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Item C06
C.6 t, BOARD OF COUNTY COMMISSIONERS County of Monroe Mayor Heather Carruthers,District 3 IleOI1da Keys Mayor Pro Tern Michelle Coldiron,District 2 �p.° Craig Cates,District I David Rice,District 4 Sylvia J.Murphy,District 5 County Commission Meeting January 22, 2020 Agenda Item Number: C.6 Agenda Item Summary #6389 BULK ITEM: Yes DEPARTMENT: Employee Services TIME APPROXIMATE: STAFF CONTACT: Pam Pumar(305) 292-4459 N/A AGENDA ITEM WORDING: Approval to enter into a new contract with Advanced Urgent Care for medical services, including random drug screenings based on reasonable suspicion or post accidents, and new hire physicals as needed for safety sensitive employees and firefighters in Key West and Key Largo, with service coming to Marathon soon. ITEM BACKGROUND: We are requesting approval of this new contract with Advanced Urgent Care to provide medical services seven days a week in all three areas of the keys for random, reasonable suspicion,post incident/accident and new hire physicals for safety sensitive and Firefighters as needed. The vendor has locations as follows: Advanced Urgent Care 1980 N. Roosevelt Blvd., Key West, FI 33040 (Lower Keys) *Advanced Urgent Care 13365 Overseas Highway Marathon, FL 33050 (Middle Keys) Advanced Urgent Care 100460 Overseas Highway Key Largo, FL 33037 (Upper Keys) *As of now Middle Keys location is not yet open. Upon opening for business all the terms of this contract will apply to all three locations. PREVIOUS RELEVANT BOCC ACTION: None—new contract CONTRACT/AGREEMENT CHANGES: Contract Packet Pg. 109 C.6 STAFF RECOMMENDATION: Approval. DOCUMENTATION: Final - Employment Medical Services Advanced Urgent Care 12.23.2019 Attachment A. Report of medical examination general physical - 022316 Attachment B Medical-Examination-Report-(MER)-Form-MCSA-5875 Attachment C OSHA_Respirator_Questionnaire Attachment#D Physical Exam Summary FINANCIAL IMPACT: Effective Date: 01/22/2020 Expiration Date: Total Dollar Value of Contract: Total Cost to County: Current Year Portion: Budgeted: Source of Funds: Ad Valorem CPI: Indirect Costs: Estimated Ongoing Costs Not Included in above dollar amounts: Revenue Producing: If yes, amount: Grant: County Match: Insurance Required: Yes Additional Details: REVIEWED BY: Cynthia Hall Completed 12/23/2019 5:14 PM Bryan Cook Completed 12/26/2019 10:12 AM Assistant County Administrator Christine Hurley Completed 12/26/2019 11:11 AM Budget and Finance Completed 12/26/2019 2:15 PM Maria Slavik Completed 01/02/2020 3:18 PM Kathy Peters Completed 01/02/2020 3:44 PM Board of County Commissioners Pending 01/22/2020 9:00 AM Packet Pg. 110 C.6.a AGREEMENT EMPLOYMENT PHYSICAL SERVICES TABLE OF CONTENTS SECTION ONE - Scope of Services SECTION TWO - County Forms and Insurance Forms ATTACHMENTS: A. Post-offer and Fit for Duty Physical Forms (4 pages) 2 B. DOT Physical (9 pages) C. Respirator Physical (9 pages) D. Fire Fighter Physical (17 pages) T a� �s a 0. Packet Pg. 111 C.6.a 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 Bruce L. Boros, M.D., P.A. d/b/a Advanced Urgent Care Center of the Middle Keys & Key West , 1709 Atlantic Blvd., Key West 33040, and Bruce L. Boros, M.D., P.A. d/b/a Advanced Urgent Care Center of the Upper Keys, 100460 Overseas Hwy Ste. 1, Key Largo, FL 33037) (collectively, the two Advanced Urgent Care Center entities are referred to as "Contractor"). 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. T 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 cv and shall assume professional responsibility for the services to be provided. Contractor shall v 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: Advanced Urgent Care 1980 N. Roosevelt Blvd., Key West, FI 33040 (Lower Keys) 0 it *Advanced Urgent Care 13365 Overseas Highway Marathon, FL 33050 (Middle Keys) Advanced Urgent Care 100460 Overseas Highway Key Largo, FL 33037 (Upper Keys) 0. *As of now Middle Keys location is not yet open. Upon opening for business all the terms of this contract will apply to all three locations. 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. 2 Packet Pg. 112 C.6.a F. Appointments will be available throughout the business hours of the facility: Monday — Sunday 8:00 a.m. — 8:00 p.m. daily (lower keys) Monday — Friday 8:30 a.m. — 6:30 p.m. and Saturday and Sunday 9:00 a.m. — 5 p.m. (upper keys) Monday — Friday (Times to be determined) (Middle Keys). Walk-ins will also be accepted if an appointment cannot be reasonably scheduled. G. The facility will be available 24 hours a day, 7 days a week for post accident, random and reasonable suspicion alcohol and drug screening. • The Human Resources office will contact Advanced Urgent Care 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. H. Appointments will be seen by the contractor in a reasonable and timely .2 fashion. I. The Contractor will provide the County with at least a 24 — 48 hour turnaround time for the receipt of any drug and/or physical results. J. The Medical Review Officer will be available for contact by the Monroe County BOCC or its employees to answer questions about the effect of prescribed drugs. Part of the requirements set forth by the State of Florida drug free workplace policy, which Monroe County has adopted, and the Department of Transportation, the County must have a qualified Medical Review Officer"MRO" perform drug screening services. The MRO receives lab reports from the laboratory (as governed by regulations); Reviews lab reports for integrity, authenticity, false negatives, and false positives; interprets M 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 U) independent contractors shall not be an employee of or have any contractual 0 relationship with County. L. All personnel engaged in performing services under this Agreement shall be fully (n 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 3 Packet Pg. 113 C.6.a 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 January 22, 2020 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. cv Section 6. PAYMENT TO CONTRACTOR cv 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. 0 Section 7. CONTRACT TERMINATION it 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 0. A. CONTRACTOR hereby agrees that he has carefully examined the RFP, his response, and this Agreement and has made a determination that he/she has the personnel, equipment, and other requirements suitable to perform this work and assumes full responsibility therefore. The provisions of the Agreement shall control any inconsistent provisions contained in the specifications. All specifications have been read and carefully considered by CONTRACTOR, who understands the same and agrees to their sufficiency 4 Packet Pg. 114 C.6.a for the work to be done. Under no circumstances, conditions, or situations shall this Agreement be more strongly construed against COUNTY than against CONTRACTOR. B. Any ambiguity or uncertainty in the specifications shall be interpreted and construed by COUNTY, and its decision shall be final and binding upon all parties. C. The passing, approval, and/or acceptance by COUNTY of any of the services furnished by CONTRACTOR shall not operate as a waiver by COUNTY of strict compliance with the terms of this Agreement, and specifications covering the services. D. CONTRACTOR agrees that County Administrator or his designated representatives may visit CONTRACTOR'S facility (ies) periodically to conduct random evaluations of services during CONTRACTOR'S normal business hours. E. CONTRACTOR has, and shall maintain throughout the term of this Agreement, appropriate licenses and approvals required to conduct its business, and that it will at all times conduct its business activities in a reputable manner. Proof of such licenses and approvals shall be submitted to COUNTY upon request. �s F. Pursuant to Florida Statute §119.0701, Contractor and its subcontractors shall comply with all public records laws of the State of Florida, specifically to: i. Keep and maintain public records that ordinarily and necessarily would be _ required by Monroe County in the performance of this Agreement. ii. Provide the public with access to public records on the same terms and conditions that Monroe County would provide the records and at a cost that does not exceed the cost provided in Florida Statutes, Chapter 119 or as otherwise provided by law. iii. Ensure that public records that are exempt or confidential and exempt from public records disclosure requirements are not disclosed except as Ir- 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. U) 0 IF THE CONTRACTOR HAS QUESTIONS REGARDING THE ° APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE W CONTRACTOR'S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS CONTRACT, CONTACT THE CUSTODIAN OF PUBLIC RECORDS, BRIAN BRADLEY, AT (305) 292-3470, brad ley® ria n(@.rnon roe ou ty- l.e ov, c/o Monroe County Attorney's Office, 1111 12t" St., Suite 408, Key West FL E 33040. 