses or visual acuity
separately corrected to 20140 (Sachem or better with
corrective lenses, distant binocular acuity of least 20140
(Suellen) in both eyes wall or without corrective lenses,
field oaf vision of at least 70degriew in [lie horizontal
meridian in cacti eye. and (lie ability to recognize the colors
of traffic signals and devices showing standard red, green
and amber,
(11) F irst perceives a raised whispered voice in the better
car not less (Iran 5 feet with or without the use of hearing
aid, or, iriested by use oran archomearic device, does not
have an average hearing loss in the better car greater than
40 decibels at 500 tiz, 1,000 I-hr and 2.000 I-Iz with or
WitimUl as hearing device when the audiormaric device is
calibrated to the American National Standard (formerly
ASA Standard) Z24.5-195 I :
(I 2di) Does not use any drug or substance identified in 21
CFR 1308,11 Schedule 1, an amphetamine. a narcotic, or
other habit-forming drug,
(if) Does not use any non -Schedule I drug or substance that
is identified in the labor Schedules in 21 part 1308 except
when the use is prescribed by a licensed medical
practitioner, as defined fit § 382.107. %%-Ile is familiar %vidi
the driver's medical history and has advised the driver that
the substance will not adversely affect the driver's ability to
safety operate a commercial motor vehicle,
0 3) rise no current clinical diagnosis or
alcoholism
INSTRUCTIONS TO THE MEDICAL EXAMINER
accompanied by" is designed to include a clinical diagnosis of
a cardiovascular disease (1) which is accompanied by
symptoms of syncope, airspace, collapse or congestive
cardiac failure'. and/or (2) which is likely to cause syncope,
dyspnea, collapse or congestive cardiac failure.
It is the intent of the FMCSRs to render unqualified, a
driver who has a current cardiovascular disease which is
accompanied by and/or likely to use symptoms of syncope,
dyspnea, collapse, or congestive cardiac failure.
However, the subjective decision of whether the nature and
severity of an individual's condition will likely cause
symptoms of cardiovascular insufficiency is on an individual
basis and qualification rests with the medical examiner and
the motor carrier. In those cases where there is an
occurrence of cardiovascular insufficiency (myocardial
infarction, thrombosis, etc.), it is suggested before a driver is
certified that he or she have a normal resting and stress
electrocardiogram (ECG), no residual complications and no
physical limitations, and is taking no medication likely to
interfere with safe driving.
Coronary artery bypass surgery and pacemaker
implantation are remedial procedures and thus. not
unqualifying. Implantable commander defibrillators are
disqualifying due to risk of syncope Cournaffin is a medical
treatment which can improve the health and safety of the
driver and should not, by its use, medically disqualify the
commercial driver The emphasis should be on the underlying
medical condition(s) which require treatment and the general
health of the driver. The FM SA should be contacted at (202)
366-4001 for additional recommendations regarding the
physical qualification of drivers on cournadin,
(See Cardirwasular Advisory Panel Guidelines for the
Medical examination of Commercial Motor Vehicle Drivers
at: hit if prics-1,cir, i.rK)Wnjh':�W.
.................................................................................................
Respiratory Dysfunction
§391.41(b)(6)
A person is physically qualified to drive a commercial motor
vehicle if that person:
Has no established medical history or clinical diagnosis of a
respiratory dysfunction fikery to interfere with ability to control
and drive a commercial motor vehicle safely.
Since a driver must be alert at all times, any change in
his or her mental state is in direct conflict with highway safety.
Even the slightest impairment in respiratory function under
emergency conditions (when greater oxygen supply is
necessary for performance) may be detrimental to safe
driving.
There are many conditions that interfere vain oxygen
exchange and may result in incapacitation, including
emphysema, chronic asthma, carcinoma, tuberculosis,
chronic bronchitis and sleep apnea. if the medical examiner
detects a respiratory dysfunction, that in any way is likely to
interfere with the driver's ability to safely control and drive a
commercial motor vehicle, the driver must be referred to a
specialist for further evaluation and therapy. Anticoagulation
therapy for deep vein thrombosis and/or pulmonary
thromboembofism is not unqualifiang once optimum dose is
achieved, provided lower extremity venous examinations
remain normal and the treating physician gives a favorable
recommendation,
(See Conference on Pulmonary/Respiratory Disorders and
Commercial Drivers at:
....... . ................. . .............
