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01/22/2020 Agreement a' ° t' Kevin Madok, CPA ' Clerk of the Circuit Court&Comptroller—Monroe County, Florida DATE: August 5, 2020 TO: Bryan Cook, Director Employee Services ATTN: Pamela Planar,Administrator Human Resources(c�(� FROM: Pamela G. Hancock)d&. SUBJECT: January 22" BOCC Meeting Attached is an electronic copy of die following item for your handling. C6 Contract with Advanced I Jrgent 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. - Should you have any questions please feel free to contact me at (305) 292-3550. cc: County Attorney Finance File KEY WEST MARATHON PLANTATION KEY PK/ROTH BUILDING 500 Whitehead Street 3117 Overseas Highway 88820 Overseas Highway 50 High Point Road Key West,Florida 33040 Marathon,Florida 33050 Plantation Key,Florida 33070 Plantation Key,Florida 33070 305-294-4641 305-289-6027 305-852-7145 305-852-7145 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(.2 pages) B. DOT Physical (9 pages) C. Respirator Physical (3 pages) D. Fire Fighter Physical (20 pages) 1 MONROE COUNTY CONTRACT FOR EMPLOYMENT PHYSICAL SERVICES THIS AGREEMENT ("Agreement") is made and entered into this 22ndday of January , 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. 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: 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, Fl 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. 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 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 fashion. 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 3 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. 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 6. CONTRACTOR'S ACCEPTANCE OF CONDITIONS A. CONTRACTOR hereby agrees that he has carefully examined the RFP, his response, and this Agreement and has made a determination that he/she has the personnel, equipment, and other requirements suitable to perform this work and assumes full responsibility therefore. The provisions of the Agreement shall control any inconsistent provisions contained in the specifications. All specifications have been read and carefully considered by CONTRACTOR, who understands the same and agrees to their sufficiency 4 for the work to be done. Under no circumstances, conditions, or situations shall this Agreement be more strongly construed against COUNTY than against CONTRACTOR. B. Any ambiguity or uncertainty in the specifications shall be interpreted and construed by COUNTY, and its decision shall be final and binding upon all parties. C. The passing, approval, and/or acceptance by COUNTY of any of the services furnished by CONTRACTOR shall not operate as a waiver by COUNTY of strict compliance with the terms of this Agreement, and specifications covering the services. D. CONTRACTOR agrees that County Administrator or his designated representatives may visit CONTRACTOR'S facility (ies) periodically to conduct random evaluations of services during CONTRACTOR'S normal business hours. E. CONTRACTOR has, and shall maintain throughout the term of this Agreement, appropriate licenses and approvals required to conduct its business, and that it will at all times conduct its business activities in a reputable manner. Proof of such licenses and approvals shall be submitted to COUNTY upon request. F. Pursuant to Florida Statute §119.0701, Contractor and its subcontractors shall comply with all public records laws of the State of Florida, specifically to: i. Keep and maintain public records that ordinarily and necessarily would be required by Monroe County in the performance of this Agreement. ii. Provide the public with access to public records on the same terms and conditions that Monroe County would provide the records and at a cost that does not exceed the cost provided in Florida Statutes, Chapter 119 or as otherwise provided by law. 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. IF THE CONTRACTOR HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE CONTRACTOR'S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS CONTRACT, CONTACT THE CUSTODIAN OF PUBLIC RECORDS, BRIAN BRADLEY, AT (305) 292-3470, bradley-brianmonroecounty-fl.gov, c/o Monroe County Attorney's Office, 1111 12th St., Suite 408, Key West FL 33040. 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 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. Section 11. EMPLOYEES SUBJECT TO COUNTY ORDINANCE NOS. 010 AND 020-1990 The CONTRACTOR warrants that it has not employed, retained or otherwise had act on its behalf any former County officer or employee subject to the prohibition of Section 2 of Ordinance No. 010-1990 or any County officer or employee in violation of Section 3 of Ordinance No. 020-1990. For breach or violation of this provision the COUNTY may, in its discretion, terminate this agreement without liability and may also, in its discretion, deduct from the agreement or purchase price, or otherwise recover the full amount of any fee, commission, 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 6 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. 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 7 Agreement. Section 20. NONDISCRIMINATION COUNTY and CONTRACTOR agree that there will be no discrimination against any person, and it is expressly understood that upon a determination by a court of competent jurisdiction that discrimination has occurred, this Agreement automatically terminates without any further action on the part of any party, effective the date of the court order. The parties agree to comply with all Federal and Florida statutes, and all local ordinances, as applicable, relating to nondiscrimination. These include but are not limited to: 1) Title VII of the Civil Rights Act of 1964 (PL 88-352) which prohibits discrimination in employment on the basis of race, color, national origin; 2)Title IX of the Education Amendment of 1972, as amended (20 USC ss. 1681-1683, and 1685-1686), which prohibits discrimination on the basis of sex; 3) Section 504 of the Rehabilitation Act of 1973, as amended (20 USC s. 794), which prohibits discrimination on the basis of handicaps: 4) The Age Discrimination Act of 1975, as amended (42 USC ss. 6101-6107) which prohibits discrimination on the basis of age; 5) The Drug Abuse Office and Treatment Act of 1972 (PL 29-255), as amended, relating to nondiscrimination on the basis of drug abuse; 6) The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (PL 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; 7) The Public Health Service Act of 1912, ss. 523 and 527 (42 USC ss. 690dd-3 and 290ee-3) as amended, relating to confidentiality of alcohol and drug abuse patient records; 8) Title VIII of the Civil Rights Act of 1968 (42 USC ss. 3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; 9) The Americans with Disabilities Act of 1990 (42 USC s. 1201), as may be amended from time to time, relating to nondiscrimination on the basis of disability; 10) Monroe County Code Chapter 13, Article VI, which prohibits discrimination on the basis of race, color, sex, religion, national origin, ancestry, sexual orientation, gender identity or expression, familial status or age; and 11) any other nondiscrimination provisions in any Federal or state statutes which may apply to the parties to, or the subject matter of, this Agreement. Section 21. COVENANT OF NO INTEREST COUNTY and CONTRACTOR covenant that neither presently has any interest, and shall not acquire any interest, which would conflict in any manner or degree with its performance under this Agreement, and that only interest of each is to perform and receive benefits as recited in this Agreement. Section 22. CODE OF ETHICS COUNTY agrees that officers and employees of the COUNTY recognize and will be required to comply with the standards of conduct for public officers and employees as delineated in Section 112.313, Florida Statutes, regarding, but not limited to, solicitation or acceptance of gifts; doing business.with one's agency; unauthorized compensation; misuse of public position, conflicting employment or contractual relationship; and disclosure or use of certain information. Section 23. NO SOLICITATION/PAYMENT The COUNTY and CONTRACTOR warrant that, in respect to itself, it has neither employed nor retained any company or person, other than a bona fide employee working solely for it, to solicit or secure this Agreement and that it has not paid or agreed to pay any person, company, corporation, individual, or firm, other than a bona fide employee working solely for it, any fee, commission, percentage, gift, or other consideration contingent upon or resulting from the award or making of this Agreement. For the breach or violation of the provision, the CONTRACTOR agrees that the COUNTY shall have the right to terminate this Agreement without liability and, at 8 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. 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 enforc&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 9 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 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: 10 • 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 Contractors 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 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. 11 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 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 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: $1,000,000/$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. 12 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. IN WITNESS WHEREOF, the parties hereto have caused these presents to be executed as of -.- indicated below. 1 1 BOARD OF COUNTY COMMISfiIONERI .,� WOK, CLERK OF MONROE C UNTY, FLORIDA; o ( / n By: G. By: — as Deputy Clerk eathe arruthers, Mayor ,c, o Date: BRUCE L. BOROS, MD, P.A. d/b/a ADVANCED URGENT CARE CENTER OF Witnesses: THE MIDDLE KEYS & KEY WEST a ,. By: By: -�< �. Print Name: Print Name: Bruce L BorosMO Title: Owner Date: 03/31/2020 BRUCE L. BOROS, MD, P.A. dlbla ADVANCED URGENT CARE CENTER OF Witnesses: THE UPPER KEYS ,{ VI 4'7 By: By: /i f< /-!. - Print Name: Print Na e: Bruce L Boros MO--' Title: Owner Date: 03/31/2020 APPROVED AS TO FORM MONROE COUNTY ATTORNEY'S OFFICE: ' Digitally signed by Cynthia L.Hall CalipI nthia ,WII,o=Monroe �a �,/ CO:N:cn COCCoµ Hall. ball- 13 R^1 tM1lapmonrcemunty-M1gov. Date'.d@00803 0B0..11.0<'00' SECTION ONE SCOPE OF SERVICES EMPLOYMENT PHYSICAL SERVICES The scope of services to be provided on an as needed basis by the Provider and may include, but not be limited to, the following. The forms to be reviewed and completed by the Contractor are attached to this agreement (Attachments A - C). All results will include: • Written interpretation of test results in common terms and written explanation of the significance of each abnormality or written explanation of those results which are outside the normal range. • Examining physician's written recommendation concerning future action on any condition considered outside the normal range. • Written recommendation of specific reasonable accommodations in accordance with the ADA. SERVICE FEE 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. 