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Item F05 F.5 `, County of Monroe y,4 ' �, "tr, BOARD OF COUNTY COMMISSIONERS Mayor Heather Carruthers,District 3 �1 `ll Mayor Pro Tem Michelle Coldiron,District 2 The Florida.Keys ��` �)-.���`� � Craig Cates,District 1 David Rice,District 4 w � Sylvia J.Murphy,District 5 County Commission Meeting November 17, 2020 Agenda Item Number: F.5 Agenda Item Summary #7514 BULK ITEM: Yes DEPARTMENT: Employee Services TIME APPROXIMATE: STAFF CONTACT: Pam Pumar(305) 292-4459 N/A AGENDA ITEM WORDING: Approval of updated contract with Physician's Health Center (PHC)to allow increased rates for services provided by the vendor and increases to required liability insurance, as required by Risk Management. ITEM BACKGROUND: PHC is one of several health care providers that provides employment physicals, including pre-employment physicals, fitness for duty exams, annual physicals, and drug tests. PHC has requested changes to the following services under their existing contract including: • Drug Screen from $40 to $45, • They no longer do after hour drug testing, • Hepatitis B testing from $72 to $85, • Typhoid from $56 to $70, and • Urine testing for Nicotine went from $10 to $56. General Liability Insurance Requirements Combined Single Limit increased from $300,000 to $1,000,000. Per Person Minimum limits acceptable went up from $200,000 to $1,000,000. Per Occurrence went up from $300,000 to $1,000,000 and Property Damage went up from $50,000 to $300,000. Worker's Compensation requirements increased Bodily Injury by Accident $1,000,000. Bodily Injury by Disease, policy limits from $500,000 to $1,000.000. Bodily Injury by Disease by each employee increased from $100,000 to $1,000,000. General Liability Including Combined Single Limit increased from $300,000 to $1,000,000. PREVIOUS RELEVANT BOCC ACTION: 6-10-2014, the Board approved the first contract with Richard L. Dolsey, PHC, Inc. dba sician's health Center, inc. to provide employment physicals (Item C-6). CONTRACT/AGREEMENT CHANGES: Contract Packet Pg. 151 F.5 STAFF RECOMMENDATION: Approval. DOCUMENTATION: Employment Medical Services CONTRACT PHYSICIANS HEALTH CENTER 10-2020 Old PHC Contract with Strike Thru version Attachment A. Report of medical history (2) -PHC Attachment A. Report of medical history (3) -PHC Attachment B DOT PHC Attachment C Respirator PHC clean General Liability PHC and Worker's Comp Professional Liability Ins. FINANCIAL IMPACT: Effective Date: 11/17/2020 Expiration Date: None Total Dollar Value of Contract: TBD Total Cost to County: These work-related medical services are acquired on an as-needed basis. There is no way to accurately forecast utilization of this one provider. In 2020, the County spent a total of$1900 with PHC. Going forward, the annual estimate is expected to be similar. Current Year Portion: Budgeted: Yes Source of Funds: CPI: Indirect Costs: Estimated Ongoing Costs Not Included in above dollar amounts: Revenue Producing: If yes, amount: Grant: County Match: Insurance Required: Yes Additional Details: N/A REVIEWED BY: Bryan Cook Completed 10/26/2020 10:55 AM Assistant County Administrator Christine Hurley Completed 11/02/2020 3:55 PM Cynthia Hall Completed 11/02/2020 9:05 PM Purchasing Completed 11/03/2020 8:12 AM Packet Pg. 152 F.5 Budget and Finance Completed 11/03/2020 8:18 AM Maria Slavik Completed 11/03/2020 8:49 AM Liz Yongue Completed 11/03/2020 9:31 AM Board of County Commissioners Pending 11/17/2020 9:00 AM Packet Pg. 153 F.5.a AGREEMENT EMPLOYMENT PHYSICAL SERVICES TABLE OF CONTENTS SECTION ONE - Scope of Services o SECTION TWO - County Forms and Insurance Forms .2 ATTACHMENTS: A. Post-offer and Fit for Duty Physical Forms B. DOT Physical ca C. Respirator Physical W N N 0 0 0 0 0 0. 0 1 Packet Pg. 154 F.5.a MONROE COUNTY CONTRACT FOR EMPLOYMENT PHYSICAL SERVICES 5th October 2020 THIS AGREEMENT ("Agreement") is made and entered into this day of by MONROE COUNTY ("COUNTY"), a political subdivision of the State of Florida, whose address ca is 1100 Simonton Street, Key West, Florida 33040 and Richard L. Dolsey, PHC, Inc. dba Physicians Health Center ("CONTRACTOR"), whose address is at 1448 N. Krome Ave, Suite 101, Florida City, FL 33034. JA 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. cV CONTRACTOR warrants that it is authorized by law to engage in the performance of the activities herein described, subject to the terms and conditions set forth in these Agreement documents. The CONTRACTOR shall at all times exercise independent, professional judgment and shall assume professional responsibility for the services to be provided. Contractor shall provide services using the following standards, as a minimum requirement: A. The CONTRACTOR shall maintain adequate staffing levels to provide the services required under the Agreement. B. The contractor is responsible for obtaining proper releases from the employee or prospective employee in order to discuss the results with Monroe County BOCC. C. The contractor will provide the required services at the location of: 1448 N. Krome Ave. Suite 101 Florida City, FL 33034 Phone: 305-245-0222 Fax: 305-246-3700 D. All urine screens will conform with the standard chain of custody protocols mandated by state and federal regulations. E. The Contractor will have an employee designated as coordinator or facilitator to assist in the communications with the Monroe County BOCC's primary contact personnel. F. Appointments will be available throughout the business hours of the facility: Monday — Friday 8:00 a.m. — 5:00 p.m. Walk-ins will also be accepted if an appointment cannot be reasonably scheduled. 2 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 PHC after Hours Service. • The authorized Human Resources representative or the authorized .2 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. 2 Packet Pg. 155 F.5.a H. Appointments will be seen by the contractor in a reasonable and timely fashion. I. The Contractor will provide the County with at least a 24 — 48 hour turnaround time for the receipt of any drug and/or physical results. J. The Medical Review Officer will be available for contact by the Monroe County BOCC or its employees to answer questions about the effect of prescribed drugs. Part of the requirements set forth by the State of Florida drug free workplace policy, which Monroe County has adopted, and the Department of Transportation, the County must have a qualified Medical Review Officer"MRO" perform drug screening services. The MRO receives lab reports from the laboratory (as governed by regulations); Reviews lab reports for integrity, authenticity, false negatives, and false positives; interprets JA lab results, including verification of lab positives; reports lab reports to the employer (as defined by rules and regulations). N 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 andLU 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 CL trained, as necessary, to perform laboratory tests and/or assist in all phases of the examination. Section 3. COUNTY'S RESPONSIBILITIES 3.1 Provide all best available information as to the COUNTY'S requirements for the Scope of Services described in Section One to this Agreement. 3.2 Designate in writing a person with authority to act on the COUNTY'S behalf on all matters concerning said services. Section 4. TERM OF AGREEMENT 4.1 The term of this contract will be for one (1) year beginning June 10, 2015 and shall automatically renew for successive one year terms unless and until either party gives the other notice of cancellations in accordance with the terms set forth in Section 7. 0. Section 5. COMPENSATION Compensation to CONTRACTOR is outlined in the Scope of Services —Section One. Section 6. PAYMENT TO CONTRACTOR 3 Packet Pg. 156 F.5.a 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. Payment is expected in 30 days. 6.2 Continuation of this Agreement is contingent upon annual appropriation by Monroe County Board of County Commissioners. JA Section 7. CONTRACT TERMINATION .2 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. cv 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, e® 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 e® 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. 4 Packet Pg. 157 F.5.a 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. Upon completion of the contract, transfer, at no cost, to the public agency a all public records in possession of the contractor or keep and maintain public records required by the public agency to perform the service. If the contractor transfers all public records to the public agency upon completion ca of the contract, the contractor shall destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure requirements. If the contractor keeps and maintains public records upon A completion of the contract, the contractor shall meet all applicable .2 requirements for retaining public records. All records stored electronically must be provided to the public agency, upon request from the public agency's custodian of public records, in a format that is compatible with the information technology systems of the public agency. 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 Z CONTRACT, CONTACT THE CUSTODIAN OF PUBLIC RECORDS, PAM PUMAR, AT 305-292-4459, , c/o MONROE COUNTY EMPLOYEE SERVICES, GATO BUILDING, 1100 SIMONTON ST., KEY WEST FL 33040. CL Section 9. NOTICES Any notice required or permitted under this agreement shall be in writing and hand delivered or Z 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 ru To the CONTRACTOR: Richard L. Dolsey, PHC, Inc. dba Physician's Health Center E 1448 N. Krome Ave., #101 Florida City, FL 33034 0. 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 5 Packet Pg. 158 F.5.a 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 JA r- The CONTRACTOR warrants that it has not employed, retained or otherwise had act on its behalf M 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. cv 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. Fn 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. ru 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 LU 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 6 Packet Pg. 159 F.5.a COUNTY and CONTRACTOR agree to reform the Agreement to replace any stricken provision with a valid provision that comes as close as possible to the intent of the stricken provision. Section 15. ATTORNEYS FEES AND COSTS The COUNTY and CONTRACTOR agree that in the event any cause of action or administrative proceeding is initiated or defended by any party relative to the enforcement or interpretation of this Agreement, the prevailing party shall be entitled to reasonable attorney's fees, and court 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. JA Section 16. BINDING EFFECT .2 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. N Section 17. AUTHORITY Each party represents and warrants to the other that the execution, delivery and performance of LU this Agreement have been duly authorized by all necessary County and corporate action, as required by law. LU 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. CL Section 19. COOPERATION e® In the event any administrative or legal proceeding is instituted against either party relating to the formation, execution, performance, or breach of this Agreement, COUNTY and CONTRACTOR agree to participate, to the extent required by the other party, in all proceedings, hearings, processes, meetings, and other activities related to the substance of this Agreement or provision of the services under this Agreement. COUNTY and CONTRACTOR specifically agree that no party to this Agreement shall be required to enter into any arbitration proceedings related to this Agreement. Section 20. NONDISCRIMINATION COUNTY and CONTRACTOR agree that there will be no discrimination against any person, and it is expressly understood that upon a determination by a court of competent jurisdiction that discrimination has occurred, this Agreement automatically terminates without any further action .2 0. on the part of any party, effective the date of the court order. The parties agree to comply with all LU Federal and Florida statutes, and all local ordinances, as applicable, relating to nondiscrimination. These include but are not limited to: 1) Title VI I 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 7 Packet Pg. 160 F.5.a 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 JA 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 N or state statutes which may apply to the parties to, or the subject matter of, this Agreement. Section 21. COVENANT OF NO INTEREST W cv cv 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 toLU 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 e® The COUNTY and CONTRACTOR warrant that, in respect to itself, it has neither employed nor retained any company or person, other than a bona fide employee working solely for it, to solicit or secure this Agreement and that it has not paid or agreed to pay any person, company, corporation, individual, or firm, other than a bona fide employee working solely for it, any fee, commission, percentage, gift, or other consideration contingent upon or resulting from the award or making of this Agreement. For the breach or violation of the provision, the CONTRACTOR agrees that the COUNTY shall have the right to terminate this Agreement without liability and, at its discretion, to offset from monies owed, or otherwise recover, the full amount of such fee, commission, percentage, gift, or consideration. Section 24. PUBLIC ACCESS The COUNTY and CONTRACTOR shall allow and permit reasonable access to, and inspection .2 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 8 Packet Pg. 161 F.5.a 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 JA 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 N duties of such officers, agents, volunteers, or employees outside the territorial limits of the COUNTY. Section 27. LEGAL OBLIGATIONS AND RESPONSIBILITIES .� cv Non-Delegation of Constitutional or Statutory Duties. This Agreement is not intended to, nor shall it be construed as, relieving any participating entity from any obligation or responsibility imposed upon the entity by law except to the extent of actual and timely performance thereof by any participating entity, in which case the performance may be offered in satisfaction of the obligation or responsibility. Further, this Agreement is not intended to, nor shall it be construed as, authorizing the delegation of the constitutional or statutory duties of the COUNTY, except to the extent permitted by the Florida constitution, state statute, and case law. Section 28. NON-RELIANCE BY NON-PARTIES No person or entity shall be entitled to rely upon the terms, or any of them, of this Agreement to enforce or attempt to enforce any third-party claim or entitlement to or benefit of any service or program contemplated hereunder, and the COUNTY and the CONTRACTOR agree that neither >_ the COUNTY nor the CONTRACTOR or any agent, officer, or employee of either shall have the authority to inform, counsel, or otherwise indicate that any particular individual or group of individuals, entity or entities, have entitlements or benefits under this Agreement separate and apart, inferior to, or superior to the community in general or for the purposes contemplated in this Agreement. Section 29. ATTESTATIONS CONTRACTOR agrees to execute such documents as the COUNTY may reasonably require, including, but not being limited to, a Public Entity Crime Statement, an Ethics Statement, and a Drug-Free Workplace Statement, Lobbying and Conflict of Interest Clause, and Non-Collusion Agreement. Section 30. NO PERSONAL LIABILITY No covenant or agreement contained herein shall be deemed to be a covenant or agreement of .2 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 9 Packet Pg. 162 F.5.a 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 JA 33.1 General Insurance Requirements for Other Contractors and Subcontractors. N 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: • 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 0. 