Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Item H1
H.1 ;4y ' ?� "r BOARD OF COUNTY COMMISSIONERS County of Monroe Mayor, Mayor Michelle Coldiron,District 2 �� {sJ ` °' Mayor Pro Tem David Rice,District 4 -Ile Florida.Keys Craig Cates,District 1 Eddie Martinez,District 3 w Mike Forster,District 5 County Commission Meeting March 17, 2021 Agenda Item Number: H.1 Agenda Item Summary #7921 BULK ITEM: No DEPARTMENT: Emergency Services TIME APPROXIMATE: STAFF CONTACT: James Callahan (305) 289-6088 9:30 AM BOARD OF GOVERNORS AGENDA ITEM WORDING: BOG approval for the second of two optional one-year contract extensions with Life Extension Clinics, Inc. ("Life Scan") to perform annual physical examinations of Monroe County Fire Rescue personnel in accordance with NFPA 1582 for the period 03/21/2021 through 03/20/2022. ITEM BACKGROUND: MCFR is seeking approval to renew our existing contract with Life Scan for the second of two (2) optional one-year terms. By opting to renew the contract for an additional year, the current cost of$395.00 per physical will remain the same and will avoid any increase in cost. NFPA 1582 recommends all active firefighters, regardless of age, to have an annual physical and stress test. Life Scan provide these services at a cost of$395.00 per physical. Each physical includes a stress test. The County will provide a treadmill. The program can be expanded to other County departments and constitutional offices if desired. Life Scan provides all labor, materials, equipment, machinery, tools and apparatus to perform all work and services. They operate from a mobile medical unit, which will be located at a centralized site within the County that is convenient for firefighters. PREVIOUS RELEVANT BOCC ACTION: BOG approval on 04/15/2020 (Item H.2) for the first of two optional one-year terms to expire on 04/15/2021. CONTRACT/AGREEMENT CHANGES: Life Scan contract extension for the second of two optional one-year extensions. STAFF RECOMMENDATION: Approval DOCUMENTATION: Life Extension Clinics - 2nd Renewal Expires 3-20-2022 Packet Pg. 1488 H.1 Life Extension Clinics - 1st Renewal Expires 4-15-2021 Life Extension Clinics - Original Agreement Expires 3-20-2020 Life Scan COI - Received 02-25-2021 FINANCIAL IMPACT: Effective Date: 03/21/2021 Expiration Date: 03/20/2022 Total Dollar Value of Contract: Approx. $69,200.00 Total Cost to County: $69,200.00 Current Year Portion: $69,200.00 Budgeted: Yes Source of Funds: Emergency Services Operating Budget/530316 CPI: No Indirect Costs: N/A Estimated Ongoing Costs Not Included in above dollar amounts: N/A Revenue Producing: No If yes, amount: N/A Grant: No County Match: No Insurance Required: Yes, attached Additional Details: Refer to the notes below. A total of$69,200.00 is currently budgeted in FY21 for Annual Physicals covering approximately 175 career and volunteer firefighters at$395.00 each. 03/18/21 141-11500 - FIRE& RESCUE CENTRAL $52,000.00 Annual Physicals 03/18/21 101-11001 - MEDICAL AIR TRANSPORT $6,800.00 Annual Physicals 03/18/21 404-63100 - FIRE& RESCUE KW AIRPORT $5,200.00 Annual Physicals 03/18/21 148-12000 FIRE& RESCUE COORDINATO $2,800.00 Annual Physicals 03/18/21 001-12001 FIRE ACADEMY $1,200.00 Annual Physicals 03/18/21 148-14000 FIRE MARSHALL $1,200.00 Annual Physicals Total: $69,200.00 REVIEWED BY: Pedro Mercado Completed 03/01/2021 8:49 AM James Callahan Completed 03/01/2021 11:00 AM Purchasing Completed 03/01/2021 11:34 AM Budget and Finance Completed 03/01/2021 3:04 PM Packet Pg. 1489 H.1 Maria Slavik Completed 03/01/2021 3:16 PM Liz Yongue Completed 03/01/2021 3:54 PM Board of County Commissioners Pending 03/17/2021 9:00 AM Packet Pg. 1490 H.1.ai E SECOND RENEWAL AGREEMENT CONTRACT FOR SERVICES LIFE EXTENSION CLINICS,INC. MONROE COUNTY THIS SECOND RENEWAL AGREEMENT is made and entered into on the 17th day of March , 2021 by and between MONROE COUNTY, a political subdivision of the State of Florida whose address is 1100 Simonton Street, Florida 33040 (hereinafter referred to as "County"), and Life Extension Clinics Inc., a business having its primary business location at: W 1011 N. MacDilI Ave.,Tampa, Florida 33607 (hereinafter the "Contractor"). WITNESSETH: WHEREAS, on the 21" of March 2018 the parties entered into an agreement (hereafter Original Agreement) for the provision of physical examinations for Monroe County Fire Rescue staff,and 0 WHEREAS,the Original Agreement provided for two (2)one-year renewal terms; and WHEREAS,pursuant to the terms of the Original Agreement,the Contractor has informed the County in writing of its desire to renew the Agreement; and ca WHEREAS, the parties find that it would be mutually beneficial to enter into this first renewal agreement; N NOW THEREFORE, IN CONSIDERATION of the mutual promises and covenants set forth below,the parties agree as follows: X LU Section 1. In accordance with Paragraph 2 of the Original Agreement, the County exercises the option to renew the Original Agreement for the second of the two(2) one-year terms. This term will commence on March 21,2021 and terminate March 20,2022. N Section 2. Except as set forth in Section 1 of this First Renewal Agreement, in all other respects, the terms and conditions set forth in the Original Agreement remain in full force and effect. THE REMAINDER OF THIS PAGE HAS BEEN INTENTIONALLY LEFT BLANK. X Packet Pg. 1491 H.1.ai E IN WITNESS WI ERI O1', each party has caused this agreement to be eXCcuted by a duly authorized representative. � (SEAL) BOARD OF COUNTY COMMISSIONERS A"I TF ST: KEVIN ILfiADOK, CLERK. OF N40NROE COUNTY. FLORIDA Deputy Clerk Mayor/Chairman 0 LII L I NSIO NROE COUNTY ATTOnN4EY ., N1CS, INC. Z1��J1/Jc FO r cn l ASN U A Die 2/24/21 0 STATE OF: � COUNTY OF: Subscribed and sworn to (or affirmed) before me, by means of R1 physical presence or ❑ online cv cv CD notarization. on r k- --. (elate) by & r t Ck&— r) (name of affiant). 1-le CIS is personally know to me or has produced (type of identification) as identification. 'Ld; Public Stnte of Florida ifer L Conneliy ff mmission GG 327822os�14f2'if20 3 , U J 1 X J U Packet Pg. 1492 ,WURYQ Kevin Madok, CPA .� ... Clerk of the Circuit Court& Comptroller—Monroe County, Florida 6c~'eoe coo�4 E DATE: April 23, 2020 TO: Chief James Callahan Fire Rescue/EMS 0 Cheri Tamborski Executive Administrator c FROM: Pamela G. Hanco C. X SUBJECT: April 15t'BOCCBOG meetings Attached is an electronic copy die following item for your handling: D3/I2 1st Renewal Agreement, first of two optional one-year contract extensions,with Life ) Extension Clinics, Inc. to perform annual physical examinations of Monroe County Fire Rescue _ personnel in accordance with NFPA 1582. Should you have any questions, please feel free to contact me at(305) 292-3550. N N LO X X cc: County Attorney Finance File KEY WEST MARATHON PLANTATION KEY PK/ROTH BUILDING 500 Whitehead Street 3117 Overseas Highway 88820 Overseas Highway 50 High Point Road Key West,Florida 33040 Marathon,Florida 33050 Plantation Key,Florida 33070 Plantation Key,Florida 33070 305-294-4641 305-289-6027 305-852-7145 305- Packet Pg. 1493 H.1.b E FIRST RENEWAL AGREEMENT CONTRACT FOR SERVICES LIFE EXTENSION CLINICS, INC.. MONROE COUNTY THIS FIRST RENEWAL AGREEMENT is made and entered into on the 151h day of Aril .2020 by and between MONROE COUNTY,a political subdivision of the State of Florida whose address is 1100 Simonton Street, Florida 33040 (hereinafter referred to as 0 "County"), and Life Extension Clinics Inc., a business having its primary business location at: °' 1011 N. MacDill Ave.,'Pampa, Florida 33607 (hereinafter the "Contractor"). WITNESSETH: N WHEREAS, on the 2151 of March 2018 the parties.entered into an agreement (hereafter Original Agreement) for the provision of physical examinations for Monroe County Fire Rescue staff, and 0 WHEREAS,the Original Agreement provided for two(2) one-year renewal terms;and WHEREAS,pursuant to the terms of the Original Agreement,the Contractor has informed the County in writing of its desire to renew the Agreement;and ca WHEREAS, the parties rind that it would be mutually beneficial to enter into this first N renewal agreement: N LO NOW THEREFORE, IN CONSIDERATION of the mutual promises and covenants.set forth below, the parties agree as follows: X Section 1. In accordance with Paragraph 2 of the Original Agreement, the County exercises the LU option to renew the Original Agreement for the first of the two (2) one-year terms. This term will commence on March 21,2020 and terminate March 20,2021. Section 2. Except as set forth in Section 1 of this First Renewal Agreement, in all other respects, the terms and conditions set forth in the Original Agreement remain in full force and effect. Q THE REMAINDER OF THIS PAGE'"HAS BEEN INTENTIONALLY LEFT BLANK. Packet Pg. 1494 H.1.b E -_,g.Zq�,JN WITNESS WHEREOF, each party has caused this agreement to be executed by a duly -�.;atathorizeq representative. �- \EAL ` i a BOARD OF COUNTY COMMISSIONERS ). f, ATTEST. KEVIN MADOK, CLERK OF MONROE COUNTY -LORIDA opt�: >.� • �� By By: Mayo Chai n Deputy Clerk 2 0 s a LIFE tSIO " ''LINICS, INC. N C. t-' Title: t- 1 o O NIKE of F*Wa ??•ATE O�: l oi"I G, lly —- G 327822 3 COUNTY OF: Hi 1 )!;I , U� 1-, ca Subscribed and sworn to (or affirmed) before me, by means of 0 physical presence or CI online cv notarization, on jar, Zc:3 Z 0 LO (date)by (name of affiant). I-Ie s personally known to me or has produced (type of LU X identification)as identification. o, O ROE COU r EY M:KWE S y . BOARD OF GOVERNORS OF FIRE P ASSIST. b NTY A RNFY AND AMBULANCE DISTRICT I OF F � °«,.N MONROE COUNTY FLORIDA �' t' l 2v A� r . By i A1"T� IN MA K,CLERK Mayor/Chairperson ®Y� DEP CLERK Packet Pg. 1495 H.1.b A a' CERTIFICATE OF LIABILITY INSURANCE 01/2812 zo MfODin THIS CERTIFICATE 1S 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(les)must 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 conferrights to the certificate holder In lieu of such endorsements. PRODUCER acT Cinda Groves 0.E.Wilson Insurance,Inc 727 535.0524 P 727 536-9828 1475 Belcher Rd S L cind1190OW1150n.com Largo FL 33771 Auto-Owners Insurance Company 18988 O INSURED iwsumg am Admi I Insure ce Company 24856 Life Extension Cllnics,lnc.DHA Life Scan Wellness Centers j=Rjg c Transportation Insurance Company 12408 1011 N.Macdill Ave Tampa FL 33607 C O COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: N THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD C INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR 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, I TYPE OF INSURANCE L MENPOLH T mmmonnrffl POU EXP LIMITS )( COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1'000 OOO A CwMs•MADE ®OCCUR DAMAC>,4% ANTED 100 000 X X 062312-20690745 11/1012019 1111012020 . 10.0110 C AOV IWMRY S1,000,000 O sNLAGG 1 LIMITAPP SPER 'A 2 000 000 X POLICY JECTIN LOc P a 2 000 000 _ s AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1 000 000 A X ANY AUTO 130DILY UUURY(Per Pawn) S ALLOWNED SCHEDULED X X 4169162800 0911812019 0911812020 BODILY MURY(Per eccideM) $ W X HIRED AUrOSAUTOS AUTOS N AUTOS SCHEDULED PROPERTY DAMAGE S CD LO UMBRELLA LIAB OCCUR GHO.CI)i!<TN4E §v EXCESS UA13 M 622BEDATF WORKERS COMPENSATION x P(R OT4. AND EMPLOYERS'LIABILITY O ANY PROPRIETOMPARTNEWFXECUTIVE 91 CIO ALCIDE S1,000,000 C (OMFFI� 1 NH) EXCLUDED? N NIA X WC 6 56600287 1112912019 1112912020 31,000,000 r-Ln _ X s desaibeunder 1 c. Y ni 1 000000 B Medical Professional Liability E0000037691-03 0513112019 0513112/20 2,000,000 Aggregate Retroactive Date:5/3112001 2,000,000 Each Claim DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORO 101.Additional Remuka Schedule,may be it MIA 11Certificate holder Is additional Insured on the general liability and auto liabilitywith repect to work performed by the insured. A �NIF ►CJ1 a Medical Professional Liability Additional Coverages: Sexual Abuse $1.000,000 Each Clalmi$1,000,000 Aggregate C O Network Security&Data PrivacyLiabill $1 000 000 Each Clalml 1 000,000 Aggregate N CERTIFICATE HOLDER CANCELLATION C X Monroe County Board Of County Commissioners SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1100 Simonton 5t ACCORDANCE WITH THE POLICY PROVISIONS. Key West,FL 33040 AUTHORIZED REPRESENTATIVE O 01988-2014 ACORD CORPORATION. Ail rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Packet Pg. 1496 H.1 c GJt C°UR"° o: Kevin Madok, CPA ►b �` Clerk of the Circuit Court& Comptroller— Monroe Count Florida •�Roz COUNT. Y1 DATE: March 28, 2018 c TO: Debbie Lofberg -� Emergency Services 0 FROM: Pamela G. Hancock, D.C. 0 SUBJECT: March 21st BOCC Meeting Attached is an electronic copy of Item C7, Contract with Life Extension Clinics, Inc. to LU perform annual physical examinations of Monroe County Fire Rescue personnel in accordance with NFPA 1582, for your handling. Should you have any questions,please feel free to contact me at ext. 3130. Thank you. U ca cv cc: County Attorney cv Finance File x LU LU KEY WEST MARATHON PLANTATION KEY PK/ROTH BUILDING 500 Whitehead Street 3117 Overseas Highway 88820 Overseas Highway 50 High Point Road Key West,Florida 33040 Marathon,Florida 33050 Plantation Key,Florida 33070 Plan 305-294-4641 305-289-6027 305-852-7145 305- Packet Pg. 1497 H.1 c CONTRACT FOR SERVICES �s Mow* THIS AGREEMENT is made and entered into on the day of �� c 2018 by and between MONROE COUNTY, a political subdivision of the State of Florida whose address is 1100 Simonton Street, Florida 33040 (hereinafter referred to as "County"), and Life Extension Clinics Inc., a business having its primary business location at: 1011 N. MacDilI Ave., 0) Tampa, Florida 33607 (hereinafter the "Contractor"). WITNESSETH: WHEREAS, the County is desirous of obtaining the services of a knowledgeable and qualified individual or entity to perform physical examinations for Monroe County Fire Rescue staff, and 0 WHEREAS, the provision of such services shall mutually benefit the parties hereto and the residents of Monroe County, Florida. NOW THEREFORE, in consideration of the covenants herein contained, it is mutually agreed between the parties as follows: 1) SCOPE OF THE WORK: The Contractor, with the exception of a treadmill to be \ provided by the County, shall furnish all labor, materials, equipment, machinery, tools and apparatus to perform all work or services specified in Exhibit 1, Request for Proposal (RFP) #17- 601 and any addenda to the RFP, attached hereto and made a part hereof by this reference and hereinafter referred to as the "work" or "services". Unless expressly modified by this Agreement or future amendments to this Agreement, the terms and conditions of the RFP and any addenda LU will be binding on the parties. 