Item C21 BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: March 19. 2014 Division: Employee Services
Bulk Item: Yes X No _ Department: Human Resources
Staff Contact Person/Phone#: Pam Pumar X4459
AGENDA ITEM WORDING: Approval to amend contract with Key West Urgent Care, Inc. to _
provide employment physical services.
ITEM BACKGROUND: On April 20, 2014, this contract will expire. Key West Urgent Care has
agreed to continue to provide the services as in the current contract at no increase in fees.
PREVIOUS RELEVANT BOCC ACTION: The BOCC approved the original contract on April 20,
2011.
CONTRACT/AGREEMENT CHANGES: Section 4: The contract is amended to provide that the
term of the contract will be automatically renewed unless one party terminates the agreement. Section
7: The contract is amended to provide that either party can terminate without cause, on sixty(60) days'
notice to the other party. Section 8: The contract is amended to include new language required by
Florida Statutes section 119.0801(2)regarding public records.
STAFF RECOMMENDATIONS: Approval
TOTAL COST: approx. $1 100 yr INDIRECT COST: BUDGETED: Yes X No
DIFFERENTIAL OF LOCAL PREFERENCE:
COST TO COUNTY: anprox. $1 100 yr SOURCE OF FUNDS: Ad Valorem
REVENUE PRODUCING: Yes— No X AMOUNT PER MONTH Year
APPROVED BY: County Atty �JMB/Purlaasing Risk Management
DOCUMENTATION: Included X Not Required
DISPOSITION: AGENDA ITEM#
Revised 7/09
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
CONTRACT SUMMARY
Contract#
Contract with:Key West Urgent Care Effective Date: March 19, 2014
Expiration Date:
Contract Purpose/Description: First Amendment to renew contract and add Florida Statute
requirement regarding public records.
Contract Manager: Pam Pumar 4459 Human Resources
(Name) (Ext.) (Department)
for BOCC meeting on March 19,2014 Agenda Deadline: March 4, 2014
CONTRACT COSTS
Total Dollar Value of Contract: Approx$1,100 Current Year Portion: $150.00
yr
Budgeted? Yes X No_ Account Codes: 001-06500-510-316-
Grant: $ _ - _ -
County Match: $
ADDITIONAL COSTS
Estimated Ongoing Costs: $ /yr For:
(Not included in dollar value above) (eg.maintenance,utilities, janitorial,salaries,etc.)
CONTRACT REVIEW
Changes Date Out
ate In/, Needed� eviewer
Division Director `1 Yes❑No 9 --al �-
Risk Management a Yes❑NoRl 01
O.M.B./Purchasing " Yes❑No❑ � �w - -�
County Attorney f Yes[:]No n C
Comments:
OMB Form Revised 9/11/95 MCP#2
FIRST AMENDMENT TO CONTRACT
FOR EMPLOYMENT PHYSICAL SERVICES
This is an amendment ("Amendment") dated March 19, 2014 is entered into by
and between Monroe County ("County") and Key West Urgent Care, Inc. ("Contractor").
WHEREAS, the County and Contractor entered into a Contract for Employment
Physical Services ("Agreement") on April 20, 2011, whereby Key West Urgent Care, Inc.
agreed to furnish employment physical services; and
WHEREAS, the current contract expires on April 20, 2014 and the County
continues to need the services listed in the Agreement; and
WHEREAS, in accordance with Florida Statutes 119.0701(2) provides that "each
public agency contract for services must include a provision that requires the contractor
to comply with public records law"; and
NOW THEREFORE, in consideration of the mutual covenants contained herein
the parties agree to amend Sections 4, 7 and 8 of the Agreement is revised to read as
follows:
1. Paragraph 4.1 of the Agreement is revised to read as follows:
Following the expiration of the initial term and any subsequent terms listed in
paragraph 4.2, this Agreement shall automatically renew for successive one-year
terms unless and until either party gives the other notice of cancellations in
accordance with the terms set forth in paragraph 7 below.
2. Section 7, CONTRACT TERMINATION, in the Agreement is revised to read as
follows:
Either party may terminate this Agreement because of failure of the other party to
perform its obligations under the Agreement. Either party may also terminate this
Agreement without cause, on sixty (60) days' written notice to the other party in
accordance with Section 9 of this Agreement. The COUNTY shall pay contractor
for all work performed through the date of termination.
3. A new paragraph (F) is added to Section 8 of the Agreement (CONTRACTOR'S
ACCEPTANCE OF CONDITIONS), as follows:
F. Pursuant to Florida Statutes 119.0701, Contractor and its subcontractors shall
comply with all public records laws of the State of Florida, specifically to:
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.
4. All other terms and conditions of the Agreement remain in full force and effect.
IN WITNESS WHEREOF, the parties hereto have caused this Amendment to be
executed the day and year first above written.
(SEAL) Board of County Commissioners
Attest: Amy Heavilin, Clerk of Monroe County
Deputy Clerk Mayor/Chairman
(CORPORATE SEAL) Key West Urgent Care, Inc.
Attest:
By J014 e Ta
Print Name
Title_ VWi7Er- U MONROE COUN"FY ATTORNEY
AP LOVED AS TOVOR
NTHIA L. BALL
ASSISTANT COUNTY ATTORNEY
Date f p �-
u
MONROE COUNTY
CONTRACT FOR
EMPLOYMENT PHYSICAL SERVICES
THIS AGREEMENT("Agreement")is made and entered into this 20th day of April,2011,by
MONROE COUNTY("COUNTY"),a political subdivision of the State of Florida,whose address
is 1100 Simonton Street,Key West, Florida 33040 and KEY WEST URGENT CARE.INC.
("CONTRACTOR"),whose address is 1501 Government Road,Key West:FL 33040
Section 1. SCOPE OF SERVICES
CONTRACTOR shall do,perform and carry out in a professional and proper manner certain
duties as described in the Scope of Services—Section One—which is attached hereto and
made a part of this agreement.
CONTRACTOR shall provide the scope of services in Section One for COUNTY.
CONTRACTOR warrants that it is authorized by law to engage in the performance of the
activities herein described,subject to the terms and conditions set forth in these Agreement
documents. The CONTRACTOR shall at all times exercise independent,professional judgment
and shall assume professional responsibility for the services to be provided. Contractor shall
provide services using the following standards,as a minimum requirement:
A. The CONTRACTOR shall maintain adequate staffing levels to provide the
services required under the Agreement.
B. The contractor is responsible for obtaining proper releases from the
employee or prospective employee in order to discuss the results with
Monroe County BOCC.
C. The contractor will provide the required services at the location of:
Key West Urgent Care,Inc.
1501 Government Road
Key West, FL 33040
Phone: 305-295-7550
Fax: 305-296-3010
D. The Contractor will have an employee designated as coordinator or
facilitator to assist in the communications with the Monroe County BOCC's
primary contact personnel.
E. Appointments will be available throughout the business hours of the facility:
Monday—Friday 8:00 a.m.—3:30 p.m. Walk-ins will also be accepted
if an appointment cannot be reasonably scheduled.
F. Appointments will be seen by the contractor in a reasonable and timely
fashion.
G. The Contractor will provide the County with at least a 24—48 hour
turnaround time for the receipt of any results.
H. 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
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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).
I• 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.
J. All personnel engaged in performing services under this Agreement shall be fully
qualified, and, if required, to be authorized or permitted under State and local law
to perform such services.
Section 2. QUALIFICATIONS NECESSARY OF CONTRACTOR
The CONTRACTOR must certify at least annually that all staff members, independent
contractors, subcontracted work, if any, all service providers it uses, engages or manages,
comply with Health Insurance Portability and Accountability Act(HIPAA) privacy and
security rules.
Physical examinations will be conducted by, or under the direct supervision, of a
physician or medical doctor currently licensed and practicing general medicine in the
State of Florida. The examining physician may employ assistants properly licensed and
trained, as necessary, to perform laboratory tests and/or assist in all phases of the
examination.
Section 3. COUNTY'S RESPONSIBILITIES
3.1 Provide all best available information as to the COUNTY'S requirements for the
Scope of Services described in Section One to this Agreement.
3.2 Designate in writing a person with authority to act on the COUNTY'S behalf on all matters
concerning said services.