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. 10 Packet Pg. 163 F.5.a The acceptance and/or approval of the Contractor's insurance shall not be construed as relieving the Contractor from any liability or obligation assumed under this contract or imposed by law. The Monroe County Board of County Commissioners, its employees and officials will be included as "Additional Insured" on general liability policies. 33.2 General Liability Insurance Requirements For Contract Between County And Contractor Prior to the commencement of work governed by this contract, the CONTRACTOR shall obtain General Liability Insurance. Coverage shall be maintained throughout the life of the contract and include, as a minimum: v, • Premises Operations .2 • Bodily Injury Liability • Expanded Definition of Property Damage The minimum limits acceptable shall be: $300,000 Combined Single Limit (CSL) cv If split limits are provided, the minimum limits acceptable shall be: $200,000 per Person Z $300,000 per Occurrence ca $ 50,000 Property Damage An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy, its provisions should include coverage for claims filed on or after the effective date of this contract. In addition, the period for which claims may be reported should extend for a minimum of twelve (12) months following the acceptance of work by the County. The Monroe County Board of County Commissioners shall be named as Additional Insured on all policies issued to satisfy the above requirements. 33.3 Workers' Compensation Insurance Requirements Prior to commencement of work governed by this contract, the CONTRACTOR shall obtain Workers' Compensation Insurance with limits sufficient to respond to the applicable state statutes. In addition, the CONTRACTOR shall obtain Employers' Liability Insurance with limits of not less 2 than: $1,000,000 Bodily Injury by Accident $1,000,000 Bodily Injury by Disease, policy limits $1,000,000 Bodily Injury by Disease, each employee 0. 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. ll Packet Pg. 164 F.5.a 33.4 Professional Liability Requirements Recognizing that the work governed by this contract involves the furnishing of advice or services of a professional nature, the Contractor shall purchase and maintain, throughout the life of the contract, Professional Liability Insurance which will respond to damages resulting from any claim arising out of the performance of professional services or any error or omission of the Contractor arising out of work governed by this contract. The minimum limits of liability shall be: $250,000 per occurrence and $750,000 aggregate JA Section 34. INDEMNIFICATION N The CONTRACTOR does hereby consent and agree to indemnify and hold harmless the COUNTY, its Mayor, the Board of County Commissioners, appointed Boards and Commissions, Officers, and the Employees, and any other agents, individually and collectively, from all fines, suits, claims, demands, actions, costs, obligations, attorney's fees, or liability of any kind arising out of the sole negligent actions of the CONTRACTOR or substantial and unnecessary delay caused by the willful nonperformance of the CONTRACTOR and shall be solely responsible and answerable for any and all accidents or injuries to persons or property arising out of its performance of this contract. The amount and type of insurance coverage requirements set forth hereunder shall in no way be construed as limiting the scope of indemnity set forth in this paragraph. Further the CONTRACTOR agrees to defend and pay all legal costs attendant to acts attributable to the sole negligent act of the CONTRACTOR. At all times and for all purposes hereunder, the CONTRACTOR is an independent contractor and not an employee of the Board of County Commissioners. No statement contained in this agreement shall be construed so as to find the CONTRACTOR or any of his/her employees, contractors, servants or agents to be employees of the Board of County Commissioners for Monroe County. As an independent contractor the CONTRACTOR shall provide independent, >_ professional judgment and comply with all federal, state, and local statutes, ordinances, rules and regulations applicable to the services to be provided. The CONTRACTOR shall be responsible for the completeness and accuracy of its work, plan, supporting data, and other documents prepared or compiled under its obligation for this project, and shall correct at its expense all significant errors or omissions therein which may be disclosed. The cost of the work necessary to correct those errors attributable to the CONTRACTOR and any damage incurred by the COUNTY as a result of additional costs caused by such errors shall be chargeable to the CONTRACTOR. This provision shall not apply to any maps, official records, contracts, or other data that may be provided by the COUNTY or other public or semi-public agencies. 2 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 LU between the parties. 12 Packet Pg. 165 F.5.a 0 IN WITNESS WHEREOF, the parties hereto have caused these presents to be executed on the 5th day of October 20 20 0 (SEAL) BOARD OF COUNTY COMMISSIONERS OF MONROE COUNTY, FLORIDA ca Attest: Kevin Madok, CLERK JA By by As Deputy Clerk Mayor/Chairmancu .2 Richard L. Dolsey, PHC, Inc. dba Physician's Health Cen r W by `V K Pa e Chief Operating Officer l' CJ Approved as to form and content: t, Monroe County Attorney's Office 10-5-2020 CL CJ CJ 0 0 76 0 m 0 0. m 13 Packet Pg. 166 F.5.a SECTION ONE SCOPE OF SERVICES EMPLOYMENT PHYSICAL SERVICES a 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 JA significance of each abnormality or written explanation of those results which area outside the normal range. • Examining physician's written recommendation concerning future action on any condition considered outside the normal range. t� • Written recommendation of specific reasonable accommodations in accordance with the ADA. N N SERVICE FEE DRUG SCREEN: When requested, a drug screen will (Collection, Lab, MRO be performed by the physician's tech review) 10 panel State and will be either scheduled or done $45.00 s Requirement on a walk-in basis. DRUG SCREEN: When requested, a drug screen will (Collection, Lab, MRO be performed by the physician's tech z review) 5 panel and will be either scheduled or done $45.00 Department of on a walk-in basis. Transportation Requirement Medical Review Officer The MRO receives lab reports from $5.00 (MRO)REVIEW the laboratory (as governed by regulations); Reviews lab reports for integrity, authenticity, false negatives, and false positives; interprets lab results, including v) verification of lab positives; reports 2 lab reports to the employer(as defined by rules and regulations). BLOOD ALCOHOL When requested, Blood Alcohol (Collection, Lab, MRO Screens will be performed by the o review) physician's tech. and will be either $35.00 0 scheduled or done on a walk-in W basis. After hours testing for post-accident, $175.00 plus E random and reasonable suspicion cost of on- alcohol screen. site services 14 Packet Pg. 167 F.5.a (which is cost of test being performed) BREATH ALCOHOL When requested, may be used for o screening. If breath alcohol screen is $35.00 positive, a blood screen will be performed. After hours testing for post-accident, $175.00 plus random, and reasonable suspicion cost of on- alcohol screening. If breath alcohol site services JA screen is positive, a blood screen will (which is � be performed at the rate designated cost of test above. being performed) PPD- TB screen When requested, a PPD-TB screen will be scheduled and performed by the $25.00 physician's tech. during the facility's normal business hours. HEPATITIS A When requested, a Hepatitis A $82.00 inoculation will be scheduled and performed by the physician's tech. w during the facility's normal business s hours. � HEPATITIS B When requested, a Hepatitis B inoculation(s)will be scheduled and $85.00 x 3 s v) performed by the physician's tech. z during the facility's normal business $40.00 Titer hours. TYPHOID When requested, a Typhoid inoculation will be scheduled and performed by the $70.00 with physician's tech. during the facility's advanced normal business hours. notice TETANUS When requested, a Tetanus inoculation $20.00 will be scheduled and performed by the y physician's tech. during the facility's normal business hours. 0 DIPHTHERIA When requested, a Diphtheria inoculation will be scheduled and $27.00 2 performed by the physician's tech. during the facility's normal business hours. o 61=0 >% E 0 DOT PHYSICAL: When requested, a DOT physical will a. (SEE ATTACHMENT be scheduled and performed by the $45.00 "B" to be completed by physician during the facility's normal employee and physician) business hours. Includes exam and E physician review of employee health history and job description. 15 Packet Pg. 168 F.5.a 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 "A" to be completed by business hours. Includes exam and employee and physician) physician review of employee health history and job description. Physician may also perform a urine drug screen if requested separately by Monroe County BOCC. _ FITNESS FOR DUTY When requested, a Fitness for Duty W PHYSICAL (SEE Physical may be requested at any time ATTACHMENT"A" to be by the employer in the employee's $100.00 completed by employee respective area of work. The exam will and physician) be scheduled during the facility's normal business hours. Includes physician review of employee health history, exam, review of job duties and medical records if necessary. Physician may also perform a urine drug screen if requested separately by z Monroe County BOCC. RESPIRATOR When requested, a Respirator physical PHYSICAL (SEE will be scheduled and performed by the ATTACHMENTS "C" physician during the facility's normal $45.00 for PART I& II to be business hours. Includes exam and physical �C completed by employee physician review of employee health clearance to and physician) history and job description. wear Physician may also perform a urine respirator. drug screen if requested separately by Monroe County BOCC. Also required: Chest X-ray and S irometr . 2 CHEST X RAY Chest X Ray is normally done in conjunction with the Respirator $40.00 physical if there is an issue with the o s iromet results. a. SPIROMETRY Normally done in conjunction with the w Respirator physical. All employees who use a respirator will have a $30.00 Spirometry when hired. Normally done in conjunction with the �t 16 Packet Pg. 169 F.5.a HEARING/AUDIOGRAM appropriate physical. May be requested $20.00 separately by Monroe County BOCC. 76 CHEMICAL Tests Glucose (sugar), kidneys, liver(1 $20.00 PANEL/CMP tube of blood drawn). 0 CBC 2 Test to see if Anemic; if any infections $20.00 within the body; if dehydrated (test from 1 of the tubes of blood drawn). UA DIP Normally done in conjunction with the $15.00 DOT physical. URINE TESTING FOR When requested, a nicotine test will be $If on our s NICOTINE USE performed by the physician's tech. and CCF - $56.00 will be either scheduled or done on a If collection walk-in basis only - $20.00 CD 0 0 0 0 0 0. 0 17 Packet Pg. 170 F.5.a SECTION TWO: COUNTY FORMS AND INSURANCE FORMS LOBBYING AND CONFLICT OF INTEREST CLAUSE --SWORN-ST-AT-EMENTAJNDER-ORDINANCE NO:-0104990 MONROE COUNTY, FLORIDA ETHICS CLAUSE JA r- .2 "RICHARD_L. DOLSEY, PHC, Inc. dba PHYSICIANS HEALTH CENTER" (Company) "...warrants that he/it has not employed, retained or otherwise had act on his/her behalf any W former County officer or employee in violation of Section 2 of Ordinance No. 010-1990 or any `V 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 LU otherwise recover, the full amount of any fee, commission, percentage, gift, or consideration z paid to the former County officer or employee." LU LU (S. - re Date: / I�• ? ca CL STATE OF: CL COUNTY OF: HiCemi- Subscribed and sworn to (or affirmed) before me on (date) by f`C vm (name of affiant). He/She is ersonally known o me or has produced 2 (type of identification) as identification. ��*�►�•., IVIS E.VELUNZA *; MY COMMISSION#GG 930591 ;� NOTARY PUBLI EXP o IRES:November 17,2023 Xrcr Bonded Thfu Notwy Public Underwritws / J] My Commission Expires: a � 18 Packet Pg. 171 F.5.a NON-COLLUSION AFFIDAVIT I Kevin J. Page Florida City, FL of the city of according to law on my oath, and under penalty of perjury, depose and say that 0 rr _ - 1. I am 14,'�� a dT ►�/ of the firm of i[r.41 em M t/ the bidder making the Proposal for the project described in the Request for Proposals for and that I executed the said A proposal with full authority to do so; .2 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 Lu of restricting competition; and ca 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 Lu this affidavit in awarding contracts for said project. rn ___--- (Si t Da �a U CL te: � ' CL STATE OF: COUNTY OF: 0 Subscribed and sworn to (or affirmed) before me on 0 (date) by (name of affiant). He/She is personally known to me or has produced (type of identification) as identification. 0 0. NOTARY PUBLIC 0 My Commission Expires: 19 Packet Pg. 172 F.5.a DRUG-FREE WORKPLACE FORM The undersigned vendor in accordance with Florida Statutes Section 287.087 hereby certifies that: RICHARD_L.DOLSEY. PHC. INC.dba PHYSICIANS HEALTH CENTER -: -_-(Name of Business co 1. Publishes a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace a and specifying the actions that will be taken against employees for violations of such y 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 contenders to, any violation of Chapter 893 (Florida Statutes) or of any controlled substance law of the United States or any state, for a violationLU occurring in the workplace no later than five (5) days after such conviction. LU 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 LU implementation of this section. As the person authorized to sign the statement, I certify that this firm complies fully with the above requirements. '' ature) Date: STATE OF: COUNTY OF: baA Subscribed and sworn to (or affirmed) before me on g 66-1020 (date) by � (name of affiant). He/She s personally known to me or has produced (type of identification) as identification. 