2) TERM: This Agreement shall become effective on the date of execution, for a term of 2 two (2) years. At the end of this term, the County has the option of renewing this agreement for two (2) one year terms. Should the Contractor wish to renew the Agreement, it should relay that information to the County in writing at least 60 days.prior to the expiration of the 2-year term. 0 3) PAYMENTS: The County shall pay the Contractor for work or services provided under this Agreement as provided in Exhibit 2 to this Agreement and made a part of this Agreement by this reference. The County reserves the right to deduct from any Contractor invoice an amount for defective or nonconforming work or for work not provided but invoiced. The County shall remit payment in accordance with the Florida Prompt Payment Act, Florida LU Statutes Section 218.70 et seq. 4) INDEMNIFICATION: The Contractor shall indemnify and hold harmless the County and its agents and employees from and against all claims, damages, losses and expenses, Packet Pg. 1498 H.7 c including attorney's fees arising out of or resulting from the performance of its work under this Agreement, where such claim, damage, loss or expense is caused, in whole or in part, by the act or omission of the Contractor, or anyone directly or indirectly employed by the Contactor, or anyone for whose acts any of them may be liable, regardless of whether or not it is caused in part by a party indemnified thereunder. In any and all claims against the County, or any of its agents or anyone directly or indirectly employed by the Contractor, or anyone for whose acts any of them may be liable, indemnification obligation under this paragraph shall not be limited in any way by a limitation on the amount or type of damages, compensation or benefits payable by or for the Contractor, under workers' compensation acts, or other related policies of insurance. The parties acknowledge specific consideration has been exchanged for this provision. N 5) MODIFICATIONS TO AGREEMENT: This Agreement, together with any exhibits, LU task assignments and schedules, constitutes the entire agreement between the County and the Contractor and supersedes all prior written or oral understandings. This Agreement and any exhibits, task assignments and schedules may only be amended, supplemented or canceled by a written instrument duly executed by the parties hereto. 6) INSURANCE: The Contractor, at its own expense, shall keep in force and at all times maintain during the term of this Agreement: a. Professional Liability Insurance: Professional Liability Insurance issued by responsible insurance companies and in a form acceptable to the County, with combined single limits of not less than One Million Dollars b. General Liability Insurance: General Liability Insurance issued by responsible insurance companies and in a form acceptable to the County, with combined single limits of not less than One Million Dollars ($1 for Bodily Injury and Property Damage per occurrence. E C. Automobile Liability Insurance: Automobile Liability coverage shall be in the minimum amount of One Million Dollars ($1,000,000) combined single limits for Bodily Injury and Property Damage per accident. d. Workers' Compensation Coverage: Full and complete Workers' Compensation 1, Coverage, as required by State of Florida law, shall be provided. e. Insurance Certificates: The Contractor shall provide the County with Certificate(s) of Insurance on all the policies of insurance and renewals thereof in a form(s) acceptable to the County. Said Liability Policies shall provide that the Monroe County Board of County Commissioners, its employees and officials will be included as "Additional Insured" on all policies, except for Workers' Compensation. The County shall be notified in writing of any reduction, cancellation or substantial change of policy or policies at least thirty (30) days prior to the effective date of said action. All insurance Packet Pg. 1499 H.1 c policies shall be issued by responsible companies who are acceptable to the County and licensed and authorized under the laws of the State of Florida. 7) ATTORNEY'S FEES: In the event of any legal action to enforce the terms of this Agreement each party shall bear its own attorney's fees and costs. 8) GOVERNING LAW: This Agreement shall be governed, interpreted and construed according to the laws of the State of Florida. 2 0 9)' COMPLIANCE WITH STATUTES: It shall be the Contractor's responsibility to be aware of and comply with all federal, state and local laws. - 10) VENUE: Venue for any legal action by any party to this Agreement to interpret, construe or enforce this Agreement shall be in a court of competent jurisdiction in and for Monroe County, Florida and any trial shall be non jury. 0 11) ASSIGNMENTS: Contractor shall not assign any portion of this Agreement without the written permission of the County. 12) TERMINATION: If either party fails or refuses to perform any of the provisions of this Agreement or otherwise fails to timely satisfy the provisions hereof, either may notify the other parry in writing of the nonperformance and terminate the Agreement or such part of the Agreement as to which there has been delay or a failure to properly perform. The Contactor may N cancel the Agreement, for good cause, upon ninety (90) days prior written notice to the County. The County retains the right to terminate the Agreement, in part or in its entirety, with or without cause upon thirty (30) days prior written notice. Any work completed or services provided prior 2 to the date of termination shall, at the option of the County, become the property of the County. The County is only responsible for payment for (work completed or services provided) prior to the effective date of termination. 13) INDEPENDENT CONTRACTOR: The Contractor shall perform the services under this Agreement as an independent contractor and nothing contained herein shall be construed to be inconsistent with this relationship or status. Nothing in this Agreement shall be interpreted or construed to constitute the Contractor or any of its agents or employees to be the agent, Ch employee or representative of the County. Q 14) RIGHT TO AUDIT RECORDS: In performance of this Agreement, the Contractor shall keep books, records, and accounts of all activities related to the Agreement, in compliance y with generally accepted accounting procedures, as adopted by the Department of Financial Services, as set forth in Rule 691-61.0012, Florida Administrative Code, as amended or LU superseded from time to time, or the Auditor General. Books, records, and accounts related to the performance of this Agreement shall be open to inspection during regular business hours by an authorized representative of the office and shall be retained by the Contractor for a period of E Packet Pg. 1500 H.1 c three (3) years after termination of this Agreement for accounting related records and for other public records, five (5) years after termination of this Agreement, or for any longer periods of time as may be required by applicable retention schedules. All books, records, and accounts related to the performance of this Agreement shall be subject to the applicable provisions of c Chapter 119 and Section 401.30, Florida Statutes. No reports, data, programs or other materials produced, in whole or in part for the benefit and use of either party, under this Agreement shall be subject to copyright by the other party in the United States or any other country. W 2 15) PUBLIC ACCESS. Public Records Compliance. Contractor must comply with c Florida public records laws, including but not limited to Chapter 119, Florida Statutes and Ch Section 24 of article I of the Constitution of Florida. The County and Contractor shall allow and r- permit reasonable access to, and inspection of, all documents, records, papers, letters or other "public record" 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 contract and related to contract performance. The County shall have the right to unilaterally cancel this contract upon violation of this provision by the Contractor. Failure of the Contractor to abide by the terms of this provision shall be deemed a material breach of this ) contract and the County may enforce the terms of this provision in the form of a court proceeding and shall, as a prevailing party, be entitled to reimbursement of all attorney's fees and costs associated with that proceeding. This provision shall survive any termination or CO expiration of the contract. N The Contractor is encouraged to consult with its advisors about Florida Public Records Law in order to comply with this provision. Pursuant to F.S. 119.0701 and the terms and conditions of this contract, the Contractor is required to: (1) Keep and maintain public records that would be required by the County to perform the service. (2) Upon receipt from the County's custodian of records, provide the County with a copy of the requested records or allow the records to be inspected or copied within a reasonable time at a cost that does not exceed the cost provided in this chapter or as otherwise provided by law. (3) Ensure that public records that are exempt or confidential and exempt from public records disclosure requirements are not disclosed except as authorized by law for the duration of the contract term and following completion of the contract if the contractor LU does not transfer the records to the County. (4) Upon,completion of the contract, transfer, at no cost, to the County all public records in possession of the Contractor or keep and maintain public records that would be Packet Pg. 1501 H.1 c required by the County to perform the service. If the Contractor transfers all public records to the County upon completion 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 c completion of the contract, the Contractor shall meet all applicable requirements for retaining public records. All records stored electronically must be provided to the County, upon request from the County's custodian of records, in a format that is compatible with' the information technology systems of the County. 0 (5) A request to inspect or copy public records relating to a County contract must be Ch made directly to the County, but if the County does not possess the requested records, the r- County shall immediately notify the Contractor of the request, and the Contractor must LU provide the records to the County or allow the records to be inspected or copied within a reasonable time. 0 IF THE CONTRACTOR HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE CONTRACTOR'S DUTY TO PROVIDE ) PUBLIC RECORDS RELATING TO THIS CONTRACT, CONTACT THE CUSTODIAN OF PUBLIC RECORDS, BRIAN BRADLEY, AT (305) 292-3470 16) UNAUTHORIZED ALIEN WORKERS: Monroe County will not intentionally award a publicly funded contract to any contractor who knowingly employs unauthorized alien workers, constituting a violation of the employment provisions contained in 8 U.S.C. Section 1324a(e) Section 274A(e) of the Immigration and Nationality Act "INA". The County shall y consider a contractors intentional employment of unauthorized aliens as grounds for immediate 2 0. termination of this Agreement. 17) FEDERAL TAX ID NUMBER: The Contractor shall provide to the County their E Federal Tax ID Number or, if the Contractor is a sole proprietor, a Social Security Number. 18) EMPLOYMENT: The Contractor shall not engage the services of any person or persons now employed by the County, including any department, agency, board or commission thereof, to provide services relating to this contract without written consent from the County. 19) PUBLIC ENTITY CRIMES: 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 a public entity, may not be awarded or perform work as LU a contractor, supplier, subcontractor, or consultant under a contract with a public entity, and may not transact business with any public entity in excess of the threshold amount provided in s.287.017 for CATEFORY TWO for a period of thirty six (36) months from the date of being placed on the convicted vendor list. Packet Pg. 1502 H.1 c 20) CONSTRUCTION OF AGREEMENT: The parties hereby acknowledge that they fully reviewed this Agreement, its attachments and had the opportunity to consult with legal counsel of their choice, and that this Agreement shall not be construed against any party as if they were the drafter of this Agreement. c 21) CONTINUED MANAGEMENT BY THE NAMED PARTIES: Continuation of the Agreement is contingent on continued management by Dr. Anthony Capasso, Medical License 0 #ME6951. Noncompliance with this provision is grounds for the County to terminate the ) 2 Agreement for default. The County can only agree to substituted management by a written c modification signed by both parties. 