Section 4. TERM OF AGREEMENT
4.1 The initial Agreement term will be for one 1
2011, and renewable at the County's option for two (2)aadditi additional beginning
the 20th day
a nef year l
terms.
4.2 The terms of this Agreement shall be from the effective date hereof and continue for
a period of one year. This Agreement shall be automatically renewed for successive one-
year periods until either party gives the other notice of cancellation in accordance with the
terms set forth below. The Contractor must provide the Contractor with at least thirty(30)
days notice of intent to terminate. If either party desires to modify this Agreement, it shall
notify the other In writing at least thirty(30) days prior to the effective date of such
modification. In the case of proposed modification the party receiving the notification of the
proposed modification shall itself notify the other party within ten (10)days after receipt of
notice of its agreement to the proposed modification. Failure to do so shall terminate this
Agreement.
3
Section 5. COMPENSATION
Compensation to CONTRACTOR is outlined in the Scope of Services—Section One.
Section S. 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. COUNTY may terminate this Agreement with or without
cause upon thirty (30) days notice to the CONTRACTOR. COUNTY shall pay CONTRACTOR
for work performed through the date of termination.
Section 8. 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 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.
4
Section 9. NOTICES
Any notice required or permitted under this agreement shall be in writing and hand delivered or
mailed, postage prepaid, to the other party by certified mail, returned receipt requested, to the
following:
To the COUNTY: Human Resources Administrator
1100 Simonton Street, Suite 2-268
Key West, Florida 33040
To the CONTRACTOR: Key West Urgent Care, Inc.
1501 Government Road
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 a Agreement with a public entity for the construction
or repair of a public building or public work, may not perform work as a CONTRACTOR,
supplier, subcontractor, or CONTRACTOR under Agreement with any public entity, and may not
transact business with any public entity in excess of the threshold amount provided in Section
287.017 of the Florida Statutes, for the Category Two for a period of 36 months from the date of
being placed on the convicted vendor list.
Section 13. GOVERNING LAW, VENUE, INTERPRETATION, COSTS AND FEES
This Agreement shall be governed by and construed in accordance with the laws of the State of
Florida applicable to Agreements made and to be performed entirely in the State.
In the event that any cause of action or administrative proceeding is instituted for the
enforcement or interpretation of this Agreement, the COUNTY and CONTRACTOR agree that
venue shall lie in the appropriate court or before the appropriate administrative body in Monroe
County, Florida.
Section 14. SEVERABILITY
If any term, covenant, condition or provision of this Agreement(or the application thereof to any
circumstance or person) shall be declared invalid or unenforceable to any extent by a court of
competent jurisdiction, the remaining terms, covenants, conditions and provisions of this
provision of this Agreement shall be valid and shall be enforceable to the fullest e Agreement, shall not be affected thereby; and each remaining term, covenant, condition and
by law unless the enforcement of the remaining terms, covenants, conditions an xtent permitted
d 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 attomey's fees, and cou
costs, as an award against the non-prevailing party.
conducted pursuant to this Agreement shall be in ac rt
ord Mediation proceedings
da initiate l
County. d and
Procedure and usual and customary procedures requiance red by the Circuit Court of Monroe
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
6
the right to seek such relief or remedy as may be provided by this Agreement orb FloridaThis Agreement shall not be subject to arbitration. Y law.
Section 19. COOPERATION
In the event any administrative or legal proceeding is instituted against either
the formation, execution, performance, or breach of this Agreement, C t lating to
CONTRACTOR agree to participate, to the extent required by the other and
proceedings, hearings, processes, meetings, and other activities related to the substance of this
Agreement or provision of the services under this Agreement. COUNTY and CONTRACTOR
specifically agree that no party to this Agreement shall be required to enter into any arbitration
proceedings related to this Agreement.
Section 20. NONDISCRIMINATION
COUNTY and CONTRACTOR agree that there will be no discrimination against any person,
and it is expressly understood that upon a determination by a court of competent jurisdiction that
discrimination has occurred, this Agreement automatically terminates without any further
on the part of any party, effective the date of the court order. The parties agree to comply withall 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 em to ent on the basis of national origin; 2)Title IX of the Education Amendment of 1972, as amended (20 USC ss. 681-
1683, and 1685-1686), which prohibits discrimination on the basis of sex, 3
) Section the
Rehabilitation Act of 1973, as amended (20 USC s. 794), which prohibits discriminat ono of 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 fAmericans with Disabilities Act of 1990 (42 USC s. 1201), asr ay ben mended fr m housing;of 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. Y PP Y
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
7
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 bonafide employee working solely for it, any fee,
commission, percentage, gift, or other consideration contingent upon or resulting from the award
or making of this Agreement. For the breach or violation of the provision, the CONTRACTOR
agrees that the COUNTY shall have the right to terminate this Agreement without liability and, at
its discretion, to offset from monies owed, or otherwise recover, the full amount of
commission, percentage, gift, or consideration. such fee,
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
COUNTY and the CONTRACTOR in this Agreem nt and thetacquisition of any tcommof the
erc al
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 an
public
when performing their respective functions under this Agreement within the tern torriaC�mi s 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 responsibili
imposed upon the entity by law except to the extent of actual and time) ty
any participating entity, in which case the performance may be Offered en sat sfaction thereof
thby
e
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.
8
Section 28. NON-RELIANCE BY NON-PARTIES
No person or entity shall be entitled to rely upon the terms, or any of them, of this Agreement to
enforce or attempt to enforce any third-party claim or entitlement to or benefit of any service or
Program contemplated hereunder, and the COUNTY and the CONTRACTOR agree that neither
the COUNTY nor the CONTRACTOR or any agent, officer, or employee of either shall have the
authority to inform, counsel, or otherwise indicate that an
y particular or group of
individuals, entity or entities, have entitlements or benefits under this'ndividual 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,
Drug-Free Workplace Statement, Lobbying and Conflict of Interest Clause, and Non-Collusion
including, but not being limited to, a Public Entity Crime Statement, an Ethics Statement, and a
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/ er 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 ma
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
9
to provide satisfactory evidence of the required insurance, shall not extend deadlines specified
in this contract and any penalties and failure to perform assessments shall be imposed as if the
work commenced on the specified date and time, except for the CONTRACTOR's failure to
provide satisfactory evidence.
The CONTRACTOR shall maintain the required insurance throughout the entire term of this
contract and any extensions specified in the attached schedules. Failure to comply with this
provision may result in the immediate suspension of all work until the required insurance has
been reinstated or replaced and/or termination of this Agreement and for damages to the
COUNTY. Delays In the completion of work resulting from the failure of the CONTRACTOR to
maintain the required insurance shall not extend deadlines specified in this contract and any
penalties and failure to perform assessments shall be imposed as if the work had not been
suspended, except for the CONTRACTOR's failure to maintain the required insurance.
The CONTRACTOR shall provide, to the COUNTY, as satisfactory evidence of the required
insurance, either:
• Certificate of Insurance
or
• A Certified copy of the actual insurance policy.
The County, at its sole option, has the right to request a certified copy of any or all insurance
policies required by this contract.
All insurance policies must specify that they are not subject to cancellation, non-renewal,
material change, or reduction in coverage unless a minimum of thirty(30)days prior notification
is given to the County by the insurer.
The acceptance and/or approval of the Contractor's insurance shall not be construed as
relieving the Contractor from any liability or obligation assumed under this contract or imposed
by law.
The Monroe County Board of County Commissioners, its employees and officials will be
included as "Additional Insured"on general liability policies.
33.2 General Liability Insurance Requirements For Contract Between County And
Contractor
Prior to the commencement of work governed by this contract, the CONTRACTOR shall obtain
General Liability Insurance. Coverage shall be maintained throughout the life of the cont and include, as a minimum: ract
• 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
10
An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy, its
provisions should include coverage for claims filed on or after the effective date of this contract.
In addition, the period for which claims may be reported should extend for a minimum of twelve
(12)months following the acceptance of work by the County.
The Monroe County Board of County Commissioners shall be named as Additional Insured on
all policies issued to satisfy the above requirements.
33.3 Workers' Compensation Insurance Requirements
Prior to commencement of work governed by this contract, the CONTRACTOR shall obtain
Workers' Compensation Insurance with limits sufficient to respond to the applicable state
statutes.