Hypertension
§391.41(b)(6)
A person is physicafty qualified to drive a commercial motor
vehicle if that person:
Has no current clinical diagnosis of high blood pressure likely
to interfere with ability to operate a commercial motor vehicle
satisfy.
Hypertension alone is unlikely to use sudden
collapse', however, the likelihood increases when target organ
damage, particularly cerebral vascular disease, is present.
This regulatory criteria is based on FMCSA% Cardiovascular
Advisory Guidelines for the Examination of CMV Drivers,
which used the Sixth Report of the Joint National Committee
on Defection, Evaluation, and Treatment of High Blood
Pressure (1997),
Stage I hypertension corresponds to a systolic BP of
140-159 mmHg and/or a diastolic BP of 90-99 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
140190. It less than 1601100 certification may be extended
one time for 3 months
A blood pressure of 160-179 systolic and/or 100-109
diastolic is considered Stage 2 hypertension, and the driver is
not necessarily unqualified during evaluation and institution of
treatment The driver is given a one time certification of three
months to reduce his or her blood pressure to less than or
equal to 140190 A blood pressure in this range is an absolute
indication for anti -hypertensive drug therapy. Provided
treatment is well tolerated and the driver demonstrates a BE
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 180 (systolic) and
110 (diastolic) is considered Stage 3. high risk for an acute
BP -related event. The driver may not be qualified, even
temporarily, until reduced to 140190 or less and treatment is
wall tolerated. The driver may be certified for 6 months and
biannually (every 6 months) thereafter if at recheck BP is
140190 Or less,
Annual recertification is recommended If the medical
examiner does not know the severity of hypertension prior to
treatment.
An elevated blood pressure finding should be confirmed
by at least two subsequent measurements on different days.
Treatment includes nommarmaciskiffic and
phannaccloffic modalities as well as counseling to reduce
other risk factors. Most anthypertensive medications also
have side effects, the importance of which must be judged on
an individual basis. Individuals must be alerted to the hazards
of these medications while driving. Side effects of
somnolence or syncope are parliculary undesirable in
commercial drivers.
Secondary hypertension is based on the above stages.
Evaluation is warranted if patient is persistently hypertensive
on maximal or near -maximal doses of 2-3 pharmacologic
agents. Some causes of secondary hypertension may be
amenable to surgical intervention or specific pharmacologic
disease.
(See Cardiovascular Advisory Panel Guidelines for the
Medical Examination of Commercial Motor Vehicle Drivers at:
jlkl /f wwv fin dotwin xxxxxxN
hm
Rheumatic, Arthritic, Orthopedic, Muscular,
Neuromuscular or Vascular Disease §391.41 (b)(7)
A person is physically qualified to drive a commercial motor
vehicle if that person:
Has no established medical history orclaucal diagnosis of
rheumatic, arthritic, orthopedic, muscular, neuromuscularor
vascular disease which interferes with the abiloy to control
and operate a commercial motor vehicle safely,
Certain diseases are known to have acute episodes of
transient muscle weakness, poor muscular Coordination
(ataxia), abnormal sensations firarestmeard, decreased
muscular tone firrypolordid, visual disturbances and pain
which may be suddenly incapacitating. With each recurring
episode, these symptoms may become more pronounced
and remain for longer perrods, of time. Other diseases have
more insidious onsets and displays ptoms of muscle
wasting (atrophy), swelling and parestherea, which may not
suddenly incapacitate a person but may restrict herher
movements and eventually interfere with the ability to safely
operate a motor vehicle, In many instances these diseases
are degenerative in nature or may result in deterioration of
the involved area.