22) Notices - Any notice of other communication from either party to the other pursuant to this agreement is sufficiently given or communicated if sent by registered mail, with proper postage and registration fees prepaid, addressed to the party for whom intended, at the following addresses: For County: For Contract to: Emergency Services CEO Life Extension Clinics, Inc. Attn: Chief James Callahan Ms. Patricia Johnson ca 490 63rd Street Ocean, Suite 140 1101 N. MacDill Avenue Marathon, FL 33050 Tampa, FL 33607 N 23) Nondiscrimination. Contractor agrees that there will be no discrimination y against any person, and it is expressly understood that upon a determination by a court of 2 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. Contractor agrees to comply with all Federal and Florida statutes, and all local ordinances, as E applicable, relating to nondiscrimination. These include but are not limited to: 1) Title VII of 2 the Civil Rights Act of 1964 (PL 88-352) which prohibits discrimination on the basis of race, color or 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 0 504 of the Rehabilitation Act of 1973, as amended (20 USC s. 794), which prohibits discrimination on the'basis of handicaps; 4) The Age Discrimination Act of 1975; as amended (42 USC ss. 6101-6107) which prohibits discrimination on the basis of age; 5) The Drug Abuse Office and Treatment Act of 1972 (PL 92-255), 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 E 1968,(42 USC s. et seq.), as amended, relating to nondiscrimination in the sale, rental or Packet Pg. 1503 H.1 c financing of housing; 9) The Americans with Disabilities Act of 1990 (42 USC s. 1201 Note), as may be amended from time to time, relating to nondiscrimination based of disability; 10) Monroe County Code Chapter 14, Article II which prohibits discrimination on the basis of race, color, sex, religion, national origin, ancestry, sexual orientation, gender identify or expression, familial status or age; 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. 0 24) 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 U- r- any extent by a court of competent jurisdiction, the remaining terms, covenants, conditions and - N 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 LU 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. Contractor and County 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. 25) Binding Effect: The terms, covenants, conditions, and provisions of this CO Agreement shall bind and inure to the benefit of Contractor and County and their respective legal '✓ representatives, successors, and assigns. N 26) Authority. Each party represents and warrants to the other that the execution, y delivery and performance of this Agreement have been duly authorized by all necessary County 0. and corporate action, as required by law. LU 27) Adjudication of Disputes or Disagreements. Contractor and County 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 no resolution can be agreed upon within 30 days after the first meet and confer session, the issue or issues shall be discussed at a public meeting of the Board of County Commissioners. If the issue or issues are still not resolved to the 0 satisfaction of the parties, then any party shall have the right to seek such relief or remedy as may be provided by this Agreement by Florida law. 28) Cooperation. In the event any administrative or legal proceeding is instituted N against either party relating to the formation, execution, performance, or breach of this X Agreement, Contractor and County 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. Contractor and County Packet Pg. 1504 H.1 c specifically agree that no party to this Agreement shall be required to enter into any arbitration proceedings related to this Agreement. 29) Covenant of No Interest. Contractor and County covenant that neither presently has c any interest, and shall not acquire any interest, which would conflict in any manner or degree with its performance under this Agreement, and the only interest of each is to perform and receive benefits as recited in this Agreement. 2 0 30) Code of Ethics. County agrees that officers and employees of the County recognize and.will be required to comply with the standards of conduct for public officers and employees. .2 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 LU public position, conflicting employment or contractual relationship; and disclosure or use of certain information. c 31) No Solicitation/Payment. Contractor and County 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 CO solely for it, any fee, commission, percentage, gift or other consideration contingent upon or W N resulting from the award or making of this Agreement. For the breach or violation of this provision, Contractor agrees that 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 y of such fee, commission, percentage, gift or consideration. 0. LU 32) Non-Waiver of Immunity: Notwithstanding the provisions of Sec. 768.28, Florida Statues, the participation of the Contractor and County in this Agreement and the acquisition of any commercial liability insurance coverage, self-insurance coverage, or local government insurance pool coverage shall not be deemed a waiver of immunity to the extent of liability coverage, nor shall any contract entered into by the County be required to contain any provision for waiver. 33) 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 . N any public agents or employees of the County, when performing their respective functions under X this Agreement within the territorial limits of the County shall apply to the same degree and LU extent to the performance of such functions and duties of such officers, agents, volunteers, or employees outside the territorial limits of the County. Packet Pg. 1505 H.1 c 34) 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 0 constitutional or statutory duties of the County, except to the extent permitted by the Florida Constitution, State Statute, and case law. r_ 35) Non-Reliance by Non-Parties: No person or entity shall be entitled to rely upon the N 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 Contractor and County agree that neither the Contractor nor the County 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. 36) Attestations. Contractor agrees to execute such documents as the Lessor may ca reasonably require, to include a Public Entity Crime Statement, an Ethics Statement, and a Drug- '✓ Free Workplace Statement. N 37) No Personal Liability. No covenant or agreement contained herein shall be y deemed to be a covenant or agreement of any member, officer, agent or employee of Monroe . 0. 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. 38) Execution in Counterparts. This Agreement may be executed in any number of counterparts, each of which shall be regarded as an original, all of which taken together shall constitute one and the same instrument and any of the parties hereto may execute this Agreement 0 by signing any such counterpart. Ch THE REMAINDER OF THIS PAGE HAS BEEN INTENTIONALLY LEFT BLANK. Packet Pg. 1506 H.1 c IN'41V'ITNESS WHEREOF, each party has caused this agreement to be executed by a y 'duly autliofized;xepresentative. (SEAL)- BOARD OF COUNTY COMMISSIONERS ?' ATTEST:-,KEVIN MADOK, CLERK OF MONRO CO TY, F DA a a B Mayor/Chairman X O `i- J Mp = LIFE EXTE SIGN C , INC. .... a �o By a on LU .. N �1.0 � � Title: 72,1: STATE OF FLORIDA ca COUNTY OF MONROE / CD N S P/27 n to (or affirmed) and subscribed before me this day of , 2018, by >/'icilt \ Personally Known OR Produced Identification N Type of Identification Produced��/ • 1�l 1 , �/�,�/S(� 2 X 1 (Signature of Notary Public - State of Florida) � 1 � � (Print, Type, or Stamp Commissioned Name of Notary Public) ��tARyAo DAVID A.CASTELLI NOTARY PUBLIC cn STATE OF FLORIDA Q Comm#GG005564 r"'r✓ct its' Expires 10/8/2020 COU AT C;''ivrY M a� ��a1fED S PEDRO MERCAD ASSISTANT C UNTY ,3 I Date Packet Pg. 1507 H.1.c ;4c R CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 33/06/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THI: CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIE: BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZEI >- REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject t the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to th certificate holder in lieu of such endorsement(s). CONTACT O PRODUCER E, 0.E.Wilson Insurance,Inc. PHONE 727 535-0524 WC o. 727 536-9828 1475 Belcher Rd S E-MAIL cinda@oewilson.com Largo FL 33771 INSURERS AFFORDING COVERAGE NAIC# INSURER A: Auto-Owners Insurance Company 18988 INSURED INSURERB: Admiral Insurance Company 24856 L_ O Life Extensions Clinic,lnc.DBA LifeScan INSURERc: Transportation Insurance Company 12408 C 1011 N.Macdill Ave INSURER D Tampa FL 33607 INSURER E: INSURER F: X 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 PERIOI INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THI CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM,' EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. O INSR ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY TYPE OF INSURANCE LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 A CLAIMS-MADE ®OCCUR DAMAGE TO RENTED $1 OO,000 X X 20690745 11/10/2017 11/10/2018 MED EXP An oneperson) $10,000 PERSONAL i£ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X PR0 POLICY LOC PRODUCTS-COMP/OP AGG $2,000,000 JECT OTHER: $ CD AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000 CD (Fa accident) N A X ANY AUTO BODILY INJURY(Per person) $ CD ALL OWNED SCHEDULED i AUTOS AUTOS X 4159162800 09l18/2017 09/18/2018 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE ug X HIRED AUTOS X AUTOS $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ PEXCESS LIAB CLAIMS-MADE AGGREGATE $ 1 DED RETENTION$ $ WORKERS COMPENSATION PER OTH- a)AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $1,000,000 2 C OFFICER/MEMBER EXCLUDED? ❑N N/A X WC 6 56600287 11/29/2017 11/29/2018CID (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 B Medical Professional Liability E0000037691-01 05/31/2017 05/31/2018 2,000,000 Aggregate CID Retroactive Date:5/31/2001 2,000,000 Each Claim 0 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) rr U Certificate holder is additional insured on the general liability and auto liability A OV D Y RISK�v1ANAGEMENT . with repect to work performed by the insured. Medical Professional Liability Additional Coverages: BY Sexual Abuse $1,000,000 Each Claim/$1,000,000 Aggregate DAT Network Security&Data Privacy Liability$1,000,000 Each Claim/$1,000,000 Aggregate WAIVER W, _ ygg_ CERTIFICATE HOLDER CANCELLATION Monroe County Board of County Commissioners SHOULD ANYOFTHEABOVE DESCRIBED POLICIES BECANCELLED BEFOR THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED I 1100 Simonton St ACCORDANCE WITH THE POLICY PROVISIONS. Key West, FL 33040 AUTHORIZED REPRESENTATIVE � —" — > ¢, ©1988-2014 ACORD CORPORATIO ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Packet Pg. 1508 Exhibit 1 H.1.c IFE c SCAN 0 Wellness Centers U) 00 0 RFPRESPONSE: POLK COUNTY Request for Proposal Title: CD CD N FIREFIGHTER ANNUAL PHYSICALS P 17-601 X LU CD Due Date: 2 Wednesday, August 9, 2 17 2:00 p.m. EST LIFE EXTENSION CLINICS, INC. dba: Life Sean Wellness Centers 1011 North MaeDill Avenue Tampa, Florida 33607 (813) 876-0625 Patricia Johnson, CEO Packet Pg. 1509 EXHIBIT Aii FV 0 U) TABLE OF +CO1'ti TEWS x TAB 1: Letter of Transmittal TAB 2: Personnel Requirements TAB 3: Reporting Capabilities TAB 4: Mobile Testing TAB 5: Comprehensive Safety and Security Program ca TAB 6 GastCD W N CD TAB 7: Subcontractors(Attachment B) CD TAB 8: Medical Laboratory TAB 9: Proof of Insurance TAB 10: Additional Information Polk County RFP 17-601 Firefighter Annual Physicals Packet Pg. 1510 H.1.c TAB 1: LETTER OF TRANSMITTAL Legal Name: Life Extension Clinics,Inc. DBA: Life Scan Wellness Centers Corporate Address:. 