In addition, the CONTRACTOR shall obtain Employers' Liability Insurance with limits of not less
than:
$100,000 Bodily Injury by Accident
$500,000 Bodily Injury by Disease, policy limits
$100,000 Bodily Injury by Disease, each employee
Coverage shall be maintained throughout the entire term of the contract.
Coverage shall be provided by a company or companies authorized to transact business in the
state of Florida.
33.4 Professional Liability Requirements
Recognizing that the work governed by this contract involves the furnishing of advise or services
of a professional nature, the Contractor shall purchase and maintain, throughout the life of the
contract, Professional Liability Insurance which will respond to damages resulting from any
claim arising out of the performance of professional services or any error or omission of the
Contractor arising out of work governed by this contract.
The minimum limits of liability shall be:
$250,000 per occurrence and $750,000 aggregate
Section 34. INDEMNIFICATION
The CONTRACTOR does hereby consent and agree to indemnify and hold harmless the
COUNTY, its Mayor, the Board of County Commissioners, appointed
Officers, and the Employees, and any other agents, individually d collectively, from all fines,
suits, claims, demands, actions, costs, obligations, attorneys 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.
11
At all times and for all purposes hereunder, the CONTRACTOR is an independent contractor
and not an employee of the Board of County Commissioners. No statement contained in this
agreement shall be construed so as to find the CONTRACTOR or any of his/her employees,
contractors, servants or agents to be employees of the Board of County Commissioners for
Monroe County. As an independent contractor the CONTRACTOR shall provide independent,
professional judgment and comply with all federal, state, and local statutes, ordinances, rules
and regulations applicable to the services to be provided.
The CONTRACTOR shall be responsible for the completeness and accuracy of its work, plan,
supporting data, and other documents prepared or compiled under its obligation for this project,
and shall correct at its expense all significant errors or omissions therein which may be
disclosed. The cost of the work necessary to correct those errors attributable to the
CONTRACTOR and any damage incurred by the COUNTY as a result of additional costs
caused by such errors shall be chargeable to the CONTRACTOR. This provision shall not apply
to any maps, official records, contracts, or other data that may be provided by the COUNTY or
other public or semi-public agencies.
The CONTRACTOR agrees that no charges or claims for damages shall be made by it
for any delays or hindrances attributable to the COUNTY during the progress of any
portion of the services specified in this contract. Such delays or hindrances, if any, shall
be compensated for by the COUNTY by an extension of time for a reasonable period for
the CONTRACTOR to complete the work schedule. Such an agreement shall be made
between the parties.
IN W NESS WH REOF, the parties hereto have caused these presents to be executed on the
Yof 20//.
BOARD O O TY CO
MMISSIONERS
NY L. KOLHAGE, CLERK
MONROE COUNTY, FLORIDA
by
Deputy Clerk Mayor/Chairman
C�'vcaf!�i S
(CORPORATE SEAL) JOHN R. VAN TUYL, M.D.
ATTEST: KEY WEST URGENT CARE, C.
CM ao
y V2 LQ
C -2, :F`` by
Title:
c C
cv A 0NR E COUNTY ATTORNEY
c� Q A P 0%/W AST V:
12 r', CO::"JTY'ATTORNEY
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
DRUG SCREEN: FEE
When requested, a drug screen will
(Collection, Lab, MRO be performed by the physician and
review) 10 panel State will be either scheduled or done on a S50.00
Requirement walk-in basis for post accident,
random, and reasonable suspicion
dru screening.
DRUG SCREEN: When requested, a drug screen will $50.00
(Collection, Lab, MRO be performed by the physician and
review)5 panel will be either scheduled or done on a
Department of walk-in basis.
Transportation
Requirement
BLOOD ALCOHOL When requested, Blood Alcohol
(Collection, Lab, MRO Screens will be performed by the
review) physician and will be either
scheduled or done on a walk-in N/A
basis.
A testing facility must be available
24 hours a day, 7 days a week for
Post accident, random, and
reasonable suspicion alcohol
screening.
BREATH ALCOHOL (if When requested, m=and
for
available) screening. If breathreen is
positive, a blood sc N/A
performed.
If Physician wishes other
means of screeningease
rovide testin metation and
13
accuracy.
A testing facility must be 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 and performed by the
physician during the facility's normal $30.00
business hours.
A PPD-TB screen will be performed
with the new hire Firefighter physical.
HEPATITIS A When requested, a Hepatitis A
inoculation will be scheduled and
performed by the physician during the N/A
facility's normal business hours.
HEPATITIS B When requested, a Hepatitis B $155 EACH
inoculation(s)will be scheduled and (series of 3 =
performed by the physician during the Total=
facility's normal business hours. $465)
TYPHOID When requested, a Typhoid inoculation
will be scheduled and performed by the N/A
physician during the facility's normal
business hours.
TETANUS When requested,a Tetanus inoculation Combined
will be scheduled and performed by the with
physician during the facility's normal Diphthcria
business hours. below:
DIPHTHERIA When requested, a Diphtheria
inoculation will be scheduled and $75.00
performed by the physician during the
facility's normal business hours.
DOT PHYSICAL: When requested, a DOT physical will
(SEE ATTACHMENT be scheduled and performed by the
"B"to be completed by physician during the facility's normal $50.00
employee and physician) business hours. Includes exam and
physician review of employee health
history and job description.
The DOT physical is initially performed
in conjunction with a post-offer
physical.Thereafter,only a DOT
physical is performed by the physician.
Physician may also perform a urine
drug screen if requested separately by
Monroe County BOCC.
POST-OFFER When requested,a post-offer physical
PHYSICAL: will be scheduled and performed by the
SEE ATTACHMENT physician during the facility's normal $50.00
14
"B"to be completed by business hours. Includes exam and
employee and physician) physician review of employee health
history and job description.
Physician may also perform a urine
drug screen if requested separately by
Monroe Coun BOCC.
FIREFIGHTER When requested, Firefighter physical
PHYSICAL(SEE will be scheduled and performed by the
ATTACHMENTS "F"to physician during the facility's normal N/A
be completed by employee business hours. Includes exam and
and physician). physician review of employee health
history and job description.
Physician may also perform a urine
drug screen if requested separately by
Monroe County BOCC.
FITNESS FOR DUTY When requested, a Fitness for Duty
PHYSICAL(SEE Physical may be requested at any time
ATTACHMENT"A"to be by the employer in the employee's $50.00
completed by employee respective area of work. The exam will
and physician) be scheduled during the facility's
normal business hours. Includes
physician review of employee health
history, exam,review of job duties and
medical records if necessary.
Physician may also perform a urine
drug screen if requested separately by
Monroe County BOCC.
RESPIRATOR When requested, a Respirator physical
PHYSICAL(SEE will be scheduled and performed by the
ATTACHMENTS "C" physician during the facility's normal $50.00
PART I& II to be business hours. Includes exam and
completed by employee physician review of employee health
and physician) history and job description.
Physician may also perform a urine
drug screen if requested separately by
Monroe County BOCC.
In addition, requires Chest X-ray and
S iromet .
EKG Normally done in conjunction with the $50.00
Firefi ter h sical.
CHEST X RAY Chest X Ray is normally done in Physician
conjunction with the New Hire provides
Firefighter and Respirator physical if order to Key
there is an issue with the EKG or West
spirometry results. Diagnostics.
Key West
Diagnostics
15
bills County
directly
($75.00)
SPIROMETRY Normally done in conjunction with the
Respirator physical. All Firefighters
and employees who use a respirator will $90.00
have a S irom when hired.
Normally done in conjunction with the
HEARING/AUDIOGRAM appropriate physical. May be requested N/A
separately by Monroe County BOCC.
STRESS TEST(SEE Normally done in conjunction with the
ATTACHMENT"E"for new hire Firefighter physical. N/A
explanation of services to Performed thereafter for firefighters as
be performed by needed.
physician)
CHEMICAL Tests Glucose(sugar), kidneys, liver(1 $40.00
PANEL/CMP tube of blood drawn).
Firefighter Physical
CBC Test to see if Anemic; if any infections $40.00
within the body; if dehydrated(test
from 1 of the tubes of blood drawn).