0. 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 5 Packet Pg. 115 C.6.a 1100 Simonton Street, Suite 2-268 Key West, Florida 33040 To the CONTRACTOR: Dr. Bruce Boros, Advanced Urgent Care, 1980 N. Roosevelt Blvd. Key West, FL 33040 Section 10. RECORDS CONTRACTOR shall maintain all books, records, and documents directly pertinent to performance under this Agreement in accordance with generally accepted accounting principles consistently applied. Each party to this Agreement or their authorized representatives shall have reasonable and timely access to such records of each other party to this Agreement for public records purposes during the term of the agreement and for four years following the termination of this Agreement. If an auditor employed by the COUNTY or Clerk determines that monies paid to CONTRACTOR pursuant to this Agreement were spent for purposes not authorized by this Agreement, the CONTRACTOR shall repay the monies together with interest calculated pursuant to Section 55.03 of the Florida Statutes, running from the date the monies were paid to CONTRACTOR. g T Section 11. EMPLOYEES SUBJECT TO COUNTY ORDINANCE NOS. 010 AND 020-1990 The CONTRACTOR warrants that it has not employed, retained or otherwise had act on its behalf Ci any former County officer or employee subject to the prohibition of Section 2 of Ordinance No. 010-1990 or any County officer or employee in violation of Section 3 of Ordinance No. 020-1990. For breach or violation of this provision the COUNTY may, in its discretion, terminate this agreement without liability and may also, in its discretion, deduct from the agreement or purchase price, or otherwise recover the full amount of any fee, commission, percentage, gift, or consideration paid to the former County officer or employee. Section 12. CONVICTED VENDOR A person or affiliate who has been placed on the convicted vendor list following a conviction for public entity crime may not submit a bid on 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 0. 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 6 Packet Pg. 116 C.6.a 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. ATTORNEYS 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 °2 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. cv Section 16. BINDING EFFECT N The terms, covenants, conditions, and provisions of this Agreement shall bind and inure to the benefit of the COUNTY and CONTRACTOR and their respective legal representatives, successors, and assigns. Section 17. AUTHORITY Each party represents and warrants to the other that the execution, delivery and performance of this Agreement have been duly authorized by all necessary County and corporate action, as required by law. U) Section 18. ADJUDICATION OF DISPUTES OR DISAGREEMENTS it 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 0. 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 7 Packet Pg. 117 C.6.a Agreement. Section 20. NONDISCRIMINATION COUNTY and CONTRACTOR agree that there will be no discrimination against any person, and it is expressly understood that upon a determination by a court of competent jurisdiction that discrimination has occurred, this Agreement automatically terminates without any further action on the part of any party, effective the date of the court order. The parties agree to comply with all Federal and Florida statutes, and all local ordinances, as applicable, relating to nondiscrimination. These include but are not limited to: 1) Title VII of the Civil Rights Act of 1964 (PL 88-352)which prohibits discrimination in employment on the basis of race, color, national origin; 2)Title IX of the Education Amendment of 1972, as amended (20 USC ss. 1681-1683, and 1685-1686), which prohibits discrimination on the basis of sex; 3) Section 504 of the Rehabilitation Act of 1973, as amended (20 USC s. 794), which prohibits discrimination on the basis of handicaps: 4) The Age �s Discrimination Act of 1975, as amended (42 USC ss. 6101-6107) which prohibits discrimination on the basis of age; 5) The Drug Abuse Office and Treatment Act of 1972 (PL 29-255), as amended, relating to nondiscrimination on the basis of drug abuse; 6) The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (PL 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; 7) The Public Health Service Act of 1912, ss. 523 and 527 (42 USC ss. 690dd-3 and 290ee-3) as g amended, relating to confidentiality of alcohol and drug abuse patient records; 8) Title VIII of the Civil Rights Act of 1968 (42 USC ss. 3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; 9) The Americans with Disabilities Act of 1990 (42 USC s. 1201), as may be amended from time to time, relating to nondiscrimination on the basis of disability; 10) Monroe County Code Chapter 13, Article VI, which prohibits discrimination on the basis of race, color, sex, religion, national origin, ancestry, sexual orientation, gender identity or cv expression, familial status or age; and 11) any other nondiscrimination provisions in any Federal or state statutes which may apply to the parties to, or the subject matter of, this Agreement. Section 21. COVENANT OF NO INTEREST COUNTY and CONTRACTOR covenant that neither presently has any interest, and shall not acquire any interest, which would conflict in any manner or degree with its performance under this Agreement, and that only interest of each is to perform and receive benefits as recited in this Agreement. Section 22. CODE OF ETHICS it COUNTY agrees that officers and employees of the COUNTY recognize and will be required to comply with the standards of conduct for public officers and employees as delineated in Section 112.313, Florida Statutes, regarding, but not limited to, solicitation or acceptance of gifts; doing business with one's agency; unauthorized compensation; misuse of public position, conflicting employment or contractual relationship; and disclosure or use of certain information. Section 23. NO SOLICITATION/PAYMENT 0. 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 8 Packet Pg. 118 C.6.a 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 g T a� 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 cv duties of such officers, agents, volunteers, or employees outside the territorial limits of the COUNTY. Section 27. LEGAL OBLIGATIONS AND RESPONSIBILITIES Non-Delegation of Constitutional or Statutory Duties. This Agreement is not intended to, nor shall it be construed as, relieving any participating entity from any obligation or responsibility imposed upon the entity by law except to the extent of actual and timely performance thereof by any participating entity, in which case the performance may be offered in satisfaction of the obligation or responsibility. Further, this Agreement is not intended to, nor shall it be construed as, authorizing the delegation of the constitutional or statutory duties of the COUNTY, except to the extent permitted by the Florida constitution, state statute, and case law. Section 28. NON-RELIANCE BY NON-PARTIES No person or entity shall be entitled to rely upon the terms, or any of them, of this Agreement to enforce or attempt to enforce any third-party claim or entitlement to or benefit of any service or program contemplated hereunder, and the COUNTY and the CONTRACTOR agree that neither the COUNTY nor the CONTRACTOR or any agent, officer, or employee of either shall have the authority to inform, counsel, or otherwise indicate that any particular individual or group of 0. 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 9 Packet Pg. 119 C.6.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 g only, and it is agreed that such section headings are not a part of this Agreement and will not be used in the interpretation of any provision of this Agreement. Section 33. INSURANCE POLICIES 33.1 General Insurance Requirements for Other Contractors and Subcontractors. As a pre-requisite of the work governed, the CONTRACTOR shall obtain, at his/her own expense, insurance as specified in any attached schedules, which are made part of this contract. The CONTRACTOR will ensure that the insurance obtained will extend protection to all Subcontractors engaged by the CONTRACTOR. As an alternative, the CONTRACTOR may require all Subcontractors to obtain insurance consistent with the attached schedules; however CONTRACTOR is solely responsible to ensure that said insurance is obtained and shall submit proof of insurance to COUNTY. Failure to provide proof of insurance shall be grounds for termination of this Agreement. The CONTRACTOR will not be permitted to commence work governed by this contract until U) satisfactory evidence of the required insurance has been furnished to the COUNTY as specified 0 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 (n 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 E 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 0. 