Once the individual has been diagnosed as having a
rheumatic, arthritic, orthopedic, muscular, neuromuscular or
vascular disease, then he/she has an established history of
that disease. The physician, when examining an individual,
should consider the following: (1) the nature and severity of
the individual's condition (such as sensory loss or loss of
strength); (2) the degree of limitation present (such as range
of motion); (3) the likelihood of progressive limitation (not
always present initially but may manifest itself over time): and
(4) the likelihood of sudden incapacitation. If severe
functional impairment exists, the driver does not quality. In
cases where more frequent monitoring is required, a
certificate for a shorter period of time may be issued. (See
Conference on Neurological Disorders and Commercial
Drivers at:
http-://www.fmcsa.dot,govlrulesregs/medreporls,him)
Epilepsy
§3911AI(b)(8)
A person is physically qualified to drive a commercial motor vehicle
if that person:
Has no established medical history or clinical diagnosis of epilepsy
or any other condition which is likely to cause loss of
consciousness or any loss of ability to control a motor vehicle.
Epilepsy is a chronic functional disease characterized by
seizures or episodes that occur without warning, resulting in loss of
voluntary control which may lead to loss of consciousness and/or
seizures. Therefore, the following drivers cannot be qualified- (1) a
driver who has a medical history of epilepsy; (2) a driver who has a
current clinical diagnosis of epilepsy" or (3) a driver who is taking
anfisedure medication,
If an individual has had a sudden episode of a noneffileplic
seizure or loss of consciousness of unknown use which did not
require antiseizure medication, the decision as to whether that
person's condition will likely use loss of consciousness or loss of
ability to control a motor vehicle is made an an individual basis by
the medical examiner in consultation Win the treating physician.
Before certification is considered, 11 is suggested that a 6 month
waiting period elapse from the time of the episode. Fighwang the
waiting period, it is suggested that the individual have a complete
neurological examination. If the results of the examination are
negative and antaudzure medication is not required, then the driver
may be qualified.
In those individual cases where a driver has a seizure or an
episode of loss of consciousness that resulted from a known
medical condition (e.g., drug reaction, high temperature, acute
infectious disease, dehydration or acute metabolic disturbance),
certification should be deferred until the driver has fully recovered
from that condition and has no existing residual complications, and
net taking anfiselzure medication,
Drivers with a history of epilepsy/seizures off antiseizure
medication and seizure -free for to years may be qualified to drive
a CNIV in interstate commerce. Interstate drivers with a history of
a single unprovoked seizure may be qualified to drive a CMV in
interstate commerce it seizure -free and off antiseizure medication
for a 5-year period or more.
(See Conference an Neurological Disorders and Commercial
Drivers at,
http:lhvww,fmcsa,dot,gov/rulasregstmedreporls,htm)
Mental Disorders
§391.41(b)(9)
A person is physically qualified to drive a commercial motor
vehicle if that person:
Has no mental, nervous, organic or functional disease or
psychiatric disorder likely to interfere with ability to drive a motor
vehicle safely,
Emotional or adjustment problems contribute directly to an
individual's level of memory, reasoning, attention. and judgment.
These problems often underlie physical disorders. A variety of
functional disorders can cause drowsiness, dizziness.
confusion, weakness or paralysis that may lead to
incoordination, motivation, loss of functional control and
susceptibility to accidents while driving. Physical fatigue,
headache, impaired coordination, recurring physical ailments
and chronic "nagging" pain may be present to such a degree
that cereification for commercial driving is inadvisable. Somatic
and psychosomatic complaints should be thoroughly examined
when determining an individual's overall fitness to drive.
Disorders of a periodically incapacitating nature, even in the
early stages of development, may warrant disqualification.
Many bus and truck drivers have documented that "nervous
froubm" related to neurotic, personality, or emotional or
adjustment problems is responsible for a significant fraction of
their preventable accidents. The degree to which an individual
is able to appreciate, evaluate and adequately respond to
environmental strain and emotional stress is critical when
assessing an individual's mental alertness and flexibility to cope
Win the stresses of commercial motor vehicle driving.
When examining the driver, it should be kept In mind that
individuals who live under chronic emotional upsets may have
deeply ingrained malsomplive or erratic behavior patterns.