Fire fi hter Physical
LIPIDS Tests good cholesterol and bad N/A
(CHOLESTEROL) cholesterol ( one of the tubes of blood
drawn)
Firefighter Ph sical
UA DIP Normally done in conjunction with the $10.00
DOT physical
UA WITH MICRO Normally done in conjunction with the N/A
Firefi ter Ph sical
• The Contractor shall retain all records pertaining to this contract for a period of four(4)
years after the termination of this contract.
• The County, the Clerk, the State Auditor General, and agents thereof shall have access
to Contractor's books, records, and documents required by this contract for the purposes
of inspection or audit during normal business hours, at the Contractor's place(s) of
business.
16
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
"KEY WEST URGENT CARE INC."
(Company)
"...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."
(S gn ture)
Date:
STATE OF: A t
COUNTY OF: / I/')U•9�
Subscribed and sworn to (or affirmed) before me on
M arch- a1 ao
(date) by (name of affiant). He Sh is
personally known to me or has produced
(type of identification)as identification.
NOTARY PUBLI
�.�'"�n•'•••,, PAMELA L.PUMAR i
MY Commission Expires. ? Notary Public-StatS of Florida
,y glon Eaplru Na 27,2011
COMM141"E 00 727209 1
17 �7k.*wrawNaryAw.
NON-COLLUSION AFFIDAVIT
I, _TAnet (fan T of the city of4sy
�s�
my oath, and under pens ty of perjury, depose—and hat according to law on
1. I ao nef ,� /es of the firm of
c ��� the bidder making the
Prthe proje escribed in the Request for Proposals for
- I -C and that I executed the said
Nrupvsal with full authontyto 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.
Pak-
(SI
Dat l/
STATE OF: lORI tL
COUNTY OF:
Subscribed and sworn to (or affirmed)before me on
(date) by Clx
(name of affiant). H /Sh
personally known to me or has produced
(type of identification) as identification.
NOTARY PUBLIC
My Commission Expire _ " PAMELAL.PUMAR
18 - •$1e18 of Flodde
y _ orl EXON Nov 27.2011
Cortrmlp it DO 737309
� �Wit.``'•,g
a Netlorr_.NoferyA M
DRUG-FREE WORMACE FORM
The undersigned vendor in accordance with Florida Statutes Section 287.087 hereby certifies
that:
KEY WEST URGENT CARE INC.
(Name of Business)
1- Publishes a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession, or use of a controlled substance is prohibited in the workplace
and specifying the actions that will be taken against employees for violations of such
prohibition.
2. Informs employees about the dangers of drug abuse in the workplace, the business'
Policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation,
and employee assistance programs, and the penalties that may be imposed upon
employees for drug abuse violations.
3. Gives each employee engaged in providing the commodities or contractual services that
are under bid a copy of the statement specified in subsection (1).
4. In the statement specified in subsection (1), notifies the employees that, as a condition
of working on the commodities or contractual services that are under bid, the employee
will abide by the terms of the statement and will notify the employer of any conviction of,
or plea of guilty or nolo contendere to, any violation of Chapter 893 (Florida Statutes) or
of any controlled substance law of the United States or any state, for a violation
occurring in the workplace no later than five (5)days after such conviction.
5. Imposes a sanction on, or require the satisfactory
ipation in a drug abuse
assistance or rehabilitation program if such is availabl in the cemployee'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.
(Signa ure)
Date:_ t-
STATE OF: �j2��
COUNTY OF:
Subscribed and sworn to(or affirmed)before me on i/
(date) by
C ' " (name of affiant). H
Del personally known
to me or has produced
(type of i entification) as identification.
iL
ctYl��
NOTARY PUBLIC
My Commission Expi e
, sell, y PAMELA L.PC MAR
19 Notary Public-State of Florida
n MY Com6Non E*kae Now 27,2011
Cannd"im ItDD 737309
Bonded Through Nett"Nala y Assn
PUBLIC ENTITY CRIME STATEMENT
A person or affiliate who has been placed on the convicted vendor list following a convicuon
public entity crime may not submit a bid on a contract to Provide any goods or services
t for
public entity, may not submit a bid on a contract with a public entity for he construction or repo
pair
a
Of a public building or public work, may not submit bids on leases of real property to public
r
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 KEY WEST URGENT CARE INC. (Contractor's
name) nor any Affiliate has been placed on the convicted vendor list within the last 36 months.
( ig!ature)
Date:
STATE OF:
COUNTY OF:
Subscribed and sworn to (or affirmed)before me on_
LL a.l evil
(date) by I'V (name of affiant). H /�hs
personally known to me
or has produced
(type of
identification)as identification.
NOTARY PUBLIC
My Commission Expires:
,•"v'"".., PAMELA L.PUMAR
Notary Public-state of Flodda
•• My Commiseloim Expires Now 27,2011
' Commissloa E DO 737309
�►` 9andedThm*NatlonelNotaryAsmf.
20
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
injury, and property damage (includingg ), personal
losses, damages, and expenses (including attorney'snfees) which rari eoe ooutofand
n any other
with, or by reason of services provided by the Contractor or any of its Subcontractor(s)conn ncany
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.
21
WORKERS' COMPENSATION
INSURANCE REQUIREMENTS
FOR
EMPLOYMENT PHYSICAL SERVICES
BETWEEN
MONROE COUNTY, FLORIDA
AND
JOHN R. VAN TUYL, M.D.
KEY WEST URGENT CARE, INC.
Prior to the commencement of work governed by this contract,
s Contractor shall
Workers' Compensation Insurance with limits sufficient to respond to the applicableobtain
ate
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
upon request from the County. the fund
22
GENERAL LIABILITY
INSURANCE REQUIREMENTS
FOR
EMPLOYMENT PHYSICAL SERVICES
BETWEEN
MONROE COUNTY, FLORIDA
AND
JOHN R. VAN TUYL, M.D.
KEY WEST URGENT CARE, INC.
Prior to the commencement of work governed by this contract, the Contractor shall obtain
General Liability Insurance. Coverage shall be maintained throughout the life of the contract and
include, as a minimum:
• Premises Operations
• Products and Completed Operations
• Blanket Contractual Liability
• Personal Injury Liability
• Professional Liability
• Expanded Definition of Property Damage
The minimum limits acceptable shall be:
300 000 Combined Single Limit(CSL)
If split limits are provided, the minimum limits acceptable shall be:
$ 200.000 _per Person
$ 300.0_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.
23
INSURANCE REQUIREMENTS
Worker's Compensation $ 100.000 Bodily Injury by Acc.
$ 500,000 Bodily Inj, by Disease, policy Imts
$ 100,O06 Bodily Inj. by Disease, each emp.
General Liability, Including $ 300.000 Combined Single Limit
Premises Operation
Products and Completed Operations
Blanket Contractual Liability
Personal Injury Liability
Expanded Definition of Property Damage
Professional Liability $250,000 per Occurrence and
Including errors and omissions
$750,000 Aggregate
The Monroe County Board of County Commissioners shall be named as Additional
insured on general liability policy.
24
EMPLOYMENT PHYSICAL SERVICES
AI IACHMENT A
w am
MEDICAL RECORD 110.OF ATTACHED SHEETS:
REPORT OF MEDICAL HISTORY -
B TI arm s or o cla'an me a y-con nt
1 NAME OF PATIENT ILest.esL lirsf,mnclYkf U88 pn W n01 re 8Se 1p UnaUt prae
2 IDENTIFICATION NUMBER Persons
4e,HOM ' Position
E STREET ADRESS D •5 iryfreat or RFD, C ar Town.State,and C/P Corfe/ 5 E+-'
4b CICITY
STATE lad,ZIP CODE
H HURPOSE OF E%AMINA TION --'-'---•�-----
7 STATEMENT OF PATIENT'S PRESENT HEALTH AND MEDICATIONS CURRENTLY USED/Use ai ld,,onelpages if necessary/
a. PRESENT HEALTH _
b.CURRENT MEDICATION
-"- REGULAR OR INTERM.