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: 10 Packet Pg. 120 C.6.a • 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 T 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: cv • Premises Operations • Bodily Injury Liability Ir- • Expanded Definition of Property Damage The minimum limits acceptable shall be: $300,000 Combined Single Limit (CSL) If split limits are provided, the minimum limits acceptable shall be: $200,000 per Person $300,000 per Occurrence U) $ 50,000 Property Damage ° An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy, its (n 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. ll Packet Pg. 121 C.6.a 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. 0 33.4 Medical 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 g 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. cv The minimum limits of liability shall be: $1,000,000/$250,000 per occurrence and $750,000 aggregate �s 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 U) caused by the willful nonperformance of the CONTRACTOR and shall be solely responsible and 0 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 (n 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 E 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, 0. 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. 12 Packet Pg. 122 C.6.a 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. 0 �s IN WITNESS WHEREOF, the parties hereto have caused these presents to be executed as of the dates indicated below. T a� Attest: (SEAL) BOARD OF COUNTY COMMISSIONERS KEVIN MADOK, CLERK OF MONROE COUNTY, FLORIDA cv cv N By: By: Deputy Clerk Heather Carruthers, Mayor Date: BRUCE L. BOROS, MD, P.A. d/b/a ADVANCED URGENT CARE CENTER OF Witnesses: THE MIDDLE KEYS & KEY WEST U) By: By: 0 Print Name: Print Name: Title: Date: @ BRUCE L. BOROS, MD, P.A. d/b/a ADVANCED URGENT CARE CENTER OF Witnesses: THE UPPER KEYS 0. By: By: Print Name: Print Name: Title: Date: 13 Packet Pg. 123 C.6.a 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 0 outside the normal range. • Examining physician's written recommendation concerning future action on any 2 condition considered outside the normal range. • Written recommendation of specific reasonable accommodations in accordance with the ADA. T a� SERVICE FEE Notes DRUG SCREEN: When requested, a drug (Collection, Lab, MRO screen will be performed review) 12 panel State by the physician and will $55.00 Requirement be either scheduled or done on a walk-in basis. 0- Testing facility must $40.00 Oral Fluids, be available 24 hours specimen to be a day, 7 days a week collected by for post-accident, employer using random, and AUC provided Kit reasonable suspicion and Returned to drug screening. AUC DRUG SCREEN: When requested, a drug U) (Collection, Lab, MRO screen will be performed review) 5 panel by the physician and will $55.00 cas Department of be either scheduled or Transportation done on a walk-in basis. Requirement Testing facility must be $40.00 Oral Fluids, available 24 hours a specimen to be E day, 7 days a week for collected by c 0. a moving violation or employersing E an accident where a AUC provided Kit fatality occurs and returned to AUC U_ Medical Review Officer Performs MRO review $N/A Included in Fee (MRO)REVIEW Dr. Neil for drug screens for Drug Screen E J. Dash, Doctor;s Review performed by Advanced Service, 546 Franklin I Urgent Care 14 Packet Pg. 124 C.6.a Ave., Massapequa, NY 11758 BLOOD ALCOHOL When requested, Blood a (Collection, Lab, MRO Alcohol Screens will be review) performed by the $50.00 physician and will be either scheduled or done > on a walk-in basis. Testing facility must be $N/A available 24 hours a day, 7 days a week for post accident, random and reasonable drug screen. BREATH ALCOHOL When requested, may be 2 2 used for screening. If breath $45.00 alcohol screen is positive, a blood screen will be performed. If physician wishes to propose other means of screening method, please provide testing method explanation and accuracy. A testing facility must be $N/A available 24 hours a day, 7 days a week for post accident, random, and reasonable suspicion alcohol screening, PPD- TB screen When requested, a PPD-TB screen will be scheduled $25.00 > and performed by the physician's tech. during the 0 facility's normal business hours A PPD-TB screen �s will be performed with the 2 new hire Firefighter physical.. HEPATITIS A When requested, a Hepatitis $95.00 A inoculation will be E scheduled and performed 2 by the physician during the E facility's normal business hours. HEPATITIS B When requested, a Hepatitis Series of 3 Total= LL B inoculation(s)will be $80.00 $240.00 scheduled and performed EA E by the physician during the 15 Packet Pg. 125 C.6.a facilities normal business hours. TYPHOID When requested, a Typhoid Priced on Demand a inoculation will be $N/A scheduled and performed by the physician during the facility's normal business hours. TETANUS When requested, a Tetanus $N/A Combined with inoculation will be Diphtheria Below scheduled and performed by the physician during the facility's normal business hours. DIPHTHERIA When requested, a Diphtheria inoculation will $55.00 be scheduled and performed by the physician. during the facility's normal business hours. DOT PHYSICAL: When requested, a DOT Price not inclusive of (SEE ATTACHMENT physical will be scheduled $55.00 urine drug screen "B" to be completed by and performed by the employee and physician) physician during the facility's normal 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- U) offer physical. Thereafter, only a DOT physical is performed by the physician. Physician may also perform a urine drug screen if requested separately by Monroe County BOCC. POST-OFFER When requested, a post- Price not inclusive of PHYSICAL: offer physical will be urine drug screen 0. E (SEE ATTACHMENT scheduled and performed $55.00 W "A" to be completed by by the physician during the employee and physician) facility's normal business hours. Includes exam and physician review of E employee health history and job description. 16 Packet Pg. 126 C.6.a Physician may also perform a urine drug screen if requested separately by Monroe County BOCC. FITNESS FOR DUTY When requested, a Fitness Price not inclusive of PHYSICAL(SEE for Duty Physical may be urine drug screen ATTACHMENT "A" to be requested at any time by the $65.00 completed by employee employer in the employee's and physician) respective area of work. The exam will be scheduled during the facility's normal business hours. Includes physician review of employee health history, exam, and review of job description. Physician may also perform a urine drug screen if requested separately by T Monroe County BOCC. FIREFIGHTER When requested, Firefighter $55.00 Prince not inclusive PHYSICAL(SEE physical will be scheduled of EKG, Chest X- ATTACHMENTS "D" TO and performed by the Ray, Spirometry, BE COMPLETED BY physician during the Hearing/Audiogram, EMPLOYEE AND facilities normal business Stress Test, PPD-TB PHYSICIAN hours. Includes exam and screen �s physician review of employee health history and job description. Physician may also perform a urine drug screen if requested separately by Monroe County BOCC. U) Also required: EKG, 0 Chest-X-ray, Spirometry, Hearing/Audiogram, Stress Test, PPD-TB screen 2 RESPIRATOR When requested, a Price not inclusive of PHYSICAL(SEE Respirator physical will be Chest X-ray, and ATTACHMENTS "C" scheduled and performed $50.00 spirometry PART I& 11 to be by the physician during the completed by employee facility's normal business 0. and physician) hours. Includes exam and W physician review of employee health history and job description. Physician may also perform a urine drug screen if requested separately by 17 Packet Pg. 127 C.6.a Monroe County BOCC. Also required: ChestX--ray and Spirometry. EKG Normally done in $75.00 INTERPRETATION conjunction with the BY BOARD Firefighter physical CERTIFIED CARDIOLOGIST CHEST X RAY Chest X Ray is normally INTERPRETATION done in conjunction with $80.00 BY BOARD the New Hire Firefighter CERTIFIED and Respirator physical if RADIOLOGIST 0 there is an issue with the EKG or spirometry results. 