Excessively antagonistic, instinctive impulsive. openly
aggressive, paranoid or severely depressed behavior greatly
interfere with the driver's ability to drive safely. Those
individuals who are highly susceptible to frequent states of
emotional Instability (schizophrenia, affective psychoses.
paranoia, anxiety or depressive neuroses) may warrant
disqualification. Careful consideration should be given to the
side effects and interactions of medications in the overall
qualification determination. See Psychiatric Conference Report
for specific recommendations on the use of medications and
potential hazards for driving,
(See Conference an Psychiatric Disorders and Commercial
Drivers at:
htlp-://www.finesa,doLgovlrutesregs/medreports. him)
Vision
§391AI(b)(10)
A person is physically qualified to drive a commercial motor
Vehicle if that person:
Has distant visual acuity of at least 20140 (Section) in each eye
with or without corrective lenses or visual acuity separately
corrected to 20140 (gradient or better with corrective lenses,
distant binocular acuity of at least 20140 Cynarged in both eyes
with or without corrective lenses, field of vision of at least 70
degrees in the horizontal mencrour in each eye, and the ability to
recognize the colors of traffic signals and devices showing
standard red, green, and amber.
The term 'ability to recognize the colors or is interpreted to
mean if a person can recognize and distinguish among traffic
control signals and devices showing standard red, green and
amber, he or she meets the minimum standard, even though he
or she may have some type of for perception deficiency. If
certain color perception tests are administered, (such as
Ishmara, Pseudolsochromatic, Yam) and doubtful findings are
discovered, a controlled test using signal red, green and amber
may be employed to determine the driver's ability to recognize
these colors.
Contact lenses are permissible if there is sufficient evidence
to indicate that the driver has good tolerance and is well
adapted to their use. Use of a contact lens in one eye for
distance visual acuity and another lens in the other eye for near
vision is not acceptable, nor telescopic lenses acceptable for
the driving of commercial motor vehicles.
If an individual meets the criteria by the use of glasses or
contact lenses, the following statement shall appear on the
Medical Examiner's Certificate: "Qualified only if wasting
corrective lenses,'
CMV drivers who do not meet the Federal vision
standard may call (703) 448-3094 for an application
for a vision exemption
(See Visual Disorders and Commercial Drivers at:
Intlixlhisaw.fincea.dol goviruiesregs/medreporis him)
Hearing
§391.411(fi)j11)
A person is physically qualified to drive a commercial motor
vehicle if that person
First perceives a forced whispered voice in the better ear at not
less than 5 feet with or without the use of a hearing aid. or ' if
tested by use of an auctrometric device, does not have an
average hearing loss in the better ear greater than 40 decibels
at 500 Nz, 1.000 Us. and 2,000 ylz with or without a hearing aid
when the audermourn device is calibrated to American National
Standard (formerly AAA Standard) Z24 5-1951.
Since the prescribed standard under the FMCSRs is the
American Standards Association (ANSI). it may be necessary to
convert the cooperator results from the ISO standard to the
ANSI standard, Instructions are included on the Medical
Examination report form.
It an individual meets the unless by using a hearing aid, the
driver must wear that hearing aid and have it in operation at all
times while driving. Also. the driver must be in possession of a
spare power source for the hearing aid.
For the whispered voice test, the individual should be
stationed at least 5 feet from the examiner with the ear being
tested turned toward the examiner The other ear is covered.
Using the breath which remains after a normal expiration the
examiner whispers words or random numbers such as 66, 18.
23, etc. The examiner should not use only
sibilants (s sounding materials). The opposite
ear should be tested in the same manner. If the
individual fails the whispered voice test, the
audiometric test should be administered.
If an individual meets the criteria by the use
of a hearing aid, the following statement must
appear on the Medical Examiners Certificate
"Qualified only when wearing a hearing aid."
(See Hearing Disorders and Commercial Motor
Vehicle Drivers at-,
http-/Iwwwlfmcsa,doLgovlruiesregslmedreports.
him)
Drug Use
§391.41(b)(12)
A person is physically qualified to drive a
commercial motor vehicle if that person does
not use any drug or substance identified in 21
CFR 1308.11. an amphetamine, a narcotic, or
other habit-forming drug. A driver may use a
non -Schedule I drug or substance that is
identified in the other Schedules in 21 part 1308
if the substance or drug is prescribed by a
licensed medical practitioner who: (A) is familiar
with the driver's medical history, and assigned
duties, and (B) has advised the driver that the
prescribed substance or drug will not adversely
affect the driver's ability to safely operate a
commercial motor vehicle.