1011 N.MacDill Avenue Tampa,FL 336077 2 Testing Site: tan-site at location(s)determined by POLK COUNTY Phone Number: Phone:(813)876-0625 Fax:(813)876-0653 Authorized Representative: Patricia,Johnson,CEO 0 Email: lifescanhc(raol.com Incorporated: Florida.,August 1998 Medical Director: Anthony L.Capasso,M.D.,P.A. o Medical License: FL ME69518 To: Polk County Re: Request for Proposal: Annual Firefighter Physicals Solicitation#: RFP-17-601 Due Date: August 9,20017 at 2:00 PM Local Time 0 ADDEEN UMS: Life Scan;acknowledges receipt of Addendum#1 On behalf of Life Scan Wellness Centers,I am pleased to present this response to your request for proposal for RFP 17-601 Firefighter Annual Physicals to provide the proposed Project Services according to the Scope of Services. ca Life Scan proposes to provide an on-site program at a location designated by Polk County with the W options to utilize any of our ether Life Scan Centers as needed. An on-site program can help to ensure an expedient time frame for services as well as provides an caption to keep employees on-duty resulting in a ' reduction in costs,time away from the job,or even overtime. Life Scan's background is in professional medical services specifically for public safety departments with over nineteen years' experience in the development and implementation of proms for state, LU municipalities and counties to fit their specific creeds. We have recognized the vital importance of combining the key components of health,wellness,and fitness to generate the healthiest,most productive 0) employees. LJFE SCALY PUBLIC SAIFET'Y PHYSICALS Life Scan specializes in providing government agencies with public safety physical exams that comply ,® with NFPA 1582,the IAFF/IAFC Wellness Fitness Initiative,OSHA,and FDLE as well as incorporating 0 an advanced level of medical assessments for the early detection of cancer, cardiovascular diseases, and y other potentially catastrophic illnesses. Our Life Scan model of"ultrasound-aided physical exams" for Public Safety Officers has been incorporated into the medical standards for over 150 fire service and law —�- enforcement departments. As a result, we have the proven ability to identify cardiovascular disease, aneurysms,diabetes,and cancer more accurately and in much early-stages in the disease..process resulting . in a substantial, long-term disability, absenteeism, and health care cast savings to the employer and the potential for lives saved. Experts consider public safety to be among the most stressful and hazardous of all professions with long- term exposure to toxic materials and infectious disease, high-levels of physical demands, frequent spontaneous fluctuations in blood pressure resulting from the "fight to flight" response, exposure to emotionally devastating events, and the effect of shift work. Studies confirm that the average firefighter Polk County RFP 17-601 Firefighter Annual Physicals Packet Pg. 1511 H.1.c and officer has almost tree tunes the incident of Dart disease, lung disease, and cancer and dies an average of 12 years before other public employees. With the ever-increasing occupational medical risks, counties and cities must look towards new methods of prevention and intervention to protect the health and ensure the longevity of their most valuable assets...their employees. Most public safety personnel are aware of the importance of being physically fit, yet many have undetected medical issues or lack the endurance and strength to efficiently perform p their jobs,putting themselves,their peers,and citizens at risk. In professions, as demanding and hazardous as firefighting and law enforcement, being medically, physically, and mentally fit will provide your employees with the capability to perform optimally, decrease stress and stress-related Health and emotional problems, and greatly reduce the incidence of work related illnesses and injuries. o r- Life Scan has a distinctive approach to occupational medicine, The Life Scan public safety physical is an N integrated medical approach to occupational exams that combines NFPA 1582, OSHA Respirator � Medical and Mask Fit Testing, and FILE physicals with early detection of the major diseases such as heart disease, stroke, cancer, diabetes, and aneurysms before they reach a catastrophic level. It provides your employees with a thorough assessment of their Health as well as recommendations for achieving and maintaining long-term health, appropriate intervention, behavioral modifications, and methods to reduce Health risks. Each Life Scan physical exam follows state and federal guidelines with the added value ca benefit of ultrasound imaging assessments of the internal organs and cardiovascular system, more extensive laboratory blood profiles, diet and nutritional analysis,and a state-of-the-art fitness evaluation. ) A personal wellness plan with these recommendations will be provided along with a copy of the medical and fitness assessments. The Life Scan Wellness Program also includes acomprehensive fitness evaluation based on NFPA 1583 ca and the WFI recommendations. Our clinical exercise physiologists have the expertise and experience to assess the physical fitness levels of each employee in relationship to their cardiovascular and overall `V health condition. Our physiologists will recommend fitness goals and a Fitness Prescription as well as `V diet and nutritional improvements, r9 Life Scan and our medical staffing are experienced and knowledgeable in all aspects of the scope of services. As an on-going program of Health, Wellness, and Fitness, Life Scan will continue to be your team dedicated to identifying areas of concern,monitoring the recommended interventions and programs, and assuring that your employees attain and maintain the level of health and well-being that is crucial to perform their gobs optimally and greatly reduce the chance for illness and injury. Thank you for the CD opportunity to respond to this RFP for Polls County Fire Rescue. Sincerely, Patricia 3o n,CEO o X LU Polk County RFP 17-601 Firefighter Annual Physicals Packet Pg. 1512 H.1.c THE FOLLO MlNG SECTION SHOULD BE COMPLETED Alf ALL PROP[)SERS. (SUBMITTAL PAGE) Company Name: Vim. A- DBAIFicttious Name (if applicable): 0 NOTE: COMPANY NAME MUST MATCH LEGAL NAME ASSIGNED TO TIN NUMBER. ) CURRENT W9 SHOULD BE SUBMITTED WITH BID. TIN#: ` N t LU (Street No or PO Box Nu ber) (Street arrie) (City) Ly LIQ 0 cplc-\ 0--o 0 ML, F �i (County) j (State) Y (Zip Code) Contact Person: �:f -__ Cam'_ `` , o °-- Phone Number: Cell Phone Number v cV w N Email Address: °- �f--,S"'co -- N M Type of Organization: X Sale Proprietorship Partnership Non-Profit Sub-Chapter Joint Venture , Y Corporation LLC LLP Publicly Traded Employee Owned 0 State of Incorporation Fl- .2 y The Successful vendor must complete and submit this section prior to award. The Successful vendor must invoice usfng the company name listed above. 24 Revised G&W 7 Packet Pg. 1513 H.1.c July 31, 2017 POLIO COUNTY, A POLITICAL SUBDIVISION OF THE STATE OF FLORIDA A ADDENDUM #1 .FP #17- 01 0 Firefighter Annual Physicals C In This addendum is issued to clarify, add to, revise and/or delete items of the RFP Documents for � this work. This Addendum is a part of the RFP Documents and acknowledgment of its receipt should be noted on the Addendum. Contained within this addendum: Aced/Replace Ken Brush ca Procurement Specialist CD Procurement Division! CD N —••— — .. u,ennm ,i nnnouum,i ni nin.o„n��. N This Addendum sheet should be signed and returned with your y submittal. This is the only acknowledgment required. CD ry, 6 Signature. * .. Printed Name: Title: u Company: a Packet Pg. 1514 H.1.c FIREFIGHTER ANNUAL PHYSICALS t3D EN [!m #1 — ADD/REPLACE Notice of Request for Proposal 0 "RFP packages may be obtained from the Procurement Division, 330 'llMl'est Church Street, Room 150, Bartow, Florida, 33830, (863) 534-6757 or downloaded from our website at N °/ cl � n ,n c ite/loin pines ids. Respondents must submit one (1) criginai and Seven (7) copies of the proposal prier to :00 p.m. on the receiving date. Proposals must lae submitted in a �sQaled" parcel. Proposals will be publicly opened and read at 2:00 p.m. an receiving date." Replace with. �; "RFP packages may be obtained from the Procurement Division, 330 West Church Street, ) Room 150, Bartow, Florida, 330, (83) 534757 or downloaded from our website at his:/1 of � cC ) co 11s rnon our nt ids, Respondents must submit one (1) o " lnal and Seven p" of thmcue proposal prior to 2:00 p.m. on the receiving date. Proposals must be submitted in a "sealed" parcel. Proposals will be publicly opened and read at 2:00 p.m. '✓ ors receiving date." N N x LU x LU Packet Pg. 1515 H.1.c TAB 2: PERSONNEL REQUIRENIMNTS COMPANY QHALI�+'ICATTONS-General Corporates Number of years in business: 19 years Medical Director: .Anthony Capasso,M.D. Plumber of years in practice: 23 years Number of years as Medical Director for Life Scan. 13 years W 2 Life Scan's specialty and background is in the areaof prevention-based occupational, medical e services for government agencies with a specialty in public safety. We have over fourteen years experience in the development and implementation of programs for county, and state public safety departments to fit their specific needs. We have recognized the vital importance of combining the key components of health, wellness, and fitness to produce the healthiest, most productive employees.. After researching and developing a program that is specifically designed to meet the needs of public safety, we opened our first ern-site wellness center in 2001 for the City of Jacksonville. Since then we have opened.three Life Scan Wellness Centers(only open to contracted government clients) and offer on-site services to over 150 government agencies in Florida and the Southeastern states. The Life Scan program provides annual fit for duty and post ) offer exams, respiratory protection programs, vaccines, and general employee exams at the same time integrating a model of early detection and prevention. ca Life Scan is currently providing the following services to over 150 County, and Municipal,and State government agencies: N • NFPA 1582 Physicals for Police and Firefighters • NFPA 1583 Fitness for Police and Firefighters • UFFIIAFC Health and Wellness Initiative • FDLE Police Physicals • DOT and CDL Physicals � • Hazmat Physicals E • SWAT Team:Physicals 2 • Bomb Squad Physic • Pre-Employment Public Safety Physicals • OSHA Respirator Physicals • OSHA Respirator Mask Fit Testing • Fit for Duty Testing • Orr-site Program for all medical,testing • On-site -racy services • On-site blood draws • Infectious Disease testing and vaccine � Added value services including the Life Scan ultrasound-aided physical exams that complement to Public Safety Physical Examinations Polk County RFP 17-601 Firefighter Annual Physicals Packet Pg. 1516 H.1.c Life Scan Professional Contributions to Public Safety Health: 0 In recognition of their outstanding accomplishments and understanding of the unique needs of 0. fire fighters and laic enforcement officers,Patricia Johnson and Tammy Torres, on behalf of Life Scan Wellness Centers,were appointed the Medical Advisors to the • Major Cities Chiefs' Association • National Sheriffs Association 2 0 FBI LEEDA • FBI National Executive Instigate Life Scan provides Firefighter Educational. Seminars,CEU courses,and professional articles to: • Florida Fire Chiefs • Florida Professional Firefighters • Fire Rescue International • International Firefighter Smoke Symposiums • Florida.Firefighter Safety and Health.Conferences � • Florida Cancer Survivor Network ) CO N N X LU CD 2 Ch N X LU Polk County RFP 17-601 Firefighter Annual Physicals Packet Pg. 1517 H.1.c PRINCIPALS,MANAGETMENTO AND PHYSICIAN SUPERVISORY TEAM: Patricia Johnson, CEO. Patricia is the cc-founder of Life Scan and will be the liaison between the City and Life Scan. Patricia will oversee contractual issues, ensure proper invoicing, and attend meetings. 2 0 Michael .l. Terrana, CFO. Mike is the co-founder of Life Scann and serves as corporate counsel and Chief Financial Officer.. Mike is an attorney in Tampa and started his law career as an . assistant state attorney in Hillsborough County and was lead partner in his law firm for over twenty years. Pam, Desmaires, ' -BC, is the Life Scan Wellness Center Clinical. Director and Project Manager. She is responsible for the supervision of the medical specialists and for the continuing education as well as medical procedures and protocol for the Life Sea Wellness Center medical program. Pam will ensure quality control over medical reporting and records and manage scheduling timelines. Pam has developed the medical protocol for the Life Scam ultrasound-aided c physical exam program and has extensive experience with NFPA 1582 guidelines and interpretation including annual and candidate medical clearances. ca Medical Director: Anthony Capasso, M.D. Dr. Capasso has over 20 years in private medical practice. He is fully experienced in workers' compensation, post offer employment physicals, firefighter and police physicals and medical clearance, HAZMAT medical clearance, occupational medicine, and internal medicine. Dr. Capasso is the supervisory medical director and advises with medical clearance review. � Life Scare is a nationally recognized expert and educator regarding the health and fitness of police and firefighters. Life Scan has advised NFPA 1582 and the IAFFIIA.FC Wellness Fitness Initiative Committees regarding firefighter health and fitness. CD 2 c X c Polk County RF'P 17-601 Firefighter Annual Physicals Packet Pg. 1518 H.1.c CL-RRICULUM VITAE ANTHONY L. CAPASSO, WLD. Florida Medical License. ME69518 EDUCATION 0 1984-I987 Ohio State university, Columbus,Ohio, Bachelor of Science--Biology Cush Laude. 1984-1986 Cleveland State University, Cleveland,Ohio. x POST GRADUATE TRAINING 1988-1990 Ohio State College of Medicine, Columbus,Ohio 1991-1993 University of A.laba .School of Medicine, Birmingham Alabama,M.D. 1993-1994 University of Florida Health Science Center,Jacksonville Florida; Internal Medicine Internship. ) 1994 University of Hawaii Integrated Medical Residency Honolulu, Hawaii;Internal Medicine Residency 7/l/94- 12/4/94 1995-1996 University of Florida Health Science Center, Jacksonville Florida, Internal.Medicine Residency. Graduation July 1996 CD HONORS AND AWARDS 1 84-1987 Dean"s List 2 0. 1985 Summa Award,University College, Ohio State University. 1987 Graduate Cure Laude, College of Arts and Sciences,Ohio State University. 1989 Honorary Letter from the Department of Anatomy for outstanding performance, � Ohio State College of Medicine. CERTIFICATION — Diplomat of the National Board of Medical Examiners,June 1993 Diplomat ABIM, August 1998 LICENSURE State of Florida ME 0069518 x LU Packet Pg. 1519 H.1.c MEMBERSELIPS 1984-1987 National Key Honor Society, Ohio State University 1988-1993 American Medical Student's Association I991-1993 Tuscaloosa.County Medical Association 1991-1993 Larry Mayes Society 1993-1997 American Medical Association 1994-1997 ACP'Member 1.999-present Duval County Medical Society 0 C EMPLOYMENT 2007-present Life Scan Wellness Centers-Medical Director 2003-present Hospice of Jacksonville—Associate Medical Director 1997-present Smart for Life Jacksonville-Medical director 2002-present Anthony L. Capasso M.D. P.A.