2 SPIROMETRY Normally done in conjunction with the Respirator physical. All $80.00 Firefighters and employees who use a respirator will have a Spirometry when hired. Normally done in HEARING/AUDIOGRAM conjunction with the $35.00 appropriate physical. May be requested separately by Monroe County BOCC. STRESS TEST Normally done in $250.00 INTERPRETATION conjunction with the new BY BOARD hire Firefighter physical. CERTIFIED Performed thereafter for CARDIOLOGIST firefighters who are over 40 > years old and older. CHEMICAL Tests Glucose (sugar), $40.00 U) PANEL/CMP kidneys, liver(1 tube of blood drawn). Normally done in conjunction with Firefighter physical. CBC 2 Test to see if Anemic; if $30.00 any infections within the body; if dehydrated(test E from 1 of the tubes of blood 0. drawn). Normally done in E conjunction with Firefighter W physical. LIPIDS Tests good cholesterol and $65.00 U- (CHOLESTEROL) bad cholesterol (one of the tubes of blood drawn) E UA DIP Normally done in $10.00 conjunction with the DOT 18 Packet Pg. 128 C.6.a physical. UA DIP WITH MICRO Normally done in $15.00 conjunction with the Firefighter physiCaall URINE TESTING FOR $N/A NICOTINE USE a �s a� a� cv cv �s a 0. 19 Packet Pg. 129 C.6.a 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 Advanced Urgent Care ..warrants that he/it has not employed, retained or otherwise had act on his/her behalf any former County officer or employee in violation of Section 2 of Ordinance No. 010-1990 or any County officer or employee in violation of Section 3 of Ordinance No. 010-1990. For breach or violation of this provision the County may, in its discretion, terminate this Agreement without liability and may also, in its discretion, deduct from the Agreement or purchase price, or otherwise recover, the full amount of any fee, commission, percentage, gift, or consideration paid to the former County officer or employee." T cv (Signature) N Date: STATE OF: COUNTY OF: Subscribed and sworn to (or affirmed) before me on (date) by (name of affiant). He/She is personally known to me or has produced (type of identification) as identification. 0. NOTARY PUBLIC My Commission Expires: 20 Packet Pg. 130 C.6.a NON-COLLUSION AFFIDAVIT I, of the city of according to law on my oath, and under penalty of perjury, depose and say that 1. 1 am of the firm of the bidder making the Proposal for the project described in the Request for Proposals for and that I executed the said proposal with full authority to do so; 2. The prices in this bid have been arrived at independently without collusion, consultation, communication or agreement for the purpose of restricting competition, as to any matter relating to such prices with any other bidder or with any competitor; 3. Unless otherwise required by law, the prices which have been quoted in this bid have not been knowingly disclosed by the bidder and will not knowingly be disclosed by the bidder prior to bid opening, directly or indirectly, to any other bidder or to any competitor; and T 4. No attempt has been made or will be made by the bidder to induce any other person, partnership or corporation to submit, or not to submit, a bid for the purpose of restricting competition; and 5. The statements contained in this affidavit are true and correct, and made with full knowledge that Monroe County relies upon the truth of the statements contained in this affidavit in awarding contracts for said project. (Signature) Date: STATE OF: U) 0 COUNTY OF: Subscribed and sworn to (or affirmed) before me on (date) by (name of affiant). He/She is personally known to me or has produced 0. (type of identification) as identification. NOTARY PUBLIC My Commission Expires: 21 Packet Pg. 131 C.6.a DRUG-FREE WORKPLACE FORM The undersigned vendor in accordance with Florida Statutes Section 287.087 hereby certifies that: 1. Publishes a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition. 2. Informs employees about the dangers of drug abuse in the workplace, the business' policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations. 3. Gives each employee engaged in providing the commodities or contractual services that are under bid a copy of the statement specified in subsection (1). 4. In the statement specified in subsection (1), notifies the employees that, as a condition of working on the commodities or contractual services that are under bid, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to, any violation of Chapter 893 (Florida Statutes) or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than five (5) days after such conviction. U, 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 cv implementation of this section. As the person authorized to sign the statement, I certify that this firm complies fully with the above requirements. (Signature) Date: STATE OF: U) COUNTY OF: Subscribed and sworn to (or affirmed) before me on (date) by (name of affiant). He/She is personally known to me or has produced (type of identification) as identification. 0. NOTARY PUBLIC My Commission Expires: 22 Packet Pg. 132 C.6.a PUBLIC ENTITY CRIME STATEMENT "A person or affiliate who has been placed on the convicted vendor list following a conviction for public entity crime may not submit a bid on a contract to provide any goods or services to a public entity, may not submit a bid on a contract with a public entity for the construction or repair of a public building or public work, may not submit bids on leases of real property to public entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or CONTRACTOR under a contract with any public entity, and may not transact business with any public entity in excess of the threshold amount provided in Section 287.017, Florida Statutes, for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list." I have read the above and state that neither(Contractor's name) nor any Affiliate has been placed on the convicted vendor list within the last 36 months. (Signature) Date: STATE OF: cv cv COUNTY OF: Subscribed and sworn to (or affirmed) before me on (date) by (name of affiant). He/She is personally known to me or has produced (type of identification) as identification. U) 0 NOTARY PUBLIC My Commission Expires: 0. 23 Packet Pg. 133 C.6.a 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, t� and property damage (including property owned by Monroe County) and any other losses, damages, and expenses (including attorney's fees) which arise out of, in connection with, or by reason of services provided by the Contractor or any of its Subcontractor(s)in any tier, occasioned by negligence, errors, or other wrongful act of omission of the Contractor or its Subcontractors in any tier, their employees, or agents. In the event the completion of the project (to include the work of others) is delayed or suspended as a result of the Contractor's failure to purchase or maintain the required insurance, the Contractor shall indemnify the County from any and all increased expenses resulting from such delay. cv 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. U) 0 ° 0. 24 Packet Pg. 134 C.6.a WORKERS' COMPENSATION INSURANCE REQUIREMENTS FOR EMPLOYMENT PHYSICAL SERVICES BETWEEN MONROE COUNTY, FLORIDA AND 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. 0 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. aT Coverage shall be provided by a company or companies authorized to transact business in the state of Florida. cv cv 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. U) 0 a 0. 25 Packet Pg. 135 C.6.a GENERAL LIABILITY INSURANCE REQUIREMENTS FOR EMPLOYMENT PHYSICAL SERVICES BETWEEN MONROE COUNTY, FLORIDA AND ° 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: �s • Premises Operations 2 • Products and Completed Operations • Blanket Contractual Liability • Personal Injury Liability • Professional Liability g • Expanded Definition of Property Damage The minimum limits acceptable shall be: cv 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 U) (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 (s policies issued to satisfy the above requirements. 2 0. 26 Packet Pg. 136 C.6.a INSURANCE REQUIREMENTS Worker's Compensation $ 100,000 Bodily Injury by Acc. $ 500,000 Bodily Inj. by Disease, policy Imts $ 100,000 Bodily Inj. by Disease, each emp. 0 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 General Liability, including $ 300,000 Combined Single Limit �s Premises Operation Products and Completed Operations Blanket Contractual Liability Personal Injury Liability Expanded Definition of Property Damage cv 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. U) 0 ° 0. 27 Packet Pg. 137 OSHA Respirator Medical Evaluation Questionnaire (Mandatory) C.6.d Appendix C to Sec. 1910.134: Part A. Section 1. (Mandatory) Every employee who has been selected to use any type of respirator (please print) must provide the following information. Today's date Date of Birth: Name SSN: Job Title Sex: Male 0 Female 0 Home Phone: Height: (ft) (in) Weight (Ibs) Work Phone: Can you read English? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes 0 NO 0 Has your employer told you how to contact the health care professional who will review this? Yes 0 NO 0 Check the type of respirator you will use (you can check more than one category): > a N, R,or P disposable respirator(filter-mask, non-cartridge type only). b _ Other type Powered-air purifier Half-face Supplied-air Full-facepiece type(includes gas mask) Self-contained breathing apparatus Have you worn a respirator in the past?: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes 0 NO 0 If eyes,"what type(s): Physical exertion while wearing a respirator Mild Moderate Strenuous Maximum time you wear a respirator in a single day?: hours Do you exercise? . . . . . . . . . . . . . . . . . . . . . . . . . Yes No . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .If eyes,'describe how often and what exercise activities are: U) Part A. Section 2. (Mandatory)Questions 1 through 9 below must be answered by every employee who has been selected to use any type of respirator (please select eyes"or"no"). �I 0 1. Do you currently smoke tobacco, or have you smoked tobacco in the last month? Yes 0 NO 091 If Yes, how many packs per day? 1/2 or less 1 2 2 or more U) 0 How many years have you smoked? 1-9 10-19 20-29 30 or more 2. Have you ever had any of the following conditions? Seizures(fits) Yes O NO O Diabetes(sugar disease) Yes O NO O Allergic reactions that interfere with your breathing Yes O NO O 0 Claustrophobia(fear of closed-in places) Yes O NO O Trouble smelling odors Yes O NO O 3. Have you ever had any of the following pulmonary or lung problems? Asbestosis Yes O NO O 0 Asthma Yes O NO O Chronic bronchitis: Yes O NO O 0 0 Emphysema: Yes O NO O Pneumonia Yes O NO O Tuberculosis Yes O NO O Silicosis Yes O NO O Pneumothorax(collapsed lung) Yes O NO O Lung cancer Yes O NO O Broken ribs: Yes O NO O Any chest injuries or surgeries: Yes O NO O Any other lung problem that you've been told about: Yes Packet Pg. 138 OSHA Respirator Questionnaire (1) Name 4. Do you currently have any of the following symptoms of pulmonary or lung illness? Shortness of breath: Yes O NO O Shortness of breath when walking fast on level ground or walking up a slight hill/incline Yes O NO O Shortness of breath when walking with other people at an ordinary pace on level ground: Yes O NO O Have to stop for breath when walking at your own pace on level ground: Yes O NO O Shortness of breath when washing or dressing yourself: Yes O NO O Shortness of breath that interferes with your job: Yes O NO O Coughing that produces phlegm(thick sputum): Yes O NO O Coughing that wakes you early in the morning: Yes O NO O Coughing that occurs mostly when you are lying down: Yes O NO O Coughing up blood in the last month: Yes O NO O Wheezing: Yes O NO O Wheezing that interferes with your job: Yes O NO O Chest pain when you breathe deeply: Yes O NO O y Any other symptoms that you think may be related to lung Yes O NO O 5. Have you ever had any of the following cardiovascular or heart problems? Heart attack Yes O NO O Stroke: Yes O NO O 0 Angina: Yes O NO O _ Heart Failure: Yes O NO O Swelling in your legs or feet(not caused by walking): Yes O NO O Heart arrhythmia (heart beating irregularly): Yes O NO O High blood pressure: Yes O NO O Any other heart problem that you've been told about: Yes O NO O 0 6. Have you ever had any of the following cardiovascular or heart symptoms? 0 Frequent pain or tightness in your chest: Yes O NO O Pain or tightness in your chest during physical activity Yes O NO O J Pain or tightness in your chest that interferes with your job Yes O NO O M In the past two years,have you noticed your heart skipping or missing a beat: Yes O NO O 91 Heartburn or symptoms that is not related to eating Yes O NO O 0 Any other symptoms that you think may be related to heart or circulation problems: Yes O NO O 7. Do you currently take medication for any of the following problems? (s Breathing or lung problems: Yes O NO O �s Heart trouble: Yes O NO O Blood Pressure: Yes O NO O Seizures(fits):: Yes O NO O 8. If you've used a respirator, have you ever had any of the following problems? (If you've never used a respirator, check the following space and go to question 9) Eye irritation: Yes O NO O Skin allergies or rashes: Yes O NO O Anxiety: Yes O NO O General weakness or fatigue: Yes O NO O Any other problem that interferes with your use of a respirator: Yes O NO O 9.Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire: Yes 0 NO 0 OSHA Respirator Questionnaire (2) Packet Pg. 139 Name SUPPLEMENTAL: If ypu are required to use a fulkface pelce respirator or a Self-Contained Breathing Apraratus( CBA),complete the following: (if you do not, please sign below.) 10. Have you ever lost vision in either eye (temporarily or permanently): Yes Q NO Q 11. Do you currently have any of the following vision problems? Wear glasses: Yes O NO O Wear contact lenses: Yes O NO O Color blind: Yes O NO O Any other eye or vision problem: Yes O NO O 12. Have you ever had an injury to your ears, including a broken ear drum: Yes Q NO Q 13. Do you currently have any of the following hearing problems? Difficulty hearing: Yes O NO O Wear a hearing aid: Yes O NO O Any other hearing or ear problem: Yes O NO O 14. Have you ever had a back injury: Yes O NO O 15. Do you currently have any of the following musculoskeletal problems? Weakness in any of your arms, hands,legs,or feet: Yes O NO O Back pain: Yes O NO O 0 Difficulty fully moving your arms and legs: Yes O NO O Pain or stiffness when you lean forward or backward at the waist: Yes O NO O Difficulty fully moving your head up or down: Yes O NO O Difficulty fully moving your head side to side: Yes O NO O .d Difficulty bending at your knees: Yes O NO O Difficulty squatting to the ground: Yes O NO O Climbing a flight of stairs or a ladder carrying more than 25 Ibs: Yes O NO O Any other muscle or skeletal problem that interferes with using a respirator: Yes O NO O U) Any additional comments you would like to make: 0 To the best of my knowledge, the information I have provided is true and accurate. I Employee Signature Date TO BE COMPLETED BY THE EXAM INER/REVIEWER: This employee has been found to be physically able to use the following(check each(]that applies): ❑ Single use,filter mask(four attachment points) ❑ Full-faced powered cartridge-type(PAPR) ❑ Half-faced cartridge-type,negative pressure ❑ Self-contained breathing apparatus(SCBA) 0 0 Full-faced cartridge-type respirator,negative pressure Hood/helmet powered cartridge-type(PAPR) Half-faced powered cartridge-type(PAPR) Half-faced/Full-faced/Hood/Helmet(NOT positive pressure) Restrictions/Limitations(if any)when wearing a respirator: E This employee has been found to be phvsicall�r NOT able to use a respirator There is insufficient information to make a determination at this time The mandatory questionnaire has been reviewed,and the employee has been found to be physically able to use a respirator. The mandatory questionnaire has been reviewed but there is insufficient information to make a determination at this time. This respirator clearance expires 10 20 3 Q years from the date below. (If not marked, clearance expires in 1 year) Reviewer's Name(Print) Reviewer's Signature Date: Packet Pg. 140 OSHA Respirator Quesionnaire (3) ,�. l n FIGURE I<1 Form for fire deparanent physician's report Physical Exam Summary Employer: Employee's flame: Position Title: Date of Exam: Examining Physician: C Abnormal, Abnormal, Significant Changes Components Within Normal Able to Perform Cnable to Perform Noted from Prerloue Perfarmed Limits Job Tasks Job Tasks E.ssm(lf applicable) C ❑ Physical exam > ❑ Audicg= - a ❑ Pulmonary function C T=dmiU stress ❑ EKG-12lead ❑ Chest x-ray ❑ blamrnogmna ❑ PelviQ731P M x ❑ Laboratory tests Q Other U) Explanation of Abnormal Results/Significant Changes: C 0 C 0 ❑ Medically cleared to perform job tasks ❑ Denied medical clearance for current jab tasks NFPst Phy+lal[airs Summary V 017) ICCa Ealtan Packet Pg. 141 C.6.e &I (Continued.) H of P.L: MrA,Is. is a .