This exception does not apply to methadone.
The intent of the medical certification process is
to medically evaluate a driver to ensure that the
driver has no medical condition which interferes
with the safe performance of driving tasks on a
public road. If a driver uses an amphetamine, a
narcotic or any other habit-forining drug, it may
be use for the driver to be found medically
unqualified. If a driver uses a Schedule I drug or
substance, it will be cause for the driver to be
found medically unqualified. Motor carriers are
encouraged to obtain a practitioners written
statement about the effects on transportation
safety of the use of a particular drug.
A test for controlled substances is not
required as part of this biennial certification
process. The FMCSA or the anodes employer
should be contacted directly for information on
controlled substances and alcohol testing under
Part 382 of the FMCSRs.
The to "uses" is designed to encompass
instances of prohibited drug use determined by
a physician through established medical means.
This may or may not involve body fluid testing.
If body fluid testing takes place, positive test
results should be confirmed by a second test of
greater specificity The to "habit-forming" is
intended to include any drug or medication
generally recognized as capable of becoming
habitual, and which may impair the users ability
to operate a commercial motor vehicle safely.
The driver is medically unqualified for the
duration of the prohibited drug(s) use and until a
second examination shows the driver is free
from the prohibited drug(s) use. Recertification
may involve a substance abuse evaluation. the
successful completion of a drug rehabilitation
program, and a negative drug test result
Additionally, given that the certification period is
normally two years, the examiner has the option
to certify for a period of less than 2 years if this
examiner determines more frequent monitonng
is required.
(See Conference on Neurological Disorders and
Commercial Drivers and Conference on
Psychiatric Disorders and Commercial Drivers
at:
http:llwww fmcsa dot,goviruissregstmedreports
him)
Alcoholism
§391.41(b)(13)
A person is physically qualified to drive a
commercial motor vehicle if that person:
Has no current clinical diagnosis of alcoholism
The to "current clinical diagnosis of' is
specifically designed to encompass 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 counseling and/or treatment, he
or she may be considered for certification.
Cr
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1 0 Regular ons (Ste- lords, - 29 CFI} - Table of Contents
• Part Number: 1910
• Part Title: Occupational Safety and Health Standards
• Subpart I
• Subpart Title: Personal Protective Equipment
• Standard Number: 1910,134 App C
• Title: OSHA Respirator Medical Evaluation Questionnaire (Mandatory),
• GNO, Source: e-CFR
Appendix C to Sec. 1910.134: OSHA Respirator Medical Evaluation Questionnaire (Mandatory)
To the employer: Arsovers to questions in Section 1, and toguestion 9 in Section 2 of Part A, do not require a medical examination,
To the employee;
Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place that is convenient to you. To maintain your
confidentiality, your employer or supervisor must not look at or review your answers, and your employer must tell you how to deliver or send this questionnaire
to the health care professional who will review it,
Part A. Section 1, (Mandatory) The following Information must be provided by every employee who has been selected to use any type of respirator (please
print),
1. Todays date:..
1 Your name:
3. Your age (to nearest year):
4. Sex (circle one): Male/Female
5 Your height:... ft . ..................... . in,
6. Your weight _ __ INS,
7, Your lob title:..
8. A phone number where you can be reached by the health care professional who reviews this questionnaire (include the Area Code): .....................
9. The best films to phone you at this number: .................
10, Has your employer told you how to contact the health care professional who wil: review this questionnaire (circle one). Yes/No
11, Check the type of respirator you will use (you can check more than one category):
a. N, R, or P disposable respirator (fiter- mask-, non -cartridge tore only).
ti. Other type (for example, half.. or full-faceldece type, powered -air purifying, supp farl-a r, selprontained breathing apparatus),
12. Have you worn a respirator (circle one), Yes/No
If "yes," what type(s):
Part A. Section 2. (Mandatory) Questions I through 9 below must be answered by every employee who has been selected to use any type of respirator (please
ci rde 'yes" or "no").