c.ALLERGIES IlncArr}e fnsscrbrresrfroW and common foods/
e. _
8 PATIENT'SOCCtIPArION —
ec One
RIGHT HANDED
_ 10.PAST/CURRENT MEDICAL HISTORY
LEFT HANGED
CHECK EACH IIEM YES NO DON'T
KNOW CHECK EACH ITEM YES NO DON'T
Household contact vwtli anyone KNOW CHECK EACH ITEM YES NO DON'T
with tuberculosis Shortness of preach KNOW
Pam or pressure in chest Bone,joint or other deformity
Tubarculosis Be positive TB test Chronic cough Loss of finger or as
Blood in sputum PAInful or
coughing Palpitation or pounding heart at elbow tuck'
Of when shoulder
Haag trouble
Excessive bleeding after injury at Racurrenr beck pain or an
dental work High or low blood pressure back njury y
Cramps In your kegs --
Suiade attempt or plans 'Trick'or locked knee
Sleepwslk,rlg Frequent Indigestion _-'
Stomach,liver or intestinal trouble Foot trouble
Wear corrective lenses Nerve Injury
Eys surgery to tarreet vision - Gall bladder trouble or
gallstones Paralysis finNudil fn/anrpe/
Lack vision in either aye or s
Epilepsy eizure
Wear -
a hearing ax1 Jaundice or hepatitis -
Broken bones Car,lraln,see or air sickness
Stutter or stammer W FreQuent trouble sleepetg
Adverse reaction to mMicslion ear a brace or supportDepnasio
Scarlet(everSkin diseases n or excessive worry
- Tumor,growth,c Loss of memory or amnesia
Rheumatic lever yet•certcer
Hernia --- Nervous trouble of any soR
Swollen or painful joins Hemorrhoids of
Hemorrhoids or r nconeciousneas
Frequent or severe headaches add disease u
Fraqusnt or cancer,al rig oe h art dice,
Diuinesa or lainh Penrul urination cancer,stroke a hear)disease
---!g apess Bed watt
E ye trouble -' '^g erica age 12 -
%l at other radiation therapy
Hearing Cosa --._- Kidney stone or blood in unne
Chemotherapy
Sugar or albumn in urns
_
eeunen� tear infections Asbestos or tone c1+maCal
Chronic or fra u - __ Seauagy trarisnil d diseases
Q enl r,olds �- • •- ... _ _ exposure
Severe tooth or i I Race gait or Ines of weight ---
Bum UouDle Plate.Pm or ra ---
Snusitie _ Eating disorder lanoesm - d m arry bone - -
aIC I pulimie, Easy fotigabdity
Hey fever or allergic rllnrtia - __
Arthritis.Rheumatism Be- Bien told 1n cut down or
Head iNury-�— --- .i cri tx:i2ed for ateoMrt use ( I--
-_. Bursitis
Aslnma - - Used illegal substances
NSN 7540 I Thyratd trouble or goiter _ `-
00.18t BJuB _
Previous edition not usable Used loDacco-�
fi• --
Prescribed by IC-Al 'REV 5 961
FIR MR 141 CFRj 201 9 202 1
11.FEMALES ONLY
CHECK EACH ITEM YES NO DON'T DATE OF LAST MENSTRUAL DATE OF LAST PAP SMEAR KNOW PERIOD DATE OF LAST MAMMO Treated for a female disorder GRAM
Changs in menstrual pattern N11 N/A N/A
CHECK EACH ITEM, IF'YE- EXPLAIN IN BLANK SPACE TO RIGHT. LIST EXPLANATION By ITEM NUMBER. N/A
2 Have you been
ITEM YES NO 1 reheated emproyment or been stay In school because
se of:of: unable to hold a job or '��;:; �-
a.Sensitivity to chemicals,dust,sunlight,etc.
te Inabiltty to perform certain molions.
c.Inability to asstane Canon posttioro.
d.Olher medical meeo—h/yes,give rsesons.l
1 A.Have You ever been heated lot a mental condilion? l! es,
when,when,end give dele ifei l Y spseti/y
14 Have you ever beer,dewed Ide ti au
give details./ srlce7 I!l Yea,state raaaon and
15 Have you had,or have you b
Yss,deaenbs and give age of een advised to have,any operation.11/ which occurred./
1 f! eve you ever be a patient eh an
specily when,where,ev , n Y IYP0 o hospitalr 0 yes,
a!hospiral.1 Y e d names of dnclor and complete address
17.Have You wnsdted or Oman treated by Clinics,physicians h
or other p"etitionsrs wtltvn the Past S years for other Man , ealars"
derer7sMrsessyf hl yes'gNe Comp ale address o/doctor,hospifre 1nor end
1 .Have You ever Ceti reJeeted or mlila
Physical,mental,or other reasons; Ill r. aery Ce °of
rejection.! Yes,g,'ve dace and reason /or
19.Have you over been discharged from military service because of
physical,mental,or attest reasons) g!Yes, ve
tylre o1 discharge;whether honorable,other hen hotnorabe eo joend
unlrtness or unsuelaweety.l
20.Have You ever recelved,is there
lot pension or compensation lot exist� q'or have you ever applied
whatarnd, ceantedfe ngdtsability) ff/Yes,specily
Y whom,erMamount, when.why,1
22.Have you ever been diagnosed wi
give type,where,e th a reaming disability? /Il yes,
ndhow dsgnosM,)
23 LIST ALL IMMUNIZATIONS RECEIVEO
can,y t at Ave IRA w t ore _--'__._'_' —•--~ _—
or cities mentioned q e m ormauon sup y ms
t tied above to IueVah the Govemmert•complete Iranacdpt of me true a c ale to
understand that faWhaation of tiformsuon on Y medical record for a eat o my no a e. all nee an
24a.TYPED OR PRINTED NAME OF EXAMINEE vemrneent forme es Ple+lahubI by fine andlor Imprisonment,Purposes o}processing my application for thii o t s actors, sqt s,
employment or service. 1
24b.SIGNATU E
24c.DATE
NOTE: HAND TO THE DOCTOR OR NURSE, OR IF MAILED MARK ENVELOPE"TO BE OPENED BY MEDICAL OFFICER ONLY",
25.PHYSICIAN'S SUMMARY AND ELAB RATION FALL PERTINENT DA A fPhytcesn sh
develop by interview any eddmonsl medial history domed an ell comment on as
p artenf,end record any s,gredre;ant findings posdive answers en Items 7 Through I! R'rYsrewt meth
e gs here./
25a'I WE pR PR WrEp NX OF PHYSICIAN OR EXAMINER
7d6 SIGNATURE
26c DATE "--
STANDARD FORM 93 IREV Beal BACK
MEDICAL RECORD REPORT OF MEDICAL EXAMINATION
DATE OF EXAM
1 LAST NAME•FIRST NAME-MIDDLE NAME I
2. IDENTIFICATION NUMBER 3
Position
4 HOME ADDRESS(AlumOar slrea/aRFO.cpydMwn,slahrand7jP Coda) 5 EMERGENCY CONTAC7(Nenpandadppno/cnnlxdj
B. DATE OP BIRTH 7 AGE B EX
;L:E
9.RELATIONSHIP
10 PLACE O 81RTM
MALE
11.RACE
ATE BLACK AMERICAN INOIANI HISPANIC HISPANIC ASIANAPACIFIC
12a.AGENCY 12b.ORGIWIZATIONUNIT ALaSKaNA7 WHITE BLACK
ISLAND R
13.TOTAL YEARS GOVERNMENT SERVICE
a. MILITARY b.CIVILIAN
14 NAME OF EXAMINING FACIUTY OR EXAMINER,AND ADDRESS
15.RATINO Op SPECIALTY OF EXAMINER
to PURPOSE OF EkAMINATION
17.CLWICAL E1fALUATION
Mnl (C11eek each ram bt 4pp/oprtle oarumn.enter WE,irrlol evaluated.)
A.HEAD,FACE,NECK AND SCALP MAL (Chemk @GM"am In apyoprtpa column,ent777
WE"OnoEARS.GENERAL(/N7ERNAL CANALS)(Aud"scads under Hems 39 and 40) ESTICULAR
C.ORUMS(Peroofflo n)
D.NOSE R ENOOCRINE SYSTEME.SINUSESSYSTEM
F.MOUTH AND THROAT .UPPER EXTREMITIES(Shenpll,rargeo/m
G EYES.GENERAL U.FEET
(Yiaval aariyene rfx4xren order Afnrl 24 2q and!JN V.LOWER EXTREMITIES(Elicepf/ee41S
H OPTHALMOSCOPIC b>srlgdA range dngtbn)
I. PUPILS(Equelpy and reac" W.SPINE,07HER MUSCULOSKELETAL
J.OCULAR MOTILITY(Amock ad X,IDENTIFYING BODY MARKS,SCARS,rATTOOg
-tra/lslmo�errrMbr7'�epndr� Y
K.LUNGS AND CHEST SIGN,LYMPHA71CS
L.HEART(Thrum,sire.rhyMm,sounWa) Z.NEUROLOGI C(Equ"bAum hale utlderpem 41)
M.VASCULAR SYSTEM Nerk+oai0oe,era) AA.PSYCHIATRIC(SpecryanypareanaiydeNedon)
N ABDOMEN AND VISCERA(Inclucbhemfa)
NOTES: (DescAbe every ab WMNWyln detap. Ente►pelibeal Mm numberbebrs Oath Comment Conbilue M itm 4?and usO eoluplbnal s/1eeYe ynewssyy.)