�� v.o.Fire Fighter Police Officer with the department.The purpose of this annual physical is to establish Fitness for the contiouatio of those duties.He/she has enjoyed good health.WA%Irs. voiced the following question. Medical History Surgical History Medications _ D.iv1. , Orthopedic �. HIPi — ENT CVD ^Optho Asthma Other Allergies Social History ROS _ Smoke GI PPO ,Hematochezia ..._ Quit Stool caliber _ PkYr Bowel habits Exercise Alcohol G.U. _ Amount ,.,Stones _.. Frequency Hentaturia CV _Chest pain try —SOB @ Rap Cough Wheezes SOB to PH Physical Audio ._. DM Uisen physical hers �HFHL HTN _Speech range .r CVD Vision EKGIny1T Blood U) New _HR H/H _._. Fat ,Target WBC Corrected Interp Giu Stool OB Stage achieved Choi _ Positive Pulm HL3L 0 Negative FVC Rattp UA %Pied Risk LFTs Blood FEVI SGOT _ Protein S Pred SGFT _ Glucose GOT Other 111PA Physical RuM Swenowv t2 al 20M Hal Packet Pg. 142 • C.6.e FTGIM E-2 Medical examination report Form. Medical Examination 1. XA.%IE(Lisa (First) (Middle) 2.SEN ]. DATE OF Ex.AMDI,ATIONY 4. PL.A.`iT OR DIVISION 3. 54C.SEC.OR 6.00CL�.ATIO[,i EMPLOYEE NO. 7 DATE LAST E:C.A.�IIV,ATION S. REASON FOR PRESE..NT 1-N- -V(INATION ❑ PRE•PLACENIENT ❑ D.O.T. ❑ SL'RVEII.L4-XCE ❑ Il[�IIGR.ATiON © F.I.T. 9.TEMP. =PIULSE11. ESSURE 12.HE L].WEIGHT 14.TM. [US SYELLLYG � FT IN. t].VISION UNCORRECTED CORRECTED l6.COLOR YIS 0NNY (Use Code)• DISTANT RE 201 BOTH LE 20/ RE 20/ BOTH LE 2_a � 1VE.AR RE:a BOTH LE 201 RE 701 BOTH LE 20/ l7.PEMPHER,AL a Clinical Evaluadon Area Examined Use Code Remarks(Describe all"Code Is'In detail) 0 13. Head and neck g, 19. Thyroid ' ........... Lymph nodes --•------- ------------------ 20. Eye........................................................ E Fundi 21. Ears E x 22. Now and sinuses w 23; Mouth and throe U) IL 24. Teeth 23. Chest and lungs .................................. ............. Breast 26. Heart 27. Abdomen 28. Inguinal,e.g.,hernia 29. Genitalia Carte: 0--IYthin normal limits 1 —SigruEcandy abnormal X--Not examined NFPA MaoleN!umineQan Rarity If of 121 Z".CO r.dlart Packet Pg. 143 VVENUIX F FZGUM E-Z (Continue&) 30. Pelvis 3 L Anus and rectum ......................................................... Ptvstste --------- -------------------- Practoscopic 32. Spine 33. An . 34. Arms cm c ....................................................... D 35. Legs � -F�--------------------------- -_................ a 36. Petiphoul-Vascular 37. Neurologic 0 38. Emotional status 39. Other M x U) IL 40•urine dip: Glucose: Albumin: S.G.: Heme: Leukocyte-Ettetaa: Other. � ca 41.Flex 42.Step test 43.Body fat 44.Pam' 43,Audio 46.Chest x-ray(use 0. 1,or X 47.EKG(use 0. 1,or X)aad specify test aced 48. Hemccult 49. 8sck eval. 30.Tetanus 51.PPO SZ.5cress test 'Code.. 0--Within normal limits 1 —Significantly abnortnal X—Not examined MFPIi woocal esaminallon Font(I of t. ZGW Ed Packet Pg. 144 -..•�••-+•y •�-+�.•�% WN FOR FIRE DEP.iRTMErT PIfiSICONS FIGURE E,2 (Continued) 53.Other X-ray or laboratory findings cm - 54.Physician's summary,renwits,and diagnoses.including-recommendations made to patient (include code numbers for diagnoses and conditions found) 0 as as M x Us 53.Recommendadoms/Restrictions $6.R.N.signature ❑ 57.Physician's signature 0 13 38.Patient's signature 59. Work qualification;q 60.Contact person; 6l. Date: 62. initial: •Code: 0�-Within normal limits I --Sigruficantly abnormal X—Not examined MfVA Modreat tRwinsuom Farm 12 of I 200o Cotton Packet Pg. 145 C.6+X. FtGt'RB E•2 (Cantfnaed} Health History Yea No If"Yee,"Give Details. Have You Had Any Surgeries/Operations: Or your back,arm,leg,or knee? ❑ ❑ To treat a hernia? ❑ ❑ Vatican veins? Cl Cl Other operations? ❑ t.3 Have you ever bees,hospitalized? ❑ ❑ 0 Allergy--Have You Ever Had or Do You Currently Have: Serious allergy? ❑ ❑ Had teactivn to any medication? ❑ ❑ Advised not to take any medication (e.g..aspirin)? ❑ ❑ - Skin—Have You Ever Had or Da You Currently Have: 0 Hlveste mma or rash? ❑ ❑ Chronic skin problems(e.g.,cute slow to ❑ ❑ 2 heal)? � Excessive skin dryness? ❑ ❑ Aobleas with"easy bruising"? ❑ ❑ Chemfal or jewelry rash/settsitivity? ❑ ❑ Negro—Have You Ever Had or Do You Currently Have: A psychiatric or emotional problem? ❑ ❑ � Numbnesalweaimesalparalysis? ❑ ❑ �s \Dizziness or fainting spells? ❑ ❑ SaveWfmquent or migraine headaches? ❑ ❑ Head injury,concussion,or skull fracture? ❑ ❑ E Neurological disorders? ❑ ❑ Seizures or blackouts? Stroke? ❑ ❑ 0 Eyei/Ears—Have You Ever Had or Do You Currently Have: Hearing lass? Cl 11 Frequent ear infection? NI TA V441eal I!Umlmadam IFO-M{I of 12a 2CM Ertla Packet Pg. 146 C.6.e •--• •_• •_• •�rr�,tt t CKS,1.v11 I�FUIL�L\riO.%4 FOR ME OEV\ATMENT?II15iCLl%;S FIGLIM l✓•7 (Continurd.) Health History Yea No If "Yes,"Give Details. Ringing in ears? ❑ Cl Other ear problems? Cl ❑ Glaucoma or cataracts? ❑ ❑ Red eyes? ❑ ❑ Eye injury/vision lass? ❑ Cl Other eye problems(e.g..strain From 4"DT use)?❑ ❑ 0 cm - Glasses/contacts? ❑ ❑ Date of last vision screen? ❑ ❑ Head/Neck—liana You Ever Had or Do You Currently Have: Date of last dental exam: ❑ ❑ r Recent problems with teetb/dentures? ❑ Cl Frequent moult uketyinfections? ❑ ❑ 0 Sinus or hay fever? ❑ ❑ Frequent sore throats? ❑ ❑ Frequent nose bleeds? ❑ Cl Trouble with thyroid(e.g„taking thyroid ❑ ❑ medicadon)T Problem requiring radiation treatment to ❑ ❑ the neck area? Lungs--Have You Ever Had or K)c You Currently Have: Asthma or wheasing? ❑ ❑ @ U) Coughed up any blood? ❑ ❑ IL I. Sharman of breath without apparent reason? ❑ ❑ TB or a positive skin test for TB? ❑ ❑ Pneumonia or pleurisy? ❑ ❑ Do you cough every day,especially in ❑ the morning? Cl , . Pain or tightness in chest? ❑ ❑ Nfore than three episodes of bronchitis in ❑ ❑ one year? Ever smoked tobacco in any Form? ❑ ❑ How long: Yrs. Pzck.s per day:y: When quit: Had a chest x-ray? Cl ❑ Last time: NFP4 VedIcal Biarnlnarlar Fore If of 14 10M Editlan Packet Pg. 147 FIGURE E•x (Cantinmed.) Health History Yes No If"Yes,"Give Details. Heart—Have You Ever Had or Do You Currently Have: Rheumatic fever or hear murmur? Cl Cl Heart disease? ❑ ❑ Treated for heart condition? ❑ ❑ Unusually cold at bluisH-colored hands ❑ ❑ t3 at feet? cm High blood pressure,If"Yes,"how is it ❑ ❑ ❑ Mcclicine Q Diet 0 Exercise treated? Do you have a history of elevaced cholesterol? ❑ Anemia or any blood disease? ❑ ❑ > Phlebitis,varicose veins,or blood clots/ ❑ ❑. poor circulation? Chest pain with activiry7 ❑ Cl Gl—Nave You Ever Had or Do You Currently Have: Ulcers? ❑ ❑ 2 Hula!hernia? ❑ ❑ .0 Indigestion,P"or unusual burning in Vomiting of blood? ❑ ❑ Bloody/tarry bowel movements? ❑ ❑ M Colitis or nervous stomach? ❑ ❑ Yellow jaundice or hepatitis? ❑ ❑ 2 U) Problems with your pancreas? ❑ ❑ Gallbladder disease? ❑ ❑ Kldneys—Have You Ever Had or Do You Currently Have: E Bladder or kidney infections? ❑ ❑ Kidney stones? ❑ Cl Burning or discomfort on urination,or 0 frequent urination? Hernia? ❑ ❑ Blood in urine? ❑ ❑ WVA WOW rsaminallan rran(e of 2C00 Ei Packet Pg. 148 C.6.e _.••�•••�• ,• ,•�•�• ���WN kUK FIRE DEPARTMENT PHNStCLi.NS E71GLU E,2 (Condmwd) Health History Yes No If "Yes," Give Details. Mlscellaneaus—Have You Ever Had or 00 You Currently Have: Diabetes or sugar in your blood or urine? Cl ❑ Cancer of any kind? ❑ ❑ Mctscle-Skeletal--Havq You Ever Had or Do You Currently Have: � Arthritis,rheumatism.neck,back or spine injury or disease? ❑ ❑ Been treated for d back problem? ❑ ❑ M Recurrent stiffness or back pain? ❑ ❑ Bursitis,tendonids? ❑ ❑ > t3 Recurrent pulled muscles or sprains? ❑ ❑ a Hand or wrist injury or problem? ❑ ❑ Flip or knee injury or problem? ❑ ❑ Ankle or foot injury or problem? ❑ ❑ Frostbite? ❑ ❑ 2 Job requiring ltesrry lifting or standing,or sitting for tong periods of time? ❑ ❑ Any broken bones? ❑ ❑ For Females Only—Have You Ever Had or Do You Currently Have: (n Menstrual irregularities? ❑ ❑ Recurrent problems of the female organs? ❑ ❑ '@ Breast Massa or lumps? ❑ ❑ Do you practice monthly breast sell-exam? ❑ ❑ Have you ever had a mammogram? ❑ ❑ Date of lut pap smear. ❑ ❑ For Males Only—Have You Ever Had or Do You Currently Have: Pros rate or testicular problems? ❑ ❑ Breast tenderness, swelling.or lumps? ❑ ❑ E Do you practice monthly testicular selfexarn" ❑ Cl HPPIL Vgd1c&19"mirnulea Parrs tl of 13) 2=Ewtloe Packet Pg. 149 C.6.e * APPENDIX F FIGME&! (Ca1Nnusd:) Health History General Lifestyle 1. (Cbeek the rrarwer fhet bat describe you.) General health ❑ Poor J Fair ❑ Good 3 Etce Ucnt %Seatbelt use ] 0-24% ❑ 23-49% '❑ 50-74-5 O 11-100% Daily stress ❑ Low ❑ Moderate ❑ High Avenge hours sleep ❑ 5 hours or less ❑ 7-8 hours ❑ 8 hours or more Average meals daily a I meal O 2 meals O 3 or more Number of eggs per week O 0-1 ❑ 2 ❑ 3 or tr m Average number red steam meals per week ❑ 0—I O 2-3 ❑ 3 or more Avenge number of alcoholic beverages/beers ❑ 0--5 ❑ 6-14 ❑ 13 or more per week Yss Na— if"Yes,"Give Details. Do you exercise three times per week? ❑ ❑ 30-M minutes each Ursa? Identify types of exercise. ❑ ❑ Ara you more than 30%above your ideai � weight? ❑ ❑ Bare you received a oatanus booster in the last to years? ❑ ❑ Have you been im awdzaed against hepatitis B? ❑ ❑ Year immunised: Do you matte any presctlptioo meditation? ❑ ❑ Do you take uonprescripdan meditatiaq(Or over-the-counter drug)on a regular basis? ❑ ❑ CU General Lifestyle IL iu U) Do you participate In a workplace wellness/ ❑ ❑ help promotion program? CL Which of the following would you like to see oeered and would you pardcipate in? Cholesterol screen ❑ ❑ Blood pmssure scmen ❑ ❑ Weight loss ❑ ❑ +� C Nutrition program ❑ ❑ 0 Stress Management ❑ ❑ Smoking cessation ❑ ❑ CPR ❑ ❑ HFPA WOW duffilnedoo form(e at 1 20M EJR Packet Pg. 150 C.6.e _• •-• .