-private practice 2001-2003 University of Florida—Clinical Assistant Professor 1999-2000 Premier Family Care- Internal ?Medicine 1998-1999 Jacksonville Emergency Consultants -Emergency Medicine ) 1997-1998 Premier Family Care-Local Tenum 199 -1997 South Beaches Medical - Internal Medicine 1996-1998 Barnen Venus M.D.P.A. CCU intensivist CD CD ca N Packet Pg. 1520 , a po DEpkij,Ml 4T'CIF`HEALTH 9 . .` DIVISION OF MkD(CAL QOAL TY ASSURANCE ?ATE OCENSE NO.. ' CONTI"t4L NO. Lo W 111D312015 ME 69518 5W182 .-he MEDICAL DOCTOR 18miid bekAv has met allrequlreflwftx)f C he Ims and ruled of the state of FldMa. U !iplr€l#I Date: JANUARY 31, 2010 # g °# lrt'Y Wrkd L CAP ' ' 1351 13TH AVE SOUTH SUITE 110 � 'Y 1ACOOMLLE BEACH FL 32250MLIJ NA, . 4 C c . Johns H.Armstrong,MD, FA � 0 C3t9rt�ERNOR STATE SURGEON GENERAL DISPI.AY'IFNEGUIRED BY LAW n E . ,f ON DATE:JANUARY 81,2018 Yaw`1iemse nznbw Is W SM16 P use it<in SU eurmapend+erlw wuilh yaw board leuncil.gwh uterus is solely tes for nodMm dw depulmat in wri" tCD V the linwneee°s currant smiting address and Practice location Address. If YOU hwt not fMtved Your mnewel"t 94 4WO Prim Tor eapttatiaa date stauwn vn a is Ile eaw CD picssc call I4}50)465-0393. tV Use tM Mims to repot now clnnnpe.}tame c r9 s r�tltialr l tiacunnet>tetlaq�t al�rlrffi ltwr tswmc chsrnpe.=Please aaske sots w ph�elotapy of er the Anllarittg y accogotm oleo this kmm:a tan idmite license.a direr=decree or a court order. � Medics)Q u dJV Assur *On*You d w commdence of scwersl aulitre sexvk=,Them stnices give YOU the sbitity to mmw your Ut ase.updam yaw matunnd and practi" lacedom addmems and updsao your proRis lnlbrmadoo, I.Qe to 2..Click an 7nmider tletwicW W A.Click a *Nknw OW lAwnw 4.stlet:tyaur aEa»sinn S.biter the our[D mid peara sd dort sags provided in you at yvw initial license and click"apt in udm our seetre 6.Ifyou do nor.know your„ter ID and pmsswa dr Click an Met Leon ielpy"or call+our cummv contact Center at(BSil)1 leii-asgs for mmisisn¢e. MAIL TO;DEPARRf'MENT OF IHEAI"TH IMPORTANT ANNOUNCEMENT DIVtWOR OF MEDICAL QUALITY ASSURANCE LICERSUIE SUPPORT SERVICES UNIT THE DEPARTWIENT OF HEAL11 WILL NOW REVIEW _ YOUR CONTINUING EDUCATX N RECORDS AT H ilk TAI. THE TIME OF LICENSE REN AL. ALLAIwIASSEE,FLORIDA 3�31dt+ip2Q ' NAME CHMOR(ATTACH LEGAL DOCUMENTATION) TO LEARN WORE,PLEASErfflN,MM=&mm x FROM: LAST RRgT MWOLE TOC {ST I iST WEICL.E CiI4 2143,6t98 � Packet Pg. 1521 H.1.c Pamela L. Desmarais, MS, ARNP-BC 76 Certifications Registered Nurse Practitioner In the State of Florida,.license number 25512ARNP Certified Adult Nurse Practitioner from the American Nurses Credentialing Center Registered Nurse in the ate of Florida and Massachusetts Basic tlfe Support(BLS)Certification Basic Life Support Instructor Advanced Cardiac Life Support c Highlights N • American Nurses Association (ANA) Completed AAAASF accredltations • Florida Nurses Association (FNA) Completed two JCAHO accreditations Professional Experience Life Scan Wellness Centers 2012 to Present Director Clinical and Medical Operations Lead ARNP: Provide physical assessment,medical clearances,and plan of care to adults in law enforcement and fire rescue positions. Obtains k factious disease lab orator results and educates patients on infectious diseases.Administering immunizations as needed/requested. Provide counseling of patients on risk factors, nutrition, medication, smoking cessation, physical activity, and disease management Promote health screenings and healthy living. ca Cl1nlque of Paste Surgery 2008 to ` CD CD ARNP1Clinical Manager Expertly managed all surgery services, including planning,scheduling and coordination,determination of procedures and procurement of supplies and equipment.Assessed need for,ordered,obtained and interpreted appropriate lab tests.Provided pre-infra-PACU care of patients. Managed clinical and support y staff in patient care activities. x Unlverslly ofSouth f4orfda 2003 to 2012 Adjunct Faculty Instructor for College of Nursing E CD Marrcadls Plasdc S'ur.Wry 2005 to 2006 ARNPJPractice Manager Expertly managed all surgery services, including planning, scheduling and coordination,determination of E procedures and procurement of supplies and equipment.Assessed need for,ordered,obtained and Interpreted appropriate lab tests. Provided pre intra-PACU care to surgical patients. Managed clinical and support staff In patient care activities. cn RN1Reltef Charge Nurse,CVTU,Endo"opy CVTU: Maintain and recover immediate postoperative open heart patients in CVTU. Endoscxopy, Evaluate and manage schedule for both outpatients and hospitalized patients. Manage patient transfers and immediate recovery of patients. Education tJniiversity of South Florida Master of Science,Nursing University of South Florida Bachelor of Science, Nursing Packet Pg. 1522 H.1.c c 0 0 STATT OF FLOWA Ac# �iW OF HNALTH GSJAI.�IY OW LaWSE NO MONOUIS APW EE. - r* ,d�of �rrdtSlttiedFbnAe� Ca P!AM t"M COMM DESMARAIS, ) c44 CD � w2DO4004M r:RTIPMATION COMMOM r9 VWW 411112015 tb 4ll Mama of Adel#Nunm Practrdoner Ammfdod to: CD Pamob L.Daarmmis,ANP43C x Packet Pg. 1523 H.1.c ? 1 1'1T k . SILVA, RDMS, RVT CLLKICAL EXPEI.MNCE o Life Scan Wellness Centers Tampa,Florida 0. Registered Efitrasound Technologist October 2014-present Experience performing wellness screening exams for lain'enforcement officers and firefighters throughout the state of Florida � e Ultrasound screening studies include echocardiogram,carotid arteries,thyroid, abdominal organs,pelvic,prostate,and testicular o • Responsible for training and coaching all new hires as well as students in company protocols and general ultrasound training... N • Responsible for creating training manual,presentations,and training of new technologist Edward White Hospital St.Petersburg,Florida Registered i]Itrasound Technologist April 20124X-tober 2014 • Crossed-trained in cardiac sonography with experience m echocardiograms and TEE +� Experience scanning general,vascular,and cardiac ultrasound in a busy Hospital setting including in-patient,out-patient,emergency room,and operating room services Proficient in assisting in radiology procedures including PICC lines,central lines, cc biopsies,paracentesis and thoracentesis CD cv CD cv EDUCATION cv r9 Associates of Science Central Florida Institute Major:Diagnostic Medical S,onography Graduated: October 2008 • Member of the National Technical Donor Society LU (Chi.Phi Iota Chapter) Bachelor of Science University of Tampa Major;Biology Graduated: May 2005 • Member of the National Science Honor Society X Packet Pg. 1524 H.1.c c j c U- All9A��,A FEMA 7 RVt(V'7'4. COMPOMM 0 M7 UXI MUM 133478 2"o 12i12017 4�als Ar�pf��at� � 0 Co CD J N CD N M X LU 0) 2 U X LU U Packet Pg. 1525 H.1.c Qualifications — c • ARDMS registered in specialties Abdomen and OB/GYN. • BLS certified with the American Heart Association. • Eight years' experience with patient care. • Two years clinical experience in various local hospitals and clinics. 0 • Registry eligible for specialties Echocardiography,Vascular,and Neurosonology. Clinical Experience X • AB, OB/GYN,Small PartsLu • High Risk Perinatal Protocol • Paracentesis/Thoracentesis • Echocardiography,TEE • Vascular, PVR ) Professional Experience Life Scan Wellness Centers Tampa,Florida `a 40 cv CD Registered Ultrasound Technologist October 2014-Present N +' Experience performing wellness screening exams for law enforcement officers and y firefighters throughout the state of Florida 2 0. X • Ultrasound screening studies include echocardiogram, carotid arteries,thyroid, abdominal organs, pelvic,prostate, and testicular E • Responsible for training and coaching all new hires as well as students in company protocols and general ultrasound training Responsible for creating training manual, presentations,and training of new tech nologist y Education • Associates of Science In Diagnostic Medial Sonography y Broward College, Coconut Creek FL. May 2012 Lu • Bachelor of Arts and Sciences In Psychology University of South Florida,Tampa FL Dec 2005 Packet Pg. 1526 H.1.c c �1. s� 0 ZMMAWARM MnFICM7ONS TO ) lF7CRt1t3N$ ROM%M OHim)RvT(vn ) Conwim i CEFMRND SNU dR N °�wr m�6g1+a rtffiue�{. � _. U 0 r .` fJ E3 1io aeon.ra am�r rna ompmo ma cowftvs sw Nmtrl ®aNe Lb SllppW ud MM P4gpr CV CD tV CD tV M X LU tJ X J U Packet Pg. 1527 H.1.c c) DETAILED STAFFING PLAN The Life Scan program is designed specifically for public safety and the entire medical staff has extensive knowledge and experience in providing firefighter physicals. The medical staff works in teams and each of them is experienced in all aspects of the scope of services and the Life Scan program including N'FPA 1582, NFPA 1583, FDLE, OSHA Respiratory Standard, the Wellness Fitness Initiative fitness evaluations,annual medical clearances, and reporting processes. 2 0 Staffing: • The Life Scan Staffing will include three (3) Life Scan employees that are fully trained and experienced in public safety Life Scan physicals using an integrated, team.approach. • Each team member is a direct employee of Life Scary and has undergone extensive � training with Life Scan to fully understand the technical, clinical, Life Scan procedures, and individual protocols of the assessments and medical.clearances. • All Life Scan medical staffing receives annual, recurrent training in areas such as ACLS certification, Public Safety Disease Risks, Diabetes, Ha mat testing, ) Infectious Diseases, Blood borne Pathogen and Safety Protocols, Medical Reporting updates, NFPA 1582 updates, Wellness Fitness Initiate program, and Life Scan clinical updates. ca N N N Mid-Level Practitioner()VP,MS1V,or PA) 0. Life Scan maid-level practitioners perform the on-site annual and pre-employment physicals, clinical assessments,administer the infectious disease program., and medical clearances under the supervision of Dr. Capasso. Life Scan raid-level practitioners have extensive experience providing medical clearance,pre-placement employment physicals, fitness for duty,NFPA 1582 and FDLE Medical exams,the WFI, and:OSHA Respirator Medical Clearance.They each have a thorough understanding ing of the unique needs,physical requirements, and mental stress related to the profession of firefighter and corrections personnel.. ACLS Certified Ultrasound Technician The Life Scan registered ultrasound technicians are fully cross-trained in all modalities of medical ultrasound and interpretation including vascular,heart,abdominal, and general ultrasound as well as receive extensive training in the Life Scan protocols and patient education, The Life Scan ultrasound team provides a key component to the overall health assessments, early detection testing,and educadon of our patients. X Polk County RFP 17-601 Firefighter Annual Physicals Packet Pg. 1528 H.1.c Clinical Exercise Physiologist The Life Scan clinical exercise physiologists are experienced in clinical cardiac testing and interpretation., lung capacity(pulmonary function) testing and interpretation,firefighter and correctional officer fitness evaluations, diet and nutritiort,body eomposition, and all aspects of NTPA 1582,L W FPA 1583,and the FT. All Life Scan physiologists are trained and experienced 0 in OSHA Respirator Medical Testing and OSHA Mask Fit Testing protocol, ACLS Certified 0 X 0 CD ca CD N X CD U Polk County RFP 17-60 1 Firefighter Annual Physicals Packet Pg. 1529 H.1.c d) Six (6)References from other Governmental Agencies that have utilized Life Scan for >_ Similar Services: c 1. Brevard County Fire Rescue Contact:Marvena Petty Phone: (321) 633-2056 x 56414 Email:marvena.petty@brevardfl.gov 2 0 Performance Period: 2012 to present dumber of ANNUAL physicals; 550 Service Provided: LIFE SCAN Firefighter Annual and Candidate Physicals • NFPA 1582 Annual and Candidate Physicals for Firefighters x NFPA 1583 Fitness Evaluation Firefighters • IAFFIIAFC Health and Wellness Initiative • Life Scan ultrasound and advanced medical assessments for disease detection and prevention a Hazmat and Specialty Team Physicals • On-site program for all medical testing,blood draws,and X-rays ) Infectious Disease testing and vaccines OSHA Respirator Physicals for Public Safety • OSHA Respirator Mask Fit Testing for Public Safety M N 2. St,Petersburg Fire Rescue and.St.Petersburg Police Department Contact: Fire Chief James Lark Phone: (727) 893-7058 Email: James.Large@stpete.org Number of ANNUAL physicals: 330 Performance Period 2008 to present Service Provided: LIFE SCAN Annual and Candidate Police and Firefighters: E • NFPA 1582 and FILE Annual Physicals 2 • Candidate Physicals for Police and Firefighters • NFPA 1583 Fitness Evaluation for Police and Firefighters • IAFFAAFC Health and Wellness Initiative - • Life Scan ultrasound and advanced medical assessments for disease detection and.prevention • Haamat, Swat Tom,and Specialty Team.Physicals • On-site program for all medical testing,blood draws, and X-rays Infectious Disease testing and vaccines OSHA Respirator Physicals for Public Safety • OSHA Respirator Mask Fit Testing for Public Safety Polk County RFP 17-601 Firefighter Annual Physicals Packet Pg. 1530 H.1.c 2. Largo Fire Rescue Contact: Fire Chief Shelby Willis Phone: (727) 587-6740-2005 Email: marven&petty@brevardfl.gov Performance Period: 2012 to Present Number of ANNUAL physicals: 125 Service Provided: LIFE SCAN Annual and Candidate Physicals: • NFPA 1582 Annual and Candidate Physicals for Firefighters 2 • NFPA 1583 Fitness Evaluation Firefighters e • IAFF/IAFC Health and WcUncss Initiative • Life Scan ultrasound and advanced medical assessments for disease detection and prevention x • Hazmat and Specialty Team Physicals • On-site prom for all medical testing,blood draws,and -rays • Infectious Disease testing and vaccines • OSHA Respirator Physicals for Public Safety • OSHA respirator Mask Fit Testing for Public Safety � 3. Rroward Sheriff's Fire Rescue Contact: Assistant Chief Todd Leduc ca - Phone: (954) 831-8291 or(954)321-4109 Email: Todd�Leduc@sheriff.org Number of ANNUAL physicals: 650 N Performance:Period: 2014 to Present. Service Provided. LIFE SCAN Annual Firefighter Phsyicals: • NFPA 1582 Annual Physicals for Firefighters • NFPA 1583 Fitness Evaluation Firefighters • IAFFIIAFC Health and Wellness Initiative • Life Scan ultrasound and advanced medical assessments for disease detection � and prevention • Hazrnat and Specialty Teats Physicals • On-site program for all medical testing,blood draws,and X-rays • Infectious Disease testing and vaccines • OSHA Respirator Physicals for Public Safety y • OSHA Respirator Mask Fit Testing for Public Safety x Polk County RFP 17-601 Fitofighter Annual Physicals Packet Pg. 1531 H.1.c 4. Panama City Fire Department Contact. Chief Scott Flitcraft 0 Phone- (850) 872.