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 (Collection, Lab, MRO screen will be performed review) 5 panel by the physician and will $55.00 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 day, 7 days a week for collected by a moving violation or employersing an accident where a AUC provided Kit fatality occurs and returned to AUC Medical Review Officer Performs MRO review $N/A Included in Fee (MRO) REVIEW Dr. Neil for drug screens for Drug Screen J. Dash, Doctor;s Review performed by Advanced Service, 546 Franklin Urgent Care 14 Ave.. Massapequa, NY 11758 BLOOD ALCOHOL When requested, Blood (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 SN/A available 24 hours a day, 7 days a week for post accident, random and reasonable drug screen. BREATH ALCOHOL When requested, may be 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 facility's normal business hours A PPD-TB screen will be performed with the new hire Firefighter physical.. HEPATITIS A When requested, a Hepatitis $95.00 A inoculation will be scheduled and performed by the physician during the facility's normal business hours. HEPATITIS B When requested, a Hepatitis Series of 3 Total = B inoculation(s) will be $80.00 $240.00 scheduled and performed EA by the physician during the 15 facilities normal business hours. TYPHOID When requested, a Typhoid Priced on Demand 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- 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 (SEE ATTACHMENT scheduled and performed $55.00 "A"to be completed by by the physician during the employee and physician) facility's normal business hours. Includes exam and physician review of employee health history and job description. 16 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 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 physician review of employee health history and job description. Physician may also perform a urine drug screen if requested separately by Monroe County BOCC. Also required: EKG. Chest-X-ray, Spirometry, Hearing/A udiogram, Stress Test, PPD-TB screen 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 & II to be by the physician during the completed by employee facility's normal business and physician) hours. Includes exam and physician review of employee health history and job description. Physician may also perform a urine drug screen if requested separately by 17 Monroe County BOCC. Also required: Chest X-ray and S irometr . 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 there is an issue with the EKG or spirometry results. 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 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 from 1 of the tubes of blood drawn). Normally done in conjunction with Firefighter physical. LIPIDS Tests good cholesterol and $65.00 (CHOLESTEROL) bad cholesterol (one of the tubes of blood drawn) UA DIP Normally done in $10.00 conjunction with the DOT 18 physical. UA DIP WITH MICRO Normally done in $15.00 conjunction with the Firefighter physical URINE TESTING FOR $N/A NICOTINE USE 19 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." (Sign re) [ Date: 04/02/2020 STATE OF: 1 1 Ott CIQ COUNTY OF: (berg Oe- Subscribed and sworn to (or affirmed) before me on 4�21.20 (date) by ?OW,CZ COS (name of affiant). He/She is ersonally known o me or has produced (type of identification) as identification. NOTARY BLIC �n My Commission Expires: I ISO W :,C, .,. MELISSA PfltlIA ,y,�x MMM/part•SW�al Rwiaa • • if SSMIM-. I SS 0577SS 20 - SM ESSIM.Willi Nor SS.SWS •IaWEi!E`s IIsa W71at NON-COLLUSION AFFIDAVIT 1, Bruce Boros MD of the city of Key West, FL according to law on my oath, and under penalty of perjury, depose and say that 1. I am Bruce Boros MD of the firm of Bruce L. Boros,M.D., P.A. the bidder making the Proposal for the project described in the Request for Proposals for Monroe County and that I executed the said proposal with full authority to do so; 2. The prices in this bid have been arrived at independently without collusion, consultation, communication or agreement for the purpose of restricting competition,as to any matter relating to such prices with any other bidder or with any competitor; 3. Unless otherwise required by law, the prices which have been quoted in this bid have not been knowingly disclosed by the bidder and will not knowingly be disclosed by the bidder prior to bid opening, directly or indirectly, to any other bidder or to any competitor; and 4. No attempt has been made or will be made by the bidder to induce any other person, partnership or corporation to submit, or not to submit, a bid for the purpose of restricting competition;and 5. The statements contained in this affidavit are true and correct, and made with full knowledge that Monroe County relies upon the truth of the statements contained in this affidavit in awarding contracts for said project. p 4::::: (Signature) C Date: 04/02/2020 STATE OF: V IU(1da_ COUNTY OF: \ l tUCMvf Subscribed and sworn to(or affirmed) before me on `1\2120 n (date) by v].LUCQ (OS (name of affiant). He/She is ersonally known me or has produced (type of identification) as identification. NOTARY My Commission Expires: I ) I sO\20 •sitadhaahaillipaiilla21 t r:_ y� Men PIPMISau 1 Fade 10 CCal-IYn I GG Od5t I 1. lytNO.CE Ernes Nor 30.2020 I 4.A: —aro*Mail OWVY Mt I 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 nob contendere to, any violation of Chapter 893 (Florida Statutes) or of any controlled substance law of the United States or any state,for a violation occurring in the workplace no later than five (5)days after such conviction. 5. Imposes a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee's community, or any employee who is so convicted. 6. Makes a good faith effort to continue to maintain a drug-free workplace through implementation of this section. As the person authorized to sign the statement, I certify that this firm complies fully with the above requirements. (Signal re) G Date: 04/02/2020 STATE OF: o( 1 tkQ ry1�1 COUNTY OF: \ un(i Q +`1 r7 Subscribed and ]sworn to (or affirmed) before me on ``"11GI2C (date) by RUC€ 1 p(OS (name of affiant). He/She isGsonally known to me or has produced �� (type of identification) as identification. ( [�CF>�2LY'�T' NOTAR PUBLICq My Commission Expires: II 130I Nary I c. Pubk• eGate W r7orlio 65 -.It ill CoMIbMn•00 051765 7 M iare ON�n Ow p7MM 22 � fy4`a' MYOMn- IV'OMOMEYrnn. 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: 04/02/2020 STATE OF: 1 O(t o Q COUNTY OF: enCxiCOZ Subscribed and sworn to(or affirmed)before me on L42,120 (date) by 97ltACQ & D(OS (name of affiant). He/She is ite-rsonally knov>to me or has produced (type of identification) as identification. \C;5��J��`�"1'��''��J NOTARY UBLIC My Commission Expires: II 2-0 yELISSA PIETSUSZKA •y,�y,M.ry 1 Notry P MC Jame 01 Florida ',ram\ p Cal.abn a ae30.2 '. '! u Oa.,am NOVra.2020 k al a+ %IlelonsiIns,Mtn. 23 MONROE COUNTY, FLORIDA RISK MANAGEMENT POLICY AND PROCEDURES CONTRACT ADMINISTRATION MANUAL Indemnification and Hold Harmless For Other Contractors and Subcontractors The Contractor covenants and agrees to indemnify and hold harmless Monroe County Board of County Commissioners from any and all claims for bodily injury(including death), personal injury, and property damage (including property owned by Monroe County) and any other losses, damages, and expenses (including attorney's fees) which arise out of, in connection with, or by reason of services provided by the Contractor or any of its Subcontractor(s)in any tier,occasioned by negligence, errors, or other wrongful act of omission of the Contractor or its Subcontractors in any tier, their employees, or agents. In the event the completion of the project(to include the work of others) is delayed or suspended as a result of the Contractor's failure to purchase or maintain the required insurance, the Contractor shall indemnify the County from any and all increased expenses resulting from such delay. The first ten dollars ($10.00) of remuneration paid to the Contractor is for the indemnification provided for above. The extent of liability is in no way limited to, reduced, or lessened by the insurance requirements contained elsewhere within this agreement. 24 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. 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. 25 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: • Premises Operations • Products and Completed Operations • Blanket Contractual Liability • Personal Injury Liability • Professional Liability • Expanded Definition of Property Damage The minimum limits acceptable shall be: $300,000 Combined Single Limit(CSL) If split 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. 26 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. 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 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 $250,000 Aggregate The Monroe County Board of County Commissioners shall be named as Additional insured on general liability policy. 