IS OENTAL(Ptoeappvopraataymboh,sloentoexamplaa,abowarbeblvnumbero/upparandbN11110 A.)
o xx� REMARKS AND ADDITIONAL DENTAL
f �2—]_ RamwaeM r Hoo- 1<
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19.TE9T RE3ULT9(Coplea of rdults are PrefelYed as attachtlarRllS)
A URINALYSIS (1)SPECIFICGRAVITY
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(4)MICROSCOPIC //��
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NAME
IDENTIFICATION NUMBER
NO 7SHEETSATTACHED
20 HEIGHT 21 VVEIGMT MEA9UREMg AND OTHER FINDINGS
22.COLOR HAIR 23,COLOR eveS 24 BUILD
28 BLOOD PRESSURE SLENDER MedUM M 25 TEMPERATURE
IAmlalnBartb►N) EAW OBESE
ENT
A SYS. B
SITTING OIAS qBp ly( SYS, C. SYS A.81 27.PULSE(AMIsIh.sHW.
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(5mhs.) OAS
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RIGNI CORR.TO 20/ 29 REFRApTION
BY
LEFT 2O( CORR S Cx 70 NEAR VISION
31 HETEROPHORIA I Spm dy dctlyl�s) BY S CORR TO BY
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32 ACCOMMODATIONPC O
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36.FIELDOFVISION (r031 .dandscv,.)�I� UNCORRECTED
38 N
RIGHT *HTVISION(r.eluBeJand�T,,.) CORRECTED
LEFT A 37 RED LENS TEST
39.HEARING All A3B INTRAOCULggTENSION A
d0.AUDIOMETER /� RWHT LEFT
RIGHTMV ,15SV 41.PSYCNMOGICALANOPSYCHOMOTOq(Icstsulodendscole)
250 S00 1s 25e 512 iD024 204E 2 6 BODO Ilk
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LEFT
42.NOTES(ConNIUL JAND SIGNIFICANT OR INTERVAL HISTORY
03.SUMMARYOFOEFECTS/WppIAC,NpSES'Lmld (Us& s/e).s 'f'W0seaW
( bWwses with asm mnlpera)
a/ RECOMMENDATIONS•FURTHER SPECIALIST EXAMINATIONLS INDICATED(SPpi;M
GSA.PHYSICAL PROFILE
48 EXAMINEE(CAark) P U L H E S
A IS QUALIFIED FOR
B IS NOT QUALIFIEOFOR In accordance with attached job
47 IF NOT QUALIFIED,LIST DISQUALIFYING DEFECT SCri tion 45B PHYSICAL CATEGORY
ITEM NUMBER
48 TYPED OR PRINTEDA C B
NAME Of PHYSICIAN E
SIGNATURE
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51 TYPED OR PRINTED NAME OFREVIEVy1NG OFFICER OR APPROVING AUTHOI SIGNATURE
STANDARD FORM ea(Rey I'll)BABACK
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EMPLOYMENT PHYSICAL SERVICES
ATTACHMENT C
Ides irafm Meriical EvcV •uation echo '
tre
Co the rmployer..�nsNc•r%to tlut•%lit,ns in St•t tu+n 1.and to cM-stio n 9 in Scr tion 2 of f',,rt A,tlu ntd rt ur
j "�.r n n nation.
l'o the employee:C,ut ti•ou Mi � n u mt•dit al
d t Ittt �
1't,crr rm Ic, ( k t,rx):...................................................................................................
Ls
t unvc nu nt t'You. To,Ina nttain your,nfidhnii i itytry,nur vmplcynr or tiu ,ry,C•, J Yati
f,normal Workin► it -No
and ynuromplt,y,'r must it'll you how to dc•liva },ht,urs,ook t or n, ntd p Your
that Ls
r or fiend this yut•stionnain to the r must nut look at or rnvit w your a►.v L.w ,
(pit arrho,lollt)Wing information must hr pn,vidc•d by twt•ry cam to •tv., Ito'alth cum pn,fcssitmal wlx,will nwirw it.p y who has l><ti�n tie•Ita tt d to ciSe.crtY type of mspirattrr
Name:-- _._
Job Title:
Age(to nearest year):
Sex(t hevk one) O Iktuler 0 Fe male Date:-•�_
Height: Ceet_irx-lxy
Weight: lbs. Check the
type of respiratoryou will use uu�.
Phone number whre you can be n'ached more than one t.atebntry). (Y an chet•k
case person who re:iews this(include area��)health non{. O N,K or P dis
The best artridge type,only). respirahtr(filter-mask,
time to can you at this number.
type'
'0 Other type(for ex Ample,huff-ur full-facepiec e
Has Your employer told you how to contact the health care ty e'P" ared�Purifying'suPp"ed,air,self-contained
Person who will review this(chtk•k one): B pparatus).
0 Yes ❑No Have you wont a RsPirator. O Yev 0 No
"Yes,"what type(,):
Part A— Section 2(Mandatory)
(pit use her kd'yes ugh 9"no"). must be aruwered by t+vcry emplaye:e who has 'n selet.ted to use an
Y h'Te of respirator
1. Do you currently smoke tobacco,or have you smoked tobacco in the last month? .............
2.Have you ever 0 YeS O No
d. Y had any of the following conditions?
h. a
Diulw�(sugar diredse):...........................................................................................................
....... ...................................... ..............0 Yes
Allergic """"'•• O No
t'• grc reactions that interfere with bma .....
.....................................
d. Claustry Ix�hia f g""............................... 0 Yes
I' (ear of closed-in ❑No
. pluctw):
t. Tn,ul+le smelling odors: ............................................... •.................................Cl Yes O No
3. Have you ever had any of the Wowing
O Yev O No
llowin
a• Ashestc>Sis: .............
g pulmonary or lung problems? 7 Yew rJ No
CFmhronit
................................... ....J Yew
............U Ytw
P Ywrear ................................................... ...........................
>Ytw ONo
........................
................
oO
f. f uht• .....................
7 Ytw
..................... ................... No
No
g• Si lit tnis: ...............................
...................
It. f'nt•unu4ltt,r•rt(tulL,l.ye•d f ..............•.. .................................
..................
,Yts
r. f u n};t ant vr: ...... .............. ..... .............. ,r�u...... .......
I. f n+kt'n nix: ....... .................. ............. . ........... ......... ................................... ... .
.............
n� ,ht�til mlurity t,r tiuryt•rit•s: .. ........ ........
.......... ... ....................... ........ ... .
„Ih,•r fun� n,� •............. . _ .. . .... .�Yoe J.'\'u
!,I I h•m that�„u'�t IwY•,r ........ ...................
.. ........ ... .... ..
...... ... ................. .3 1'tw
J No
rnaost�e�
VIG4 ist.9s170.1 Owe mGy&30M
;. Do you c•utnrntly have any of the 5ln,rtn,w•;of I following symptoots of pulmonary or lung illness?
a. +reath: ...........
....................................................
h. Sht,rim.tiof hn•ath when ..................................................................w,ilkuly,fast tin Ievel},round or walkin u Y'w J Na
Shorin,ws of breath when walkingF, p a tilirht hill or in,line: ..........'. y,,s
with other prr,ple at an ordinary pate on lev,•I l;mund: ..••..,,•„ ]Y,% '�No
i d. have to titup far hnwth when w,,lkin� ..l No
e. Shortness of breath when gat your own pac a on lev,,I};round:..................
n washing or d •.•...•........J Yes Q No
f. Sho K n�sint;r•our;elJ........................................................
rtntws„f breath that inG•rf�•nw with your job:
.J Yes :]Nu
};. Coughing that pn,tlut.tss hlc• U YtK
...................................