-3053 Email: sfliterafa pcgov.org Number of ANNUAL physicals 75 Performance e Period: 2016 to Present. 0 Service Provided: LIFE. SCAN Annual Firefighter Physicals: ) * NTPA. 1:582 Annual Physicals for Firefighters 0 • NFPA 153 Fitness Evaluation.Firefighters • IAFFOIFC Health and'Fellness Initiative • Life Scan ultrasound and advanced medical assessments for disease detection and prevention. • Herat and Specialty Team Physicals • On-site program for all medical testing, blood draws,and X-rays • Infectious Disease testing and vaccines ca OSHA Respirator Physicals for Public Safety OSHA Respirator Mask Fit Testing for Public Safety 5. Fort Lauderdale Fire-Rescue N Contact: Jo-Ann Lor ,er,EFO,CFD,CEM Battalion Chief/Assistant Fire Marshall Phone: (954) 828-6809 Email: JLorberfortlauderdale.gov y Number of ANNUAL physicals: 450 Performance Period: 2017 to Present,. Service Provided: LIFE SCAN Annual Firefighter Physicals: NFPA 1582 Annual Physicals for Firefighters NFPA 1583 Fitness Evaluation Firefighters CD • IAFF/AFC Health and Wellness Initiative • Life Scan ultrasound and advanced medical assessments for discase detection and prevention • Hazmat and.Specialty Team Physicals • On-site program for all medical testing, blood draws,,and X-rays • Infectious Disease testing and vaccines • OSHA Respirator Physicals for Public Safety • OSHA Respirator Mask Fit Testing for Public Safety x Polk County RFP 17-601 Firefighter Annual Physicals Packet Pg. 1532 H.1.c Survey Questionnaire—Polk County >- RFC'17-MI,Fireflghter Annual Physicals _. (Name of Parson c ► Jet ywVe r) (Nan of[fait Company/Firm) Photo�Numba:., .A �,�' af- Subject Part Perf rmam Sunny of -1�1-4—4111,4 4 L I V�_ fi � Coat of Senricm- Data Cmnplctc . ' Rate eseih ot# erit ar aID a ram of 1 to 10,with 10 repressooftt;you were Ym ntklled(and would hire the flreaftdividoat*pin)and 1 MMMONItIVII that You Ware verb unuMed(and w*W e never hire the fib rt dual tXsin). Plem Mtt each Of the erg to the bed of your loww1eke. N you do not have eefiident knowie a of peat p sdomsem in a particular srvs4 leave 1t bl&nL 3 �r�y �t � Similar Work Nam: n �l . ik, NO CRITERIA Ulillfl` SCORE 1 Ability to manage cost Ability to maintain pro,Kt schedule(complete on CD W tim%arlyl CD N 5 Quality of workmanship , - } Professionalism and ability to complete exams for all Fire y and EMS positions ( - 5 Ability to communicate with Client's staff timely - (1-1i}} 6 Ability to resolve issues promptly (1-10) 7 Ability to follow require nts based on National Fire Protection Associatlon standards (1-10) CD Ability to maintain proper documentation and t omplete timely Appropriate application of technology used for the mobile testin (1-10) ! 10 gall Client satlsftcti ri and comfort level in hiring (1-20) y Ability to offer solid recommendations based on exam 11 result (1-10) L12 Ability to facilitate consensus and commitment to the plan .- of action arrion staff1-1�� :.}' { r � ' j�� � .. � �_a¢ , °. Printed.Name of Evaluator Sigoatum of EvaMl tuntor E � t, Plcasc fem armali the wmplmd survey tt►: r r' Packet Pg. 1533 H.1.c Survey Questionnaire,--Polk County► RFP 17-01,Fire titer Annual Physicals 0 7'0 �plkljns (Names of sai (Name of .t ent mp:Ryfrna) 0 Phone Numb= Email: 0 � t►f ;a g y u , c,at of Servieet: IM PICW . *Gcb of tha ed%v'*ono aKskof I ba 19,w0h10 rIPY0000ft that You were Very satbibri(aad c wOWd hire the AmwWW dnai&phi)and I reps that yem we, Very gmmtk l(sod WMM � never Mm tM 5Md al apalu). Men rate neb of the CritGeria to the beg of ymer knowbdM if � YOU do ant have=41dent knowledw of past perbmwft in a ps�r awls Mm it M&Qk. Similar Wafk Pwjea -....ti lCompktaj. NOUNIT SCORE 0 1 Ability to manage east (�-�Q? � ca CD `-- Ability to maintain project schedule(complete on- _� CD ( - �? / 04 - 11 / 04 3 Quality of workmanship (1-10) 04 Professionalism and ability to complete exams far aH Fire .. �'4 and EMS positions (1-1pj /0 5 Ability to communkate with Client's staff timely �' LU 6 Ability to resolve issues promptly (i 10� ApAtt 'f AbliltYtofollow mtljjlremanU based an National Fire »� Protection Ability1/0 � rnalntaltt - -M tlrn to i�per do�mentatlttn and mntplete �rule application Of tectatplogy used for the mobile ( 1A) A) . u Ne- id Overall Client satisfaction and comfort level in hiring Ability to offer solid recommendations based on en 11 result (1-10) 12 Ability to facilitate consensus and comrnitment to the plan - of action amons staff ( y a. 1 X Ptinttrd Name cif Evaluator Si of Evaluator Plcw tkx or stash the co napiet soNey tt►` Cam•.-. 27 RoWW OBW15 E Packet Pg. 1534 H.1.c ,an QU nxh*—Polk County Rg'P'17-604 Ft ter Annual fie oflsoa complaftf G4 - Sojak l jj Mai r U Rob"A Ofew 1d Ire dtia .&'l Wk on a roll at 1 b 1r, i."... u 1 ►#a" 0 a.var 61ra �Id®al aui 1 tw 1" � a>-- ftwrub a[ffia. 10 the,beg arf r t ado aotiYrrrllcaaw Ig a.PS r ai JIM ft SIB Work PM)"Now. t t�G ► ��WA (j UlIff l 1 Ability tortnanage CM 03 Ability to n ntaln Pro t sclwdrde(CO-- on. CD tl ti- CD 3 amalk Of workmanship naila n and abiilty to complete a for ad Fire � - ) y and EMS podooft 5 ►W11Wto communicate with aierr_ra m ftimely 11- 10) 6 Ablirtyto r&jo*e issues rompdy Ability tO fdlipW rMuftTMb lid an Natioral pare �1 E protncthm Assodat asn saindardS �SQL B Ability to maintain proper docnrmentatlon and cxrr*#e timely sAppropdm awllcii6n of t+r hrnQiogy used for die nwobge li Ciler>t sat n and carrot level In hiring 11 l billty r solid ntm.,r ndedom on m � result (11t1 11� Ability t*% c3onsen=and commftw*"t to the.piste ca of action a OP y Signahn Rom d Of�y�Ji al aA Pl c fim otr.+W OW rrpm MWVOy to 7 Re Sys Packet Pg. 1535 H.1.c Survey QueNfl"Wn—Polk Con r RFP 17-01,ftiflOter Aanmd of> "wag aaeyoy) Via ) 0 L. Susvr of + }Ci7 Cx` !'� �,.1�'7rs c Goat of'So vi + Q±J,Grp Date cmwft.-La Rafe each of the c*Wk M a mab of1 to 10,wtt6]@ woad bits SruaM dw YM WWO very=dslk t(ate# I bire the thiW }cad t ati�ywr wage very» (=d wasM e PbMS fAft Gad of the to the bed of y wr knowledgL g you do=I have Jar WV of PW t in a PArtkdRr Drat6 lmve it bh,mL Similar Work Phdm Nmw. *� tllQ C.t 'Egiq tii f l E 1 AbR ty to manage cost - } } Z1JJtyt0 maintain project :hedule ttitapiete on ca tlrn earl21#ii} CD 3 Quality of workmanship 0 } Professionalism and ability to ccmpiete exams for all Flue and EMS podtkft 10 5 Ability tocommunicatewith Cilent`s gaff timely 5 Ability to res saues.promr 7 Ability to follow requinernents based on Rational Fire -PrQtQCfion Association standards CD Abrltty to maintain proper documentatt+ n and complete $ timely g APPr+priate application ofisCt fogy !for the m�atyile WON 1-113} 1D Overall Client sattion and comfbit level In hiring (1_10) 0 :1 A Ulty to offer solid recommendations bMW care..exam- result (110} 12 Ability to facilitate Consensus and commitment to the plan of.action armongsff - } Printed N=a of Evaloalor Si8ftahn of a1uetar Plcasc hzor=Wl the cOmpleW slummy€a: � 7 o Packet Pg. 1536 H.1.c Surrey Question alm Polk County RFP 17-01,Firefighter Anumd Physic c of ;W a Yl (N a ofclion p y/FI m) Phow Number: � �62� � EMsiL i f +" X'. Subs PadParformaaft 8mvey of " 'XY&7&0'e1 ( 1 . CM Of SorvirW ire pierces: _— Rate eaeb dthe� oo a of l tol 10,with 10 rqwamdog that you wort why ad"(sad «ram hire the firmfindtvidual opus)mW I rOPMenfing that You Men os m bim tie,firmindlwldar�i �' uta�tlaiiad(eau! fte iil � 1 rate eat ar'[ eriEaria ba the ai'yaar 1maw1ebd0e, if you do not imw suffideat knwbdp of p d performance is a particular area,Wye it blouL Similar Work Pnde ct Name: Date Cmuphod. NO CRrf EM I mrr scow i Ability to manage cost ��-�? CO CD -- Ability to maintain project schedule(complete on- caa time%a ii-iCi) CD CD 3 t Quality of workmanship1-�0104 Profiesslonallsrn and ability to complete exams for all Fire and EMS PosMans 0 5 Abillty to communicate with Client's staff'timely (1-2fl 6 Ability to resolve issues promptly Ability to follow requirements based on National Fire Protection Association standards ( -10) S timiely Ablity to msirrtain proper documentation and complete 1,-20 9 Appropriate ap�icatlon of technology used for the moblle tests i�-xe� 10 Overafl Client satisfaction and comfort level in hiring o¢ 11 Ability to offer solid recommendations based on exam y result (1.-10) / 0 LilAbility to facilitate consensus and commitment to the plan of action among (1_10) Pnnted Name of Evaluator LU Signatom of Evaluator It Ple an fax or a�.maif the completed survey tad: T�^ �' -�+� t *(?OW c 2ftykw Osms ? 0&!;3 Packet Pg. 1537 H.1.c Survey Questionnalm Folk County P 17.601,Fhvfthter Annual Phyaicais 04ame ofnmon completing suWey) (Name of Client Company/Firm) Phone Number: ��-1- �2�,�• �a 't�'� 0 / , , / Subject,Pact P rforrnatux Survey of t�+ k � 'v�, / r r S, ,/�`+ . x Cost of Services:10 0,131 b, ( i�Ewe Complete 0 1-t- ' -C in* a a.Rw.•. iii�s.+..11n.ar vfV.:'IIIPYM .:: i may—.:a ......y,�-ry'.....Mk W W'.�l PtF'n•"W+- �Rate e#ciw of the n tarb O a reek of 1 to 10,wilt 10 Wnwdug mat you warm very ratbfied(aad e would hire tbifirmAndividual again)and 1 reproarting that you wee very unratlrfled(md would now byre the finatividivWuli again Mean rate each of the criteria to the test of your knowledge. if you do not have au ficient knowledge of part performance in a particular area,leave it blank. Similar Work Project Nacre: I Completed., NO CRITEAIA - UNIT SCORE 1 Ability to manage cost ca (i-10) 10 CD Ability to maintain protect schedule(Complete on- �` time/earl (1_1p, 3 Quality of workmanship Professionalism and ability to complete exams for all Fire and EMS Positions to o 5 Ability to communicate with talent's staff timely to 6 Ability to resolve issues promptly 7Ability to follow requirements based on National Fire E Protection Association standards C1_1p� i Q Ability to maintain proper documentation and complete timely Appropriate application of technology used for the mobile testis (1-10) iv --- 10 Overall Client satisfaction and comfort level In hiring (1-10) to � 11 Ability to offer solid recommendations based on exam result 1�1p� t 11 Ability to facilitate consensus and commitment to the plan of action among staff x Printed Name of Evaluator Si Evaluator Please fax or email the completed Survey to: � 27 RevkW 06ki8,rl5 Packet Pg. 1538 H.1.c c 0 0 c 0 ca CD cv CD cv cv r9 x LU LU Packet Pg. 1539 H.1.c TAB 3: REPORTING CAPABILITIES �- .,All Life Scan reports are customizable based on the individual needs and requirements of each department. Employees: Each employee will receive copies of his Life Scan examination and test results on the day of their Life Scan exam to include a summary form, lab results,EKG, exercise data, ultrasound reports and images of abnormal studies,patient educational handouts, and personal. wellness plan.. X Polls County Fire Rescue: • PCFR will receive a FIT FAIR DUTY exam report and results of Hepatitis Titers/Screenings within 14 days of the exams. • Final Evaluations will be reviewed and signed by a licensed Physician,NP, MSN,or PA. ) • PCFR will be notified by phone within 24 hours for any employee that:is found to be NOT FIT FOR DUTY, to Reporting Samples include: CD CD • FIT FOR DUTY/OSHA RESPIRATOR MEDICAL CLEARANCE C 1D N • OSHA MASK FIT TESTING REPORT X Life Scan will provide samples of patient chart forms and patient results upon request. Polk County RFP 17-601 Firefighter Annual Physicals Packet Pg. 1540 - - H.1.c FLIFE CAN FIRE DEPARTMENT CLEARANCE FORM AND OSHA RESPIRATOR CLEARANCE Wellness Centers � Employer:EOL.K Ct) 'TY'FIRE RESCUE - Patient Last Name-. First Name- Patient Patenfi IDISS#: -- _ Exam Date: EMPLOYEE MEDICAL QUALIFICATION. The examination of this employee must include a complete f physical examination at a level of specificity in accordance to 2013 N.F.P.A. 1582 guidelines with the purpose of L. determining whether there is any medical or physiological reason that may impair the employee's ability to perform the essential functions of his or her job. Disabilities,impairment,or limitations identified by the examination,which would prevent the employee from performing,the essential functions of the position,will be reported to their employer.The reviewing medical personnel should note all abnormalities which might predispose the employee to N in or aggravation of the condition due to the nature of the duties and tasks required of a firefighter employee. 