27 Attachment A MEDICAL RECORD REPORT OF MEDICAL EXAMINATION DATE OF EXAM 1.LAST NAME-FIRST NAME-MIDDLE 2.IDENTIFICATION NUMBER 3.GRADE AND COMPONENT OR POSITION 4.HOME ADDRESS(Number.street or RFD,city or town,state and ZIP Code) 5.EMERGENCY CONTACT(Name and address of contact) 6 DATE OF BIRTH 7.AGE 8.SEX 9.RELATIONSHIP OF CONTACT ❑FEMALE ❑MALE 10.PLACE OF BIRTH 11.RACE AMERICAN INDIAN/ HISPANIC HISPANIC ASIAN/PACIFIC ❑WHITE El BLACK ❑ ALASKA NATIVE ❑ WHITE ❑ BLACK ❑ ISLANDER 12a.AGENCY 12b.ORGANIZATION UNIT 13.TOTAL YEARS GOVERNMENT SERVICE a.MILITARY b.CIVILIAN 14.NAME OF EXAMINING FACILITY OR EXAMINER,AND ADDRESS 15.RATING OR SPECIALTY OF EXAMINER 16.PURPOSE OF EXAMINATION 17.CLINICAL EVALUATION MAC (Check each item in appropriate column,enter WE"if not evaluated) A MNLR- MAL_ (Check each item in appropriate column,enter WE"if not evaluated) AMR- A.HEAD.FACE,NECK AND SCALP O.PROSTATE(Over 40 or clinically indicated) B.EARS-GENERAL(INTERNAL CANALS) P.TESTICULAR (Auditory acuity under items 39 and 40) Q.ANUS AND RECTUM(Hemorrhoids,Fistulae)(Hemocult Results) C.DRUMS(Perforation) R.ENDOCRINE SYSTEM D.NOSE S.G-U SYSTEM E.SINUSES T.UPPER EXTREMITIES(Except feet)(Strength,range of motion) F.MOUTH AND THROAT U.FEET G.EYES-GENERAL(Visual acuity and refraction under items 28,29.and 36) V.LOWER EXTREMITIES(Except feet)(Strength,range of motion) H.OPHTHALMOSCOPIC W.SPINE,OTHER MUSCULOSKELETAL I.PUPILS(Equality and reaction) X.IDENTIFYING BODY MARKS,SCARS.TATTOOS J.OCULAR MOTILITY(Associated parallel movements nystagmus) Y.SKIN,LYMPHATICS K.LUNGS AND CHEST Z.NEUROLOGIC(Equilibrium tests under item 41) L.HEART(Thrust,size,rhythm,sounds) AA.PSYCHIATRIC(Specify any personality deviation) M.VASCULAR SYSTEM(Varicosities,etc.) BB.BREASTS N/A N.ABDOMEN AND VISCERA(Include hernia) CC.PELVIC(Females only) N/A NOTES:(Describe every abnormality in detail. Enter pertinent item number before each comment. Continue in item 42 and use additional sheets if necessary) 18.DENTAL(Place appropriate symbols,show in examples,above or below number of upper and lower teeth.) REMARKS AND ADDITIONAL DENTAL DEFECTS AND DISEASES 1 2 3 Restorable 1 2 3 Non- 1 2 3 Missing 1 2 3 Replaced 11 2 13 Fixed 32 31 30 Teeth 32 31 30 restorable 32 31 30 Teeth 32 31 30 by 32 31 30 Partial 0 I Teeth X X X X Dentures ( X l Dentures R L I 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 E G 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 F H T T 19.TEST RESULTS(Copies of results are preferred as attachments) A.URINALYSIS:(1)SPECIFIC GRAVITY B.CHEST X-RAY OR PPD(Place.date.film number and result) (2)URINE ALBUMIN (4)MICROSCOPIC (3)URINE SUGAR C.SYPHILIS SEROLOGY(Specify test used D.EKG E.BLOOD TYPE AND HR F.OTHER TESTS and results) FACTOR NSN 7540-00-634-6038 STANDARD FORM 88(Rev.1o•94)(EG) 88-126 Prescribed by GSA/ICMR FIRMR(41 CFR)201-9.202-1 Designed using Perform Pro.WHS/DIOR.Jan 97 NAME IDENTIFICATION NO.OF SHEETS ATTACHED MEASUREMENTS AND OTHER FINDINGS 20 HEIGHT 21.WEIGHT 22.COLOR HAIR 23 COLOR EYES 24.BUILD 25.TEMPERATURE SLENDER 0 MEDIUM ❑HEAVY DOBESE 26.BLOOD PRESSURE(Arm at heart level) 27.PULSE(Arm at heart level) A. SYS. B SYS. C. SYS. A.SITTING B.RECUMBENT C.STANDING(3mins.) D.AFTER EXERCISE E.2 MINS.AFTER SITTINGDIAS. RECUM- S5 MINS G BENT DIAS. DIAS. 28.DISTANT VISION 29.REFRACTION 30 NEAR VISION • RIGHT 20/ CORR.TO 20/ BY S. CX CORR.TO BY • LEFT 20/ CORR.TO 20/ BY S. CX CORR.TO BY 31.HETEROPHORIA(Specify distance) ESO EXO R.H. L.H. PRISM DIV. PRISM CT ONV. PC PD 32.ACCOMMODATION 33.COLOR VISION(Test used and result) 34.DEPTH PERCEPTION UNCORRECTED RIGHT LEFT (Test used and score) CORRECTED 35.FIELD OF VISION 36.NIGHT VISION(Test used and result) 37.RED LENS TEST 38.INTRAOCULAR TENSION RIGHT LEFT RIGHT LEFT 39.HEARING 40.AUDIOMETER 41.PSYCHOLOGICAL AND PSYCHOMOTOR(Tests used and score) RIGHT WN /15SV /15 250 500 1000 2000 3000 4000 6000 8000 256 512 1024 2048 2896 4096 6144 8192 LEFT WN /15SV /15 RIGHT LEFT 42.NOTES(Continued)AND SIGNIFICANT OR INTERVAL HISTORY (Use additional sheets if necessary) 43 SUMMARY OF DEFECTS AND DIAGNOSES(List diagnoses with item numbers) 44.RECOMMENDATIONS-FURTHER SPECIALIST EXAMINATIONS INDICATED(Specify) 45A.PHYSICAL PROFILE P U L H E S 46 EXAMINEE(Check) A U IS QUALIFIED FOR In accordance with attached job description. 45B PHYSICAL CATEGORY B 0 IS NOT QUALIFIED FOR 47.IF NOT QUALIFIED,LIST DISQUALIFYING DEFECTS BY ITEM NUMBER A B C E 48.TYPED OR PRINTED NAME OF PHYSICIAN SIGNATURE 49.TYPED OR PRINTED NAME OF PHYSICIAN SIGNATURE 50.TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN(Indicate which) SIGNATURE 51 TYPED OR PRINTED NAME OF REVIEWING OFFICER OR APPROVING AUTHORITY SIGNATURE STANDARD FORM 88 (REV 10-94) Attachment B Form MCSA-5875 OMB No.2126-0006 Expiration Date:11/30/2021 1. Public Burden Statement A Federal agency may not conduct or sponsor,and a person Is not requked to respond to,nor shall a person be subject to a penalty for failure to comply with a collection of Information subject to the requirements of the Paperwork Reduction Act unless that collection of Information displays a current valid 0MB Control Number,The OMB Control Number for this Information collection Is 2126-0006.Public reporting for this collection of Informal**la estimated to be approximately 25 minutes per response,hlQuding the time for reviewing Instructions,gathering the data needed,and completing and reviewing the collection of Information.All ® responses to this collection of Information are mandatory.Send comments regarding th6 burden estimate Sr any other aspect of this collection of Information,Including suggestions for reducing this burden to. information Collection Clearance Officer,Federal Motor Canter Safety Administration,MC-RRA.1200 New Jersey Avenue,SE,Washington,D.C.20590. U.S.Department of Transportation Medical Examination Report Form Federal Motor Carrier Safety Administration (for Commercial Drfver Medical Certification) r MEDICAL RECORD# SECTION 1.Driver Information(to be filled out by the driver) (or sticker) PERSONAL INFORMATION Last Name: First Name: Middle Initial: Date of Birth: Age: Street Address: City: State/Province: Zip Code: Driver's License Number: Issuing State/Province: Phone: Gender: OM 0 F E-mail(optional): CLP/CDL Applicant/Holder": 0 Yes 0 No Driver ID Verified By": Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years? 0 Yes 0 No 0 Not Sure 'UP/COL ApplicarNlstler,See kutwctlons for defletions, "Odser DVerMed By Record what type of photo ID warned to verify the Identity of the direr,e.g.,COI.drtrer's Ikense,passport. DRIVER HEALTH HISTORY Have you ever had surgery?If"yes,please list and explain below. 0 Yes 0 No 0 Not Sure Are you currently taking medications(prescription,over-the-counter,herbal remedies,diet supplements)? 0 Yes 0 No0 Not Sure If"yes:'please describe below. (Attach additional sheets if necessary) "This document contains sensitive information and is for official use only. Improper handling of this information could negatively affect Individuals. Handle and secure this information appropriately to prevent inadvertent disclosure by keeping the documents under the control of authorized persons. Properly dispose of this document when no longer required to be maintained by regulatory requirements" - Page 1 Form MCSA-5a75 OMB No.2126.0006 Expiration Date:11/30/2021 Last Name: First Name: DOS: Exam Date: DRIVER HEALTH HISTORY(continued) Not Not Do you have or have you aver had: Yes No Sure Yes No Sure 1.Head/brain injuries or illnesses(e.g.,concussion) 0 0 0 16.Dizziness,headaches,numbness,tingling,or memory 0 0 0 2.Seizures,epilepsy 0 0 Q loss 3.Eye problems(except glasses or contacts) Q Q Q 17.Unexplained weight loss 0 0 0 4.Ear and/or hearing problems Q Q Q 18.Stroke,mini-stroke(TIA),paralysis,or weakness 0 0 0 5.Heart disease,heart attack,bypass,or other heart Q Q Q 19.Missing or limited use of arm,hand,finger,leg,foot,toe 0 0 0 problems 20.Neck or back problems 0 0 0 6.Pacemaker,stents,implantable devices,or other heart 0 0 0 21.Bone,muscle,joint,or nerve problems Q 0 0 procedures 22.Blood clots or bleeding problems 0 0 0 7.High blood pressure Q Q Q 23.Cancer Q Q Q 8.High cholesterol 0 0 0 24.Chronic(long-term)infection or other chronic diseases 0 0 0 9.Chronic(long-term)cough,shortness of breath,or other 0 0 0 25.Sleep disorders,pauses in breathing while asleep, Q Q 0 breathing problems daytime sleepiness,loud snoring 10.Lung disease(e.g.,asthma) 0 0 0 26.Have you ever had a sleep test(e.g.,steep apnea)? 0 0 0 11.Kidney problems,kidney stones,or pain/problems with 0 0 0 27.Have you ever spent a night in the hospital? 0 0 0 urination 12.Stomach,liver,or digestive problems Q Q Q 28.Have you ever had a broken bone? 0 0 0 13.Diabetes or blood sugar problems 0 0 0 29.Have you ever used or do you now use tobacco? 0 0 0 30.Do you currently drink alcohol? 0 0 0 Insulin used 0 0 0 31.Have you used an illegal substance within the past two 0 0 0 14.Anxiety,depression,nervousness,other mental health O Q Q years? problems 32.Have you ever failed a drug test or been dependent on 0 0 0 15.Fainting or passing out Q Q Q an illegal substance? Other health condition(s)not described above: 0 Yes 0 No 0 Not Sure Did you answer"yes"to any of questions 1-32?If so,please comment further on those health conditions below. Q Yes 0 No 0 Not Sure (Attach additional sheets if necessary) CMV DRIVER'S SIGNATURE I certify that the above information is accurate and complete.I understand that inaccurate,false or missing information may invalidate the examination and my Medical Examiner's Certificate,that submission of fraudulent or intentionally false information is a violation of 49 CFR39035,and that submission of fraudulent or intentionally false information may subject me to civil or criminal penalties under 49 CFR 39Q.37 and 49 CFR 386 Appendices A and B. Driver's Signature: Date:_ SECTION 2.Examination Report(to be filled out by the medreai examiner) DRIVER HEALTH HISTORY REVIEW Review and discuss pertinent driver answers and any available medical records.Comment on the driver's responses to the`health history'questions that may affect the driver's safe operation of a commercial motor vehicle(CMV). (Attach additional sheets if necessary) Page 2 Form MCSA-51175 OMB No.2126-0006 Expiration Date:1 1/30/2021 Last Name: First Name: DOB: Exam Date: TESTING Pulse rate: Pulse rhythm regular:0 Yes 0 No Height: feet inches Weight: pounds Blood Pressure Systolic Diastolic Urinalysis Sp.Gr. Protein Blood Sugar Sitting Urinalysis is required. Second reading Numerical readings (optional) must be recorded. Other testing if indicated Protein,blood,or sugar in the urine may be an indication for further testing to rule out any underlying medical problem. Vision Hearing Standard is at least 20/40 acuity(Snellen)in each eye with or without correction.At Standard:Must first perceive whispered voice at not less than 5 feet OR average least 70°field of vision in horizontal meridian measured in each eye.The use of cor- hearing loss of less than or equal to 40dB,in better ear(with or without hearing aid). rective lenses should be noted on the Medical Examiner's Certificate. Acuity Uncorrected Corrected Horizontal Field of Vision Check if hearing aid used for test: ❑Right Ear ❑Left Ear ❑Neither Whisper Test Results Right Ear Left Ear Right Eye: 20/ 20/_ Right Eye: degrees Record distance(in feet)from driver at which a forced Left Eye: 20/ 20/ Left Eye: _degrees whispered voice can first be heard Both Eyes: 20/ 20/ Yes No OR Applicant can recognize and distinguish among traffic control 0 0 Audiometric Test Results signals and devices showing red,green,and amber colors Right Ear Left Ear Monocular vision 0 0 500 Hz 1000 Hz 2000 Hz 500 Hz 1000 Hz 2000 Hz Referred to ophthalmologist or optometrist? 