�,vJ%r Lnc,VJtJkJ t ERS.%.ti0 INFOR LIMON FOR FIRE DEPAILTMENT PI tt5ICtUNS F ICURE E-g (Cendited.) Health History Yes No If"Yes,"Give Details. Stood drive ❑ ❑ Health risk appraisal ❑ ❑ Saif•directed etercise ❑ ❑ Health education program ❑ ❑ Women's health ❑ ❑ Work History I. Have you ever: Been restricted in your wont or given"light duty"because of your health or injury? ❑ ❑ Left ajob because of health problems? ❑ ❑ Been injured on the job and treated by a da>:sar? ❑ ❑ Received compeatadoe for an industrial injury or illness? El ❑ �s Are you receiving any health can treatment (e.g..physical therm .ddroptaatsc, acupuncture.medicl.etr.)? ❑ ❑ 0 Been hospitalized is the tau five years? ❑ ❑ Have you had any illness or injury that we have not asked you about? ❑ ❑ Work History q: M Do you have hobbies,such as furniture Term- Ishig,painting,hunting,shooting,or mode[ W building? ❑ ❑ U) Do you moonlight or have a second job? ❑ ❑ IL Work History ill. Exposures—Have You Ever Worked Around the Following: Chemical plans? ❑ ❑ Coke oven? ❑ ❑ Construction? ❑ Cl Cotton,flat,or hemp mill? ❑ Cl Electronics plant? ❑ ❑ Farm? ❑ ❑ Fuundry? ❑ ❑ MFPA Meplcal ttsaminatton Form to at III ZCGo Edillon Packet Pg. 151 C.6.e APPENDIX F 1582-45 FIGURE>:-� (Conzrnetd) Health History Yes No If"Yea," Give Details. Hazardous waste industry? ❑ Cl Hospital? ❑ ❑ Lumber nail? ❑ ❑ ❑ ❑ Ntesal production? � Mine? ❑ ❑ Nuclear industry? ❑ ❑ cm c Paper null? ❑ ❑ Phumaceutical? ❑ ❑ Plastic production? Cl Cl Pottery mill? ❑ ❑ a Refinery? ❑ ❑ Rubber processing plant? ❑ Cl Sand pit or quarry? ❑ ❑ Service station? ❑ ❑ Shipyard? ❑ ❑ .� Shelter? - ❑ ❑ Have You Ever Worked With or Been Exposed To: Aldrin? ❑ ❑ Am3enic? ❑ ❑ Asbestm? ❑ ❑ 2 U) ❑ ❑ �Ert;ene? Benzidine? ❑ ❑ Beryllium? ❑ ❑ BIS chlormethyl ether? ❑ Cl � Cadmium? ❑ ❑ Cuban disulfide? ❑ ❑ Carbon tetrachloride? ❑ ❑ E Chlorine? Cl ❑ Chlaradane? ❑ ❑ Chlorotarm? ❑ ❑ MFPA'A461cal I!mMIM4114n Form(Ia of U 2oca EatL-.. Packet Pg. 152 C.6.e ►J rtJK tIKk.t't1;HTERS,1..%O INFORAMON FOR FIRE DEP.IRT%tVg-r pm"SICLVWS FLGL'RE tsr4 (CQntinaetd.j Health History Yes No It"Yes," Glee Details. Chlomprene? ❑ ❑ Chromates? ❑ ❑ Chromic acid rnist? ❑ ❑ Cutting oils? ❑ ❑ DDT? A ❑ ❑ C Dieldrin? ❑ ❑ Dioxin? ❑ Dust.coal? ❑ ❑ Dust,sandblasting? ❑ ❑ Dust,other? ❑ ❑ _ Ethyl dibromide? ❑ ❑ Ethylene oxide? ❑ ❑ O Extreme treat or cold? ❑ ❑ Heptachlor? ❑ ❑ 2 Hexuhlorobenzene? ❑ ❑ tsocyranates CML MDO? ❑ ❑ Loud or continuous noise? Mettury7 ❑ ❑ Methylene chloride? ❑ ❑ Microwaves,lasers? (� ❑ @ Nickel? ❑ ❑ PC8s7 ❑ ❑ IL Pesticides,herbicides? ❑ ❑ Phenois? ❑ ❑ E Phosgene? ❑ ❑ Plastics? ❑ ❑ C Radioactive materials? ❑ ❑ 0 Roofing materials? ❑ ❑ Rubber? ❑ ❑ Silica? MFVA 8fwdIcW 9mmtnaden Prone 111 of 12) 2[?00 Edltlan Packet Pg. 153 C.ti.e `� l 582- FIGLME&2 (Con6tae4) Health History Yes No If"Yes,"Glv*Getalls. Solvents/degremera? ❑ ❑ Snots And tars? ❑ ❑ Spray painting? ❑ ❑ TRL(PER chloroethylene? Vinyl chloride? CM List any toxinslchamicaWbiological hazards you Aright currently be exposed to: C a Work History IV. Jobs—Start Vita ttts Most Recent: Dote(Your to Year) Compat;F Poddon Any Work Hazartb M U) IL i certify that the above infarmation is true an4 complete to the best of my knowledge.I hereby give permission to release work-[slated irrfotseation to the proper authoria of my employer or the company for which 1 am&job applicant. C 0 Date._ ca 5 ignaturc• Examiner. kfvA WedICW bsoMRatlan Mann 112 of 2000 Edha+n Packet Pg. 154 C.6.e r- ®"r~1a r i Search A cc Z Indez YES 1 lCanata Us IFAQB I OSHA r RSS Feeds Menu occupational [ th AdmiriMmdan We Can Help let! )d Tatie tents �s •Part r. 1910 •Part ® Occupational Safety and Health ar CD •Subpart 1 •Subpart Title, Personal ® OSHA Respirator Medical EvaluatimIre(Mandatory), Source:I GPO a Appendixc.19104M,OSHA Respirator Medical Evaluationu .oire da") To questions In 1,and to questionits Sedan 2 of Part AB do not reqwt a medicol e 0 To the emplafte: t3 Your employer roLat allowarciover this questionnaireat a dme and place that is awivedent to you.To ffmintaln Vow .2 confidertilality,your emplaW or wpervisor must rot Wit at or review your a employer must tell you how tD deliverq ire 0 w the health care prVessional who will review it .� Part A.5ecdon 1.( )The followinginfiormUm moust be provided by ev&y e of r ( point). L TOWS dole: 2.Your ea 3.Your a (to nearest year): @ 4.Sex(circle )e Mitleffemale QL 5.Your In. .Your weight-, lbs. Your job Ode. 8.A phom mimber where you can be reachedl re professional who r s quesbonnalre(IrdLde the Area Code)- 9.The $Unce to phone you at this nunber: i ,Has your emplaW t0d you how to contact the healtha professional who will review ft quesdamalre(Circle oney YemNo 11.Ched Me type of respirator (you can thed more than we cotegortv)- a. N,R@ or P dkspmble r (filter-mask ), b. Other tWe(for eample, If a 'air,self-ccraired breathingra ). 12<Have you worn a resiolrator(sir )a YeWNo If t (s); Part A,Sectlon 2.( a )Questlem 1 fivough 9 below mug be arswered by every employee who has been selected to um any type of resioirator °). Packet Pg. 155 C.6.e 1.Do you currently smoke tobacco,or have Vou srnoW tobacco in Ow laq rnmft Yes/No L Haw you ever had arri of the following coroditions? a.Seizures:Yes/No b.b (sqar ):Yes/No G Affergle reactions Out kerfere with your breathing;Yes/No d.Caustrophobta(fear of dosed-in ):VesMo I e.Trouble smell :Yes/No � t3 3.Have you ever had any of the Wowingor I 7 a. :Yes/No b. :Yes/No C.Chronic brwiddtis:Y No > d.Emphysema.YesMo e. Pneumonia,Y f.T s:ftllo 0 g.Silicads.Y U h.Rieurnotiwax(collapsed ):Yes/No 1.Lung imncer:Yer4No j.Bnftn ribs".Vtsft IL kw dwst Injuries or :YWNo t!5 1.Any other l its ftt.VWvt been toldabow.YeqNo cu .Do you currentlVany of the Following syrrquaw of pUmnary or t ? a.Shor"m of :Y No U) .2 b.Shoetriess o1 breath when walking 1 ground or waWng up a s4ft hin or i :YesMo IL c SImMess of breath when waUdng with other people at an ord1mry pace on love ground.,Y No .Have to stop for breath when watking at Mw own pace On level ground:Y jN* ca e.Rnvess of breath when washing or dressingf:Yes/No f.Shortness of breath t InterWas with pir job.Yes/No g,CmhIng that p (thick sputum):Yes/No h. t wakes you ea In the morning:YesiNo I.Coughing that occurs mostly when you are Mnq down:Yes/No I.cough1v up mom In the last month:Y k.Wheezing:Yes/No I.Wheezing that Merferes with :Yes/No m.Chest palri when you breathe .Y a I Packet Pg. 156 rL Any Mw sMtorrs that you think may be related to IwV problerns:YaVNo S.Have you ever hBd mW of the bKowim carftyascular or heart OMbleft? &Heart ab&-Yes/No 0.Stroke:Yes/No r-Angina:Yes/No d.Heart faikee:YWNO e.Swelling in Vw IM or feet(not caused by wakng).YeSINO f.Heart&&ihM(heart beating Irregularly):Yes/No C 0 g.High blood pressure:Yes/No CM L- M K Any other heart problem ftt yWve been Wd about YWNo C 6.fte you ew had any of the Wowing cardiovascular or heart symptoms? a.Frequent in or Ughbrim In your chest,Yes/No b. in or tightness In Vow dwst during physical activitf.Yes/No c.Pain or lightness In your chest that Interferes with your job.Yes/No C 4.In the past two yew,have you noticed your heart skipping or missing is beat-Yesitry No 0 e.Hearftm or IrdgeWon that is not related to ea".Yes/No .2 d.Any other sympWrns that you think may be related to heart or circulation proble":YeWNG 7.Do Vw currendy take medication for any of the following problems? a.Breathing or lung problems;Yes/No E E b.Heart trouble,YesMo E M r-Blood pressure:YoKo x W d.Seizures:YaMo '@ .2 U) B.If youve usda respiratu,have you ever had any of the following proMems?(if yopive newir used a resorator,ched the fdlovAV spee W go to question CL a.Er Irritation:YeWNo C 0 b.Skin allergles or rashes:Yes/No E C,Amiety:YeWNO d.General wealwww or%W:Yes/No C 0 e.Any Ww problem that MrWas with your use of a resoraton Yes/Na E 9.Would you like tD talk to the health care professional who Ml review ft questionnaire about Vour anowers to ft questionnaire:YWWo Questbons 10 to 15 below must be answered by every ernployee who has been selected to use either a full-Faceplece respirator or a self-00ftned breathing apparatus(SM).For ernpkr"who have been selected to we other types of respirators,answering these questions Is volureary. 