3my ggra l MEDICALLY QUALIFIED: Based on the results of the annual medical examination,I find this � individual to be CLEARED under O.S.H.A. 1910.156,O.S.H.A. 1910.134,O.S.H.A. 19 10.120 regulations and the guidelines set forth by 2013 edition of N.F.P.A. 1582. D ❑ MEDICALLY QUALIFIED WITH THE FOLLOWING RECOMMENDATIONS: ❑ NOT AMICALLY QUALIFIED. Based on the results of the annual medical examination,I find this individual is NOT CLEARED under O.S,H.A. 1910.156,O.S.H.A. 1910.134,O.S.H.A. 1910.120 ca W regulations and the guidelines set forth by 2013 edition of N.F.P.A. 1582. CD This patient must be examined by a medical specialist for follow up evaluation and final clearance. The evaluation should include confirmation,diagnosis,and/or treatment of the following: CD - c44 c� m x OSHA RESPIRATOR CLEARANCE This medical evaluation determines any limitations as described in LU O.S.H.A. 1910.134 with regard to respirator use as related to the medical condition of the employee,or relating to the workplace conditions in which the respirator will be used,including whether or not the employee is medically able to use a respirator. G MEDICALLY QUALIFIED TO WEAR A RESPIRATOR. The above listed individual IS in compliance with O.S.H.A,191p.134.There are no restrictions on respirator use related to the medical condition of the employee. CD .r NOT MEDICALLY QUALIFIED TO WEAR A RESPIRATOR. �+ A follow up examination is needed to snake a final determination for respirator clearance. Based on the results of medical examination,the above listed individual is NOT CLEARED to wear a respirator based on O.S.H.A.'s standard 1910.134. x LU Medical Practitioner Information: Print Ivan= Signature: � Anthony L.Capasso,M.D.,P.A. Medical Der Uonse Number:ME 69518 Packet Pg. 1541 H.7 c LIFIE SCAN RESPIRATOR MASK FIT CLEARANCE FORM Wellness Centers Employer:. POLK COUNTY FIRE RESCUE Date: Employee Information. List Name: First Name: 0 ID/SS#. DOB: Occupation: a 2 Mask Fit Test (For Clinical Use Only c _. . Respirator Medical Clearance: ❑ Pass ❑ Fail Date of Medical Clearance: Vision Correction Required. ❑ Yes ❑ No LU If yes,what type correction used when wearing a respirator: ❑ Contact Lenses ❑ Masses ❑ None 0 Fit Testing_Results (For Clinical Use Onlv) Test Date: Test Completed. ❑ Yes ❑ No ) If No, give reason: Respirator Type: ❑ N95 Paper ❑ Full Face Negative Pressure ❑ Half Face Negative Pressure ca CD Make: Model: CD N Style: Size: Mask:Fit Test Date; _- - Fit Test Protocol Used: QMARtitative � ❑ PortaCount Model Number: Serial Number: ❑ Dynamics Occupational Fit Tester Model Number: -_ Serial Number; E Overall Fit Factor: ❑ Pass ❑ Fail Notes: (For Clinical Use Only) 0 Comments: ' Signatures x Print Patient Name Patient Signature Print Clinician Name Clinician Signature � Packet Pg. 1542 H.1.c TAB 4 MOBILE TESTI G a) Mobile Testing Location: Strategies: + Life Scan has the capability, experience,direct full-time medical staffing,and equipment to provide can-site physical exams at on-site location(s)provided by Palk County Fire Rescue. 0 All set-up,equipment,and associated costs will be the responsibility of Life Scan. + All equipment maintenance will be performer)by Life Scan and will be kept clean N and sanitized. All equipment will be kept in optimal working order or repaired/replaced within a reasonable time frame. Life Scan maintains backup of all equipment as well as service contracts to ensure timely replacement as needed. .Life Scan has the proven capability of providing all services on-site within time locations)provided by Palk County Fire Rescue(not a motorized vehicle): e o Physical Exam as outlined in the Scope of Services o Blood,,D�rawws(supplies included) ) o Chest x-rays • Equipment: All equipment used for the Life Scan program is state of the art and Co owned by Life Scan. The equipment is portable and easily set up by the Life Scan CD stafE CD N Life Scan will bring portable exam tables as well as all the equipment necessary to completely provide the comprehensive medical and fitness exams. • Ultrasound Units: Terason o EKG Stress Units; Welch Alyn,Laptop computer based • Treadmill: will be a stationary unit at the Palk..County Fire Rescue locations c Fitness Testing equipment:provided by Life Scan • .Audiometry Equipment: Welch Alyn audiometer a Vision: Titmus Vision Screener o X-ray: On-site mobile services (ML ob lex) • Blood draws at any LabCorp Patient Service Center in Florida or on-site at 0 location(s)provided by FCFR y e X e Polk County RFP 17-601 Firefighter Annual Physicals Packet Pg. 1543 H.1.c b), Scheduling Timeline: 1. Scheduling: Patient scheduling will be coordinated by PCFR to meet the needs of the department. The hours of operation, number of days and program dates will be determined by PCFR according to shifts/work hours of the employees and the number of annual firefighter physicals required, 0 2. Life Scan will be able to proceed AAb the scheduling of physicals can October 1, 2017. A. Life Scan will schedule 9 patients per day, 5 days per week (45 patients) in consecutive weeks to accommodate the successful completion of annual firefighter physicals. B. Example: 0 1. 450-500 physicals f 9 per day= approximately 11 weeks to complete the program- a. Additional days will be provided as necessary to accommodate completion of all firefighter physicals at no additional cost to the County. ca CD 2. Implementation Strategy CD A. Phase 1: Site visit with PCFR by Life Scan management team 1. Discuss program components and requirements y 2. Determine space requirements and coordinate on-site program 2 a. Minimum 4 rooms with waiting area • Physical exam • Cardiopulmonary/fitness evaluations ■ Ultrasound exams Hearing and Vision area. 3. Plan time line 4. Review and approve Patient Packet 5. Review and approve blood draw program and.LabCorp requisitions 6. Review Fit for Duty and.Respirator Medical Clearance Reports, , 7.. Review and approve reporting system � B. Phase 2: Schedule dates for blood draws and physicals 1. Nine patients per day in three intervals of three patients each � a. Example: 3 at 8:40,3 @ 11:00 am, and 3 a 2 pm b. Start time will be determined by PCFR LU Palk County RFP 17-601 Firefighter Annual Physicals Packet Pg. 1544 H.1.c C. Each physical exam will require 3 hours (3 patients will rotate between 3 portions of the program including ultrasound, physical, and cardiopulmonary/fitness. c C. Phase 3.Blood draws (2-5 weeps prior to physicals) 1. On-site at any location(s)provided by PCFR 2. LabCorp Patient Service Centers c a. Phlebotomists are certified technicians b. Facility meets all requirements established by DOT and is properly licensed. X LU D. Phase 4: Life Scan Physicals 1. Firefighter Physicals 2. Medical Requirements based on:ttFPA 1582 a. Essential Functions per'NFPA 1001 for firefighting � professional qualifications E. Phase 5: Reporting per PCFR Requirements In c) Scheduling Timeline for second fiscal year: Same formula as above within 12 monthsCD after the initial physicals. N X LU CD 2 X LU Polk County RFP 17-601 Firefighter Annual Physicals Packet Pg. 1545 H.1.c LIFE SCAN CCMMPREHENSPVE SAFETY AND SECURITY POLICY The Life Sean Comprehensive Safety and Security Policy is a safety management plan 01 designed to maintain a safe environment free of hazards and reduce risk of injuries for patients and employees. a. Processes:for employee safety and.security; 0 1. New employee orientation and education program and annual recurrent train%ng that addresses Safety Procedures: 2 i. Blood borne pathogen policy(Exhibit A) I Biohazard waste policy(Exhibit B) iii. Fire Safety X b.. Processes and procedures for facilities and equipment security 1. Life Scan will coordinate with the on-site facility manager to determine what County procedures and processes are for specific site as well as best manner to secure equipment during program. c. Emergency Preparedness Pfau. 1. Life Scan will coordinate with the ran.-site facility manager to determine what ) County procedures and processes are for specific site. d. Safety Equipment 1. Life Scan routinely maintains and tests all equipment. Any equipment utilized `a CD will be tested prior to program start on-site. 04 CD e.. Reporting to County Risk Management regarding accidents and/or damages 1. Life Scan management will receive any accident or damage reports and report n there directly to County Risk Management per County procedures.. X f. Records Confidentiality 1. Life Scan will coordinate with the on-site facility manager to determine an on-site E secure area to store records during program. CD 2. Life Scan stares all patient records in a secure facility in their corporate office with access limited to authorized Life Scan employees. 3. Life Scan follows all HIPP,A., State,and local guidelines regarding patient confidentiality and will review the process with the County prior to scheduling. X Polk County RIFP 17-601 Firefighter Annual Physicals Packet Pg. 1546 H.1.c EXHIBIT A LIFE SCAN WELLNESS; CENTERS SAFETY DEPARTMENT SU13JECT: BLOO BORNE PROVED BY: EFFECTIVE REFERENCE: PATHOGEN EXPOSURE Patricia Johnson, � DATE: � CONTROL PROCEDURES SOP l Presided Sept.22,20013 #005 ! c INTRODUCTION The Occupational Safety and Health Administration (OSHA) reports that 5..6 million U employees in the United States are at-risk of exposure to blood Marne pathogens where they work. This Bloodbome Pathogen (BBP) Exposure Control Procedure is designed to ) protect all Life Scan Wellness Centers' employees. The authority having jurisdiction for this procedure is derived from the Cade of Federal Regulations 1910.1030 and Florida Department of Health Code cites Cha ter 64E-16 of the Florida Administrative Codes. .ca �. This procedure includes the following key elements: A. Identification of,Job Classifications and tasks where there is exposure to y blood and other potentially infectious materials. B. Methods of Compliance including; -Universal precautions, E -Engineering and work practice controls, -Personal protective equipment, -Housekeeping C. Training of Employees. 0 D. Hepatitis B Prevention. E. Post-Exposure Evaluation. F. Procedures for evaluation of circumstances of an exposure incident. G. It will be the responsibility of the Life Scan Wellness Centers' Safet Department to maintain this procedure. Life Scan Wellness Centers' Bloodborne Pathogen Exposure Control Procedure will be accessible to all � 1 ¢' Packet Pg. 1547 H.1.c -The recognition of tasks, which may involve exposure. -An explanation of their use and limitations of methods to reduce exposure. These include engineering controls, work practices, and personal protective equipment (PPE) offered at no cost to all full time and part time employees. -Information on the types, use, location, handling, decontamination and disposal of PPE. An explanation of the basis of selection of PPE. -Information on the hepatitis B vaccination (HBV) to include efficacy, safety, method of administration, benefits and that it is offered at no cost to all full time and part time employees. 0 An explanation of the procedures to follow if an exposure incident occurs, including the method of reporting and medical follow up. ) The Record Information - Employee training records shall be maintained in Human CO CD Resources at a minimum for the duration of employment, These records shall include N the fallowing, CD N -The dates of the BBP training sessions, y -An outline describing the materials presented. -The naives and qualifications of persons conducting the sessions. � -The names and job titles of all persons attending the training sessions and signature of each employee. Life Scan Wellness Centers will be responsible for maintaining training records. The new at-risk fall or part time employee will be notified that training is required at the time of employee orientation. Life Scan Wellness Centers will be responsible for completing an annual review of the Blood bome Pathogen training g procedure and program, updating it as necessary. � X 3 Packet Pg. 1548 H.1.c Disposable gloves used shall not be washed or re-used after contamination. Disposable gloves shall be replaced as soon as their protective ability is compromised, such as being tom or punctured. Gloves shall be used for handling contaminated waste and for clean-up procedures. 0 For any at-risk employee who has allergic sensitivity, Wellness Centers 0) will provide hypoallergenic gloves, or powderless gloves, at not cost to the employee. Housekeeping, Engineering and Workplace Controls � X Hand washing facilities with antiseptic soap or single use antiseptic towelettes will be provided for immediate use after contamination. 0 At-Risk employees will wash hands immediately after removing gloves. Eating, drinking, smoking, applying cosmetics or lip balm, or handling ) contact lenses is prohibited in work areas where exposure to BBP is possible. Labels and other warnings, as specified in Code of Federal Regulations `✓ 1910.1030(g), will be affixed to contaminated materials to warn others. Life Scan Wellness Centers will monitor the Blood borne Pathogen program for contaminated material to be defined as Bio-Hazardous Waste. Contaminated waste will be handled in the fallowing manner: X A. All contaminated waste will be placed into appropriately marked medical waste storage containers. The Jacksonville Sheriffs Office E will contract with a certified biomedical waste disposal company to dispose of waste for Life Scan Wellness Centers. B. In areas where there is to be a clean up of infectious waste material the following procedure should be followed: I. Put on gloves and ether PPE protective equipment as necessary, Post wet floor signs if available. Apply a tuberculocidal disinfectant over the potentially infectious material in accordance with label directed use. .N 2. Clean up the contaminated material with disposable paper LU towels and place and seal in a plastic bag to be disposed of as biomedical waste. 5 Packet Pg. 1549 H.1.c If the employee declines the vaccine (Exception 4), the employee must sign the Hepatitis B declination form attached hereto_ Once completed, this form must be included in the employee's human resource medical file. The term "no cost to the employee" means there will be no out of pocket expense to the employee. 