0. «*Y"� IVIS E.VELUNZA NOTARY PUBL B`. *_ MY COMMISSION#GG 930591 y Commission Expires: d �✓ , d o a-3 -g.' EXPIRES:November 17,2023 Bonded Thru Notary Public Underwriters 2 Packet Pg. 173 F.5.a PUBLIC ENTITY CRIME STATEMENT "A person or affiliate who has been placed on the convicted vendor list following a conviction for a 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 A vendor list." .2 I have read the above and state that neither RICHARD L. DOLSEY, PHC, INC. dbaCh PHYSICIANS HEALTH CENTER (Contractor's name) nor any Affiliate has been placed on the convicted vendor list within the last 36 months. N Date: 0.2 1,- ,2® � STATE OF: FL COUNTY OF: Subscribed and sworn to (or affirmed) before me on C& ac-) date b �e yi4 I�L�_(date) y (name of affiant). He/She i personally knov�tea t� me CL or has produced (type of identification) as identification. t } NOTARY PUBLIC IVIS E.VELUNZA MY COMMISSION#GG 930591 ��/ I`�r �� o`,= EXPIRES:November17,2023 My Commission Expires: _ FOF F°Q Bonded 7hru Notary Public Underwriters O O O O 0. O O r3 Packet Pg. 174 F.5.a Monroe County Purchasing Policy and Procedures ATTACHMENT D.12 VENDOR CERTIFICATION REGARDING SCRUTINIZED COMPANIES LISTS Project Description(s): Pre-employment physicals Respondent Vendor Name: Richard L. Dorsey PHC, Inc. dba Physicians Health Center CJ Vendor FEIN: 59-2355972 Vendor's Authorized Representative Name and Title: Kevin J. Page, Chief Operating Officer Address: 1448 N Krome Ave., Florida City FL 33034 City: State: Zip: Phone Number: 305-245-0222 Email Address: �Gic��®iYlh1CYL�Y1 t t, Section 287.135,Florida Statutes prohibits a company from bidding on,submitting a proposal for,or entering into �-- or renewing a contract for goods or services of any amount if, at the time of contracting or renewal,the company N is on the Scrutinized Companies that Boycott Israel List, created pursuant to Section 215.4725, Florida Statutes, or is engaged in a Boycott of Israel. Section 287.135,Florida Statutes, also prohibits a company from bidding on, submitting a proposal for,or entering into or renewing a contract for goods or services of$1,000,000 or more,that are on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector Lists which were created pursuant to s.215.473,Florida Statutes,or is engaged in business operations in Cuba or Syria. CJ As the person authorized to sign on behalf of Respondent, I hereby certify that the company identified above in the Section entitled"Respondent Vendor Name"is not listed on the Scrutinized Companies that Boycott Israel List or engaged in a boycott of Israel and for Projects of$1,000,000 or more is not listed on either the Scrutinized Companies with Activities in Sudan List,the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List,or engaged in business operations in Cuba or Syria. I understand that pursuant to Section 287.135,Florida Statutes,the submission of a false certification may subject company to civil penalties, attorney's fees, and/or costs. I further understand that any contract with the County U may be terminated, at the option of the County, if the company is found to have submitted a false certification or = has been placed on the Scrutinized Companies that Boycott Israel List or engaged in a boycott of Israel or placed CL on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List or been engaged in business operations in Cuba or Syria. Certified By: Kevin J. Page who is authorized to sign h® on behalf of the above refere ed co an . Authorized Signature: Print Name: Kev' P Title: Chief Op >Kg Officer Note: The List are-available at the following Department of Management Services Site: htt :;', v.dms.mvflorida.eombusinesserations/state purchasing/vendor information/convicted suspended discriminatory complaints vendor lists 2 Revised BOCC 3/18/2020 .2 0. Page 82 of 92 Packet Pg. 175 F.5.a MONROE COUNTY, FLORIDA RISK MANAGEMENT POLICY AND PROCEDURES CONTRACT ADMINISTRATION MANUAL Indemnification and Hold Harmless For y Other Contractors and Subcontractors .2 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 cv any tier, their employees, or agents. cv In the event the completion of the project (to include the work of others) is delayed or suspended Lu 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 Lu delay. The first ten dollars ($10.00) of remuneration paid to the Contractor is for the indemnification provided for above. Lu The extent of liability is in no way limited to, reduced, or lessened by the insurance requirements contained elsewhere within this agreement. CL 0 0 m 0 0. Lu m 23 Packet Pg. 176 F.5.a WORKERS' COMPENSATION INSURANCE REQUIREMENTS FOR EMPLOYMENT PHYSICAL SERVICES BETWEEN MONROE COUNTY, FLORIDA AND RICHARD L. DOLSEY, PHC, INC. dba PHYSICIANS HEALTH CENTER Prior to the commencement of work governed by this contract, the Contractor shall obtain .2 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 W $500,000 Bodily Injury by Disease, policy limits `V $100,000 Bodily Injury by Disease, each employee `V 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. is 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. c, 0 0 0 m 0 0. m 24 Packet Pg. 177 F.5.a GENERAL LIABILITY INSURANCE REQUIREMENTS FOR EMPLOYMENT PHYSICAL SERVICES BETWEEN MONROE COUNTY, FLORIDA AND RICHARD L. DOLSEY, PHA, INC. dba PHYSICIANS HEALTH CENTER 0 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, 2 as a minimum: • Premises Operations • Products and Completed Operations • Blanket Contractual Liability • Personal Injury Liability `V cv • Professional Liability ' • Expanded Definition of Property Damage The minimum limits acceptable shall be: $1,000,000 Combined Single Limit(CSL) If split limits are provided, the minimum limits acceptable shall be: $ 1,000,000 _per Person _ $ 1,000,000 per Occurrence $_ 300,000 Property Damage V- 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 e® (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. 0 0 0 0 0. 0 25 Packet Pg. 178 F.5.a 0 0 INSURANCE REQUIREMENTS 0 Worker's Compensation $ 1,000,000 Bodily Injury by Acc. o $ 1,000,000 Bodily Inj. by Disease, policy Imts A $ 1,000,000 Bodily Inj. by Disease, each emp. .2 General Liability, including $ 1,000,000 Combined Single Limit _ Premises Operation Products and Completed Operations Blanket Contractual Liability Personal Injury Liability `CD V Expanded Definition of Property Damage `V Professional Liability $250,000 per Occurrence and z Including errors and omissions $750,000 Aggregate LU The Monroe County Board of County Commissioners shall be named as Additional LU insured on general liability policy. CL Fn 0 0 m 0 0. LU m 26 Packet Pg. 179 F.5.b AGREEMENT EMPLOYMENT PHYSICAL SERVICES TABLE OF CONTENTS SECTION ONE - Scope of Services 0 SECTION TWO - County Forms and Insurance Forms ATTACHMENTS: A. Post-offer and Fit for Duty Physical Forms (4 pages) B. DOT Physical (9 pages) C. Respirator Physical 41 -4' ( - pages) c� Rewi pac .2 0 CL Packet,Pg. 180 F.5.b MONROE COUNTY CONTRACT FOR EMPLOYMENT PHYSICAL SERVICES THIS AGREEMENT ("Agreement") is made and entered into this day of , by MONROE COUNTY ("COUNTY"), a political subdivision of the State of Florida, whose address is 1100 Simonton Street, Key West, Florida 33040 and Richard L. Dolsey, PHC, Inc. dba Physicians Health Center ("CONTRACTOR"), whose address is at 1448 N. Krome Ave, Suite 101, Florida City, FL 33034. U 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 N 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. e C. The contractor will provide the required services at the location of: > 1448 N. Krome Ave. Suite 101 Florida City, FL 33034 Phone: 305-245-0222 Fax: 305-246-3700 D. All urine screens will conform with the standard chain of custody protocols mandated by state and federal regulations. E. The Contractor will have an employee designated as coordinator or facilitator to assist in the communications with the Monroe County BOCC's primary contact personnel. 0 F. Appointments will be available throughout the business hours of the facility: Monday — Friday 8:30 a.m. — 5:30 p.m. Walk-ins will also be accepted if CL 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 PHC after Hours Service. • The authorized Human Resources representative or the authorized supervisor shall complete the appropriate forms either the same business day (or by the next business day if the test is after normal working hours) in order for the physician to perform the required test. • After normal working hours the employee will be tested at a location determined at the time of the call. 2 Packet iPg. 181 F.5.b H. Appointments will be seen by the contractor in a reasonable and timely fashion. I. The Contractor will provide the County with at least a 24 — 48 hour turnaround time for the receipt of any drug and/or physical results. J. The Medical Review Officer will be available for contact by the Monroe County BOCC or its employees to answer questions about the effect of prescribed drugs. Part of the requirements set forth by the State of Florida drug free workplace policy, which Monroe County has adopted, and the Department of Transportation, the County must have a qualified Medical Review Officer"MRO" perform drug screening services. The MRO receives lab reports from the laboratory (as governed by regulations); Reviews lab 0 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. .2 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. 2 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. U 3.2 Designate in writing a person with authority to act on the COUNTY'S behalf on all matters U concerning said services. Section 4. TERM OF AGREEMENT 4.1 The term of this contract will be for one (1) year beginning June 10, 2015 and shall E 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 3 Packet;Pg. 182 F.5.b 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. U Section 7. CONTRACT TERMINATION Either party may terminate this Agreement because of the failure of the other party to perform its obligations under the Agreement. Either party may terminate this Agreement without cause upon sixty (60) days' notice to the other party in accordance with Section 9 of this Agreement. The County shall pay CONTRACTOR for all work performed through the date of termination. Section 8. CONTRACTOR'S ACCEPTANCE OF CONDITIONS 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, .2 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. a, 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. 2 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. CL 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. 4 Packet,Pg. 183 F.5.b 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 2 Monroe County in a format that is compatible with the information technology systems of Monroe County. U Section 9. NOTICES W 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 .2 To the CONTRACTOR: Richard L. Dolsey, PHC, Inc. dba Physician's Health Center W 1448 N. Krome Ave., #101 Florida City, FL 33034 . Section 10. RECORDS CONTRACTOR shall maintain all books, records, and documents directly pertinent to performance under this Agreement in accordance with generally accepted accounting principles consistently applied. Each party to this Agreement or their authorized representatives shall have reasonable and timely access to such records of each other party to this Agreement for public records purposes during the term of the agreement and for four years following the termination of this Agreement. 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 CL 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, 5 Packet,Pg. 184 F.S.b 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 0 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 y 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 .2 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 0 U 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 CL 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. 6 Packet,Pg. 18`5 F.5.b Section 17. AUTHORITY Each party represents and warrants to the other that the execution, delivery and performance of this Agreement have been duly authorized by all necessary County and corporate action, as required by law. Section 18. ADJUDICATION OF DISPUTES OR DISAGREEMENTS COUNTY and CONTRACTOR agree that all disputes and disagreements shall be attempted to be resolved by meet and confer sessions between representatives of each of the parties. If the issue or issues are still not resolved to the satisfaction of the parties, then any party shall have the right to seek such relief or remedy as may be provided by this Agreement or by Florida law. This Agreement shall not be subject to arbitration. Section 19. COOPERATION In the event any administrative or legal proceeding is instituted against either party relating to the formation, execution, performance, or breach of this Agreement, COUNTY and CONTRACTOR agree to participate, to the extent required by the other party, in all proceedings, hearings, processes, meetings, and other activities related to the substance of this Agreement or provision of the services under this Agreement. COUNTY and CONTRACTOR . specifically agree that no party to this Agreement shall be required to enter into any arbitration proceedings related to this Agreement. _ Section 20. NONDISCRIMINATION COUNTY and CONTRACTOR agree that there will be no discrimination against any person, 2 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 2 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 �i 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 CL 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. 7 Packet,Pg. 186 F.5.b 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 0 comply with the standards of conduct for public officers and employees as delineated in Section 76 112.313, 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 SOLICITATIONIPAYMENT 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 Mona fide employee working solely for it, any fee, commission, percentage, gift, or other consideration contingent upon or resulting from the award .2 or making of this Agreement. For the breach or violation of the provision; the CONTRACTOR agrees that the COUNTY shall have the right to terminate this Agreement without liability and, at _ its discretion, to offset from monies owed, or otherwise recover, the full amount of such fee, commission, percentage, gift, or consideration. Section 24. PUBLIC ACCESS The COUNTY and CONTRACTOR shall allow and permit reasonable access to, and inspection of, all documents, papers, letters or other materials in its possession or under its control subject to the provisions of Chapter 119, Florida Statutes, and made or received by the COUNTY and CONTRACTOR in conjunction with this Agreement; and the COUNTY shall have the right to unilaterally cancel this Agreement upon violation of this provision by CONTRACTOR. Section 25. NON-WAIVER OF IMMUNITY Notwithstanding the provisions of Sec. 768.28, Florida Statutes, the participation of the COUNTY and the CONTRACTOR in this Agreement and the acquisition of any commercial liability insurance coverage, self-insurance coverage, or local government liability insurance U pool coverage shall not be deemed a waiver of immunity to the extent of liability coverage, nor CL shall any Agreement entered into by the COUNTY be required to contain any provision for waiver. Section 26. PRIVILEGES AND IMMUNITIES E 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. 8 Packet,Pg. 187 i F.5.b 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. 0 Section 28. NON-RELIANCE BY NON-PARTIES No person or entity shall be entitled to rely upon the terms, or any of them, of this Agreement to enforce or attempt to enforce any third-party claim or entitlement to or benefit of any service or program contemplated hereunder, and the COUNTY and the CONTRACTOR agree that neither the COUNTY nor the CONTRACTOR or any agent, officer, or employee of either shall have the authority to inform, counsel, or otherwise indicate that any particular individual or group of individuals, entity or entities, have entitlements or benefits under this Agreement separate and apart, inferior to, or superior to the community in general or for the purposes contemplated in this Agreement. y Section 29. ATTESTATIONS .N 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 U Drug-Free Workplace Statement, Lobbying and Conflict of Interest Clause, and Non-Collusion Agreement. 