0 0 Received documentation from ophthalmologist or optometrist? 0 0 Average(right): Average(left): PHYSICAL EXAMINATION 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 neglecting the condition could result in a more serious illness that might affect driving. Check the body systems for abnormalities. Body System Normal Abnormal Body System Normal Abnormal 1.General 0 0 8.Abdomen 0 0 2.Skin 0 0 9.Genito-urinary system including hernias 0 0 3.Eyes 0 0 10.Back/Spine 0 0 4.Ears 0 0 11.Extremities/joints 0 0 5.Mouth/throat 0 0 12.Neurological system including reflexes 0 0 6.Cardiovascular 0 0 13.Gait 0 0 7.Lungs/chest 0 0 14.Vascular system 0 0 Discuss any abnormal answers in detail in the space below and indicate whether it would affect the driver's ability to operate a CMV. Enter applicable item number before eoch comment. (Attach additional sheets if necessary) Page 3 Form MCSA-557S OMB No.2126-0006 Expiration Date:11/30/2021 Last Name: First Name: DOB: Exam Date: Please complete only one of the following(Federal or State)Medical Examiner Determination sections: MEDICAL EXAMINER DETERMINATION(Federal) Use this section for examinations performed in accordance with the Federal Motor Carrier Safety Regulations(42 CFR 391,41-391.49): Q Does not meet standards(specify reason): Q Meets standards in 49CFR 391.41;qualifies for 2-year certificate Q Meets standards,but periodic monitoring required(specify reason): Driver qualified for: 0 3 months 0 6 months 01 year 0 other(specify): ❑Wearing corrective lenses ❑Wearing hearing aid 0 Accompanied by a waiver/exemption(specify type): ❑Accompanied by a Skill Performance Evaluation(SPE)Certificate ❑Qualified by operation of 49 CFR 391164(Federal) ❑Driving within an exempt intracity zone(see 49CFR39142)(Federal) Determination pending(specify reason): ❑Return to medical exam office for follow-up on(must be 45 days or less): ❑Medical Examination Report amended(specify reason): (if amended)Medical Examiner's Signature: Date: ❑Incomplete examination(specify reason): If the driver meets the standards outlined In60l 1391A1,then complete a Medkal Examiner's Certificate as stated in 49CFR391.43(hL as appropriate. I have performed this evaluation for certification.I have personally reviewed all available records and recorded information pertaining to this evaluation, and attest that to the best of my knowledge,I believe it to be true and correct. Medical Examiner's Signature: Medical Examiner's Name(please print or type): Medical Examiner's Address: City: State: Zip Code: Medical Examiner's Telephone Number: Date Certificate Signed: Medical Examiner's State License,Certificate,or Registration Number: Issuing State: 0 MD 0 DO ❑Physician Assistant ❑Chiropractor ❑Advanced Practice Nurse ❑Other Practitioner(specify): National Registry Number: Medical Examiner's Certificate Expiration Date: Page 4 Form MCSA-5e75 OMB No.2126-0006 Expiration Date:11/30/2021 Last Name: First Name: DOB: Exam Date: MEDICAL EXAMINER DETERMINATION(State) Use this section for examinations performed in accordance with the Federal Motor Carrier Safety Regulations(42 CFR 391.41-391.49)with any applicable State variances(which will only be valid for intrastate operations). 0 Does not meet standards in 49 CFR 391.41 with any applicable State variances(specify reason): 0 Meets standards in 49 CFR 391.41 with any applicable State variances 0 Meets standards,but periodic monitoring required(specify reason): Driver qualified for: 0 3 months 0 6 months 0 1 year 0 other(specify): ❑Wearing corrective lenses ['Wearing hearing aid ❑Accompanied by a waiver/exemption(specify type): ❑Accompanied by a Skill Performance Evaluation(SPE)Certificate ❑Grandfathered from State requirements(State) If the driver meets the standards outlined In 49 CFR 391.1,with applicable State variances,then complete a Medical Examiner's Certificate,as appropriate. I have performed this evaluation for certification.I have personally reviewed all available records and recorded information pertaining to this evaluation, and attest that to the best of my knowledge,I believe it to be true and correct. Medical Examiner's Signature: Medical Examiner's Name(please print or type): Medical Examiner's Address: City: State: Zip Code: Medical Examiner's Telephone Number: Date Certificate Signed: Medical Examiner's State License,Certificate,or Registration Number: Issuing State: ❑MD ❑ DO ❑Physician Assistant ❑Chiropractor ❑Advanced Practice Nurse ❑Other Practitioner(specify): National Registry Number: Medical Examiner's Certificate Expiration Date: Page 5 InNe<tleat MCS6-S1175 Instructions for Completing the Medical Examination Report Form (MCSA-5875) I. Step-By-Step Instructions Driver: Section I: Driver information • Personal Information: Please complete this section using your name as written on your drivers license,your current address and phone number,your date of birth, age,gender,driver's license number and issuing state. o CLP/CDL Applicant/Holder: Check"yes" if you are a commercial learner's permit(CLP)or com- mercial driver's license(CDL)holder, or are applying for a CLP or CDL. CDL means a license issued by a State or the District of Columbia which authorizes the individual to operate a class of a commercial motor vehicle(CMV). A CMV that requires a CDL is one that: (1)has a gross combina- tion weight rating or gross combination weight of 26,001 pounds or more inclusive of a towed unit with a gross vehicle weight rating(GV WR)or gross vehicle weight(GV W) of more than 10,000 pounds; or(2)has a GVWR or GVW of 26,001 pounds or more; or(3) is designed to transport 16 or more passengers, including the driver; or(4) is used to transport either hazardous materials requiring hazardous materials placards on the vehicle or any quantity of a select agent or toxin. o Driver ID Verified By: The Medical Examiner/staff completes this item and notes the type of photo ID used to verify the driver's identity such as, commercial driver's license,driver's license, or passport, etc. o Question: Has your USDOT/FMCSA medical certificate ever been denied or issued for less than two years?Please check the correct box"yes"or"no" and if you aren't sure check the"not sure"box. Driver Health History: o Have you ever had surgery: Please check"yes" if you have ever had surgery and provide a written explanation of the details (type of surgery, date of surgery, etc.) o Are you currently taking medications(prescription, over-the-counter, herbal remedies, diet supplements): Please check"yes" if you are taking any diet supplements, herbal remedies, or prescription or over the counter medications. In the box below the question, indicate the name of the medication and the dosage. o #1-32: Please complete this section by checking the"yes"box to indicate that you have,or have ever had, the health condition listed or the"No"box if you have not. Check the"not sure"box if you are unsure. o Other Health Conditions not described above: If you have, or have had,any other health condi- tions not listed in the section above, check"Yes" and in the box provided and list those condition(s). o Any yes answers to questions#1-32 above: If you have answered"yes" to any of the questions in the Driver Health History section above,please explain your answers further in the box below the question. For example, if you answered"yes"to question#5 regarding heart disease,heart attack, bypass, or other heart problem, indicate which type of heart condition. If you checked"yes" to ques- tion#23 regarding cancer, indicate the type of cancer. Please add any information that will be helpful to the Medical Examiner. • CMV Driver Signature and Date: Please read the certification statement, sign and date it, indicating that the information you provided in Section I is accurate and complete. Page 6 NMuMlans MCS&-5$73 Medical Examiner: Section 2: Examination Report • Driver Health History Review: Review answers provided by the driver in the driver health history section and discuss any"yes" and"not sure"responses. In addition, be sure to compare the medication list to the health history responses ensuring that the medication list matches the medical conditions noted. Explore with the driver any answers that seem unclear. Record any information that the driver omitted.As the Medical Examiner conducting the driver's physical examination you are required to complete the entire medical examination even if you detect a medical condition that you consider disqualifying, such as deafness. Medical Examiners are expected to determine the driver's physical qualification for operating a commercial vehicle safely. Thus, if you find a disqualifying condition for which a driver may receive a Federal Motor Carrier Safety Administration medical exemption,please record that on the driver's Medical Examiner's Certificate, Form MCSA-5876, as well as on the Medical Examination Report Form, MCSA-5875. • Testing: c Pulse rate and rhythm, height, and weight: record these as indicated on the form. o Blood Pressure: record the blood pressure (systolic and diastolic) of the driver being examined. A second reading is optional and should be recorded if found to be necessary. o Urinalysis: record the numerical readings for the specific gravity, protein, blood and sugar. o Vision: The current vision standard is provided on the form.When other than the Snellen chart is used, give test results in Snellen-comparable values. When recording distance vision,use 20 feet as normal. Record the vision acuity results and indicate if the driver can recognize and distinguish among traffic control signals and devices showing red, green, and amber colors; has monocular vision; has been referred to an ophthalmologist or optometrist; and if documentation has been received from an ophthalmologist or optometrist. o Hearing: The current hearing standard is provided on the form. Hearing can be tested using either a whisper test or audiometric test. Record the test results in the corresponding section for the test used. • Physical Examination: Check the body systems for abnormalities and indicate normal or abnormal for each body system listed. Discuss