1. Do you currently smoke tobacco, or have you smoked tobacco in the last month: Yes/No
2, Have you ever had any of the following conditions?
a. Seizures-, Yes/No
b, Diabetes (sugar disease): Yes/No
c, Allergic reactions that interfere with your breathing: Yes/No
d. Claustrophobia (fear of closed -in places): Yes/No
a, Trouble smelling odors: Yes/No
3. Have you ever had any of the following pulmonary or lung problems?
a, Askestaisho Yes/No
b, Asthma. Yes/km
c, Chronic bronchitis, Yes/No
d, Emphysema: Yes/loo
a. Pneumonia: Yes/No
IF, Tuberculosis: Yes/No
g, silicosis; Yes/No
In. Pneurnothorax (collapsed lure: Yes/No
I, Lung cancer: Yes/No
j, Broken ribs'. Yes/No
k, Any chest injuries or surgeries: Yes/No
1, Any other lung problem that you've been told about: Yesk'No
4, Do you currently have any of the following symptoms of pulmonary or lung illness?
a, Shortness of breath: Yes/No
b, Shortness of breath when walking fast on level ground or walking up a slight bill or indine, Yes/No
c, Shortness of breath when walking with other people at an ordinary pace on level ground: Yes/No
d, Have to stop for breath when walking at your own pace on level ground: Yes/No
a, Shortness of breath when washing or dressing yourself: Yes/No
F. Shortness of breath that interferes with your job! Yes/No
g, Coughing that produces Phlegm (thick sputum): Yes/No
h, Coughing that wakes you early In the morning: Yes/No
I, Coughing that occurs mostly when you are lying down: Yest No
j, Coughing up blood in the last month: Yes/No
k, Wheezing. Yes/No
1. Wheezing that Interferes with your job: Yes/No
an, Chest pain when you breathe deeply: Yes/No
n, Any other symptoms that you think may be related to lung problems: Yes/No
5, Have you ever had any of the following cardiovascular or heart problerns?
a. Heart struck: Yes/No
b. Stroke, Yes/No
c, Angina. Yes/No
d. Heart (allure: Yealklo
a. Swelling in your legs or feet (not used by walking): Yes/No
f. Heart arrhythmia (heart beating irregularly): Yes/No
g, High blood pressure: Yes/No
K Any other heart problem that you've been told about: Yes,'N.o
6, Have you ever had any of die following cardiovascular or heart symptoms?
a, Frequent pain or tightness In your chest: Yes/No
tc Pain or tightness In your chest during physical activity: Yes/No
c, Pain or tightness in wrur chest that interferes with your job: Yes/No
d, In the past two years, have you noticed your heart skipping or missing a beat: Yes/No
a, Heartburn or Migestion that is riot related to eating: Yes/No
d, Any other symptoms that you think may be related to heart or circulation proloems, Yes/No
7, Do you currently take medication for any of the following problems?
a, Breathing or lung problems: Yes/No
b, Heart trouble: Yes/No
c, Blood pressure-. Yes/No
d, Seizures: Yes/No
B. If you' ve used's respirator, have you ever had any of the following problems? (if you've never used a respirator, check the following space and go to question
9o)
a, Eye irritation; Yes/No
b, Skin allergies or rashes: Yes/No
c, Anxiety: Yes/No
d, General weakness or fatigue. Yes/No
a, Any other problem that interferes with your use of a respirator: Yes/No
9, Would you like to talk to the Health care professional who will review this questionnaire about your answers to this questionnaire: Yes/No
Questions 10 to 15 below rout' answered by every employee who has been selected to use either a full-facepiece respirator or a self-contained breathing
apparatus (SCBA), For employees who have been selected to use other "- of respirators, answering these questions is voluntary,
10, Have you ever lost vision in either eye (temporarily or permanently): Yes/No
I L Do you currently have any of the following vision problems?