0 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 0 regarded as an original, all of which taken together shall constitute one and the same instrument U 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 E only, and it is agreed that such section headings are not a part of this Agreement and will not be used in the interpretation of any provision of this Agreement. Section 33. INSURANCE POLICIES 33.1 General Insurance Requirements for Other Contractors and Subcontractors. As a pre-requisite of the work governed, the CONTRACTOR shall obtain, at his/her own expense, insurance as specified in any attached schedules, which are made part of this 9 Packet iPg. 188 F.5.b 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: U • 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. U The Monroe County Board of County Commissioners, its employees and officials will be CL 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 10 Packet,Pg. 189 F.5.b 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 0 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 .2 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. ca In addition, the CONTRACTOR shall obtain Employers' Liability Insurance with limits of not less than: 2 $1000,000 Bodily Injury by Accident $ W 1 000,000 Bodily Injury by Disease, policy limits $1 o 00,000 Bodily Injury by Disease, each employee Coverage shall be maintained throughout the entire term of the contract. Coverage shall be provided by a company or companies authorized to transact business in the state of Florida. 33.4 Professional Liability Requirements Recognizing that the work governed by this contract involves the furnishing of advice or services CL 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 11 Packet;Pg. 190 F.5.b 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. U 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. 0 CL 12 Packet iPg. 191 F.5.b IN WITNESS WHEREOF, the parties hereto have caused these presents to be executed on the day of 20_. (SEAL) BOARD OF COUNTY COMMISSIONERS OF MONROE COUNTY, FLORIDA Attest: 4yin Madok, CLERK 0 76 By by Deputy Clerk Mayor/Chairman (CORPORATE SEAL) ATTEST: Richard L, Dolsey, PHC, Inc. dba Physician's Health Center Print name by Title: .2 1 Packet;Pg. 192 F.5.b 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. a • 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 DRUG SCREEN: When requested, a drug screen will (Collection, Lab, MRO be performed by the physician's j review) 10 panel State tech and will be either scheduled $ :W445�t Requirement or done on a walk-in basis. btu rg..t � .. �..4. DRUG SCREEN: When requested, a drug screen will (Collection, Lab, MRO be performed by the physician's review) 5 panel tech and will be either scheduled or 4f,w,. 9 0() .......... Department of done on a walk-in basis. Transportation Re uirement CL peffe e d 1 Medical Review Officer The MRO receives lab reports $5.00 (MRO) REVIEW from the laboratory (as governed by regulations), Reviews lab l Packet iPg. 193 F.5.b 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). BLOOD ALCOHOL When requested, Blood Alcohol (Collection, Lab, MRO Screens will be performed by the review) physician's tech. and will be either $35.00 0 scheduled or done on a walk-in basis. After hours testing for post- $175.00 plus accident, random and reasonable cost of on-site suspicion alcohol screen. services (which is cost of test being performed) a BREATH ALCOHOL When requested, may be used for screening. If breath alcohol screen is $35.00 positive, a blood screen will be .2 performed. After hours testing for post- $175.00 plus -- accident, random,and reasonable cost of on-site suspicion alcohol screening. If services -- breath alcohol screen is positive, a (which is cost blood screen will be performed at the of test being rate designated above. performed) PPD- TB screen When requested, a PPD-TB screen will be scheduled and performed by $25.00 the physician's tech. during the facilit 's normal business hours. HEPATITIS A When requested, a Hepatitis A $82.00 inoculation will be scheduled and performed by the physician's tech. during the facility's normal business hours. HEPATITIS B When requested, a Hepatitis B CL inoculation(s) will be scheduled and $72L00 _ 0.9. x performed by the physician's tech. 3 during the facility's normal business hours. $40.00 Titer TYPHOID When requested, a Typhoid inoculation will be scheduled and $ -.` 70,00 performed by the physician's tech. with 'INN anced during the facility's normal business ¢I tic hours. TETANUS When requested, a Tetanus $20.00 inoculation will be scheduled and 15 Packet iPg. 194 F.S.b performed by the physician's tech. during the facility's normal business hours. DIPHTHERIA When requested, a Diphtheria inoculation will be scheduled and $27.00 performed by the physician's tech. during the facility's normal business hours. DOT PHYSICAL: When requested, a DOT physical will 0 (SEE ATTACHMENT be scheduled and performed by the $45.00 "B" to be completed by physician during the facility's normal employee and physician) business hours. Includes exam and a 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 y physician. Physician may also perform a urine drug screen if requested separately by Monroe Count BOCC. POST-OFFER When requested, a post-offer physical PHYSICAL: will be scheduled and performed by (SEE ATTACHMENT the physician during the facility's $50.00 "A" to be completed by normal business hours. Includes employee and physician) exam and physician review of > employee health history and job description. Physician may also perform a urine drug screen if requested separately by Monroe County BOCC. FITNESS FOR DUTY When requested, a Fitness for Duty PHYSICAL (SEE Physical may be requested at any time ATTACHMENT "A" to be by the employer in the employee's $100.00 completed by employee respective area of work. The exam and physician) will 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. E 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 ATTACHMENTS "C" the physician during the facility's $45.00 for PART I & II to be normal business hours. Includes 1 physical 16 Packet iPg. 195 F.5.b completed by employee exam and physician review of clearance to and physician) employee health history and job wear description. respirator. Physician may also perform a urine drug screen if requested separately by Monroe County BOCC. Also required: Chest X-ray and S irometr . CHEST X RAY Chest X Ray is normally done in 0 conjunction with the Respirator $40.00 physical if there is an issue with the s iromet results. SPIROMETRY Normally done in conjunction with the Respirator physical. All employees who use a respirator will $30.00 have a Spirometry when hired. Normally done in conjunction with a IIEARING/AL1DIOGRAM the appropriate physical. May be $20.00 Ch requested separately by Monroe County BOCC. .N CHEMICAL Tests Glucose (sugar), kidneys, liver $20.00 PANEL/CMP 1 tube of blood drawn). CBC 2 Test to see if Anemic; if any $20.00 infections within the body; if dehydrated (test from 1 of the tubes of blood drawn). UA DIP Normally done in conjunction with $15.00 the DOT physical. URINE TESTING FOR When requested, a nicotine test will $-i- ,001 f O� NICOTINE USE be performed by the physician's tech. a. it CC[, and will be either scheduled or done . ➢ on a walk-in basis only m $20.00 0 CL 17 Packet;Pg. 196 F.5.b 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 U "RICHARD L. DOLSEY, PHC, Inc. dba PHYSICIANS HEALTH CENTER" (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." (Signature) Date: > STATE OF: COUNTY OF: Subscribed and sworn to (or affirmed) before me on 0 (date) by (name of affiant). He/She is CL personally known to me or has produced (type of identification) as identification. NOTARY PUBLIC My Commission Expires: 18 Packet iPg. 197 i F.5.b NON-COLLUSION AFFIDAVIT 1, of the city of according to law on my oath, and under penalty of perjury, depose and say that 1. 1 am of the firm of the bidder making the Proposal for the project described in the Request for Proposals for and that I executed the said proposal with full authority to do so; U 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 .2 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. �-- 0 (Signature) Date: STATE OF: COUNTY OF: Subscribed and sworn to (or affirmed) before me on CL (date )} by (name of affiant). He/She is personally known to me or has produced (type of identification) as identification. NOTARY PUBLIC My Commission Expires: 19 Packet iPg. 198 F.5.b DRUG-FREE WORKPLACE FORM The undersigned vendor in accordance with Florida Statutes Section 287,087 hereby certifies that: RICHARD L. DOLSEY, PHC, INC. dba PHYSICIANS HEALTH CENTER (Name of Business) 1. Publishes a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition. U 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 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. .2 As the person authorized to sign the statement, I certify that this firm complies fully with the > above requirements. E (Signature) Date: STATE OF: COUNTY OF: CL Subscribed and sworn to (or affirmed) before me on (date) by (name of affiant). He/She is personally known to me or has produced (type of identification) as identification, NOTARY PUBLIC My Commission Expires: 20 PacketiPg. 199 F.5.b 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." 0 U I have read the above and state that neither RICHARD L. DOLSEY PHC INC. dba PHYSICIANS HEALTH CENTER (Contractor's name) nor any Affiliate has been placed on the convicted vendor list within the last 36 months. (Signature) Date: .2 STATE OF: c, COUNTY OF: 0 Subscribed and sworn to (or affirmed) before me on (date) by (name of affiant). He/She is personally known to me or has produced (type of identification) as identification. NOTARY PUBLIC 0 My Commission Expires: CL I Packet;Pg. 200 F.5.b 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 Ch 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 .2 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. 0 CL 22 Packet;Pg. 20'1 F.5.b WORKERS' COMPENSATION INSURANCE REQUIREMENTS FOR EMPLOYMENT PHYSICAL SERVICES BETWEEN MONROE COUNTY, FLORIDA AND RICHARD L. DOLSEY, PHC, INC. dba PHYSICIANS HEALTH CENTER 0 U 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 y Coverage shall be maintained throughout the entire term of the contract. .2 Coverage shall be provided by a company or companies authorized to transact business in the _ state of Florida. If the Contractor has been approved by the Florida's Department of Labor, as an authorized self-insurer, the County shall recognize and honor the Contractor's status. The Contractor may be required to submit a Letter of Authorization issued by the Department of Labor and a Certificate of Insurance, providing details on the Contractor's Excess Insurance Program. If the Contractor participates in a self-insurance fund, a Certificate of Insurance will be required. In addition, the Contractor may be required to submit updated financial statements from the fund upon request from the County. 23 Packet;Pg. 202 F.5.b GENERAL LIABILITY INSURANCE REQUIREMENTS FOR EMPLOYMENT PHYSICAL SERVICES BETWEEN MONROE COUNTY, FLORIDA AND RICHARD L. DOLSEY, PHA, INC, dba PHYSICIANS HEALTH CENTER 0 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 a, include, as a minimum: • Premises Operations • Products and Completed Operations • Blanket Contractual Liability • Personal Injury Liability • Professional Liability y • Expanded Definition of Property Damage .2 The minimum limits acceptable shall be: 1 000 Combined Single Limit (CSL) U If split limits are provided, the minimum limits acceptable shall be: .2 per Person > $ 1, ,'000 per Occurrence E $� 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. CL 24 Packet iPg. 203 F.5.b INSURANCE REQUIREMENTS Worker's Compensation $_1 ,000.0_00 Bodily Injury by Acc. $_WI,QQQ 0,00 Bodily Inj. by Disease, policy Imts U $ r1,000,000 Bodily Info by Disease, each emp. I � General Liability, including $ 1,000 000_____ Combined Single Limit Premises Operation Products and Completed Operations Blanket Contractual Liability Personal Injury Liability Expanded Definition of Property Damage .2 Professional Liability $250;000 per Occurrence and Including errors and omissions $750,000 Aggregate The Monroe County Board of County Commissioners shall be named as Additional �-- insured on general liability policy- 25 Packet iPg. 204 F.5.b DATE OF E MEDICAL RECORD REPORT OF MEDICAL EXAMINATION 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 ASIANIPACIFIC ❑WHITE ❑BLACK ® ALASKA NATIVE ® WHITE ® BLACK ® ISLANDER 12a.AGENCY 12b.ORGANIZATION UNIT 13.TOTAL YEARS GOVERNMENT SERVICE a.MILITARY b.CIVILIAN O U 14.NAME OF EXAMINING FACILITY OR EXAMINER.AND ADDRESS 15.RATING OR SPECIALTY OF EXAMINER 16.PURPOSE OF EXAMINATION 17.CLINICAL EVALUATION Ca MARL- (Check each item in appropriate column,enter"NE"if not evaluated) ABMAA R' NMOAR- (Check each item in appropriate column,enter'NE"ifnot evaluated) A MALR. A.HEAD,FACE,NECK AND SCALP 0.PROSTATE(Over40 or clinically indicated) B EARS-GENERAL(INTERNAL CANALS) P.TESTICULAR (Auditory acuity under items 39 and 40) 0.ANUS AND RECTUM(Hemorrhoids,Fistulae)(Hemocult Results) N C DRUMS(Perforation) R.ENDOCRINE SYSTEM D NOSE S.G-U SYSTEM 2 E,SINUSES T.UPPER EXTREMITIES(Except feet)(Strength,range of motion) N F MOUTH AND THROAT U.FEET CL G.EYES-GENERAL(Visual acuity and refraction underitems 28,29.and 38 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 C 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 abnormakly in detail Enter pertinent item number before each comment.Continue in item 42 and use addrb'onad sheets if necessary) U O 18 DENTAL(Place appropriate symbols,show in examples,above orbelow number ofupper and lower teeth.) REMARKS AND ADDITIONAL DENTAL o 1 Nat X X X X Replaced ( X +- Fucrzd DEFECTS AND DI SEAS ES } � Restorable 1 2 3 1 2 3 Missing h 2 3 1 2 �3 restorable le by Panic_ CL 32 31 30 Teeth 32 31 30 32 31 30 Teeth 32 31 30 32 31 30 0 ! Teeth X X X X Mures ( X N DenFAlre� R L O 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 E H 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 F T T 19.TEST RESULTS lCoples of results are preferred as attachments O A.URINALYSIS:(1)SPECIFIC GRAVITY B.CHEST X-RAY OR PPD(Place,date,firm 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 10-94)(EG) 88-126 Prescribed by G$A/ICMR FiRMR(41 CFR)201-9,202-1 Designed using Perform Pro.WHS/DIOR,Jan 97 Packet iPg. 205 F.5.b NAME IDENTIFICATION NO.OF SHEETS ATTACHED MEASUREMENTS AND OTHER FINDINGS 20 HEIGHT 21.WEIGHT 22,COLOR HAIR 123.COLOR EYES 124 BUILD 25 TEMPERATURE ®SLENDER ®MEDIUM ®HEAVY ®OBESE 26.BLOOD PRESSURE(Arm at heart level) 27.PULSE(Arm at heart level) A. SYS. REa SYS. STANDING SYS. A.SITTING B.RECUMBENT C,STANDING(3mins.) D.AFTER EXERCISE E.2 MINE.AFTER SITTING DIAS. BENT DIAS. (5 MINS.) DIAS. 28.DISTANT VISION 29 REFRACTION 30.NEAR VISION RIGHT 201 CORR,TO 201 BY S. CX CORR.TO BY LEFT 201 CORR,TO 201 IBY S. CX CORR,TO BY 31.HETEROPHORIA(Specify distance) PRISM CONV. ESO EXO R.H. L.H. PRISM DIV CT PC PD U 32 ACCOMMODATION 33.COLOR VISION(Test used and result) 34.DEPTH PERCEPTION UNCORRECTED (Test used and score) RIGHT LEFT CORRECTED 0) 35.FIELD OF VISION 36.NIGHT VISION(Test used and resulf) 37.RED LENS TEST 38,iNTRAOCULAR TENSION RIGHT LEFT RIGHT LEFT 39.HEARING 40,AUDIOMETER 41.PSYCHOLOGICAL AND PSYCHOMOTOR{Tests used and score) 0) RIGHT W111 115SV 115 250 1 500 1000 2000 3000 4000 6000 8000 256 512 1024 2048 2896 4096 6144 8192 0) (J LEFTW/V 115SV 115 FLEFT 42 NOTES(Continued)AND SIGNIFICANT OR INTERVAL HISTORY .2 OL (J OL C Q e (Use additional sheets if necessary) 0) 43 SUMMARY OF DEFECTS AND DIAGNOSES(Clef diagnoses with item numbers) U 44 RECOMMENDATIONS-FURTHER SPECIALIST EXAMINATIONS INDICATED(Specify) 45A PHYSICAL PROFILE O P U L H E S (J 46.EXAMINEE(Check) OL A ®IS QUALIFIED FOR In accordance with attached job description. 