any abnormal answers in detail in the space provided and indicate whether it would affect the driver's ability to safely operate a commercial motor vehicle. In this next section,you will be completing either the Federal or State determination, not both. • Medical Examiner Determination (Federal): Use this section for examinations performed in accordance with the FMCSRs(49 CFR 391.41-391.49). Complete the medical examiner determination section completely. When determining a driver's physical qualification, please note that English language proficiency(49 CFR part 391 I l: General qualifications of drivers) is not factored into that determination. o Does not meet standards: Select this option when a driver is determined to be not qualified and provide an explanation of why the driver does not meet the standards in 49 CFR 391.41. o Meets standards in 49 CFR 391.41; qualifies for 2-year certification: Select this option when a driver is determined to be qualified and will be issued a 2-year Medical Examiner's Certificate. Page 7 Instructions MCSa.5•15 o Meets standards,but periodic monitoring is required: Select this option when a driver is deter- mined to be qualified but needs periodic monitoring and provide an explanation of why periodic monitoring is required. Select the corresponding time frame that the driver is qualified and if select- ing other, specify the time frame. Determination that driver meets standards: Select all categories that apply to the driver's certification (e.g., wearing corrective lenses, accompanied by a waiver/exemption, driving within an exempt intracity zone, etc.). o Determination pending: Select this option when more information is needed to make a qualification decision and specify a date,on or before the 45 day expiration date, for the driver to return to the medical exam office for follow-up.This will allow for a delay of the qualification decision for as many as 45 days. If the disposition of the pending examination is not updated via the National Regis- try on or before the 45 day expiration date,FMCSA will notify the examining medical examiner and the driver in writing that the examination is no longer valid and that the driver is required to be re- examined. MER amended: A Medical Examination Report Form(MER),MCSA-5875,may only be amended while in determination pending status for situations where new information(e.g.,test results,etc.)has been received or there has been a change in the driver's medical status since the initial examination,but prior to a final qualification determination. Select this option when a Medic- al Examination Report Form,MCSA-5875,is being amended;provide the reason for the amendm- ent,sign and date. In addition, initial and date any changes made on the Medical Examination Report Form,MCSA-5875.A Medical Examination Report Form,MCSA-5875,cannot be amended after an examination has been in determination pending status for more than 45 days or after a final qualification determination has been made.The driver is required to obtain a new phys- ---ieal examination and a new Medical Examination Report Form,MCSA-5875,should be completed. o Incomplete examination: Select this when the physical examination is not completed for any reason(e.g., driver decides they do not want to continue with the examination and leaves) other than situations outlined under determination pending. o Medical Examiner information,signature and date: Provide your name, address, phone number, occupation, license, certificate, or registration number and issuing slate, national registry number, signature and date. o Medical Examiner's Certificate Expiration Date: Enter the date the driver's Medical Examiner's Certificate(MEC)expires. • Medical Examiner Determination(State): Use this section for examinations performed in accordance with the FMCSRs (49 CFR 391.41-391.49)with any applicable State variances (which will only be valid for intrastate operations). Complete the medical examiner determination section completely. o Does not meet standards in 49 CFR 391.41 with any applicable State variances: Select this option when a driver is determined to be not qualified and provide an explanation of why the driver does not meet the standards in 49 CFR 391.41 with any applicable State variances. o Meets standards in 49 CFR 391.41 with any applicable State variances: Select this option when a driver is determined to be qualified and will be issued a 2-year Medical Examiner's Certificate. o Meets standards,but periodic monitoring is required: Select this option when a driver is deter- mined to be qualified but needs periodic monitoring and provide an explanation of why periodic monitoring is required. Select the corresponding time frame that the driver is qualified and if select- ing other, specify the time frame. Determination that driver meets standards: Select all categories that apply to the driver's certification(e.g., wearing corrective lenses, accompanied by a waiver/exemption,etc.). Page 8 Instructions MCSa-SS7S • o Medical Examiner information, signature and date: Provide your name,address, phone number, occupation, license, certificate, or registration number and issuing state, national registry number, signature and date. o Medical Examiner's Certificate Expiration Date: Enter the date the driver's Medical Examiner's Certificate (MEC)expires. II. If updating an existing exam,you must resubmit the new exam results,via the Medical Examination Results Form,MCSA-5850, to the National Registry, and the most recent dated exam will take precedence. III. To obtain additional information regarding this form go to the Medical Program's page on the Federal Motor Carrier Safety Administration's website at btlpd/www.fmua.doLgvvhcgulat10ns/me4icV. Page 9 Attachment C RESPIRATOR USE PHYSICAL NAME: AGE SEX: HOME ADDRESS: TELEPHONE: OCCUPATION: i agree to the release of this Information for the State and Federal regulatory purposes to the extent provided by applicable laws DATE SIGNED EMPLOYER Follow-up Medical Evaluation Physical Required.(positive response•questions I.8) []Post•Offer Physical:Medical Evaluation.Physical Required PLHCP Follow UP Medical Examination NAME: Recommendations about employee use of the respirator:Limitations- Job Title: Date Of this Follow Up App: Reasons for follow up Actions Need for follow-up evaluations- Signed: Date Signed copy of recommendation give to employee? 0 yes 0 no Date Given RESPIRATOR USE PHYSICAL j See Attached Job Description NAME: AGE: SEX: HOME ADDRESS: TELEPHONE: OCCUPATION Tare*to the release of tiffs Information-fir State and Federal regulatory purposes DATE CARDIO-PULMONARY EXAMINATION HEIGHT: WEIGHT: HEART: MURMERS: RATE: RHYTHM: ENLARGMENT: LUNGS: PULMONARY FUNCTION WITHIN NORMAL UMITS: OUTSIDE NORMAL UMITS: PA CHEST X-RAY: 1 WITHIN NORMAL UMITS: OUTSIDE NORMAL LIMITS: RECCOMENDATIONS it is my opinion that the above named patient Is or is not medically qualified to wear a respirator In the performance of his/her duties PHYSICIAN Attachment D rrr /wNA a JJ FICC'RL Eel Farm far fire department physician's report. Physical Exam Summary Employer Employee's Namt: Pmitian Title: Date of Exam: Examining Physician: • Abnormal, Abnormal, Significant Changes Components Within Normal Able to Perform Unable to Perform Noted from Previous Performed Limits Job Tasks Job Tasks Exam(If applicable) ❑ Physical exam ❑ Audiogram ❑ Pulmonary function *Treadmill stress ❑'''"'''"EKGI2 lead ❑ Chat x-ray ❑ blanmmgram ❑ Pelda'ap ❑ Cabantory tests 4 Other Explanation of Abnormal Results/Significant Changes: • Medically cleared to perform job task3 ❑ Denied medical clearance for current job tasks NM ammo mint fummry Il el» 3000 Echelon VTGCRg get ICwsirrd.l H of PL: ►4Mn is a_ v.u.Pin Fighter Police Officer with the depattment.The outpost of this annual physical is to establish limas for the continuation of then duties.He/she ha enjoyed good health.NrdMn suiud the following questions: Medical History Surgical History Medications — D.N. _ Orthopedic — HTN _ ENT — CVD —Optilo — Asthma —Other Allergies Social History ROS • —Smoke GI — PPD —Hematochesia —Quit —Stool caliber —Pkyr —ban habits Bserclas — Alcohol O.U. - Amount —Stones — frequency —Henmuia CV —Chest psis —SOB Resp —Cough Wheezes —SOS PH Physical Audio —DAS lawn physical hem —HNC —KIN —Speech range -cvo Violas EKGIT MT Blood —Near —HA WH —Par —Toga WBC- -Corrected —Gntp Giu stow OB —Stage achieved NDC_ —Positive Pular RatiP- - Negative PVC Risk_ W I Prod— LFIk — Blood FED— SOOT_ — Protein Pted— SGPT_ — Glucose GOT Odor KM areal sow seww•ta lam a acW Earn FIGURE EP Medical examination report Pone. Medical Examination 1.NAME(Lull Ifin° (Middle) 12.SEX 2. DATE OF EXAMINATION 1. PLANT OR DIVISION �5.SOC.SEC.OR 6.OCCL7.20ION 7 DATE LAST EXAMINATION EMPLOYEE NO. S. REASON FOR PRESENT EXAMINATION ❑ PREPLACEMENT ❑ D.O.T. ❑ SLRVEILAYCE ❑ LVMIGRATION ❑ ELT. 9.TEMP. 10.PULSE 11.BLOOD PRESSURE 12.HEIGHT 13.WEIGHT 14.LITMUS SHELLD/G FT I.L 15.VISION UNCORRECTED CORRECTED 16 COLOR VISION (Use Code)• DISTANT RE 101 BOTH LE R:11 RE 20/ BOTH LE 10/ NEAR RE 201 BOTH LE 10/ RE 20/ BOTH LE 101 17.PERIPHERAL Clinical Evaluadoe Are Esamined •Usm Cade Ramada(Describe an"Cede le N detai) 1. IS. Head and neck 19. Thyroid Lymph nodes 2D Eyes Fund) 21. Ean 21 Noe and titian 22. Mauch and doom 24. Teeth 23. Chao and hmp Bread 26, Heart 17. Abdomen 25. InjuinaL e.g..hernia `19. Genitalia •Code: 0—Within normal limits I —Sila6candy abnormal X—Not named ion Meal eur•w«n..1+is in :ICI eanen APPC?UI4t ISn2. FIGURE 6.2 (Cs.itireed4 ]0. Pelvis ]l. Anus and rectum Prostate Pmctoscopic 32. Spine 33. Skin 34. Amu Hands . 33. Legs Fast 34. PWPMS•Vescula 37. Nestle& 3t Emotional status 39. Ode • 40.Urine dlp: Glucose Albuntim S.G.: Hatt Leukocyte-tense Oder. 41.Flex 42.Step test 43.Body fat 44.PFT , 43.Audio 46.dreg tiny(tax O.1.or X) 47.EKG(use O. I.or X)and specify tee used 4$.Henault 49. Back oval. 30.Tetanus St.FPO 52 Suess test •Code: 0—Within normal limits I —Significantly abnormal X—Not examined FM**al lamination rem Ord 121 2003 Scaler ...... _ -..'"Lyn Mt VIM OLS1RT>it]T PXISICLIV6 EIGL7tL LL (CeMinwdl 5i.Other a-ray or laborataty findings • K.Physician's Nmmary,RNYke.and diagnoses.including-recommendations made to parka (include coda numbers toe diagnoses and conditions]amid) !d.RecanrcndWadRcaa cdats 56.R.N.signature 0 57.Physician's signature o II.Padent's signaan 59. Work qualification: 60.Contact person: 61 Daze: 62.Initial: L •Code: 0—Widen ninon'limits I —Significantly abnormal X—Na examined aIM/WWI WNNM fern If of 221 2000 Lalean I3 2..3t Ftaxa E.2 (Gmdsurvt.i Health History Yes No If"Yes,"Give Details. Have You Had My Surgsrloa/Opantlons: On your back.as leg.or tame? 0 ❑ To treat a berms? 