10.Have you ever lost vision In either eye(temporarily or perrnaner*):VeWNo 11.Do Mi asrendy have any of the following vWm problems? a.Wear axbct Was:Yes/No b.Wear glazes:Yes/No Packet Pg. 157 c Color blind'.Yes/No d.Any other a"orb ' 9mblem:Yes/No 11 Kave you am had an kdury to your ears,WudWQ a broken ear drum.YNNo 13.Do you currently have any of the following hearing probkm? a.Difflaft hearing:Yes/No b.Wear a hearing aid:Yes/No c.Any other heating or car pralblem:Yes/No 14.Have you ever had a back Injury:Yes/No 15.Do m currenty have any of the Mming musculo"dal problem? M a.Weaknew In any of your arms,hands,legs,or feet Yes/No b.W On:YesM* > c.Dfffkxdty fully m&Ang your arms and legs:Yes/No d.Pain or stiffness.when M Wan forward or backward at the waist Yes/No e.Difficulty fully mwAng your head up or down,Yes/No 0 F.Urnity Uly moving your head side to side;YesiNo .2 g.131111way bending,at your knees:Yes/No h.Difficulty squatting to the ground-.Yes/No 1.Climbing a flight of stairs or a ladder carrying more than 25 lbs:Yes/No E E J.Any other musdq or skaietal"lam that interferes wilh using a respirator:Yes/No Part B Any of the following questions,and other quesdons not listed,my be aaled to the qm0onnatre at the dWeUon of the health care MWessional who will E M re-view ft%wWrinaire. x W 1.In your present job,are you working at Ugh Atudies(over 5,001)feet)or m a plm that has krwer than normal arno"of oxygen:Yes/No '@ .2 U) If Nm*do you have feelings of daness,shorMess of breath,pounding in your dvA or other syrnptoms when youre working under Ouse condillons: Yes(No IL 2.At work or at hoaw.have you ever been iardous alrborm chemKals(e.g.,gasm fumes,or dust},or have you corne Into a sldn contact with hazardous chemicals.YeVNo If W,'nme the ftmicals if ....................... ....... ................-—----- ............... ................ ................................ ............. ............ 3.Have you ever worked with any of the materials,or under any of the aDrdtions,fisted below: a.Asbestos:YesMo E b,So(e.g.,m.sandblasting):YWNo c.Tungstffftbalt(e.g.,grinding at weldng this material).Yes/No d."urn,YWRo a.Alurnintm Yes/No f.Coal(for eximple,mining):Yes/No Iron:Yes/No Packet Pg. 158 h.'rin:Yesfflo 1.Dtdw eftrornents:YW/NO J.Any QdW hnardOUS expoWeS'YeWNO IfW,1 describe these expowm,, .............................--—----——,--___- - .......................... ..................... ...................... .............. 4.Ustam second jobs or side businesses you have._ S.List your preinaus ............ ................................................ M U ....................... ........... .......... .............. C 0 6.Ust your currem and prewous hobbles:_, CM L_ D 7.Have you been In the milftry senvion?Yes/No C M If Nes,'were you eVosed to biological or chemical ager"(either A Wring or combat).YeVNO > 8,Have you ever worked an a KAZMAT teem?Yes/No 9.Odwr don medications for breathng aM lung problems,heart trouble,Uood preswe,and selzures menftmd earlier In this quesbonnake,are you taking 0 any other medications for any reason(including am dwmmler owdcadons),Yes/No C If lym'name the medications;if you know them:- 0 Ia.will you be using any of the follow ng losms with your respirator(s)? .2 'a a. HEPA Filters.Yes/No 0 2 b.Canstas(for eample,gas masks):YesJNo C.CartrOges.L Yesmo E E 11.How often are yw expected to use the respirator(s)(cirde*VW at'rW for all answers that apply to you)?, (n E a.Escape"(no reme):Yes/No Mx W b.Emergency rescue only,Yes/No '@ .2 U) c.Less than 5 hours par we&-Yes/No CL d.Less then 2 hours per day:YeQNo ,2 to 4 hours pu OW.Yes/No C 0 E f,Over 4 ham per day;YeqNo 12.During ft period you are using ft respirator(s),is your work effbet: a.Ught"dun 200 kcal per hour):Yes/No C 0 E tf rong does Ws period last during ft average s ....................................... Eamples of a light work effort are sitting while writing,typing,dra",or peftmaV light asseaftv work;or sUmfing while operating a drill press(13 tbs.)or conitrolling mactines. b.Moderate(20D to 350 kcal per how):Yes/No Ef W,'how"does thW Wod last during ft average shift. _mlns. Examples of moderate wo*aftrt are sitting while nailing or Ong;driving a truck or bus In urban traft smrdng while drilling,nallirg,parkrining assembly work,at bvd&rhV a modamte load(about 35 Pas.)at trunk le%vi;wallang on a Wid surface about 2 mph or down a 5-dWee grade about 3 mph;or pushing a whedbarrow with a leavy load(about 100 tbs.)an a level surface.c.Heavy(ab*wi 350 kcal per hour):Yes/No I Packet Pg. 159 If),es,O how long does this period last durini;"&m-a"shft:-hrs--m1n& E,iamptes of heavy work are lilting a heovy load(about SO lbs.)from it*now looxw waist or ShQuWw,woricing on a loadmi;docit.&am0g;standing wNle brkWaying or cwpping oserip;waimnii up an 8-degree grade about 2 mph,drnbing stairs with a t"load(about 50 lbs.). 11 Will you be wearing protective doMing and/or"Oprnent(odw than the respirator)when yWte Long YCW eeswator:YeSINO 11 describe des protective dothft arid/or eciulpment:- .......... 14.W111 you be woe4ng Linder hA cwditions(temperature exceeding.77 deq.F)®YeQNo IS.Will you be worldnq u*er humid coindidons:YWNo I&DemAba the work WI be doing while Wre using V=yespiratmis): ............ C ..... 0 ......-1-1-1.1.1--,.............................. ...... cm L- M 17.OesWbe any special or hazardous awididons you mot encounter when you're using yow respirabx(s)(for example,confined spaces,W."Veatening gaws).. C ........... M ..........-111............... 16.Pmmde ft following Irformboci,0 you Wow It For each boxic substaom that yodil be exposed to when VWre tZing Vour respirator(s): Name of the first tmc substance: Estimated ma-Amurn opmre Wei per shift: M Duration of exposure per shift, .................. C Name or tM secorid tDWc submance- 0 EWmated ma)dmum exposure level per shft-. buradon,of exposure per sWt. Name of Ow third bmde substame; Estiffiated inaAmum exposure taVal PC Shift' Durationof erpostme W Shift-,.,............................. ........................................................ ........... The name of"ouvr tordc uhnames dat you'll be eWmd to wNte Wrig your respirator: E E 19.Desoibe"sliecial responsibilides yoOl have while using ymr reVrator(s)that may affect Me safety and vyeU-beinii of otlers(for examitle,rescue, E M secrylly). x W 163 FR 1152, n®6,IM;63 FR 20M,April 23, 1999;76 FR 33607,Ue 6,2011;77 FR 4M9,Aug.7,20121 .2'@ U) CL 0 Next SWWWd(191fi L34 App D) 0 lattOnS(5MndaFdS 29 CFR,'-TWe of Contents C Freedom of information Act I hMcy&SftWtyStatwwnt I Disdaimiars I ImportantWeltSitallokes. I International iContactUs 'WeOmme,000311-OSRA(6742) 1 M C 0 WWOV.OW.VW E Packet Pg. 160 ffi�IRAWIICWRJU-SE P-HY-SICAL'----- NAME: AGE; 5EX: ............... HOME ADDRESS: ......... ............................ .......... ....... ............. TELEPHONE: OCCUPATION- ............ M 0 .2 E E E m x W []Follow-up Medical Evaluation Physical Required.(positive response-questions 1-8) '@ .2 U) C]Post-Offer Physical:Medical Evaluation.Physical Required CL C 0 E C 0 E Packet Pg. 161 C.6.e .,A �,., ,.� r, ,_ .rvFollow Medical PLHCIP Examination NAME Recommendations about employee use of the respirator.Umitations- Job Title: Date Of this Fallow Up A p: Reasons for follow up C r a �� �® _ �,,,, D ca „e ,® _. C ®, .m....,m„� Actions Need for follow,up evaluations- (as X U) „ .. C 0 Signed:9 m �,,.r ,,,,,,. . ..,. „. Date Signed copy of recommendation give to employee? ❑ yes ❑ no Date Given: Packet Pg. 162 RESPIRATOR USE PHYSICAL .............................................. . .... ....... ........... See Attached Job Description NAME- AGE- SEA; ..................... ............... ........................................................... 'TOME ADDRESS: TELEPHONE: OCCUII 0 . . .........- cm M ............ I I iifiiii r ffi T�s F"i ion ford wi ida Irai ri r ---------- ................-......... ........... ----------------- --.......... 0 ....... EXAMINATION ........................... .................... .2 HEIGHT: WEIGHT: ............ E E MURMERS, RATE. RHYTHM: ENLARGMENT: E M -.............. ---------------- ................ x W 1"W .2 V) PULMONARY FUNCTION WITHIN NORMAL LIMITS: OUTSIDE NORMAL LIMITS: (L .............. PA CHEST X-RAY."I WITHIN NORMAL LIMITS; OUTSIDE NORMAL LIMITS. E .......... -------------------- E ......................................................................I -..............-........ ............. ...I.......... ............................. .......-........................... .................. .......... ,................... It Is my opinion that the above named patient Is ....... or is not......................... medically qualified to wear a respirator In the performance of histher duties FVVIUAV-....................... I.-................ ........... Packet Pg. 163