a, Wear contact lenses: Yes/No
b, Wear glasses: Yearklo
c. Color blind: Yes/No
d, Any otiver eye or vision problem., Yes/No
12, Have you ever had an injury to your ears, including a broken ear drurn: Yes/No
13, Do you currently have any of the following hearing problems?
a. Difficulty hearing. Yes/No
b, Wear a hearing aid: Yes/No
c. Any other hearing or ear problem-, Yewipm
14, Have you ever had a back injury: Yestlea
15. Do you currently have any of the following musculoskeletal problems?
a, weakness in any Of your arms, hands, legs, or feet: Yes/No
b, Bark pain: Yes/No
c. Difficulty fully moving your arras and legs: Yes,'fro
d, Pain or stiffness when you lean forward or backward at the waist; Yes/No
a. Difficulty fully moving your head up or down: Yes/No
f, Difficulty fully moving your head side to side: Yes/No
g, Difficulty bending at your knees: Yes/No
h, Difficulty squatting to the ground: Yes/No
i, Climbing a flight of stairs or a ladder carrying more than 25 lbs: Yes/No
j, Any other muscle or skeletal problem that interferes with using a respirator: Yes/No
Part B Any of the following questions, and other questions not listed, may be added to the questionnaire at the discretion of the health care professional who will
review the questionnaire.
1. In your present job, are you working at h gh altitudes (over 5,000 feet) or in a place that has lower than normal amounts of oxygen: Yes/No
If "yes," do you have feelings of dizziness, shortness of breath, pounding in your chest, or other symptoms when you're working under these conditions: Yes/No
2. At work or at home, have you ever been ex ' Dosed to hazardous solivents, hazardous airborne chern-lods (e,g,, gases, fumes, or dust), or he you come into
skin contact with hazardous chemicals: Yes/No
If "yes," name the chemicals if you know them: . ........................
3. Have you ever worked with any of the materials, or urAer any of the conditions, listed below
a. Asbestos: Yes/No
b, Rica ha-g., in sandblasting): Yes/No
c, Tungsten/cobalt (e,g,, grueling or welding this material): Yes/No
d, Beryllium: Yes/No
a, Aluminum: Yes/No
I, Coal (for example, m ning)., Yes/No
9, from: Yes/No
h, Tim YesiNo
i, Dusty environments: Yes/No
j, Any other hazardous exposures: Yes/No
If "yes,". describe these exposures:
4. Ust any second jobs or side businesses you have:
5, List your previous occupations:
6. List your current and previous hobbies:
7. Have you been in the military services? Yes/No
If "fires," were You exposed to biological or chemical agents Neither in training or combat): Yes/No
& Have you ever worked on a HAZIAAT Learn? Yes/No
9, Other than medications fix breathing and lung problems, heart trouble, blood pressure, and seizures mentioned earlier in this questionnaire, are you taking
any other medications for any reason (including over -the -counter med-catesoo, Yes/No
If "Yes," name the med cations if you know them:
W, %l I you be using any of the following items w th your resp retorts)?
a, HEPA Filters: Yes/No
b, Canisters (for example, gas masks): Yes/No
c, Cartridges: Yes/No
11, How often are you expected to use the respirator(s) (circle 'We' or "no" for all answers thot apply to you)?.