0 ❑ Urns.'veins? 0 ❑ Other potions? • 0 0 base you mar ken Immolated? 0 0 Allergy—Have You Ever Had or Do You Germanely Have. Serious allergy? 0 0 Bad racdae to any medieadoa? ❑ 0 Advised out to rah any medication Skin—Have You Ever Had or Do You Currently Haw: Havplecams or rash? 0 ❑ ark skis problems(e{,ems slow m 0 0 Mary? Esentive skin hymut 0 0 Problems olds'easy bruising" 0 0 Chemical arjewslry ruh/umidvity? ❑ ❑ Hoare—Have You Ever Had or Do You Currently Haw: A gyddauk ar mradana(problem? 0 0 NamMaalweaimeadywlye(a? ❑ ❑ 'Diadems or fainting spills? ❑ 0 Severslfayueet at minim headaches? ❑ ❑ Head Injury,ems:usdan,or skull fracture? ❑ ❑ Nnroladcd disorders? ❑ 0 • Seirns sr blackouts? 0 0 Smoke? ❑ ❑ Eyes/tars—Have You Ever Had at Da You Currently Have: Hearing loss? 0 0 Frequent tar infections? ❑ 0 NM Mogul iYwln,pn Pam(a et In 2000 Ellen _. ... ... rn.tIt aaa A.W IMtJIUTAnos FOR FIRE OEP AATHENT PI MICLW5 FEGCRt&t fCentrewd) Health History Yes No If"Yet,"Give Details. Ratline in eaa? 0 0 Other or problems? ❑ 0 Glaucoma or cataracts? 0 0 Red eyes? ❑ ❑ Eye injury/vision loss?. • 0 0 Odor eye ptabkms(e.g..strain from VOT ae7?in 0 Glasses/contacts? 0 0 Date of last vision rereen? 0 0 Head/Neck—Have You Ever Had or Do You Currently Have: Dam of last decal exam: 0 0 Recent problem with meth/dannns? 0 0 Frequent mouth ulaMnhcdons? 0 0 Sinus or hay lever? 0 0 Frequent sore thetas?s? 0 0 Frpmt nose bleeds? 0 0 Trouble with thyroid(e.g.,taking thyroid 0 0 mtliwdog7 Problet requiring radiation«earmet m 0 ❑ the neckoe/ Lunpa—Have You Ever Had or Do You Currently Have: Asthma a wMnly7 0 0 Coughed up any blood! 0 0 5hatmms of broth without apparent mason? ❑ ❑ TEars padl'w skin arst yea TB? ❑ 0 Pneumoda of pleurisy? 0 0 Do you cough every day.especially in 0 0 the moraine? Pain or tightness in chat? 0 0 More than three episoda of bronchitis in 0 0 one year/ Ever smoked tobacco in any form? 0 0 How tonr Yrs. Packs per day: When quit Had a chest x-ray? 0 0 Last time: Nu%%tier tewwnMu Peres n A in a0m Emits Hati- FiCL'RE CS (Cer,enwd.) Health Hletory Yee No II"Yes,"Give Details. Heart—Mn You Ever Had or Do You Currently Have: Rheumatic fever or Man murmur? 0 0 Heart disease? 0 0 Treated for heart condition? 0 0 Unusually cold or bluish eolond hands 0 0 of feet? ,High blood pressen.If Yes:how is it 0 0 '] Medicine O Dist Cl Esercise tinted? Do you have a history of elevated cholesterol? ❑ ❑ Anemia or any blood dierase? ❑ 0 Phlebitis,varicose veins.or blood clots/ 0 ❑. pa circulation? On pia with aetiviry? 0 0 GI—Have You Era Had or Do You Currently Have: Ulcers? ❑ ❑ Maul hanla? 0 0 indldertiam palm a unusual bunting In stomach? ❑ ❑ Vomiting of blood? 0 ❑ Bloody/tarry bowel movements? 0 0 Colitis or servals stomach? 0 0 Yellow lamdixabepadds? 0 ❑ •Problems with your pinatas? 0 0 Gallbladder disease? 0 0 lUdnays—Has You Ever Had or Do You Currently Have: Bladder or kidney infections? ❑ 0 Klan stones? 0 0 Bunting of discomfort on urination,of frequent urination? 0 0 Hernia? ❑ 0 B load in wine! 0 0 rm~es.aniwsee Pr II ef In scab Eddie ........._, •.. .. ..,..%1I N pail FIRE OEP.NTTIE(T?HYEICLANE FEGLRt Lt (Cauin ud) Health History We No If"Yes," Give Details. Miscellaneous—Have You Ever Had or Da You Currently Have: Diabetes or tutu in your blood or urine? 0 ❑ Cancer of any kind? 0 0 Muscle-Skeletal—Have You Ever Had or Do You Currently Have: Arthritis,rheumatism,neck.back.or spine injury or disease? ❑ 0 Boat treated for a back problem? 0 0 Remount stiffness or bock pairs? 0 0 Bursitis,tendonids? 0 0 Recurrent pulled muscles or nproins? 0 0 Hand or Mist injury or problem? 0 0 Hip or knnlryury or problem? 0 0 Ankle or foot injury or problem? 0 ❑ Frostbite? ❑ 0 lab remidkmsmp Wry tlfdae er tuadln8,or ❑ ❑ Any brokan bow? 0 0 For Females Only—Have You Evar Had or Do You Currently Nave•. Mammal inegdaddn? 0 0 Returns pobl m+of die female tapas? ❑ 0 Breast maw a lumps? 0 0 Do you practice monthly lout seV<nm? ❑ 0 Have you ern had a mammogram, 0 0 Date of tut pap smear. 0 0 For Males Only—Have You Ever Had or Do You Currently Have: Prostate or testicular problems? ❑ 0 Brent tenderness, swelling,or lumps? 0 0 Do you practice moodily esdnular eifenam? ❑ 0 urn v.s.r£Yne..au,F.. IF r IX Seep ammo • AITINDIR F 1382-2 FIGURE L4 (C.w .L) , • Health History General Lifestyle I. (case at mown OW bee eosnbs real Geed health O Poe 7 Fair 7 Good 7 EaceUent %Scatbellye O 0-24% O 23•19% O 10-7+% O 71-100% Deily sad 7 Low O Madams 0 Egli Avenge tours deep O 6 hewn or los O 7-1 hour O g haws at men Avenge meals daily 7 l meal O 2 meals 0 3 or more Nwnber of eggs per week O 0-1 O 2 O 3 or mare Avenge number red neat meals per week O 0-1 O 2-3 0 3 or mom Avenge mmbar of akohole beverages/beers O 0 5 O 6-14 O 13 ar man pa week ' Yes No- II"Yee,"Give Details. Do you eascin dices dmu per week? 0 0 30-40 data actt time? Idenify t a of samba 0 0 M yaroan for 30111 above yam idol ❑ . ❑ Namd ?yne veal a"Waal ban!:lee sb ❑ ❑ Ham you Wee immogead spdmbapsdds St ❑ ❑ Yam ienanI .n• Do you mks my puaodpdca madkatlom7 0 0 Do you take eonpresaiptios mdadoa((er ❑ ❑ orer•desar dam ter an a agar bum} General Lifestyle L Do youpwadpas to a workplace wellness/ ❑ 0 „help ptmmed oe program? Which of the MIcovI il would ma like to see offend wed would you peed.poee Iet .Choeas soi rase ❑ 0 Blood presseeusemen 0 0 Wet`w lay ❑ ❑ „ I Nuahloe program 0 ❑ Sous manapnent ❑ 0 • Smoking caution 0 0 CM ❑ ❑ MIN VMes 4wNmeen mww le IT 2000 Elton . _. ._..,,,.,"r,,.c nun t ERi AND INFORMATION FOR TIRE DEPARTMENT PI MICLe43 FIGL?R 14 fCeesaend/ Health History Yes Na ft"Yes,"Give Details. aloof drive 0 0 Health risk appraisal 0 0 Self-directed excels ❑ ❑ Health education program ❑ 0 Women's health 0 0 Work History I. Have you avec: Been restricted in net work or``tvn"light duty"because of your bealth or Injury? 0 0 Left a job because of health problems? 0 0 Ben injured oe the job and seabed by a doctor? ❑ ❑ Received compemados toe as Iaduauial Injury or'Unaa.? 0 0 Ate you mein**my health can treatment tMOW y acupuncture,medcel.slnri 0 0 Beenho.Nulnd la the tan five yeast 0 0 Han yes had any Mans or injury that we have oat asked you about? 0 ❑ Wort Minn L• Do you ben bobbin,mach as handcars ream inhiae.11�ndW.huadq,shoodag.or model ❑ ❑ �Do you mooaignoe hang second job? ❑ ❑ Work History It Exposures—Have You Ever Worked Around the FotWwing: Chemical plate? 0 0 Coke one 0 0 Consowdon? ❑ ❑ Conon,Fax,or hemp mill? 0 0 Electronics plant? ❑ 0 • Farm? ❑ ❑ Foundry? 0 0 MM Mahal earswemm Tamer tat acco EdNam • APPENDIX F 12a2—I3 FIGURE U2 IC mineed.) Health History Yes No II"Yes;Give Details. Hazardous waate industry? 0 0 Hospital? 0 0 Lumber auf i ❑ 0 Mara)production? 0 0 Mins? 0 0 ?Nuclear industry? 0 0 Papa mill? ❑ 0 Pharmueudcal? ❑ ❑ Plank production? 0 0 Pottery mill? 0 0 Pam? ❑ ❑ Rubber pros sing plant? ❑ 0 Sand pits Quarry? 0 0 Service aadoa? 0 0 Shipyard/ ❑ ❑ Smelter? ❑ ❑ Have You Ever Worked With or Ban Exposed Ter Aidrin? ❑ ❑ . Artesia ❑ ❑ Attetm? ❑ ❑ Aimee? 0 0 Beraidne? 0 0 Beryllium?. 0 0 813 chlamrethyl eta? 0 0 Cadmium? 0 0 Carbon disulfide? 0 0 Carbon tetrachloride? 0 0 Chlorine? 0 0 • Chloradam? 0 0 Chlorotann? 0 0 PIPE talcs tllwrnsse PION DO M In 20E0 eauan ,•cp. wcmc.na rut IKL IIUEITERa.t%0 INFORAMON FOR FIRE o EP.WTN ENT IW,10ENNE FIGURE 4E (C..eintd.) Health History Yes No B"Yes, Give Details. Chloroprene? 0 0 Chromata? 0 0 Chromic acid mist? 0 0 Cutting oils? 0 0 DDT? ❑ ❑ Oieldrin? 0 0 Dioxin? 0 0 Oust.cool? 0 0 Dust.sandblasting? 0 0 Dist other? 0 ❑ Ethyl dibtomide? ❑ 0 Ethylene oxide? 0 0 Eauema hater cold? ❑ ❑ Hquchldl ❑ ❑ Hnxaehlombetwm7 0 0 tsacysnam(TDL lOq? 0 0 Laud orcoodnuau noise? 0 0 Me g ❑ ❑ Methylene chloride? 0 0 Mtcrosew,lasers/ 0 0 Nickel? 0 0 b. PCBs? ❑ ❑ Pesticides,herbicidal 0 0 Phenols. ❑ ❑ Phosgen? 0 0 Radioactive materials? 0 0 Roofing materials? 0 0 Rubber? 0 0 Silieal 0 0 pen t al eumineMn eerie III at rn MOO Edison APPV OIR► ISae- mugs (Ceetinsei) Health History Yea Ho H"Yes,"GM NSW. Sol•entt/dryreMeret ❑ ❑ Scat ad tan? 0 0 Spay painting? 0 ❑ TRI/PER chktaethykr? 0 0 Vinyl chloride? 0 0 Cut any mxlas/chem(calwbiulogical hands you might currently be exposed to: Work History N. Jobe—Stitt rah the Moat Ramat Dab(Yen se Year) Coapasy redden My Week Bawds f entity that the eon Ldmmalaa Is cue=deomalem to dm best of my knowledge.(hereby sire permission to tense woak-relard information to the proper eudar(des of my employer or the company for which!am a Job appfcanc Dam Signature: • Eaamiotn /WM MMtY tualnelen rwln Its Msal eaoo!Mtge . I Search )1!1-V ti':`r C.1. 1_4`1T a to Pinder iEneswnal!Camas lb IMP I Amato/mu OSHA NewsklRr ASS Feed Menu Occupational Safety i1 Health Admb'straton We Can Help O RepuleuoM(Standard-29 CM)-Tilde d Contents •Part Number. 1910 •Part TIS: Occupational Safety and Health Standards •Subpar! •Subpar rt TWa: Personal Protective Equipment •Warlaard Number: 1910.04 Ape C •T1tie: OSHA Rookery;Medal EYaluaticn Questo ake(Mandatory). •GPO Source: e#R Appendix C b Sec.1910434:OSHA Respirator Medial Evaluation Questionnaire(Mandatory) To We employer:Answers b gsesdo s In Section 1,and to qunbon 9 n Sectlan 2 of Part A,do not requ re a medial nomination. To the employee: Your employer magt Now you to answer ties gsesoanake dare ramma voting hors,cc at a Imo and pad that Is mneNert to you.To malnedn your conadenbaaly,your employer or Ngeresor axe rot loot No-review your answers,and your employer mist WI you how b dower or send this questionnaire to the health are professional who wail review R Part A.Section 1.(Mandatory)The followed irapmaapm oust be moaned by every emplo/ee who has been selected in Ilse any type of respirator(please min°. 1.Tadals date: 2.Your name: 3.Your age(b nearest year): 4.Sex(neck ore):Mak/Femak S.Year height R. In 6.Your weight: Re. 7.Your job tee: 8.A phone amber where tau on be reacted by the health ore polessional who reviews Ws questaralre(Indale We Area Code): 9.The best tee to phone you at Ws limber: 10.Has cur employer told you how to contact the health care professional who wit review dos questiarelrt(circle me):Yes/No 11.Check the type of respirator you will use(you on dad more than are category): a._N,R,o-P disposable respirable(Nor-mash non-oditlge type Oey). b._Oder qpe(fen temple,half-or M-laceplece type,powered-air paiWlg,suPp eclair,sex-maaired breading spares). 12.Maw you woo respirator(Ode one):Yes(No II yes,'what type(s): Part A.Section 2.