458 PHYS CAL CATEGORY 2 B IS NOT QUALIFIED FOR 4T IF NOT QUALIFIED LIST DISQUALIFYING DEFECTS BY ITEM NUMBER A B C E 48 TYPED OR PRINTED NAME OF PHYSICIAN SIGNATURE U 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) Packet;Pg. 206 F.5.b NO.OF ATTACHED SHEETS; MEDICAL RECORD REPORT OF MEDICAL HISTORY 1.NAME OF PATIENT (Last first middle) 2.IDENTIFICATION NUMBER 4a.HUME STREET ADDRESS (Street orCity or I own;State;an e . Zil U U U 7.STATEMENT OF PATIENTS PRESENT HEALTH AND MEDICATIONS CURRENTLY USED (Use additional pages if necessary) a b.CURRENT MEDICATION C U U U c.ALLERGIES Onclude insect bites/siings and common foods)8.PATIENT'S OCCUPATION N RIGHT HANDED LEFT HANDED N CHECK EACH ITEM YES NO DON T CHECK EACH ITEM YES NO ANT CHECK EACH ITEM YES NO DONT KNOW KNOW KNOW Household contact with anyone ortness a r 6-re-a-tF Bone,joint or otEer a rmr W with tuberculosis Pain or pressure in chest Coss of finger or toe Tuberculosis or positive TB test Chronic coug Painful or"trick"shoulder — Blood In sputum or when Palpitation or pounding heart or elbow U coughing > Heart-t-roulAe Recurrent back pain or any Excessive bleeding after injury or g or loamblER pressure back injury dental work ramps in your legs I ric or locked knee U Suicide attempt or plans rrequent in igestion Foot trouble sm Sleepwalking tomac ,+veror intestinal trou a erve njury Wear corrective lenses Gall bladder trouble or Paralysis (including infantile) Eye surgery to correct vision gallstones pi epsyor seizure Lack vision in eit er eye laundice or hepa itis Car,tram,sea or air sickness U Wear a hearing aia ro en nes requent trou e s eep ng -Stutter or stammer -Adverse reaction to medication Depression or excessive worry U ear a race or BacR support n iseases Loss of memory or amnesia Ca ca et fever I umor,growth,cyst,cancer ervous trouble of any sort Rheumatic fever Pernia Periodso unconsciousness CL swollen or pain loins RemoRoids or rectal disease Parent/sibling with diabetes, Frequent or severe heaaacKes Frequent or Painful urination cancer,stroke or heart disease Dizziness or rainting spells wett ng since age 12 T--ra-y or of er m at on t erapy Eye trou a Maney stone or MR i uunne Lnernotherapy Hearing loss Sugar or albumin in urine Asbestos or toxic chemical U Recurrent ear infections SexualiVy transmittedili—seases exposure Chronic or frequent colds Recent gain or loss o weig Plate,p-1n-0-rr0dTn any bone Severe tooth or gum trouble Eating disorder(anorexia bulimia, sYfalgability Sinusitis etc) Been told to tut down or Ray rever or allergic rhinitis Arthritis,Rheumatism,or criticized for alcohol use Reaa injury Bursitis Used illegal substances Asthma hyroid trouEle or goiter 1:015acco NSN 7540-00-181-8368 Previous edition not usable Prescribed by ICMR/GSA FIRMR(41 CFR)20".202-1 Packet iPg. 207 i F.5.b 11.FEMALES ONLY DON'T UAIL01- DATE DATE CHECK EACH ITEM YES NO KNOW KNOW ?ER1O0 GRAM Treated for a female disorder N/A N/A N/A N/A Change in menstrual pattern N/A CHECK EACH ITEM.IF7=FaW WTM W5WE FO RIGHI.LIST ExPU9TATFMWM TIR NUMBEFE ITEM - 12.Have you been refused employment or been unable to hold a job or stay in school because of. U a.Sensitivity to chemicals,dust sunlight,etc. ¢ b.lnabi ity to perform certain motions. c.Inability to assume certaln positions. er me ;ca reasons s yes,g ve reasons:,. (t3 13.Have you ever been treated for a mental condition? (If yes,specify when,where,and give details.) � 14.Have you ever been denied life insurance? (If yes,state reason and give details.) 1 S.Have you had,or have you been advised to have,any operation. (Ifyes,describe and give age at which occurred.) Ca ] 11" o- specify when,where,why,and name of doctor and complete address of hospital.) 17.Have you consulted or been treated by clinics,physicians,healers, N or other practitioners within the past 5 years for other than minor illnesses? Of yes,give complete address of doctor,hospital,clinic,and m details.) physical,mental,or other reasons? (If yes,give date and reason for rejection.) 19.Have you ever been discharged from military service because of `L physical,mental,or other reasons? (if yes,give date,reason,and Ca type of discharge;whether honorable,other than honorable,for unfitness or unsuitability.] CL . -awk you ever receive 5 Invie"pen g,-or nave you ever apple- for pension or compensation for existing disability? (Ifyes,specify what kind,granted by whom,and what amount when,why.) .2 21,Have you ever been arrested or convicted of a crime,other than minor traffic violations. of yes,provide details.) NA > 22.Have you ever been diagnosed with a learning disability? ¢fyes, s give type,where,and how diagnosed.) or clinics mentioned above to furnish the Government a complete transcript of my medical record for purposes of processing my application for this employment or service.I ¢ nry understand that falsification of information on Govemment forms is punishable by fine and/or imprisonment. NO I U ' TJ Physician snall comment n all positive answers in Items through develop by interview any additional medical history deemed important,and record any significiant findings here.) CIL m (REV.6A6) Packet;Pg. 208 Form MCSA-WS okte Ill 2tzs�000e 6rWraeart Darr. pwk swidm stator Wa AFedor!agancrMWfWomrdMaspauar,anda palm nknotngllwdmreapmrdto norahaaapenesbe mapenaltyfmGOunmeenrp�rankhaeoaecuanaikrbrntatbnarbjecttosire the PapnwoikaaductrerrActunreaslutcokcdonoflnramatmndkp4patarrrentwkd0WQn dNro"TM0MeGNOWnwnbarrathkIMomwdmcoaectbnh212&OWPueacrgmrrktp(rditt*Oetion� atkOWwwdoekeowaudtobeapprc&rAi l'25.,*maperrhporm illjor4themneimnsomft"MucowAgg*mkgtkedatamededandeanpktkgr�dreeMwtnytMmOecikna[inbmwdon.Aa men repillinift to ft coftel afink"rrat;Mammandatory,Sad aonralregeidrgrheatwrdenutknauorutrotheraspectdtfriaoolkalanorirdarnntlorcbtdudMrgttggeatratnfcrreducktptlrlstarrdartaoc Ydarmadon Cehttlon oeannteoff�fedoras MomrCarla 5+4tyAd�.Mtlstratbr4 ktC•NRiI t200NeKhrtgA+Rnue.SE.watkkgtutc RG ZOd90. FFeld«°;rIu �P°"'�°^ Medical Examination Report Form Safetylldminhitratim (for CommeRWCrImMe kalCerli aft) MEDICAL RECORD ff SECTION 1.Driver Information(to be&Ned out by the driver) (or sticker) 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 OF E mail(optional): CLP/CDL Applicant/Holdera: Q Yes ONO Driver ID Verified Byi Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2years? Yes O No O Not Sure •CLTImLApplonlAlNderSeekdfwrctloleterdeM1dtMer "DdrerlQYedlkd6 RemidwlmttrpeafpbttogruslaaEtnrnrr4ieldtnlrtorNeddreta9.C4t.ddrefsMrrnsef�P .2 CL Have u ever had surgery?If W you rgery "yes. please list and explain below. O Yes ONO Q Not Sure I Are you currently taking medications(prescnptlon,over-the-coun(er,herbalrernedres;diet supplements)? QYes O NoO Nat Sure If"yes,"please describe below. i 0 CL 2 (Attach additional sheets ifnecessary) "`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 authadzed persons.Properly dispose of this document when no longer required to be anaintained by regulatory requirements" Page 1 Packet iPg. 209 F.5.b FemMCSA•sa7'3 oMM&21260M EVWM1onDikt 11/30/2021 Lasf Name First Name: DOB: Exam Date: �.._._ Not Not Doyou have or have you mr had: Yes No Sure Yes No Sure 1.Head/braln injuries or Illnesses(e.g concussion) Q Q Q 16.Dizziness,headaches,numbness,tingling,or memory 0 0 O 2.Seizures,epilepsy O O O loss 3.Eye problems(exceptglassesorcontacts) O O O 17.Unexplained weight loss O O 0 1 B.Stroke.mini-stroke(TIA),paralysis,or weakness UM 4.Ear and/or hearing problems D Q D O O O 5.Heart disease,heart attack,bypass,or other heart O O O 19.Missing or limited use of arm,hand,finger,leg,font,toe Q Q 0 problems 20.Neck or back problems O O O ou b.Pacemaker,scents,implantable devices,or other heart Q O Q 21.Bone,muscle,joint,or nerve problems Q Q Q procedures 22.Blood clots or bleeding problems 0 O O 7.Nigh blood pressure Q O O 23.Cancer 0 O O S.High cholesterol O O O 24.Chronic(long-terml Infection or other chronic diseases Q O O 9.Chronic(long-term)cough,shortness of breath,or other Q Q Q breathing problems 25.Sleep disorders,pauses in breathing while asleep, 0 O Q daytime sleepiness,loud snoring 10.Lung disease(eg,asthma) O O O 26.Have you ever had a sleep test(e.g,sleep apnea)? O Q Q 11.Kidney problems,kidney stones,or pain/problems with O O O 27.Have you ever spent a night in the hospital? 0 O O urination 12.Stomach,liver,or digestive problems O O 0 28.Have you ever had a broken boned Q O 0. y 13.Diabetes or blood sugar problems 0 O O 29.Have you ever used or do you now use tobacco? Q Q O Insulin used O O O 30.Do you currently drink alcohol? 0 O O 31.Have you used an Illegal substance within the past two O O O 14.Anxiety, pression,nervousness,other mental health O O O years? p CL 15.Fainting or passing out 32.Have you ever failed a drug test or been dependent on O O 0 O Q Q an illegal substance? Other health condition(s)not described above: Q Yes O No Q Not Sure Did you answer'yes'to any of questions 1-32?If so,please comment further on those health conditions below. Oyn ONO 0 Not s (Attach additional sheets if necessary) 0 U 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 Examiners Certificate,that submission of fraudulent or intentionally false Information Is a violation of 4 -CfR 390.35CL ,and that submission of fraudulent or intentionally false information may subject me to civil or criminal penalties under 42 CfR 39U7 and 42. Appendices A and B. - Driver's Signature: Date. m SECTION 2.Examination Report(to be filled out by the medical examiner) s° s• Revfewand discuss perrinent drrveranswers and anyavailable medical records.Commenton the dnver%responses to the`health history'questions tharmoy affect the driver's safe ope►atbn ofa commercial motorvehicle(CM10 (Attach additional sheets if necessary, Packet iPg. 210 F.5.b Fenn MCSA-Se75 OMB Na 2126-0005 Fxpiration Date:I Last Name: First Name: DOB: Exam Date P u1se rate: Pulse rhythm regular.Q Yes Q 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 moy be an indication for further testing to rule our any underlying medical problem. U IL- Vision Hearing Standard is at least 20140 acuity(5nellen)in each eye with or without correction.At Standard:Must first perceive whispered voice at not less than 5 feet OR overage least 70'field of vision in horizontal meridian measured in each eye.The use ofcor- hearing loss of less than o►equal to 40 dl f in better ear(w:rh or without hearing aid).. ►ective 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 U Whisper Test Results Right Ear left Ear Right Eye: 20/ 20/_ Right Eye: degrees Record distance(in feed 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 reco gnize ognize and distinguish among traffic control 00 AudiomatricTest Results signals and devices showing red,green,and amber colors Right Ear Left Ear `2 Monocular vision 00 S00 Hz 1000 Hz 20DO Hz 500 Hz 1000 Hz 2000 Hz Referred to ophthalmologist or optometrist? 00 Received documentation from ophthalmologist or optometrist? 00 Average(right): Average(left); CL • ji 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. > AIM 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. BodySystern Normal Abnormal Body System Normal Abnormal 1.General Q Q 8.Abdomen Q Q 2.Skin Q Q 9.Genito-urinary system Including hernias Q Q 3.Eyes Q Q 10.Back/Spine Q Q 4.Ears p Q 11.Extremities/joints Q Q S.Mouth/throat Q Q 12.Neurological system including reflexes Q Q 6.Cardiovascular Q Q 13.Gait Q Q 7.Wngs/chest Q O 14.Vascular system Q O Discuss any abnormal answers in derail in the space below and indicate whether it would affect the driver's ability to operate a CMV. CL Enter applicable item number before each comment, (Attach additional sheers if essaryy lsa e 3 Packet iPg. 211 F.5.b For1nMC3A-feyf 0M0No.21264X106 ExpkadmDate: Iasi Name: First Name: D08: Exam Date: Please complete only one of the following(Federal or State)Medical EKaminer Determination sections, MEDICAL EXAMINER DETERMINATION Use this section for examinations performed in accordance with the red ral Motor Carrier Safety Regulations(40,( FR 0 Does not meet standards(specify reason) Q Meets standards in 4 ;$.. . qualifies for 2-year certificate Q Meets standards,but periodic monitoring required(specify reason): Driver qualified for. Q 3 months Q 6 months O 1 year O other(specify): ❑Wearing corrective lenses ❑Wearing hearing aid ❑Accompanied by a waiver/exemption(specify type): ❑ Accompanied p by a Skit!Performance Evaluation(SPFa Certificate El Qualified by operation of 49,CFR ❑Driving within an exempt intracity zone(see j {,-,FR j !,,,, j jodVrQ.Q ❑Determination pending(specifyreason): ❑Return to medical exam office for follow-up on(must be 45 days or less): ❑Medical Examination Report amended(specifymoson) (ifamendedl Medical Examiners Signature: Date: []Incomplete examination(specifyreason): If the driver meetsthe standards eudined In 41M, VA1;then complete a Medial hambter's CertiRcate as stated in as appropriate. I have performed this evaluation for certification.I have personally reviewed all available records and recorded information pertaining to this evaluation, .2 and attest that to the best of my knowledge I believe it to be true and correct a, Medical Examiners Signature: U Medical Examiners Name(please print or type): Medical Examiners Address: City: State: Zip Code: Medical ExaminersTelephone Number. Date Certificate Signed: Medical Examiners State Ucense,Certificate,or Registration Number: Issuing State: ❑MO ❑DO ❑Physician Assistant ❑Chiropractor ❑Advanced Practice Nurse ❑Other Practitioner(specify) National Registry Number. Medical Examiners Certificate Expiration Date .N 0 CL U 2 Page a Packet iPg. 212 F.5.b FoM MOA-Sps OMB No.212 EgAmUm date:I Las[Name: First Name: B:_____:Exam Date: Use this section for examinations performed in accordance with the Federal MotorCarrier Safety Regulations C .341 v igh anyaop ii able State voria aces(which wili my be valid for intrastate operations). Q Does not meet standards in L40 with any applicable State variances(specify reason): Q Meets standards in 49_CFR 391.41 with any applicable State variances t'Meets standards,but periodic monitoring required(specify reason): Driver qualified for: O 3 months O ti months C) 1 year O other(specify): ❑Wearing corrective lenses ❑Wearing hearing aid ❑Accompanied by a waiver/exemption(specify type): ❑Accompanied by a Skip Performance Evaluation(SPE)Certificate ❑Grandfathered from State requirements(State) If the dram meetsthe standads entlined In QR —j%M with b(e State vadaaaes,then co e app�ca nrplete a Medical fxanriner's GrtitkaM,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: °a Medical Examiner's Name(please print or type}: Medical Examiners Address: City: State: Zip Code. y Medical Examinerslelephone Number: Date Certificate Signed: .2 Medical Examiner's State License,Certificate,or Registration Number: Issuing State: ❑MO ❑DO ❑Physician Assistant ❑Chiropractor ❑Advanced Practice Nurse CL ❑Other Practitioner(specify): National Registry Number. Medical Examiner's Certificate Expiration Date: 0 CL U 2 Page 5 PacketiPg. 213 �na>tic�lou�sass ! F.5.b Instructions for Completing the Medical Examination Report Form (MCSA-5875) 1. step-By-step Instructions Driver: Section 1: Driver information • Personal Information:Please complete this section using your name as written on your drivels license,your current address and phone number,your date of birth,age,gender,driver's license number and issuing state. 0 o CLP/CDL Applieant/Holder: Check"yes"if you are a commercial learnels 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(GVWR)or gross vehicle weight(GVW)of more than 10,000 U 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. y o Driver ID Verified By:The Medical Examiner/staff completes this item and notes the type of photo ID used to verify the drivels identity such as,commercial driver's license,driver's license,or passport,etc. o Question: Has your USDOTIFMCSA 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`hot 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 CL 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- W 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 1 is accurate and complete. Page 6 Packet iPg. 214 F.S.b fnstweslau�-ens 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`fires"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 U 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-5975. 