a. Escape only (no rescue): Yes No
b. Emergency rescue only: Yes/No
c, Less than 5 hours per week: Yes/No
d, Less than 2 hours per clay: Yes/No
a. 2 to 4 hours per day: Yesirkto
f, Over 4 hours per day., Yes/No
12. During the period you are using the respiratisr(s), is your work effort,
a, Light (less than 200 kcal per hour)o Yes/No
If 'Yes," how long does this period last during the average shift: fire, rains,
Examples of a light work effort are sitting while writing, typing r drafting, or performing light assembly work; or standing white operating a drill press (1 .3 lbs,) or
controlling machines,
b, Moderate (200 W 350 kcal per hour): Yes; Edo
If"Yes," how long does this period last during die average shift: fires ........... mins,
Examples of moderate work effort are sitting while nailing or filing, driving a truck or bra; in urban traffic; standing while drilling, nailing, performing assembly
work, or transferring a moderate load (about 39- bs,) at trunk level; walking on a level surface about 2 mph or down a 5-degree grade about 3 mph; or pushing
a wheelbarrow with a heavy load (about IDD lbs.) on a level surface, c, Heavy (above 350 kcal per hour); Yes/No
If "yes," how long does this period last duung the average shift- fire, miss,
Examples of heavy work are lifting a heavy load (about 50 ibs,) from the floor to your waist or shoulder; working on a loading dock, shoveling; standing while
bricklaying or chipping castings; walking Lip art 8--c1egree grade about 2 mph; climbing stairs with a heavy load (about 50 ibs,),
13, Will you be wearing protective clothing and/or eqUipfflent (other then the respirator) when you're using your respirator: Yes/No
If 'Yes," describe this protective clothing and/or Win pment:
14. Will you be working order hot conditions (temperature exceeding 77 deg, F); Yes No
15, Will you be working tinder humid conditions: Yes No
16, Describe the work you'll be doing while you're using your respiTator(s):
17. Describe any special or hazardous conditions you might encounter when you're using your res'pirator(s) (for example, confined spaces, life -threatening
gases):
18. Provide the followneJ information, if you know it, for each toft subsurice that you'll be exposed to when you're using your respirator(s):
Name of the first toxic substancev.
Estimated maximurn exposure level par shift:
Duration of exposure per smfty
Narne of the second toxic substance ............................................
Estimated maximurn exposure level per shift:
Duration of exposure per shift:
Name of the third toxic substance:_ .
Estimated maximium exposure level par shift:
Duration of exposure per smfb.
The name of any other toxic substances ftwt you'll be exposed to wh fe using your respirator:
19. Descr&- any special, responsibilities you'll have while using your respirator(s) that may affect die safety and well-being of others (for example, rescue,
security):
[63 FR 1152, Jlarr 8, 1998; 63 FR 20098, Apr 12 3, 1998; 76 Fly 33607, June 8, 2011; 77 Fly 46949, Aug, 7, 2012]
0 Next Standard (1910, 134 Apo D)
0 Regulations (Standards - 29 CFR) -fable of Contents
Freedom of Information Act I privacy & Security Statement I Discalmers I Important Web Site Notices I International I Contact its
U5,1vepartrivintref tabor i Oc;--patlor.,alSafety &tlealtliAdmiroStrat!.Ii I 21H, --onst tut1:1 Ave., My, Washington, DC 20210
Telephone � SIL-321 -OSHA (6742) 1 Wr
www,i)W..gov
-&,
........................................................................................
RESPIRATOR USE PHYSICAL
..............................................................................................
NAME: AGE-. SEX:
TELEPHONE: OCCUPATION:
fagree -t-o-tWe-r-elease -oT-tWis-ire fo-rm-a-ti-on-To-r-tFie-Mate -a-n-a-Fe-di-r-aT'Feg—u]5fory —purposes iE-tFe-extent -prow lTeWEy-a-p-pTi-ca-M-elaw—s
- - - - - - - -------------------------------- ------- --------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------
nFollow-up Medical Evaluation Physical Required. (positive response -questions 1-8)
[-]Past-Offer Physical: Medical Evaluation. Physical Required
NAME:
Job Title:
Date Of this Follow Up Apo:
Reasons for follow-up
Actions
PLHCP Follow UP Medical Examination
J
Recommendations about employee use of the respirator., Limitations -
Need for follow-up evaluations -
Signed: Date Signed
copy of recommendation give to employee? E) yes 0 no Date Given:
[
|
^See Attached Job Description
RESPIRATOR USE PHYSICAL
-
NAME- AGE- SEX;
HOME ADDRESS:
TELEPHONE: OCCUPATION:
l ItFF-r-e-Fea-se 'Stg� poses
----- -
tfATG- -ST3NELi -
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ZRIlffiffifflow
OUTSIDE NORMAL LIMITS:
OUTSIDE NORMAL LIMITS:
|t|smyopinion that the above named patient is. orisnot medically qualified towear arespirator inthe
performance ofhis/her duties