(Mandatory)C estae 1 arWgh 9 beim meat be arswered by every(Migx who has been seected b'Se any type of respratto(pease &de yes"or*not). 1.Do you currently smoke tobacco,a have you smoked tobacco In the last math:Yes/No 2 Maw hear had any of the following condition? a.Seizures:Yes/No b.Diabetes(sugar disease):Yes/No c Merck reactions that interfere with sour breaking:Yes/No tl.Oatatraplobu(fear ofdosedwh paces):Yes/No C.Tm b e Smebg odors:Yes/No 3.Nave You ter had any of the foibwlrg pulmonary or lung problems? a.Asbestosis:Yes/No b.Asthma:Yes/No c.Drone teondtds YWNo tl,Ernprylema:YesNo e.Pneumonia:Yes/No f.Ttternicas:Yes/No g.Slates:Yee/No h WMunbt orar(collapsed lug):YfyNo I.bang once:Yes/No J.Draken ribs:Yes/No k Any dkst Injures or sugerles:Yes/No I.Any titer lug problem that p ye been told about Yes/No 4.Do you arse/Sly have any of the fo4cw iq syanpoms of pulmonary a lug Igness? a,9mrinea of breath Yes/No b.Shortness of breath eaten walking fast on level ground or waling w a slight NI or Iodine:Yes/No c Shrines of breath when wedng with titer petple at an ordinary pace n level ground:Yes/No d.Nave to stop for breath when walking at you own pace n level Stand:Yes/No e.Shortness of breath when washing or dressing seurset:Yes/No 9'o g ss of breath'at Interfe6 with sot Job:Yes/No g.CowaNng that predicts phlegm(bah spoon):Yes/No h.Coughing that wakes you tarty In the momng:Yes/No 1.Cagtdng tat teats mostly when sea are tiring dater.Yes/No J.co glrg up blood in the last malt Yes/No k Wheezing:YeS/No I.YReeakg that merferes with sour Job:Yes/tlo m.Chest pen when sou breathe deeply Ye/No n.Mn other*teams that you dirk maybe tided to lurg protests:Yes/No 5.Have you ever had any of the following ardbvasaiar or heart problems? a.Heart Mmck:Yes/No b.Stroke:Yes/No c Angina:Yes/No d.Heart failure:Yes/No e.Swans in yaw kgs or feet(not caused by walling):Yes/No f.Heart arrtrydmda(heart beating kregSwty):Yes/Na g.High bacdpresstse:Yes/No h My other hest astern that ywhe been told about Yes/No 6.Nave you ever had any of the ldbwtng ar6avescSar at heart sbotatoins7 a.Frequent palm or tightness h your diet Yes/No b.Past or tightness In Icr lest during plat ai acditr YWNc c.Pain a*thew In yak chest that Interferes with your job:Yes/No d.In the past two yeas,have yw roaad your heart dipping a miseng a beat:Yes/No e.Heartburn or Irdgekdoo that Is not related to nag:Yes/NO d.My am symptoms that you dirk may be mad to head a OrOMdon protlen6:Yes/No 7.Do you army*„hs mediation for any of the Stowing problems? a.Brewing at lap problems:Yes/NO b.Heart bate:Yes/NO c Mood pease:Yes/No d.Sams:Yes/No 13.1f yahe used a narrator,ran you ever had any of the folavdrg problems?(If aim newt toed a n nthrator,rhea the blowing space and go to question 9:) a.Eye krlatbn:Yes/No b.Skin alergia or rashes:Yes/No C.Medery:Yes/NO C.-GensatwmJmessoSegue:YesINo e.Any Ohs weary 1Nt interferes with yar use of a respirator:Yes/No 9.Would mu Me to talk to Me heath are admiral who well resew eve weolbrra&e abed tour drawers to Ws paeCiaWlre:Yes/No Queen,ID to l5 below must be answered**ay empaee whet has been seieaed to me atr a attar alece resprator are seN-mntaaed breadth apparatus(Yds).For employees who have been selected to tse other hpa Of resp rabrs.answering Mesa quotas b watery. IS Haw you ever Ist ears to oar eye(IempoanN a per enemy):Yes/No II.too you osrrdy have any of the following can emblems? a.Wear=tact laws:Yes/Nc b Wear games:YesMo Color bard:Yei/No d.MyO w sw a vision poEWn:Yes/No 12.Nave you ever led an friary lo your ears,belittling a brim ear dnln:Yes/No 13 Do you omeMty have mot the foaming heating problems? a Delany hearing:Yes/No b.Wears hewing aid Yes/No A My sdher bearing or ear problem:Yes/No 14.Nave you mu had a bark*Jury:Ye/No 15.Do You aareaty hen any of the Nam Ing mis0Joskeletal problem? a.Weab,s in wry diem arms,hands k¢,a feet Yes/No b.flack path:Ya/No c OtfladN Aly mere your win and legs:Ye/No d.Pain or smear when you lean forward or badevard at to waist Yes/No e.Moab My meng ma head to or dawn:Yes/No t DAWN hay mating your head side to side:Yes/No g.Ddda*y bendng at your Imes:Yes/No h.DYfia/ty naDg t the ground:YeINo I.Climbing a fight al Mks or a ladder orrytrg mere than 25Ibs:Yes/No J.My other musda of delete problem Net Medea with mire a resprda:Yes/Ho Part efurry title fdb,Wg Resod,and other ghesterd not kg*may be added to to questionnaire a the discretion of the Math ore prahfdmel who wet teem to guastlawee. 1.In War preset Jog are you wading at No albedeaNM;SOW feet)or in a plan that has lower than normal amavas Walborn YeyNo HIM"do ma hoe(ratings of driblets shortness of breath,paadrq in yow dent a other symptom when were woddre weer these tmdtcld: Ya/No 2.At war*a at Net have you ever been beoed lo hazardous sdvents,Mtardaa airborne thence,(e.g.,gases, an or Mt),a bee you home IntO sten mtad with h aardoo demlob:Yes/No If reme the demlo6 if yw New ten:___._... i teals WttnNriuryed wah any of the aaralab,a under any of the oddade,aged below: a Asbestos Yes/No t 5ao(e.g.,naStlastngh Yes/No t Tungsten/cobalt Care.,rein or waking des material):Yea/No d fletybem Ye/No e.A*naum Yes/No C Coal be tam*,Ming):Yes/No g.Iron YWNo h.Th Yes/No L Dusty emeaenanb:YeWfeo j.Amy ohe Warden exasures:Yes/No Nes.'describe these erpaares:__.._ e.Iktany stood lobs a fide 4&Mses pi have. 5.Ust war rem o s oawa crd: &lM sow current and piteous hobbles: 7.Haw kw been I be nary sran?VaMa If'yes,'were yvu aimed b bldogrul or chemical sera Leber a training or eanbal).Yes/No 8.Kra you mer waked on a 14.A114AT team?Yea/No 9.Other man medba a far traaddn9 and KM wobleMS,heart trouble blood pressure,and seawes'neatened earlier In this pu5SlionWre,are mu bang arry other medolb8 kn my mason(edldeg ores braawter mMOYom):Yes/NO nee"name be meditations N you Mow bah: 10.Will you be Wig eery or the follow ng Nen with your rasprawr(s)? a. HEIM ypters:Yes/No b.paean I! e'mele,gas mean Yes/No c Carvid9es:Yes/No II.How Men are you evened b use the respirator(s)(drat'yes'or Ysd'for e1 answers that awry toyour: a Hope osy(ro rescue):Ye/No b.Emeryensy rescue crib Yes/No c las ben Shari per week:Yes/No d.Ins ben 2 tan per day:Yes/No e.2 to awes per day Vu/NO E Over 4 tans per day:Yes/No l2.Dube de period you are st g de respreb(s),Is Ram work emit a.USN Ilea than 200 kcal pa how):Yes/No It Yes:Ins long does On pried last drag the enrage are hes. a s. eampleo of a Npmwod effort era awry wide wdWe,typing.drObq,a petkrma Nphl assembly work;or starchy wide opemdng a did Press(1 3 bs.)or beolhq machnes. b.Modena(200 b 3501aal per how):Yet/NO If'yes;sew long dam be period last OWN be range INC In. arts. Safla of moderate work Mort art attirg whir min)or fang;dndeg a trio*or bus In urban trek;stamina wide dr aeg,nary,performing assembly wan or irrdetrvsg a modeate load(oboe 35 bs)at trunk esel;wane on a lba Mans;bosh 2 mph or downs 5-degree grade On 3 mph;or pusNrq a wheWarraw Mass a Nay mad(about 100 to.)on a lest aerate.c.Heald Naha 350 kW pr kw):Yes/No If Nes,"leer king don tits pried lest shying the retype slit trs. Jars. besides of heavy waken I%ng a heavy load(about SO It.)Gem the Boa a your rage or shoulder,wattle co a bailing dud:shoats*startling wipe Oddgeg or dsppig cringe we0k9 W an B deda 6rede abed 2 marl climbing stairs Mu .heavy load(about 50I126.). 13.Will you be weadrg psotadht dated aedWa easement Corer than the settler)when Writ wag your tesarakr:Yes)No Ii ws.desolbe et protege doting ardor equipment: 1e.We you be wading veer hot conditions(tampenbre emadng 77 deg.F):YeslNo IS.WO you be waked urger limed ccS ad:Yes/No 16.Dealhe We work woyl be doing wink you're using yea respeaer(s): 17.Dnosbe any tedt or hnardous=din you made en comet Men Voice 8019 Pa(espiabor(s)(fa eomae.conked Spars,Bfe-pveabnng gawk 18.Fronde the!Slowly kdmMbco,it you taw It,far each lode sttstance that you'll be exposed a when you're Wag vow respkaosr(s): Name of the NM bow substance: Eder!madmure a essre keel per shift Nation of Wove pie shift Name of the served kick sublessee: Bdfmaled medrnum measure lest per stilt Nation of tempi'per shift Name of the gird tote pbsbra: Bbmaled mldmun emosure level per silt: Duration of immure pie daft: Ikenmo.tweeter ndc phtbros tlW ywS be emmed a white using sow raarab: 19.Macsibe anyspear responsmiliges sty have wale using mar resybasa(s)that may affect the safety and wea•bekg as veers(fa enmae,rescue, seaway): (63 FR 1167,Jan.8,19911;63 FR 20098,Apt 23, I998:76 FR 33607,June 8,1011:77 FR 469e9,Aug.7,30121 O Net SOMN(tea 134 Alp 0) O Mwbums(SWtS•M OR;•Tale a[agents Freedom of Information Act a Macy&Secsty Sidemen I Declaimers I Important Web Se Nikes I InternaaaW I Codas Us b5 peprmen of Late I Opglpe,el SUM 6 PtaabWSN.auon I l%eemmuab,A.. fed,Warwebw Q Mille TNeame'e0e311O51a(6741)I fly rw..OAw.gn A ® DATE IM W MIDYYYT) CERTIFICATE OF LIABILITY INSURANCE 07/27/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policylies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemen(s). PRODUCER CONTACT NAME: Mary Storti PHONE(NC (g17)266-6850 FAX do Paychex Insurance Agency.Inc. E-MAILNo,Exe. _. ._ lac,Nog E ADDRESS: bscerts a chex.com 150 Sawgrass Drive ADDaass: P @P Y _ Rochester, NY 14620 INSURER(S)AFFORDING COVERAGE NAIC/ INSURER A: American Zurich Insurance Company _ 40142 INSURED INSURER B: Paychex Business Solutions.LLC AIL Emp:Brace L Boros MD PA 911 PanoramaaTrail South INSURER C:___ Rochester.NY 14525 INSURER D' _ INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:20FL0951018022 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTRINSD SWND I MMIDDPEFF MMIODPOUCVEXP LIMITS TYPE OF INSURANCE POLICY NUMBER IIMMNO/YYYYIIMMNDIYYYYI COMMERCIAL GENERAL LIABILITY , EACH OCCURRENCE S " DAMAGE TO RENTED - CLAIMS-MADE I I OCCUR i pREM19EB LE a occurrence) $ _.._. MED EXP(Any one person) $_. _. . • • PERSONAL BADV INJURY 1I$ GEN'L ILANW IIHdT AGGREGATE LIMIT APPLIES PER IEK ,Vr GENERAL AGGREGATE $ -__-.'VOLT;4- JEECT— -_ LOC BY PRODUCTS-COMPIOP AGG $ i OTHER �•Y! 7/27/2020 $ _ AUTOMOBILELIABIIITY DATE yy COMBINEDEaacident) 51NGLE LIMB $ ANY AUTO w,.Ma T�Yael.. BODILY INJURY(Per person) $ OVMED I I SCHEDULED I INJURY AUTOS BODILY INJURY(Per accident) S AUTOSONLY HIRED [I NON VNY PROPERTY DAMAGE $ AUTOS ONLY • AUTOS ONLY (Per scoi6len1) _ 1a UMBRELLA LIPS OCCUR EACH OCCURRENCE I $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ I DEC RETENTIONS I S WORKERS COMPENSATION X PER [ER I AND EMPLOYERS'LIABILITY STATUTEf r ANYPROPRETORIPARTNERJExECUTIVE TIN EL EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED', IN NIA WC 12-68-329-00 06/01/2020 06/01/2021 - (MandatoryfnNH) E L DISEASE•EA EMPLOYEE $ 1,000.000 If yes describe under DESCRIPTION OF OPERATIONS below . EL DISEASE-POLICY LIMIT $ 1,000,000 Location Coverage Period: 06/01/2020 06/01/2021 Client# 20003287-FL DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,AddXlonal 0.emar s Schedule,may be attached II more space I.required) Coverage is provided for Bruce L Boros MD PA only hose co-employees 1709 Atlantic Blvd of,out not subcontractors KEY WEST,FL 33040 to CERTIFICATE HOLDER CANCELLATION Monroe County BOCC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1111 12th Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Suite 408 ACCORDANCE WITH THE POLICY PROVISIONS, Key West,FL 33040 AUTHORIZED REPRESENTATIVE IQuJAIP ©1988-2015 ACORD CORPORATION. All rights reserved. /� OP ID:NF a►`Oao CERTIFICATE OF LIABILITY INSURANCE RATE oT, ' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHOR® REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDDIONAL INSURED,the pollsy(Ies)must be endorsed N SUBROGATION IS WANED,subteen to the Wes and conditions of the policy,certain policies may require an erldoremneol. A statement of this certificate does not confer rights to the certificate holder In lieu of such ender/emends). PRODUCER 305.294A877 CONTACT The Fullers,Inc 305-294 3025 PROM FAX 1432 Kennedy Drive - .