2 • Testing: o 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. { y second reading is optional and should be recorded if found to be necessary. .2 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. lit this next seniors,you will be completing either the Federa r State determination, not both. • Medical Examiner Determination(Federal): Use this section for examinations performed in accordance with the FMCSRs( ji.41-31.4 ).Complete the medical examiner determination section completely.When determining a driver's physical qualification,please note that English language proficiency(49 Cl~R p 11: General qualifications of drivers)is not factored into that determination. 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. Meets standards in 49 CFR 391AI;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. Packet iPg. 215 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 U 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 n 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- ical 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 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. • Medical Examiner Determinations(State):Use this section for examinations performed in accordance with the FMCSRs(49, FR 9l,4l- .49 with any applicable State variances(which will only be valid for intrastate operations).Complete the medical examiner determination section completely. CL 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 391AI 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 Packet iPg. 216 F.5.b huts ileac NWL4 67S 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(MEQ 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. U 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 _ .do as/nie !i .2 c 0 CL Pa e 9 Packet iPg. 217 P F.5.b J '`0 41 T;,.f I;.; search !a° ;I +; w'``S''I•'I.,�t=t A tog lMkX jftftpmWjCdWA49W JFAQI I AWAOSM Menu ftupado2tsdetv HeWlh We Can help •29 CrR)•TWO or COWS 0 U •Part Numbon 1910 •Part and Haft Standamb •Subpaft I • rt : Personal Pt •Mndard Numben 1910.134 App C Oymel Eva e( ). •6 R AppwmN C to Sm 191 Eval es Ire(Mande ) To to 4LeMm W SeWon 1,ard to quesbon 9 m SKdm 2 of Pat A,do aeon reepr re i .2 To the Yav emOW nml am you 10 a at a Imo ard Oam thot is axwagent.to you.To onBIrtdn yaw _ amfi6endalty,your wOW or sa enint na at or reAw vour mmwf=6 vW Mv amMW OW tel you how to ddw or send thls qunbmm to the th tare wM Mftw It Part A.Section 1.( )The lnbmdm nxist be pmAM by my effOoyee who has Ww selected m use&V Wp of r (Own ). . 1.TOWS > t.Your dame' 3 Yaw age(to nearest vw),. 4.Sax(drde ):Maleff 5.Yaw hdght R In. 6.Your w Its. 7.Your &A phone mgnW whem You an be readied by the health care ptoftWonal who mwiews INN quatimmire(kcluft the Arva C )-,W..............m..p.--Mw., w aa. a. CL S. Into to phone you at 10.Has vw ar&w told you hcpw to amwt the bulth ore profaskoW wle wig r e(dfdg ):Y IL Chml the Mpe of you wN m(you con ded more than am category); a. N,R,or P dsposWA r (IVW rat ). b: OdW type(Eor 6MOil.ham or -*, tHt9 ). 12.HaveAu wom a reWkator( ):Yoft IfNm*whetW9j- ftn A.Sectim 2.(M ) 1 through 9 bdow mot be answered by my wokme who has bee MkWad to use mv type of MWator or I+o'. Packet,Pg. 218 F.5.b 1.Do you car wrift toW=or have you wAmd aft to On last morM:Yesft t have You over had any of the falknrrhg rei IL Seltures:Yetm b.DW*tas(super ):Yes/No e.AQergrc N&Mm that o with your bmadft Yes/Ho d (rear of OWWA PIM):Yes/ft r.TrouMe wrieftV odors;YmM 76 I Km you em had any of the toWMOO pknomyor pmg 7 a Asbesloft Yes/NO w b :Yes/No c Chalk bonditls Yes/Na a ovhvnffw.YWHO e.Amummis.Ye0b r.T :vas,INa .2 Yw" h (collapsed pxg):Yes/No L Ug mincer:Yealmo CL J.Broken ribs:Yes/No C k Any dust*rh s or unwim Yegw I.Any other kma problan that you've been raid about YOWIG 4.Do you currently have any of the&&w&g YpVWm of or lane Mness7 8.Shortness of breath:Yes/No to, of both when walidog to on level ground w wapdng up a sirpht hill or WdMe:Yes/No c of breath when►wapdng with other at an onftry pace on lend Bnaw4:Yes fNo d.Have to stop for breath when walking at yaw own pace on kevel ground:Yes/No 0 e.ShwMM of bfuth when vadko a :Yes/tVo U 1.SwMess of breath M hVArlem with yt„r Job:Yes/Na CL 2 g that Produm phlegm(thkk s fin):YOWM h that wakes you e*In are :Yes/No b. the oonrrs m*rW when You are lying down:Ye i;ft J. to blood hr the test mWeL VWNo k.Whadw.Yoft I.Wtwiing that hderlbres with your job:Yeufdo m.Chest petn when Vou .YeWNo Packet iPg. 219 F.5.b a Any dher wpWWm that you time may be r to imp pMbI&M1 YeSft 5.Here ym,ever had any of the ft11&AV cardw4ascuiar or heart Y a.Heart attiCk YOft b.Stroke:Yes/No C.Aeglna:Yes/No d.Heart fall re:YeM e.Swd&g is yonr logs or feet(rapt mused by wd"):YWWo 0 U f.Haft afthmis(Dart beating in ly):Yes/No 0.High blood pressure:YWft h.Any other Mart problem that you've been told about:Yet/No &Here You ens had any of the k0owing CSnOvneulat or Bart i a Requenit pain or OWItnus In your dnest:Yes/No b.Fain or Opm In your dnest during plVskid adW.YeM � G Pain or #n your Brest tlnet va roar Job:YWNo 5n d.In the past two years,have you noticed Yea heart or ffdwq a but Yes/No e,Hcarlbum or MigeMn that Is not related to eating:YeslNo d.ft other symptoms duet you bnk may be relaW to heart or circulation problems:Yes/No CJ 7.Do you curaany tali mekation for any of the kilorri ng i a.& or hag .Yevm b.Heart trouble:Yelft > a Mood pressure:Yas/No d.smurat:Ywft IL if yaM used a,reMirator,have you ever had any of the Mowft pr0lems7(if yodve new used a vesorstor,dxKk ft fdlowhV space and go to question U) a.EYe bylta n:Yom � b.Sian alleroas or rashes:YaMo 0 c.Aradety:Yesft U d.General weahun or :Yes/No CL 2 e.Any other"ern n that interfwas vrilh Mr ape of a respirator:Yeoft !.Would you We to Wk to the health am Wenional who will review lira a about yea anvws to 00 quWWWW re:Yeyho � QuasOM 10 to 15 below must be arras wed by every emOops who has been selected to use either a fiOlauiplm resprator or a set Apparatus(Sii'BA).Bon who have been soeded to sera other types of respirators,a Cress is volunary. 10.Have You eve lost vision In dther en(lemporaft or parmanaft:Yesilfto 11.Do you am*have any of the fallowing vision 7 a,Wear mrad Wsm,Yoft b.Wear Packet;Pg. 220 F.5.b c.Color Mid:Yewfo d Arry odw eye or Vision :YeOo 11 Nave You ever had an hiLmy to your ears,WAOV a brdum ear drum:Yes/No Ll Do you arrm*have mW of iha UWMM haarbha i a.txmoft twaft Yem b.wear a akh YeOft c.Any other or far pmblenc Yes/No u 14.Haw!Yw ever had a bade kW.YWM � 15.Do you have arty of the 7 a.Weaknm in any of your ams►hw%,kA or feet:YOWN® b.sack pale:YWM tw My Vow arms and Fogs:YesMo d.FWn or sUffnes when you lean(orward or bKkvwd at the walst:Yes/No 0. f*moring yow head up or down:YWHo .2 f.Oifliaft fiy nin(I ym heed side to We:Y g.DMkWW b&WhV atYW Mees.YWNo U h AD ft gmure.Yeyflo i. a of sitlrs a a rr�e then 25 Ibs:YaWNo �.Arryaft musda or simleW problem that Inuffives with u*V a respirator:YeOo parts Any of the fai and other Onswu rat isted,may be added to the ire at the d en of the heab Care l who wiH FrAw fh4 a. 1.in yarr present job are you vvwft at NO aMudes(over 5,OW feet)or m s place oral than lower Ow owmW amourds of :YeWlo if"yes"do Vora taut ke4no of 6UWms&shoom of Wealk pmm&g m yarn lost,or otter SpTOWN when you're worft under these mrrdOMI.YCENO 2.At work or at bw4 have you ever been to huwft a Obwm dwrocals(e.g.,gases,hams,or duslj,or have you Dome tnto OM witactuO Is:YesINo 1f Nt%"manta the if You know don: ca I Howe You ever worked wM ant►of the mateWs,or under erry of the awdbwc96 listed 2 a. :Yiatft to S lkm(e g.,4n SardusOvk.Yesmo c.T (egg.,grurdbhg or ):YOM � d Buy&m yes/Ho e. WOW f.Coal(for mmm0e,nnb ft,Yw/Wo g loom Yesmo Packet iPg. 22'1 F.5.b h.Th Yellido 1.Dully emomraft Yevft k+rrsyoUta hUOnkKN OMMM:MIND if'ltes►"dam"MM COMM 4.Ust any sf=4 lobs aside Ydu have. _ a S.fist you prewar 0 6,tlst vour wmntard pvmm habUm 7.Have yar been In the r d" ?YOM* � If'ks"wesv you opmed to Woloplml or dmfdal (eWa a or ).YOM &Have ym ever worked an a HAMAT teem?Yea/H0 9.Odw than tlam for aM WR pvVem heart mAle,b'ood pressure,and saftres marooned eadler in this questWumire,are you MWM ashy allser medcom ow any 0wer-the ns):YaM ?� If'yese•name the meomwe it you know� ... 10.Wdl you be using any 0f Ute foWw ng Items with yam (s)7 a.MEPA -YesMo cJ b.Carnteers((Or emoft gait ).VOMO c :YeWo 11,How often are you amted to use Use resprator(s)(dede'W or lr e'for eft anwws dW ap*to Yar)?: IL Umpe 0*(no rescue):YWHO b, room wir.Yes/ls0 c.tsss than 5 hmrs per week:Ye Vwo d.lrss ftn 2 hours per day:YesNo e.2 to 4 bars per day:YeVft f.Owr 4 bars per day.Yet/No 12 the period you are uft 0* tor(s),is your work effort CL a.tight(less dean 200 kcal per hart Y If'vet,"how lane does U is P&W last durlrq the average sltUt._„w.,.„ „a—,u hrs oaalrrn. of a tight work effort are slang while ywift typrg,draft",0r p&fcnmM 09M m=W work;or white *g a drill press(13 Ms.)or m b.Modma(300 to 3501wd per Mora):YeVW iflas,•how"dos M pffW last theaverayeshiR„, ,.._.._.__.._.. has• .,.,w, .,.. „rolro. bwqft of work efl6rt are while 0r Ong,drivkg a truck or he h urban V8ft 6Ur4q wMe ,pe work or wordsift a moderate load(abet 33 lbs.)at trunk Serel; at a level sarface abm 2 mph or down a 3 mph;or pushing a whodbarrow Mlh a Maw toad(about 100 Iba.)at a level w4M.c.Heave(above 350 kal per hark YeM Packet iPg. 222 F.5.b 1r W how bV does tM MW last d EampksofheaWworkma hwvy I (abM SO Pa.)fimft OW WWwaft Or SIMWW,wwftc"& brWW&#V or ,wamV up an B 2 a hmq lad( )• 13.Wo You be wewkv pr andl ( )When ywre using Your tevirator.Y It 14.WW ym be w&kM unde hot middens(Wqmrawe exmft 77 ft P):YeSIM 15.VM Vou be wofto under kftd :YOM 0 16.DewLbe dw work Vml be dobV whft vWfe r s): U 17.Oesatbe&W RmW or knardme condat m you might ena urAm when yn*e using vour raq*ator(s)(tor exae oe,mdmed spacer Gh ftntudM gas"), I&mo&Ore roMmft bdarmatkm%d you Imaw 1%krr each W*wAsW=that yrXM to mgmW to when jWfe u6fnq your MOWS): m buraUm or -$,U. ........ ,.n ............... N DuratIm of enmire per dft Nvne or ft third Emnated marl %hit: U Duration of m9mia per .,.,tmA ...,be exposed tow leslWaW. ._ 19.Desoibe&W specad responsibVides yuA have wMe using s)dut may affal the sdety and wel of COM(tar emnPle,rmcA seox*): 163 FR 1 IS2,Jan.6,19W,63 FR 20090,APW 23,1998,76 FR 33607,Am C 2011:77 PR 46M,Aug.7,20121 5 1l910.331 ®) s fSWdm&_ '29 CFR,,•Title of Omtents 0 ReWomollrOmmuftAct I hMcy&SeumtySWermPt 1 DWalmm I lavart3at Web SMe Kokes 1 bftmWwW COAWUS U uS. d I 0=*W"Sdfty&t*MAdffdW&bWm 1 200 ConARiALMAve,NW,w 4IDl M210 CL rN 3tt 16saaf 1 Packet iPg. 223 F.5.b RESPIRATOR USE PHYSICAL NAME AGE, 5,EX, ���.��..��.��.m........wm..w�.�.�.�.M...w............w HOME ADDRESS: TELEPHONE: OCCUPATION: of this Ingunmarenor Bie grate OR a ►y pu o e ent proWaia Gy appR2565 s .2 (:]Follow-up Medical Evaluation Physical Required.(positive response•quest s 1- 1 OPost-Offer Ph cal:Medical Evaluation.Physical Required 0 CL Packet iPg. 224 F.S.b PLHCP Follow UP Medical Examine on NAME: Recommendations about employee use of the aspirator:Urnitatlons- Job Title; Date 01 this Poilow Up ARP Reasons For follow up w 0 . U U .2 U Actions Need for Fdbw up evaluations 8 U U Signed: Date Signed copy of recommendation give to employee? ❑yes ❑no Date Given Packet iPg. 225 F.5.b R>;5►PIRAT R usE PHvsIc.AL �.� See Attad"Job Description NAME; SEx: HOME ADDRESS: ..� .e� �.;� . . �.a .�m .a,� �� .. _.�.e� 0 ° LEPHONE: OCCUPATION: spreem aT n:orma nor teMan rcga�'a ®N purposes R ! U Y IATI HEIGHT: WEIGHT: HART: MURMERS: RATE: RKYiIiM ENLARCAWM., Lur�s:� PULAiINARY FUNCTION WITHIN NORMAL LIMITS: OUTSIDE NORMAL LIMITS: PA FST X-RAY: WITHIN NORMAL.LIMITS: OUTSIDE NORMAL LIMITS: CL REC�OMENDATr4Ms 2 It Is my apinlon that the above named patient Is or is not ___rneftaly quallBed to wear a respirator M the performance of Wdher duties Packet;Pg. 226 F.5.c Please wait... If this message is not eventually replaced by the proper contents of the document,your PDF viewer may not be able to display this type of document. 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Windows is either a registered trademark or a trademark of Microsoft Corporation in the United States and/or other countries.Mac is a trademark of Apple Inc.,registered in the United States and other countries.Linux is the registered trademark of Linus Torvalds in the U.S.and other countries. tJ U) .2 tJ CL tJ N 0 U$ U 4, 0 r- 0 U U Packet Pg.227 ::]MEDICAL RECORD REPORT OF MEDICAL EXAMINATION DaTE F.S.d' 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 ❑BLACK ❑ ALASKA NATIVE ❑ WHITE ❑ BLACK ❑ ISLANDER 12a.AGENCY 12b.ORGANIZATION UNIT 13.TOTAL YEARS GOVERNMENT SERVICE U �a.MILITARY b.CIVILIAN (B 14.NAME OF EXAMINING FACILITY OR EXAMINER,AND ADDRESS 15.RATING OR SPECIALTY OF EXAMINER 0) 16.PURPOSE OF EXAMINATION tJ 17.CLINICAL EVALUATION NOR- ABNOR- NOR- AB MAL (Check each item in appropriate column,enter'NE"if not evaluated) MAL MAL (Check each item in appropriate column,enter'NE"if not evaluated) A.HEAD,FACE,NECK AND SCALP O.PROSTATE(Over 40 or clinically indicated) N 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 t7 D.NOSE S.G-U SYSTEM E.SINUSES T.UPPER EXTREMITIES(Except feet)(Strength,range ofmotion) CL 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) CL _ 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 CL 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 O N.ABDOMEN AND VISCERA(Include hemia) CC.PELVIC(Females only) N w NOTES: (Describe every abnormality in detail.Enter pertinent item number before each comment.Continue in item 42 and use additional sheets if necessary) U ` 4- 0 r_ O 18.DENTAL(Place appropriate symbols,show in examples,above or below number of upper and lower teeth.) REMARKS AND ADDITIONAL DENTAL DEFECTS AND DISEASES 0) 1 2 3 Restorable 1 2 3 0 Non- X X X X Replaced I X ) Fixed 1 2 3 Missing 1 2 3 1 2 3 32 31 30 Teeth 32 31 30 restorable 32 31 30 Teeth 32 31 30 by 32 31 30 Partial 0 Teeth X X X X Dentures I X ) Dentures R L 1 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 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.10-94)(EG) 88-126 Prescribed by GSA/ICMR FIRMR(41 CFR)201-9.20_ . Designed using Perform Pro,WHS/DIOR,Jan 97 Packet Pg.228 NAME IDENTIFICATION NO.OF SHEETS ATTACHED F.5.d MEASUREMENTS AND OTHER FINDINGS 20.HEIGHT 21.WEIGHT 22.COLOR HAIR �23.COLOREYES �24.13UILD 25.TEMPERATURE SLENDER MEDIUM HEAVY OBESE 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.AFl RECUM- STANDING SITTING DIAS. BENT DIAS. (5 MINS.) DIAS. 28.DISTANT VISION 29.REFRACTION 30.NEAR VISION RIGHT 20/ CORR.TO 20/ BY S. CX CORR.TO BY U LEFT 20/ CORR.TO 20/ BY S. CX CORR.TO BY 31.HETEROPHORIA(Specify distance) ESO EXO R.H. L.H. PRISM DIV. CT PRISM CONV. PC PD 32.ACCOMMODATION 33.COLOR VISION(Test used and result) 34.DEPTH PERCEPTION UNCORRECTED 0) 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 scc 250 500 1000 2000 3000 4000 6000 8000 RIGHT W/V /15SV /15 256 512 1024 2048 2896 4096 6144 8192 LEFT W/V /15SV /15 RIGHT LEFT 42.NOTES(Continued)AND SIGNIFICANT OR INTERVAL HISTORY A .2 CL tJ CL CL tJ M (Use additional sheets if necessary) 43.SUMMARY OF DEFECTS AND DIAGNOSES(List diagnoses with item numbers) ff7 U 4- 0 r- O 44.RECOMMENDATIONS-FURTHER SPECIALIST EXAMINATIONS INDICATED(Specify) 45A.PHYSICAL PROFILE FTU L H E S 46.EXAMINEE(Check) A IS QUALIFIED FOR In accordance with attached job description. 