P gm(thick sputum):
rJ No
h. Coughing that wakes a ]Yes
you earl in tt1�
Y �morning::............... ]No
i. Coughing that occurs mOstl when
o ..........................'J Yes
1. Coughing up blood in the Yyou are lying down:
�]No
k. last month: ...................................................... .............0 Yes Q N
avhtY•/Llg' U
!. 4Y}x•e/ing that intc•rfetrs K, ........................................................................................................... ........
Q Yc's iJ No
Chest with your job:
❑Yes ❑No
m. pdin when you brrathe deeply: ']Yes ]
n. Any other. toms that think .............................................................................................. No
P you may he related to Iproblems: ❑Yes U No
'rnK .................. .............. ❑
................
S.Have you ever had any of the following canUov sc or heartt problems rJ Yes No?
a. Hedrt attack. .........
b.c. Angina:.........................................................................................................................................................❑Yes �]No
d.
e. Swart failure: ................ ........... .................................................................................................... ...❑Yes ❑No
llin
K in your legs or feet(not caused by Walking)::................. .............. ❑Yas ❑No
arrhythmia(heurt btwtin
f. Heart
g irregularly): ................................ O Yc•s ❑No
g.
blood pressure:
h. Any ether heart problem that ......................................................................................................................❑Yes D No
You've been told about ......❑Yee ❑No
6.Have you ever had any of the following ..........................................................................❑Yes ❑No
caidiovasculu as heat sympttrms?
a. Frequent pain or tightness in your chest: ....................
c.b. pPauin aT ghmtness your chest during t. PhYsiral activity: ........ ...............................................................❑Yes ❑No
.ss in your t hE•st that into
J. In past two Ye+us,have you notit•ed��with your lab......... .......................❑Yes •❑No
J Heartburn a your heart skipping or missin ea ❑Yc's ❑No
f. Any other m dtgeshan that is not related to eating:................................heat:...................................O Yes ❑No
sY Pk'ms that you think may be related to hedrt o ........❑Yes ❑No
r emulation problems: ....................❑Yes �]No
7. Do you cwnndy talkie medication for any of the following problems?
J. Breathing or lung problems:
C.
Blood art prnsbw+e: ........................................................... ..............................................................................O Yes ❑No
d. Seiiun•s(fits). .................................................................................................................. .............................❑Yes No
............................................... ❑Yes 'J No
U Yes
8.If you've caved a RsPirator,have you ever had any of the following problems? J No
(If never usod a nwpiratur go to(lut'stion 9)
a. Ev,•irritation:............
........................................................'• skin Alergies or rashes: ...
........................................................
. . c�erH•r,il cv,•,+kix•�ti a ...................... o
. r
r f,�tiy,uc•:........ ..................................................... J n
Othvr i,n,hlem that interfi•nh N ith ... .
......................
war m� �'••••
I'ir.ilor caw•:........... ............................ J 1',r•
0........ ... .
J Y,w 1.3 No
En*xRn 3
VCA'hst86M1 n*Mry8•MM
9.Would you like to talk to the health rare professional who will review this questionnaire about your
.trwwvrs to this yutwtionnairy: ...................
Qutwtiorv; 11)to 13 below must he answered by rct•ry employm who hats teem selet red
err to use cithelrat hill-fat -Picua mtipiratur
a tiedf-contained hwathing apparatus(SCBA).For emPloytvas who have Farm tiekv ted to use•other tyPts of nwPirators,
attswenng,theca yua+tiorts is voluntary.
10. Have you ever lost vision in either eye(temporarily or permanently): ...........
11.Do you currently have any of the following vision problems?
a. Near t ontact lerneas:..............................
....................................................................................................................................................7 Yt g 0 No
b. year Illasws
C. Color blind:..................................... ............................................Q Yts ❑No
d. Other eye or vision pnlblem:................. ....................................................................................................❑Yes 0 No
.....».......................................................................❑Yeas U No
12.Have you everhad an injury to yourears includ ins a broken ear drum:...................................................0 Yeas
❑No
13.Do you currently have any of the following hearing problems?
a. Difficulty hearing:
.....................................................................................❑yes 0 No
b. Wear a herring did;........................................._.........
..........................................................................❑Yes ❑No
t-. Any other hearing or ear Problem:..............................................................................................................O Yes O No
14.Have you ever had a back injury:..............................I................
15.Do you cunvntly have any of the following musculoskeletal problems?
a. Weakness in any of your arms,hands,legs,or feet:..................................................................................0 Yes O No
b. Buck Pain:.....
V. Difficulty fully moving your arms and le�................................................................................................0 Yes ❑No
.........................................................................
d. Pain or stiffness when you lean forward or backward at the waist ................... Yes O No
e. Difficulty •............................................ ❑Yes 0 No
full moving a ...........
tY Y g,your head up or down: ..........................
f. Diffit-ul .................................. ...............O Yes ❑No
tY�Y Wing your head side to side: .........."'
g. Difficulty bending at your knees: ❑Yes ❑No
h. . ................................
..........O Yes 0 No
Dif&Ztlty squatting to the
i. Climbing a flight of stairs or a ladder currying more than?5 Its.. U Yes ❑No
•....................................................... ❑Yes ❑No
I. Any other muscle orske+Idol Problem thut inkrferes with using a r pirattrr:.....................................0 Yes 0 No
PAd B
Any of the following questions,and other questions not listed,may be added to the yuestionnairr at the disc retiun of the health
t.tee m4i ssional who M ill review the questionnaire.
1.In your present job,are you working at high altitudes(over 5,000 feet)or in a place that has lower
than Ix)rmal anitioilLs tf oxv)vetl;,,.,,,,,,
.....................................I....
Yt�s
or of or sy mptorns r.•Ix.rl you'n-working;under thew:tuntlitionti:
]No.......................................
J Yes •J No
2:\t work or at home,have you ever been evpomed to hazanlous solvents, haze rtious airborne chemicals
(t' 1;•1;t�t'�. f"Ifies,or.lu.t),4r have you tome mto.km t onlat t ith hazardous,Imnnr.tl+..............
RESPIRATOR USE
PHYSICAL
Name
'age__.____ Sex
Home Address
Telephone
Occupation
Length of Employment
1 agree to the release of this information for State and Federal regulatory Purposes to the
extent provided by applicable laws.
DATE
SIGNED
EIviPLOYER ❑Follow-up Medical Evaluation Physical
Required. (Positive response—Question 1-8).
❑Post-Offer Physical: Medical Evaluation
Physical Required.
9.Would you like to talk to the,health care professional who wall
review to this questionnaire, i1w this m,,,questionnji bout your
........................................................................................................................................ Y(S Q'No
Qu0sti0l's 10 to 13 holow MuSL Ix.j1j,
Tv("PlOWN.,%%-hu hLs been.qt?k,,t,,d
;tvt'n�j by(!VL
—tions L s vt)IL,lltjry. Plov"who have been seIvt:tL%d nsPiritoror
"these qut 'FP"r-Itus(SCOA).For en; '? 'I"'Ifcof'"n(�J hn!,jthinl,, to us",Iith r
10-FIAVVYOU ever lost vision in either eye(t"Porar"Y OrPernumntly)' to Wit!othvr type of n-srinitors,`nswIrin8
U.Do you currently h4veAnv of the following vision problems? QN0
,I. Wear )nWa!ernes. "
h. Color blinSLisses:..... ..............................................................................Q C3 Yes C3"qo
d:....... ..................................................................... .......... Y(S
..........................................................................................d- Other eye or vision pn)blLtn:................................................................................................................. .C3 Yes No
I—' Have you ever had an injUry to your eats,including a broken eardrum:. ............Q Yes
13.Do YOU currently have any of the f0flowing hearing problems?b. Ca No
a. Difficulty heitring
WearLi hearing AiLL..............................................................................................................................................
e. Any other hearing Or ear Problem: ...........Q Yes Q No
Q Yes 0 No
iury, C3 Yes
14.Have you ever had a back in C3,,4()
1-1.Do you cuumtly have any of the Q Yes C3 No
a. Weaknessinanyofyour4ru.following Musculloskeletal problems?LN hinds,legs,or feet:
B"pain:
C. Difficulty ....................................................C3 Yes Q No
fully moving Your arms and lep: Q Yes C)NO
..........................
ed* Pain or stiffness when you lean JbrWaW or backward 41;the waisL............................................................0
...................Q Yes (3 No
Difficulty hLHY moving your ❑head up ordow,= C3 Yes 13 No
Q Yes C3 No
f Difficulty fiAY moving Your head side to side.........................................