`1`. - .—.. Key West,FL 3304E P"• 001C°L _BOROBRi _ Norman Fuller C93n.esVA o. POURER- _ T/1 1 -- -_ Dr.Bruce L Bros FeA:First Community Inlelmeece y InauCo. 1388E 1709 Atlantic Blvd. wNene: Key West FL 3301E Mw MRc: S OURER O: INSURER!: wmelF; COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAW BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTI RESPECT TO WHIN This CERTIFICATE MAY BE ISSUED OR MAY PERTMN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN WY HAVE BEEN REDUCED BY PAm GLARES. MM'i �' DR ' SOUCY EFP ' ROLLa lilE - LTN TYPE OP MBMNCE POUCY mum mimonril dNOMrt51 URNS GENERAL IJAMLITY EACH OCCURRENCE 5 2,000,DO0 A CoaEERCIAL GENERAL Lyman* X 0S 0005815582400 06IS620 OBNS121 'wMDF TO RENTID . .. r premsEs LFavvX�o1 3• ._ CLAMS-WOE IXI occult mED EXP(Ay meco l ,5 5,000 X Business Owners PERSONAL A.rn AWRY 5 2,000,000 GENERAL AGGREGATE s 4.000.000 G2NL AGGREGATE LMIrPWIIES PER. PRGDULTS.CORNiIGG .s 2,0(0,00E X POLICY PisnfO{ LOC _•S _. _AumMOesaluaun eereraa IBKNMI I31T couMNEDselraeuer s Re ANYNEO OOBI EeDJ All OWNED BY EQOLY INAMY;Per won) S. REDLY INJURY(Ps mJW) s SCHEDULED Amos • .HMEDnUT09 WAN. 4 PROPERTY sM E[ I $ 5 UMBRELLA UM OCCUR AS LO LIU only EACH OCCURRENCE s FACERS Les CLAIMS-MOE AGGREGATE .3 —... DEDUCTIBLE _ .5 RETENTION 3 ' I WORKERS COMPENSATION VC STAY,- Om.I MIND EMPLOYERS.UART' YIN ANY RSICPNARTERhIlCIITVE E.L.EACH ACCIDENT 3 OFFC EXCLUDED? ERMEMNEA EXCLED? n N/A — ILWnenM SKI I EL DISEASE-EA EMPLOYEE!5 xye{eoeew. _.__ . - -_—__ DEPTENOF OPERATIONS Wow LL INSEAM-BouCY LNn I SGIU s DIESCIUSTION OF LfMATCNS I LOCATIONS'VEICE=(ROHE ACME 101.AMMpM Roods edfSN we ORM IS UReey Doctere 00ka. Cardllcsts Molter hi an addldonal Insured as par form Ilimin-o..,I.L,.L,. CERTIFICATE HOLDER CANCELLATION MONBOCC SHOUDNR OF DE ABOVE DESCRY FCUCWIEECANCELLEDEWORE Monroe Courtly BOCC 11E EIPMATMN DATE THEREOF, NOTICE S LL BE DELABED IN ACCORDANCE WTI V.POLICY PROVISIONS. Risk Management 1100 Simonton St AMMONIUM Key West,FL 33040 Norman Fuller 4� .1 CORPORATION. Al dying naesnd. ACORD 20(200IN0a) The ACORD name and logo an regisel.ad marksof D POLICY NUMBER: BBOP 99.371.0909 Bankers Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This erdorsement modifies insurance provided under the following: BUSINESSOWNERS LIABILITY COVERAGE FORM SCHEDULE* IName Of Person Or Organization: 'Information required to complete this Schedule.if not shown on this endorsement.will be shown in the Declare- Sons. The following is added to Paragraph C. Who Is An Insured: 4. Any person(s) or organization(s) shown in the Schedule is also an additional insured, bul only with respect to(lability for'bodily injury", 'properly damage cc 'personal and advertising injury' caused In 'Mole or in pan, by your acts or omis- sions or the acts cc omissions of those acting on your behalf in the performance of your ongoing operations or in connection with your premises owned or rented by you. BBOP 99.371.0909 0 ISO Properties,Inc.. 2001 Page 1 of 1 O 2011 Edson MONROE COUNTY,FLORIDA REQUEST FOR WAIVER OF INSURANCE REQUIREMENTS It is requested Mai the insurance requirements,as specified in the County's Schedule of Insurance Requirements,be waived or modified on the following contract. Contncror/Vendor Bruce L Boros MD PA d/b/a Advanced Urgent Care Project or Service: Employment Physical Services ContnnwNcndor Address&.Phone 4: 1980 N. Roosevelt Blvd, Key West, FL 33040 (305) 294-0011 General Scope of Work: Provide occupational health physical and testing services for Monroe County employees. Reason far Waiver or Our current policy limits are not consistent with the default Modification: requirements of the County however they are adequate for the acuity and risk of the contracted services to be provided which is lower than the general medical services our business renders to the public. Policies Waiver or Modification will apply to: Healthcare Providers RRG HP-18130064-01, claims made coverage. 250.000 Per claim/750,000 aggregate _ Signet=oiConl clor/Veldor: _ Dale: 9/it agolg Approved Not Approved Risk Management Signature; �r /1 Q Dine: 1� io'I County Administrator appeal: Approved: Not Approved: Board of County Commissioners appeal: Approved: Not Approved: Meeting Date Adminionditc Insination 7500.7 IN ACORD® CERTIFICATE OF LIABILITY INSURANCE DATE Tmo zozom THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. ' IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAAEACT Kathy O'Neil Cunningham Group PHONE •EMI. (708)697-6417 - — FAX -- _ 7234 W. North Ave-Suite 101 ADDRESS: ADDRESS'. k(708)69 -I6417 INSURER/SI AFFORDING COVERAGE _ RAC tl Elmwood Park IL 60707 INsuRERA: Healthcare Professional Risk Retention Group _ INSURED INSURERB: _ Bruce L Boros MD PA dba Advanced Urgent Care: INSURERo: dba Advanced Urgent Care of the Middle Keys and Key West; INSURER D: dba Adwanced Urgent Care Center of Upper Keys INSURER 1709 Atlantic Blvd., Key West FL 33040 INSURER F: COVERAGES CERTIFICATE NUMBER: 410 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INsR TYPEOFIHBUMXGE ADDL SUER POLICY EFF POLICY EXP ---- - -- LM INSD WVD POLICY NUMBER (MM/DDIYYYI'I IMMIDDIYYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE ',5 DAMAGE TO RENTED - CLAIMS-MADE OCCUR PREMISES(Ea occurrence) 15 MED _ Yone O I 5 INAGGREGATE PERSONAL&ADV INJURY $ GE 'L AGGRE GATE LIMIT APPLIES PER'. li GENERAL AGGREGATE S POLICY PR0. JECT LOG PRODVQ$-COMPrOP AGO 5 AUTOMOBILE APPROVED RISK LIABILITYs COMBINED SINGLE LIMIT accident) ANY AUTO BODILY INJURY Per pawn) ' OWNED SCHEDULED 04-96-2020 BODILY INJURY(Per accoclen0`s _--- AUTOS ONLY AUTOS HIRED HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY '. (Per accident) $ $ UMBRELLA LIA9 OCCUR EACH OCCURRENCE• S EXCESS LIAB CLAIMS-MADE AGGREGATE _ _ $ _ DED RETENTIONS $ ,WORKERS COMPENSATION PER OTH- I AND EMPLOYERS'LIABILITY YIN STATUTE ER ANYPROPRIETOWPARTNENEXECUTIVE ELEACH ACCIDENT $ OFFICER/MEMBEREXCLUDED7 NIA _ Mandatory in NHl E L.DISEASE-EA EMPLOYEE $ f y describe under — -- - DESCRIPTIONOFOPERATIONSbelow EL.DISEASE-POLICY LIMIT $ A Medical Professional LiabIlity i HP-18130064-02 08/30/2019 08/30/2020 Per Clalim $250,000 Claims Made Coverage Annual Aggregate $750,000 • DESCRIPTION OFOPERAI1ONS ILocAnoNS I VEHICLES ACORD 101,Additional Remarks Schedule,may be attached II more space Is required) Specialty: Urgent Care/Cardiology/Diagnostic Imaging-No Surgery Additional Covered Locations: 100460 Overseas Hwy,Key Largo FL 33037 13365 Overseas Hwy..Ste 102,Marathon FL 33050 3704 North Roosevelt Blvd, Key West FL 33040 See attached additional insured endorsement for the schedule of providers CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Monroe County Board of County Commissioners ACCORDANCE WITH THE POLICY PROVISIONS. 500 Whitehead St. AUTHORIZED REPRESENTATIVE Key West FL 33040 Kathy O'Neil O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Named Insured: Bruce Boros, MD, PA dba Advanced Urgent Care Policy#: HP-18130064-02 Endorsement 17 Endorsement Effective Date:4/3/2020 This endorsement changes the policy. Please read it carefully. Additional Insured Roster Endorsement It is hereby understood and agreed,subject to the terms and conditions of this policy,the following are an Additional Insured but only with respects to the NAMED INSURED professional activities on a shared limit basis. Name Specialty Limits Retroactive Date Bruce L. Boros, MD Physician Shared 8/30/2013 Kris M. Bly, DO Physician Shared 8/30/2013 Donald L. Dixon, MD Physician Shared 8/30/2013 David A Erlandson, MD Physician Shared 8/30/2013 Steven L Lawyer, DO Physician Shared 5/8/2018 Zivko Z.Gajic, MD Physician Shared 8/14/2017 Kimberly [Jones, MD Physician Shared 6/2/2017 .Cynthia L.Johnston, MD Physician Shared 6/25/2018 Pedro Ramos, PA PA Shared 7/19/2018 Steven Tersheshee, PA PA Shared 6/20/2018 Darlene Fischer, PA PA Shared 6/26/2018 Cindy Logue,ARNP ARNP Shared 3/22/2018 David Campbell-O'Dell,ARNP ARNP Shared 2/28/2018 Steven C. Eccher, MD Physician Shared 9/21/2017 Jennifer Clay,ARNP ARNP Shared 8/30/2015 Kathy O'Connell, NP NP Shared 10/1/2015 Melissa Kerrick,ARNP ARNP Shared 3/15/2019 David Anthou, PA-C PA-C Shared 9/16/2018 Silvia Peters, PA PA Shared 12/31/2018 Joseph T. Morelli, DO Physician Shared 1/8/2019 Dorothy Denise Doane, C-FNP C-FNP Shared 1/14/2019 Jennifer Lynn Angelilli,ARNP ARNP Shared 1/20/2019 Kevin Holcombe, MD Emergency Shared 1/30/2019 Medicine Rebecca Baur, PA PA Shared 10/1/2018 Sheila Debow,ARNP ARNP Shared 4/1/2019 Bart Gershenbaum, DO Emergency Shared 8/1/2019 Medicine Dhanmatee Lynn Chatoo, NP Nurse Shared 12/13/2019 Practitioner 1 e.zlmax a Profession)Ru4 Peten,mn Group.Inc an.eeroenr Ale 052418 Named Insured: Bruce Boros, MD, PA dba Advanced Urgent Care Policy it: HP-18130064-02 Thomas Morrison, MD Emergency Shared 1/15/2020 Medicine Laura Berni, NP Nurse Shared 1/14/2020 Practitioner Manuel Miguelez, PA Physician Shared 3/2/2020 Assistant John P. O'Connor Physician Shared 4/2/2020 All other terms,conditions, exclusions and endorsements of this policy remain the same. 9Poktw, James T. Farrell, DO President 2 Healthcare Professionalsk Retention Group,mc. indorsement Ais Rsx41s