45B.PHYSICAL CATEGORY U B 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 U 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) Packet Pg.229 Form MCSA-5875 OMB No.2126-0006 Expiratio Public Burden Statement A Federal agency may not conduct or sponsor,and a person is not required to respond to,nor shall a person be subject to a penalty for failure to complywith a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number.The OMB Control Number for this information collection is 2126-0006.Public reporting for this collect of information is estimated to be approximately 25 minutes per response,including 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 this burden estimate or any other aspect of this collection of information,including suggestions for reducing this burden to: Information Collection Clearance Officer,Federal Motor Carrier Safety Administration,MC-RRA,1200 New Jersey Avenue,SE,Washington,D.C.20590, Federal Motor narrier nsportation Medical Examination Report Form Federal Motor Carrier Safety Administration (for Commercial Driver Medical Certification) MEDICAL RECORD I SECTION 1.Driver Information(to be filled out by the driver) (orsticker) CU Last Name: First Name: Middle Initial: Date of Birth: Age: 0 Street Address: City: State/Province: Zip Code: U Driver's License Number: Issuing State/Province: Phone: Gender: 0 M 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 *CLP/CDL Appli cant/H older:See instructions for definitions. **Driver ID Verified By:Record whattype ofphoto ID was used to verifythe identity ofthE driver,e.g.,01,driver's license,pass W r • y Have you ever had surgery?If"yes;'please list and explain below. O Yes 0 No 0 Not SL N CL CJ CL CL Cal CJ T Are you currently taking medications(prescription,over-the-counter,herbal remedies,diet supplements)? 0Yes 0 NoO Not Su 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 information appropriately to prevent inadvertent disclosure by keeping the documents under the control of authorized persons. Properly dispose of this document wh no longer required to be maintained by regulatory requirements.** Packet Pg.230 Form MCSA-5875 OMB No.2126-0006 Expiratio F.5.e' Last Name: First Name: DOB: Exam Date: Not N Do you have or have you ever had: Yes No Sure Yes No Si 1.Head/brain injuries or illnesses(ag.,concussion) O O O 16.Dizziness,headaches,numbness,tingling,or memory O O l 2.Seizures,epilepsy O O O loss 3.Eye problems(exceptglasses orcontacts) O O O 17.Unexplained weight loss O O l 4.Ear and/or hearing problems O O O 18.Stroke,mini-stroke(TIA),paralysis,or weakness O O l 5.Heart disease,heart attack,bypass,or other heart O O O 19.Missing or limited use of arm,hand,finger,leg,foot,toe O O l problems 20.Neck or back problems O O l 6.Pacemaker,stents,implantable devices,or other heart O O O 21.Bone,muscle,joint,or nerve problems O O l procedures 22.Blood clots or bleeding problems O O l 7.High blood pressure 0 0 0 23.Cancer 0 0 l 8.High cholesterol 0 0 0 24.Chronic(long-term)infection or other chronic diseases 0 0 l 9.Chronic(long-term)cough,shortness of breath,or other 0 0 0 25.Sleep disorders,pauses in breathing while asleep, 0 0 l 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.,sleep apnea)? 0 0 l 11.Kidney problems,kidney stones,or pain/problems with 0 0 0 27.Have you ever spent a night in the hospital? 0 0 l urination 2 28.Have you ever had a broken bone? O l 12.Stomach,liver,or digestive problems O O O 13.Diabetes or blood sugar problems O O O 29.Have you ever used or do you now use tobacco? O l Insulin used O O 30.Do you currently drink alcohol? 0 0 cu 31.Have you used an illegal substance within the past two O O l W 14.Anxiety,depression,nervousness,other mental health 0 0 0 years? problems ur 32.Have you ever failed a drug test or been dependent on O O l 15.Fainting or passing out O O O an illegal substance? cu .2 N Other health condition(s)not described above: O Yes O No O Not St CL CJ CL CL CJ Did you answer"yes"to any of questions 1-32?If so,please comment further on those health conditions below. O Yes O No O Not St T (Attach additional sheets if necessary Bu I certify that the above information is accurate and complete.I understand that inaccurate,false or missing information may invalidate the examination 0) and my Medical Examiner's Certificate,that submission of fraudulent or intentionally false information is a violation of 49 CFR 390.35,and that submissic of fraudulent or intentionally false information may subject me to civil or criminal penalties under 49 CFR 390.37 and 49 CFR 386 Appendices A and B. cu Driver's Signature: Date: SECTION 2.Examination Report(to be filled out by the medical examiner) • • Review and discuss pertinentdriveranswers and any available medical records.Comment on the driver's responses to the"health history"questions that may affect th driver's safe operation ofa commercial motor vehicle(CMV). (Attach additional sheets if necessary) Packet Pg.231 Form MCSA-5875 OMB No.2126-0006 Expiratio F.5.e' Last Name: First Name: DOB: Exam Date: MMMMMM Pulse rate: Pulse rhythm regular:O Yes O 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,orsugor in the urine may be an indication for further testing to F- rule out any underlying medical problem. Vision Hearing Standard is at least20140 acuity(Snellen)in each eye with or without correction.At Standard:Must first perceive whispered voice at not less than 5 feet OR average Ou least 70°field of vision in horizontal meridian measured in each eye.The use ofcor hearing loss of less than or equal to 40 dB,in better ear(with or without hearing c 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 C Whisper Test Results Right Ear Left I a)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 U Applicant can recognize and distinguish among traffic control 00 Audiometric Test Results signals and devices showing red,green,and amber colors Right Ear Left Ear Monocular vision 00 500 Hz 1000 Hz 2000 Hz 500 Hz 1000 Hz 2000 Hz y Referred to ophthalmologist or optometrist? 00 12 Received documentation from ophthalmologist or optometrist? 00 Average(right): Average(left): The presence of a certain condition may not necessarily disqualify a driver,particularly if the condition is controlled adequately,is not likely to worsen, is readily amenable to treatment.Even if a condition does not disqualify a driver,the Medical Examiner may consider deferring the driver temporarily. R-, Also,the driver should be advised to take the necessary steps to correct the condition as soon as possible,particularly if neglecting the condition coup result in a more serious illness that might affect driving. CL Check the body systems for abnormalities. Body System Normal Abnormal Body System Normal Abnorn 1.General O O 8.Abdomen O O 2.Skin O O 9.Genito-urinary system including hernias O O 3.Eyes O O 10.Back/Spine O 4.Ears O O 11.Extremities/joints O O 5.Mouth/throat 0 0 12.Neurological system including reflexes 0 0 6.Cardiovascular 0 0 13.Gait 0 0 7.Lungs/chest O O 14.Vascular system O O Discuss any abnormal answers in detail in the space below and indicate whether it would affect the driver's ability to operate a CIVV Enter applicable item number before each comment. (Attach additional sheets if necessary Packet Pg.232 Form MCSA-5875 OMB No.2126-0006 Expiratio F.5.e' Last Name: First Name: DOB: Exam Date: Please complete only one of the following(Federal or State)Medical Examiner Determination sections. Use this section for examinations performed in accordance with the Federal(irlotor Carrier Safety Regulations(49 CFR 391.41-391.49); O Does not meet standards(specify reason): O Meets standards in 49 CFR 391.41;qualifies for 2-year certificate O Meets standards,but periodic monitoring required(specify reason): Driver qualified for: O 3 months O 6 months O 1 year O other(specify): ❑Wearing corrective lenses ❑Wearing hearing aid ❑Accompanied by a waiver/exemption(specify type): ❑Accompanied by a Skill Performance Evaluation(SPE)Certificate ❑Qualified by operation of 49 CFR 391.64(Federal) ❑Driving within an exempt intracity zone(see 49 CFR 591.6z)(Federal 0 ❑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): ar (if amended)Medical Examiner's Signature: Date: ❑Incomplete examination(specify reason): CJ If the driver meets the standards outlined in 49 CIFIR 391.41,then complete a Medical Examiner's Certificate as stated in 49 CFIR 31. 3( ),as appropriate. I have performed this evaluation for certification.I have personally reviewed all available records and recorded information pertaining to this evaluatic W and attest that to the best of my knowledge,I believe it to be true and correct. Medical Examiner's Signature: .2 Medical Examiner's Name(please print or type): CL Medical Examiner's Address: City: State: Zip Code: CJ Medical Examiner's Telephone Number: Date Certificate Signed: CLL Medical Examiner's State License,Certificate,or Registration Number: Issuing State: CL ❑ MD ❑DO ❑Physician Assistant ❑Chiropractor ❑Advanced Practice Nurse F® ❑Other Practitioner(specify): 100 National Registry Number: Medical Examiner's Certificate Expiration Date: Packet Pg.233 Form MCSA-5875 OMB No.2126-0006 Expiratio F.5.e' Last Name: First Name: DOB: Exam Date: U sethissection for examinations performed in accordance with the Fecfera!Motor Carrier Safety Regulations(49 CFR 391.41 397.49) �ritfl any applicable Stat, variances p will only be valid for intrastate operations). eet standards in 49 CFR 391.41 with any applicable State variances(specify reason): O Meets standards in 49 CFR 391.41 with any applicable State variances O Meets standards,but periodic monitoring required(specify reason): Driver qualified for: O 3 months O 6 months O 1 year O 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(FIR 31. 1,with applicable State variances,then complete a Medical Examiner's Certificate,as appropriate. 1 have performed this evaluation for certification.I have personally reviewed all available records and recorded information pertaining to this evaluatic U 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: CJ Medical Examiner's Telephone Number: Date Certificate Signed: Medical Examiner's State License,Certificate,or Registration Number: Issuing State: JA ❑ MD ❑DO ❑Physician Assistant ❑Chiropractor ❑Advanced Practice Nurse 12 ❑Other Practitioner(specify): 2 N National Registry Number: [Medical Examiner's Certificate Expiration�Dt,- CJ CL CJ CL ca CL Packet Pg.234 Instructions MCSA-5875 Instructions for Completing the Medical Examination Report Form (MCSA-5875) L Step-By-Step Instructions Driver: Section 1: Driver information Personal Information: Please complete this section using your name as written on your driver's 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 0 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 (GVWR) or gross vehicle weight(GVW) 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 2 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. cs 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 CL supplements): Please check"yes" if you are taking any diet supplements, herbal remedies, or I-_ prescription or over the counter medications. In the box below the question, indicate the name of the medication and the dosage. T C o #1-32: Please complete this section by checking the"yes"box to indicate that you have,or have ever had, m 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). a� 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 45 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 1 is accurate and complete. Packet Pg.235 Instructions MCSA-5875 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 0 Examination Report Form, MCSA-5875. Testing: o 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. A 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 .5 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 CL vision; has been referred to an ophthalmologist or optometrist; and if documentation has been c, received from an ophthalmologist or optometrist. ,CL W 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. a- 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 c ony-pleting either the Federal or State determination, not berth. Medical Examiner Determination (Federal): Use this section for examinations performed in accordance with the FMCSRs ( 9 CFR 391. 1-391. 9). Complete the medical examiner determination section completely. When determining a driver's physical qualification,please note that English language proficiency(49 CFR part 391.11: 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. Packet Pg.236 Instructions MCSA-5875 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 UO - 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 Ch 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- .2 teal 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 CL 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 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. 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.). Packet Pg.237 Instructions MCSA-5875 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 (MEQ 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 http://www.fmcsa.dot.gov/regulations/medical. 2 0 .2 CO CL Packet Pg.238 1910.134 App C-OSHA Respirator Medical Evaluation Questionnaire ... https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.... F.S.f By Standard Number / 1910.134 App C- OSHA Respirator Medical Evaluation Questionnaire (Mandatory). ■ Part Number: 1910 E2IIII-,=c-hn=ie-nI, ■ Part Number Title: Occupational Safety and Health Standards ■ Subpart: 1910 Subpart I ■ Subpart Title: Personal Protective Equipment ■ Standard Number: 1910.134 App C ■ Title: OSHA Respirator Medical Evaluation Questionnaire (Mandatory). ■ GPO Source: e-CFR U Appendix C to Sec. 1910.134: OSHA Respirator Medical Evaluation Questionnaire (Mandatory) To the employer: Answers to questions in Section 1, and to question 9 in Section 2 of Part A, do not require a medical examination. To the employee: Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place 2 that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers, and your employer must tell you how to deliver or send this questionnaire to the health care professional who will review it. Part A. Section 1. (Mandatory) The following information must be provided by every employee who has been selected to use any type of respirator(please print). CL 1. Today's date: 2. Your name: 3. Your age (to nearest year): 4. Sex (circle one): Male/Female 5. Your height: ft. in. 6. Your weight: lbs. 7. Your job title: 8. A phone number where you can be reached by the health care professional who reviews this questionnaire (include the Area Code): 9. The best time to phone you at this number: Packet Pg.239 1 of 10 11/2/2020,8:45 PM 1910.134 App C-OSHA Respirator Medical Evaluation Questionnaire ... https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.... F.S.f 10. Has your employer told you how to contact the health care professional who will review this questionnaire (circle one): Yes/No 11. Check the type of respirator you will use (you can check more than one category): a. N, R, or P disposable respirator(filter-mask, non-cartridge type only). b. Other type (for example, half- or full-facepiece type, powered-air purifying, supplied-air, self- contained breathing apparatus). 12. Have you worn a respirator(circle one): Yes/No If"yes,"what type(s): 0 Part A. Section 2. (Mandatory) Questions 1 through 9 below must be answered by every employee who has been selected to use any type of respirator(please circle "yes" or"no"). 