9. Difficulty bending at your knees... ....................................................
h. Dd&-Wty squatting .................................................................................................................Q Yes Q No
i.
Clirabinga to the ground: .................................................................................................................Q Yes Q No
flight of stairs or a ladder aurying more than 25 U: Q Yes Q No
j- Any Other muscle orskeletal problem that intL-rf6,-.s with using a respirator C3 Yes Q No
Part B U Yes C3 No
Any of the following questions,And other questions not listed,Indy beidded
care Professiorml who will review the questionndir,,
to the questionnaire at the dkcavtion of the health
I.In Your present job, ,te you wod"ng at high altitudes(overSAO feet)or pie ahas lower
thAn nonnal amounts of oxygen Lac that
"other-sympton.is when you're working tinder these Conditions: C)Yes Q No
2-At wodc or-at home,have you ever been eVoseako
............................................Q Yes C)L%40
(e.&pses,fumes,or dust),or have you come hazardous Solvents,haLudoug airboniechemic.
into in contact with hazardous chemkalm
CJ Yes C),%40
MCA InSL'xma We 1(yu,IM)
. 3.-Have YOU orerwnrlwdwith any of the mam*riads,prwnd*nanyof the conditions,2isv,d jej*w*a' Asm~vrz-._________.____._.___
h. �&u�^�iva^nJ�L��n�j ---------''—^-'--`~—'------~^.,------.
c /unl,,-xvnl,.okdt�^���nJin�nr~,�bq�d`��------'----~-'—~~'--�----'----.--�Yc� ���m
`i 8,�1Sunr -_______—.-_,______is~~^��p---^--'-^----.--'--^-----�]l�s L\,m
V. Aluminum: '-------~''-'~—
| -------~-'--______ —'-^'~'--------........._xY,m QNo
� L ��l���m� ___--��^----�_�~-------��� ��
& /nnr: --__~_ -.- -------'----'--�-----------'-[3�� ��Nw
� T�:.....................
'---'~-''--^''~-^--.'---�--' -- --��T,S
� Duw�vnrbnnown�: ____--^^------'--'----'---_----_�]Y\� J--
� Or��6uz^^dmuyex[�aU�y _-^.-_.�-----''--^--�--'^--~ -----'--��Yvy [�--
�~yc�~J'��6eUmyeexyoeum� ---''~---'^--~'^-^^'-'-'---'-^-'------.-----'C]�� CJ-~
4.List any second jobs orside businesses you have.
S.List your previous occup.1tions:
6.List your clarrent,and]Previous bobbies:
7.Have you been in the miliwy services?
9.Other thAn medications for breathing and lung problems,
mentioned earlier in das questionjuim,am you taking head trouble,blood pressum,and seizures
(incuding over-the,-c-ounter medication.):... any other medications forany mason
If"Yes,"name the medications if you know C3 es
10.Will you be using any of the foaowing items With Your mspimtolls)?
a. HEPA Filters:
YL No
11.How Often am You expected to use the mspir Q YLS 13 No
d. Esuipe only(no rescue):
- e. ^=""hours per Jar____^.__....__. ......J��� [X��
� {��r�6m����6av '�--~--'---~~~-^---'---'
^'---~--'-�---'---_.._~____.______,.-'--~---'~---'--��� ���o
------,-.-----�-c3 Y=" C)No
� �
MICA 1114.4011 Dire II1tZUq
12 During the periud you arr using the nespirator(s),is yourwork effort
J. L►g,ht(kss than 1Uo kCal per hour):..........
s, how lon•dues th. .....................
L is 17"riod last during the,&ve'rage shift.
Ex.a mpks of a light work effort im sitting while writing, •`h�'�-miss.
li};ht assembly work,or st uldilig w•h►lea ratin, typing,,dr,&fling,or l�e'rfomiing
h. .1 lodcrito(3l)to t30 k�,&l per hour 1"3 ) ntrullin
!,a dnll prnss
If"}�es,,.how }...........................................`.... Il+s. or ra b nl,&e•11ine�S.
lu►!; • his riud _1_hrs.
...L Yes 7 Ne
► ,&eke t 1'e' I,&st Bunn►thcr � g, sht1L ....................... �
E�camples of modetrate work e�Ih�:t arc, b ,&vcr,&�e�
f sitting while n,&iling or fill r drivin, �'
url+dn traffic;standing while drilling,nailing ),a truck or bus in
a mode'rite load(ab out 33 Ibs.)Jt trunk levee.w Ikin�ml,assembly work,or tr,&ntsferrin•
a 311e'e ev}grade about 3 mph,or pushing },an,&level surface about 2 b
,& level surf�c:e.
F b,&whe�e!lb,&crow with heavy luad('About 100 lbs.)n
or down
C. Heavy(above 13)kcal pe'•r hour):..........
If"Yes,"how long dues this ........................................
Examplrs of lXNA work noel last during the average shill` .. .. 0 Yes 0 lVo
"Y ,&re ling a heavy Judd(about 3o lbs. 60m ter w
or shoulder,working on,&loading dmk,shovelin ) the dO°r to Yoe waist
walk►ng,up an> ebne}7 ode,&bout 2 stJnding while brie:klaying or chipping bs;
°1FK.climbing stairs with,,heavy load(,&bout 30 Ibs.).��
13.WO you be wearing Protective dothin
using your respirator................ g for e1lrupment(other than the res
If this P�ror)when oa'
„yam,„describe Pr clothing any(/or equipment................. .y....R.......0 Yes ,No
14L WM you be worm under S hot conditions(te"Pen'tum
IS-W1V you be working under humid conditions: exceeding 77p)F�,,,,, .......................0 Yes O No
................... ............................................................................0 Yes ❑No
17.Describe any speC1W or haz rdous conditions
(for eXaarple,confined YO11 ought encounterwhen you're using o
spaces.life-tltrt±at�"g�k g}' urrespirator(s)
18.Provide the following infomration,if you know it,for each
when you're using your toxic substance drat ou'll b
respimtor{s):
Y e exposed to
Name of the first toxicsub.,Luxe:
Estimated maximum exposure level pershiR:
MCA[at-WU Due101200
Duuration of("NI"urt.,[Wr shift:
Nacre of the x Lond tutu subst.uxh:
Estimatitf nmximum arum level pershifh
Duration of et pr shift:
N' a of the third toxic substance
Estimated maximum exposure level per shift:
Duration of exposurepershift
The name of other toxic substeS that youti be exposed to
while using you"�Por.
19.De i f nY special Mpanyibilibles y�71 have while usingY
others(for example
Wscue,secur.
r(
s)that auy affect the safety,rnd well-being of
S(CI frnt-YGQ3 U.uc IIYtZrq
f
PLHCPFoiiow.0 Medc
Exanjinatdi�ojnj�
p iemloyee iY
Job title.. Copy of`wommen"ion given to Cinployee?0 yes p Yo
Date of this follow-up; R`l:OmmenJ.jhortis about cmployL.e use of Use ns
V mlitions- pica tor:
Reasons forfoUow.up
Actions:
!Need for foIIow-up medkaj evaluation
Signed; Date signed:
Date givem
SMATOR USE
PHYSICAL
See Attached Job Description
NAME
AGE SEX
HOME ADDRESS
TELEPHONE OCCUPATION
LENGTH OF EMPLOYMENT
I agree to the release of this injornration for State and Federal regulatory purposes
DATE
SIGNED
CARDIO-PULMONARY EXAMINATION
1. HEIGHT___ WEIGHT
2. HEART:
Mumiers: Rate
ythm Enlargement
3. LUNGS:
Pulmonary Function Within Normal Limits
Outside Normal Limits
4. PA CHEST X-RAY:
Within Normal Limits Outside Normal Limits
5. RECOMNIENDATIONS:
It is'my opinion that the above named patient is_
is not
qualified to wear a Respirator is the performance of his/her duties. medically
PHYSICIAN