1. Do you currently smoke tobacco, or have you smoked tobacco in the last month: Yes/No 2. Have you ever had any of the following conditions? a. Seizures: Yes/No b. Diabetes (sugar disease): Yes/No c. Allergic reactions that interfere with your breathing: Yes/No -- m d. Claustrophobia (fear of closed-in places): Yes/No CL e. Trouble smelling odors: Yes/No 3. Have you ever had any of the following pulmonary or lung problems? y a. Asbestosis: Yes/No b. Asthma: Yes/No c. Chronic bronchitis: Yes/No d. Emphysema: Yes/No e. Pneumonia: Yes/No f. Tuberculosis: Yes/No g. Silicosis: Yes/No h. Pneumothorax (collapsed lung): Yes/No Packet Pg.240 2 of 10 11/2/2020,8:45 PM 1910.134 App C-OSHA Respirator Medical Evaluation Questionnaire ... https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.... F.S.f i. Lung cancer: Yes/No j. Broken ribs: Yes/No k. Any chest injuries or surgeries: Yes/No I. Any other lung problem that you've been told about: Yes/No 4. Do you currently have any of the following symptoms of pulmonary or lung illness? a. Shortness of breath: Yes/No U b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline: Yes/No c. Shortness of breath when walking with other people at an ordinary pace on level ground: Yes/No d. Have to stop for breath when walking at your own pace on level ground: Yes/No e. Shortness of breath when washing or dressing yourself: Yes/No f. Shortness of breath that interferes with your job: Yes/No g. Coughing that produces phlegm (thick sputum): Yes/No h. Coughing that wakes you early in the morning: Yes/No -- m i. Coughing that occurs mostly when you are lying down: Yes/No j. Coughing up blood in the last month: Yes/No k. Wheezing: Yes/No y I. Wheezing that interferes with your job: Yes/No m. Chest pain when you breathe deeply: Yes/No n. Any other symptoms that you think may be related to lung problems: Yes/No 5. Have you ever had any of the following cardiovascular or heart problems? a. Heart attack: Yes/No b. Stroke: Yes/No c. Angina: Yes/No d. Heart failure: Yes/No Packet Pg.241 3 of 10 11/2/2020,8:45 PM 1910.134 App C-OSHA Respirator Medical Evaluation Questionnaire ... https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.... F.S.f e. Swelling in your legs or feet (not caused by walking): Yes/No f. Heart arrhythmia (heart beating irregularly): Yes/No g. High blood pressure: Yes/No h. Any other heart problem that you've been told about: Yes/No 6. Have you ever had any of the following cardiovascular or heart symptoms? a. Frequent pain or tightness in your chest: Yes/No 0 b. Pain or tightness in your chest during physical activity: Yes/No c. Pain or tightness in your chest that interferes with your job: Yes/No d. In the past two years, have you noticed your heart skipping or missing a beat: Yes/No e. Heartburn or indigestion that is not related to eating: Yes/No d. Any other symptoms that you think may be related to heart or circulation problems: Yes/No 7. Do you currently take medication for any of the following problems? a. Breathing or lung problems: Yes/No -- m b. Heart trouble: Yes/No CL c. Blood pressure: Yes/No d. Seizures: Yes/No 8. If you've used a respirator, have you ever had any of the following problems? (If you've never used a respirator, check the following space and go to question 9:) a. Eye irritation: Yes/No b. Skin allergies or rashes: Yes/No c. Anxiety: Yes/No d. General weakness or fatigue: Yes/No e. Any other problem that interferes with your use of a respirator: Yes/No 9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire: Yes/No Packet Pg.242 4 of 10 11/2/2020,8:45 PM 1910.134 App C-OSHA Respirator Medical Evaluation Questionnaire ... https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.... F.S.f Questions 10 to 15 below must be answered by every employee who has been selected to use either a full- facepiece respirator or a self-contained breathing apparatus (SCBA). For employees who have been selected to use other types of respirators, answering these questions is voluntary. 10. Have you ever lost vision in either eye (temporarily or permanently): Yes/No 11. Do you currently have any of the following vision problems? a. Wear contact lenses: Yes/No b. Wear glasses: Yes/No 0 c. Color blind: Yes/No d. Any other eye or vision problem: Yes/No 12. Have you ever had an injury to your ears, including a broken ear drum: Yes/No 13. Do you currently have any of the following hearing problems? a. Difficulty hearing: Yes/No b. Wear a hearing aid: Yes/No c. Any other hearing or ear problem: Yes/No -- m 14. Have you ever had a back injury: Yes/No CL 15. Do you currently have any of the following musculoskeletal problems? a. Weakness in any of your arms, hands, legs, or feet: Yes/No y b. Back pain: Yes/No c. Difficulty fully moving your arms and legs: Yes/No d. Pain or stiffness when you lean forward or backward at the waist: Yes/No e. Difficulty fully moving your head up or down: Yes/No f. Difficulty fully moving your head side to side: Yes/No g. Difficulty bending at your knees: Yes/No h. Difficulty squatting to the ground: Yes/No i. Climbing a flight of stairs or a ladder carrying more than 25 Ibs: Yes/No Packet Pg.243 5 of 10 11/2/2020,8:45 PM 1910.134 App C-OSHA Respirator Medical Evaluation Questionnaire ... https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.... F.S.f j. Any other muscle or skeletal problem that interferes with using a respirator: Yes/No Part B Any of the following questions, and other questions not listed, may be added to the questionnaire at the discretion of the health care professional who will review the questionnaire. 1. In your present job, are you working at high altitudes (over 5,000 feet) or in a place that has lower than normal amounts of oxygen: Yes/No If"yes," do you have feelings of dizziness, shortness of breath, pounding in your chest, or other symptoms when you're working under these conditions: Yes/No 0 2. At work or at home, have you ever been exposed to hazardous solvents, hazardous airborne chemicals (e.g., gases, fumes, or dust), or have you come into skin contact with hazardous chemicals: Yes/No If"yes," name the chemicals if you know them: 3. Have you ever worked with any of the materials, or under any of the conditions, listed below: a. Asbestos: Yes/No b. Silica (e.g., in sandblasting): Yes/No c. Tungsten/cobalt (e.g., grinding or welding this material): Yes/No -- m d. Beryllium: Yes/No CL e. Aluminum: Yes/No c f. Coal (for example, mining): Yes/No g. Iron: Yes/No h. Tin: Yes/No i. Dusty environments: Yes/No j. Any other hazardous exposures: Yes/No If"yes," describe these exposures: 4. List any second jobs or side businesses you have: 5. List your previous occupations: Packet Pg.244 6 of 10 11/2/2020,8:45 PM 1910.134 App C-OSHA Respirator Medical Evaluation Questionnaire ... https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.... F.S.f 6. List your current and previous hobbies: 7. Have you been in the military services?Yes/No If"yes,"were you exposed to biological or chemical agents (either in training or combat): Yes/No 8. Have you ever worked on a HAZMAT team?Yes/No 0 9. Other than medications for breathing and lung problems, heart trouble, blood pressure, and seizures mentioned earlier in this questionnaire, are you taking any other medications for any reason (including over- the-counter medications): Yes/No If"yes," name the medications if you know them: 10. Will you be using any of the following items with your respirator(s)? a. HEPA Filters: Yes/No .2 b. Canisters (for example, gas masks): Yes/No c. Cartridges: Yes/No 11. How often are you expected to use the respirator(s) (circle "yes" or"no"for all answers that apply to you)?: a. Escape only (no rescue): Yes/No CL b. Emergency rescue only: Yes/No c. Less than 5 hours per week:Yes/No d. Less than 2 hours per day:Yes/No e. 2 to 4 hours per day: Yes/No f. Over 4 hours per day: Yes/No 12. During the period you are using the respirator(s), is your work effort: a. Light(less than 200 kcal per hour): Yes/No If"yes," how long does this period last during the average shift: hrs. mins. Examples of a light work effort are sitting while writing, typing, drafting, or performing light assembly work; or standing while operating a drill press (1-3 lbs.) or controlling machines. Packet Pg.245 7 of 10 11/2/2020,8:45 PM 1910.134 App C-OSHA Respirator Medical Evaluation Questionnaire ... https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.... F.S.f b. Moderate(200 to 350 kcal per hour): Yes/No If"yes," how long does this period last during the average shift: hrs. mins. Examples of moderate work effort are sitting while nailing or filing; driving a truck or bus in urban traffic; standing while drilling, nailing, performing assembly work, or transferring a moderate load (about 35 lbs.) at trunk level; walking on a level surface about 2 mph or down a 5-degree grade about 3 mph; or pushing a wheelbarrow with a heavy load (about 100 lbs.) on a level surface. c. Heavy(above 350 kcal per hour): Yes/No If"yes," how long does this period last during the average shift: hrs. mins. 0 Examples of heavy work are lifting a heavy load (about 50 lbs.) from the floor to your waist or shoulder; working on a loading dock; shoveling; standing while bricklaying or chipping castings; walking up an 8-degree grade about 2 mph; climbing stairs with a heavy load (about 50 lbs.). 13. Will you be wearing protective clothing and/or equipment (other than the respirator)when you're using your respirator: Yes/No If"yes," describe this protective clothing and/or equipment: .2 14. Will you be working under hot conditions (temperature exceeding 77 deg. F): Yes/No 15. Will you be working under humid conditions: Yes/No 16. Describe the work you'll be doing while you're using your respirator(s): CL 2_ 0 17. Describe any special or hazardous conditions you might encounter when you're using your respirator(s) (for example, confined spaces, life-threatening gases): 18. Provide the following information, if you know it, for each toxic substance that you'll be exposed to when you're using your respirator(s): Name of the first toxic substance: Estimated maximum exposure level per shift: Duration of exposure per shift: Name of the second toxic substance: Estimated maximum exposure level per shift: Duration of exposure per shift: Name of the third toxic substance: Estimated maximum exposure level per shift: Duration of exposure per shift: The name of any other toxic substances that you'll be exposed to while using your respirator: Packet Pg.246 8 of 10 11/2/2020,8:45 PM 1910.134 App C-OSHA Respirator Medical Evaluation Questionnaire ... https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.... F.S.f 19. Describe any special responsibilities you'll have while using your respirator(s) that may affect the safety and well-being of others (for example, rescue, security): [63 FR 1152, Jan. 8, 1998; 63 FR 20098, April 23, 1998; 76 FR 33607, June 8, 2011; 77 FR 46949, Aug. 7, 2012] UNITED STATES DEPARTMENT OF LABOR Occupational Safety & Health Administration 200 Constitution Ave NW Washington, DC 20210 t.800-321-6742 (OSHA) TTY www.OSHA.gov .2 FEDERAL GOVERNMENT White House Severe Storm and Flood Recovery Assistance Diaster Recovery Assistance DisasterAssistance.gov USA.gov a No Fear Act Data U.S. Office of Special Counsel OCCUPATIONAL SAFETY & HEALTH Frequently Asked Questions A- Z Index Freedom of Information Act- OSHA Read The OSHA Newsletter Packet Pg.247 9 of 10 11/2/2020,8:45 PM 1910.134 App C-OSHA Respirator Medical Evaluation Questionnaire ... https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.... F.S.f Subscribe to the OSHA Newsletter OSHA Publications Office of Inspector General ABOUT THIS SITE Freedom of Information Act- DOL Privacy & Security Statement U Disclaimers Important Web Site Notices Plug-ins Used by DOL Accessibility Statement .2 c Packet Pg.248 10 of 10 11/2/2020,8:45 PM 1 o9/zs/zozo 9 �►�� CERTIFICATE OF LIABILITY INSURANCE DATE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND ORALTER 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 CONTACT Claudia Sacasa AAI NAME: Brown&Brown Insurance Homestead Florida pAH CNN. Ext: (305)247-5121 FAX No): (305)248-8543 1780 N Krome Avenue E-MAIL csacasa@bbinsfl.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Homestead FL 33030 INSURERA: Hartford Casualty Insurance Company 29424 O INSURED INSURER B: Twin City Fire Insurance Company 29459 0 Richard L Dolsey PHC Inc,DBA:Physicians Health Center INSURER C: OM Management,Inc. INSURER D: 4483 NW 36 Street#120 INSURER E: Miami Springs FL 33166-7260 INSURER F: COVERAGES CERTIFICATE NUMBER: 20-21 Master Liability 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS Ca CERTIFICATE MAYBE 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 AUULbUbK POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MWDD/YYYY) (MWDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ N CLAIMS-MADE Fx_]OCCUR PREM SESTOEa oNcurrrence $ 300,000 MED EXP(Any one person) $ 10,000 � A 21 SBM T08521 05/02/2020 05/02/2021 PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000CIL X POLICY ❑ PRO ❑ LOC PRODUCTS $ 2,000,000 wr JECT (, OTHER: Liability and Medical $ 1,000,000 AUTOMOBILE LIABILITY GO�fo4'MeDn SINGLE LIMIT $ 1,000,000 CIL Ea accident ANYAUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED 21 SBM T08521 05/02/2020 05/02/2021 BODILY INJURY(Per accident) $ O AUTOS ONLY AUTOS X HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY /� AUTOS ONLY Per accident ug $ UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LAB O CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 C) B OFFICER/MEMBER EXCLUDED? ❑ N/A 21 WEC AH5315 O5/02/2020 O5/02/2021 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000CIL If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Employment Practice Liability& Aggregate 1,000,000 B Fiduciary Liability 21 HC 0338773-19 07/12/2019 07/12/2020 J DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) U CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Monroe County BOCC ACCORDANCE WITH THE POLICY PROVISIONS. 1111 12th Street, AUTHORIZED REPRESENTATIVE Suite 408 Key West FL 33040 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Packet Pg.249 F.5.h' AC R ERTIFICATE QF LIABILITY INSURANCE E:DAT:E(MMIDWYYYY) 24/2020 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 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 ri hts to the certificate holder in Ileu of such endorsements. PRODUCER CONTACT NAME: PROFESSIONAL CASUALTY PHONE . 954 473-5011 472-FAJ 3982 8211 West Broward Blvd Ste 400 n®ale : dbrahm rofessionalcasuai cor .com Plantation,FL 33324-9966 INSURER(Sl AFFORDING COVERAGE NAIC M INSURER A: Care Risk Retention Group INSURED INSURER B: Physicians Health Center INSURER C 83 36 Street INSURERD: Suite 120 INSURERE: U Miami, FL 33166 INSURER F: COVERAGES CERTIFICATE NUMBER: 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 TYPE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP LTR POLICYNUMBER MM Y) ImmmDrMyl LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-AAADF E OCCUR PREMISES Ea REM S MED EXP(Any oneperson' $ PERSONAL&ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER,_ GENERAL AGGREGATE S N O. POLICY 0 JECT [:]LOC PRODUCTS-COMPIOP AGG S OTHER: $ '2 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person! $ CIL _ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY{Perawdenq S (J HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY Per.cadent S W UMBRELLA LIAB OCCUR EACH OCCURRENCE $ In EXCESS LIAB HCLAIMS.MADE AGGREGATE S DED I RETENTIONS $ WORKERS COMPENSATION I OTH- JD AND EMPLOYERS'LIABILITY y I N STATUTE ER (B ANY PROPRIETORIPARTNERIEXECUTNE OFFICER(MEMSER EXCLUDED? NIA E,L EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S O N Professional In A PPG0900002 1/20/2020 1/20/2021 $250,000 Per claim Liability O $750,000 Aggregate tm CIL DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES IACORD 101,Additional Remarks Schedule,may be attached It more space Is required) Retroactive Date 9112/2001 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Monroe County BOCC ACCORDANCE WITH THE POLICY PROVISIONS. 1111 12th Street,Suite 408 AUTHORIZED REPRESENTATIVE Key West,FL 33040 198 -2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Packet;Pg. 250