0 If a routine booster dose(s) of Hepatitis B vaccine is recommended by the U.B. Public Heats Service at a future date, a booster will be made available to all employees in the 2 same manner as described above for Hepatitis B vaccination. POST EXPOSURE EVALUATION AND FOLLOW UP X If employees follow the prevention guidelines as presented in this policy, an exposure incident to a BBP should be a rare event. However, if the employee does have an exposure incident it shall be reported, investigated and documented. Employees who have been exposed to BBP shall report the incident through normal Worker's ca Compensation (WC) procedures; by first notifying their supervisor, completing incident report and WC First Report of Injury report. After exposure, all costs of care will be ) treated as a workman's compensation incident. Titers (or retesting of immunization) will be offered after completion of the series if five years has elapsed since completing the series. ca CD CD N PROCEDURE FOR EVALUATION OF AN EXPOSURE INCIDENT X When an exposure incident occurs, it will be the responsibility of Life Scan management to investigate the circumstances, develop an incident report, distributing it to the W President of Life Scan Wellness Centers CD OTHER UNREGULATED WASTE , Sanitary Napkin Disposal - OSHA considers the disposal of sanitary napkins an effective engineering control against exposure to blood. Sanitary napkins do not require bio-hazardous labeling or disposal. Plant Service Workers (PSW) will be provided and It is mandated that gloves be worn when handling trash with waste bags being kept � away from the body. OSHA does not generally consider discarded feminine hygiene products, used to absorb menstrual flow, to fall within the definition of regulated waste. The intended Packet Pg. 1550 H.1.c EXHIBIT B Life'Scan Wellness Centers Biohazard Waste Plan-Employee Education (Florida Administrative Cade 64E-16) Life Scan educator will provide an initial (within 30 days of employment) and yearly education for all employees on the proper handling and disposal of Biohazard NVaste. 0 Objectives: � 2 The employee will be able to: a identify `sharps' and `non-sharps' which is designated as a`biohazard' - identify the `faint of Origin' at the clinic and onsite properly prepare and stare completed`sharps' container(s)and/or`bio-hazard' red bag(s)for scheduled disposal demonstrate Universal Precautions when handling all potential `biohazard' materials locate the 'Bio-Hazard' binder containing the most current Health Department guidelines,up to date employee signed education,previous surveys and be prepared with this information for an onsite Health Department survey properly clean up a `bio-hazard' spill ) I. Bio-hazard Sharp and Non-sharps a. Sharps are considered any needle that has been contaminated with blood whether is be from a blood draw, vaccine injection or a PPD test. b. Non-sharps(absorbent or non.-absorbent)item(s)that are considered"soaked"in blood or ether bodily fluids considered potentially a `biohazard'. They may be disposable rubber gloves, extension tubes used for blood draws, gauze and/or band-aids. Scant amount of blood is not considered a`biohazard'. 11. Universal Precautions 0) All personnel will need to use proper hand washing before and after the blood draw. 2 Cloves must be worn during a blood dray and when corning in contact with a contaminated surface(s)with bodily fluids. III. Point of Origin and Sharps Disposal a. Point of Origin is a roam where biohazard waste is generated such as the designated room for blood draws. When working"off site"an area will is designated away from potential exposure to other people. After utilizing a needle on a client whether it is from a blood draw,vaccine or PPD testing,there roust be a sharps container within a short distance from the person providing these services. All needles will be single use and properly disposed of immediately. There should be no cross contamination of vaccine or PPD substances or materials. Any potentially contaminated materials will be documented and disposed of immediately in a Bio-Hazard container. Packet Pg. 1551 H.1.c EXHIBIT C: LIFE SCAN EQUIPMENT MAINTAINANCE PROGRAM: _ Life Scan has routine maintenance and calibration of all medical equipment on an annual basis according to the recommendations of the manufacturers. All equipment maintenance will be performed by Life Scan and will be kept clean and sanitized. All equipment will be kept in optimal working order or repaired/replaced within a reasonable W time frame. Fife Scan maintains backup of all equipment as well as service contracts to ensure 0 timely replacement as needed. Poly County will have the ability to inspect all equipment. x r - +T�1YffllM`lN hl k4'�'Ad 4�'+ Jt {tr _ Y! IIyytt i.r6. !!{{ A lil 14 q i�l I�1 N CD N N 0. E CD �Nk - Terason Ultrasound Unit with Sony Printer Welch Alyn Easy One Spirometry Unit Welch Alyn EKG/Stress Unit Welch Alyn Audiometry Unit x Titmus"Vision Tester Polk County RFP 17-601 Firefightcr Annual Physicals Packet Pg. 1552 H.1.c c 0 0 C 0 Co CD cv CD cv cv r9 x LU LU Packet Pg. 1553 H.1.c Attachment "A" COST 1'1' G (STJ-BN TrAL PAGE) — Cost per employee for all " requirements and items to be performed annually as defined in the RIP Document. Cost f shall be inclusive of all costs 657.00 Per Employee W associated with the annual I ' physical exam including overhead,indirect costs,etc. .N i x O fter costs for additional services to be used by the County on a case by case basis.The prices below must be separate and will=be included in the cost scoring criteria. Chest X-Ray: Optional annually,required,a ) 'minimum every five(5)years $ 65.00 Respirator Fit Testing(SCB.A Face piece Fit ca W TestfN-95 Respirators) $ 40.00 CD N CD Hepatitis B Test(antigen) $ 55.00 N Hepatitis B Titer(antibody) $ 30.00 x Hepatitis B Vaccine(3 per series) $ 65.00 each Q i 2 Hepatitis A Test(antigen.) $ 55.00 Hepatitis A,Titter(antibody) $ 30.0 'Hepatitis A Vaccine(2 per series) $ 65.00 each JPPD Test- $ 5.00 Attachment IIBII CO TRACTOR E Packet Pg. 1554 H.1.c AFFIDAVIT CERTIFICATION IMMIGRATION LA'IAI'S SOLICITATION NO.: RFP 17-601 PROJECT NAME: Firefighter Annual Physical POLK COUNTY WILL NOT INTENTIONALLY AWARD COUNTY CONTRACTS TO ANY CONTRACTOR WHO KNOWINGLY EMPLOYS UNAUTHORIZED ALIEN WORKERS, CONSTITUTING A VIOLATION OF THE EMPLOYMENT PROVISIONS CONTAINED IN 8 U-S.Ce SECTION 1324 a(e) {SECTION 274A(e) OF THE IMMIGRATION AND 0 NATIONALITY ACTT(-IW) c POLK COUNTY MAY CONSIDER THE EMPLOYMENT BY ANY CONTRACTOR OF UNAUTHORIZED ALIENS A VIOLATION OF SECTION 274A(e) OF THE INA. SUCH VIOLATION BY THE RECIPIENT OF THE EMPLOYMENT PROVISIONS CONTAINED IN SECTION 274A(e) OF THE INA SHALL BE GROUNDS FOR, UNILATERAL � CANCELLATION OF THE CONTRACT BY POLK COUNTY. BIDDER ATTESTS THAT THEY ARE FULLY COMPLIANT WITH ALL APPLICABLE IMMIGRATION LAWS (SPECIFICALLY TO THE 1986 IMMIGRATION ACT AND SUBSEQUENT AMENDMENTS), C parka amen' :: ° .. w � Sig kture Title a cc STATE OF: COUNTY OF: Th foregoing instrument al signed and acknowledged before me this day of y �o , by a who (Print or Type Name) x LU has produced E as identif'cation. ype of Identification and Number) 0) Notary Public Signature 4 f Pdn ed Name of Notary Public DAVID A.CAS rEUJ �+ NOTARY PUBLIC STATE OF FLORIDA M A Nota iraticrs Packet Pg. 1555 H.1.c Attachment "B" SUBCONTRACTOR - (SLBNUTTAL PAGE) Please list below the name and address of subcontractors to be used in conjunction with this RPP (If applicable). I, 0 x 2. 0 3. N N N 4. x 5. 6. � x Packet Pg. 1556 H.1.c TAB 8 MEDICAL LABORATORY LabCorp Regional Office: Laboratory Corporation of America 5610 W.LaSalle Street Tampa,FL 33607 c Life Scan will provide an on-site Mood draw Program. Life Scan patients aye also able to have wa 0 c ent Service Center within the United States, blood draws done at any LabCorp Pati LabCorp Patient Service Centers within 25 miles of Bartow: � 1. LabCorp 2142 E EDGEWOOD DR LAKELAND,FL 33803 � 2. LabCorp 1120 HAVENT)ALE BLVDNW WINTER.HAVEN,FL 33881 3. LabCorp ) 3131 L.AKELAND HILLS BLVD STE 1 LAK:ELAND,FL 33805 4. LabCorp ca W 607 S ALEXANDER ST STE 107 110 PLANT CITY,FL 33563 cv CD 5. LabCorp cv 2209'NORTH BLVD W STE B DAVENPORT,FL 33837 CD Polk County RFP 1.7-601 Firefighter Annual Physicals Packet Pg. 1557 dug. 1 2017 3;23Pfi 11n. 808--p. 2.- -,. H.1.c c SAN E;pF, } {-D, .04rFog Ill,I Ill I v' 4' pn7' TIJ dam' S & :A., 410 CD W cv CD cv . .. « r! t 1 ���t.t�att �t �e A�"feQt�4'1 • `raC�a��p�� � !� � MROWW ) lam $ Y{ X ' o n aa�a s•YPHIU$ ROLQtlr rc�. ►ar is . t�ntl�s�i:tMM .�P� �iild'1!lP�tS' LIMNALIM Pow TaxouLyw x ✓+ia1/91[I'SiI� W�'��J1i,�' .. Air �1iL �• •` ®' e ay f`[f C p W MW CONMACTYOUR kbft TCYTOk°ANY Tip Packet Pg. 1558 H.7 c c 0 0 C 0 Co CD cv CD cv cv r9 x LU LU Packet Pg. 1559 H.1.c CERTIFICATE OF LIABILITY INSURANCE D�LTEttuwr+oY1 Oa103r201� 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 IELOW. 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(les) must be endonllsd. 0 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 sndom a. PRODUCER _ . O.E.Wilson Insurance,Inc. 727 5354M rFAx 72 536-9825 1476 Belcher Rd S clad Ituom.coni Largo FL 33771 _ .Auto-Owners Insurance COMIMY LNSURED ibnMil.,Admiral Insurance COm -_ '' 2400 Life Extensions Clinlc,inc. r- 1011 N.Macdlll Ave _ -- O Tampa FL 33607 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 INDICATE). 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. - TYPE OF INSURAMM DR NUMBER IMMM X COMMERCIAL 6 NMJ14,..UANLrrY U 1 000 000 r A MM8 X I DE I uR DAMAGE AI 100 000 � 20690746 I IMO111'6 11110117 110.1)(10 1 000 000 AGGRInLIMITAPPLI PER, 2 000 Q00 X PMJGY LOC s2,000,000 OTHERF s AUTOMOBILE LIABLTrY gatMNEDfliaLE LIMIT $1 000 990 W A ANY ALIT'4 BDI)NLY INJURY�arperswo S CV X . --_.. _..- ALL OWNED SCHEDULED 4159162800 09M SM 6 09M8M 7 BODILY INJURY(Per �ad®m) s AUTOS AUTOS Q HIREa AUTOS �( NON-OWNED PROPERTY t]AMAt3E AUTOS ; 3 UMBRELLA LIAB OCCUR _ EXCESS LIAR HQLAIM 3 WORKERS CQMPENCATION PER ME TH AND 9MPLOYEM LJABtL.n'r ""' "... ANY PROPRIETORIPARTNEWEXECUTIVE[ { N f A I I T EN Ixc�LDa �_i PLOYE t! dpGllb!tlf)dar P.L ---P9LJCY UMIT Medical Professional Liability E0000037591-01 0513IMT 05/31/16 2,000,000 Aggregate B Retroactive Date:513112001 2,000,000 Each Claim DUMPMN OF 4W ErtATiONs 1 LOCATE I VIN S(ACORD 10i,Additional Rmwaft Schedule,may be aaaehed H mom apses to rephad) .� contractorli"mingopoik-county.not Sexual Abuse $1,000,000 Each Cla"l.000,000 Aggregate y Network Sccurtty 8 Data Privacy Liability$1,000,000 Each Claiml#1,000,000 Aggregate 2 CJ O CERTIFICATE HOLDER CANCELLATION N Polk County SHOULD ANYOFTHEABOVEDESCIBBED POLICIES SE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 330 West Church Street ACCORDANCE WITH THE POLICY PROVISIONS. Bartow,FL 33830 REORESENT4,"M Phone:(863)604-6080 - - -- 0 1988.2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD dame and logo arse registered marks of ACORD Packet Pg. 1560 H.1.c ° ' CERTIFICATE OF LIABILITY INSURANCE �' 10/31/2016 � THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND COWERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELLOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITU'M A CONTRACT BETWEEN THE ISSUING INSIURER(S), AUTHORIYIED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT: R the csroftets holder Is an ADDITIONAL INSURED,the pol"Iss)mawt be andorsoO, IF 4U®ROGATION!S WAIVED,gubjm to tlm Wm and cnndlgons of the policy,rarteln pollclas my mqufm an andonmrA Ed. A sbftnwnt on this CartHlGm do"not CoRfar"011ft to tha ISredf Mate holder In Neu of such ends • . Wff Valerie 73cn*ya n-whaelor - PrinoftvV Insurance Services, .Inc. P NVE M,Rho fs13)288-82'I© it�kal I8191Be5-4911 5402 W. Laurel St:. esMv4Iteeler8primegrmng ns.cCml � Suits 220 MU"Al AFFORWO COVMA E NAIL t Tampa BL 33607 A� 1U&M Pr.lerr d X..=". Ca 1 3346 elsuTmN e IriEEM •Sactension Clinics, Inc Ec- 1011 IN I`tatcDill Avc Da N Tampak >FL 33607 ete COVERAGES -CERTIFICATE NUMSER;Ma6103116405 REMJONNIJfYIpER: 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 WHIci,Tht1s CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 18 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONOM15NS OF SUCH POLICIES,LIMITS SHOVM MAY HAVE BEEN REDUCED BY PAID CLAIMS. O CQa1111MRiNAM.SAL LIA UW EACH OWURRENCE CLAIMS-MADE ]f O=m L_J st PERSOML A ACV IKILIRY GERI AGGREOATEpLRMNT APPLIES PER: wNERAI. E4#ATE ! POLICY J ,T L�l LOC PRODUCTS_C.OIAPOOP Ada; S AUTOV40LE LIABILM CD - IBMi ANY AB PTf) BOdLY IN 4URY If'R Imo) e CD N AL CS EO LE[L OU BODILY RAY III moddw) iCD zo HIRER AUTOS pa = E N umoffluAum OJUZSS LIAN EACH OCCURRI:I�NlE mma •® 4I AJ AtXIREIIATLlogni - # R # S AND LIAEIL" YIN AWPROPRIETC1RMARTN NIA. L. CGI EACH i 1,©M10,08$ irmw axasaoosaa O5 �11lze/sold il/I!$/2017 eL E-EA EMPLOY S_ ><.000 000 � OFOFE'AA7gN8eraav E.LiNBEABJ POmYLIMAIT s 1 OC@ GGI1 1 1 unit RIPlM4Ml d'QT'CitATR9Nl6l LL4CrA71dlN!t 1 7+i1,ABddanal WywilWGf eaprtltMa,af.y be sd4ca�d k n�a•paea N�*9'�I�MI ____-- '�. U CERTIFICATE HOLDER CANCELLATION 8M0=ANY OF THE ABOVE 0=14 IFSI POLICIES BE CANCFI.I.ED BgFM FM T.UM RHATIONAL PLlI~=SE8 THE EXPIRATION DATE THEREOF wom WILL BE DEUvgRSD IN LU ONLY ACCORDANCE W"THE POLICY PROVISION& AUTMM'ORiLW PWJ t9MTA1M E 211sasses #AO77387/ .5rrc. C. . � 01SII 2014ACt RID CORPORATION. All r hft reamo& 5 ACORD 26(20'14101) The ACORD name and logo are registered marks of ACOPM INlle?B IFpt�7i ¢' Packet Pg. 1561 H.1.c ns Re�qu"t for Taxpayer arse s to In Form rettaatsr.Da not (Rev.�rnl�201) identification Number and Certification :and Ito the Ira DwWWOM of the Trs"W r,t Fiewer�Sarviaa _ Mauve(ra+shown on yahr irncamne tax,;orate) . Life E)ftnsiOn Cllrhitts,trdc 0. slness srrti CY steers.if diffemat from atmvs g� Life Scm Wellness centers Check aPPrOPOWS box for federal teas Wn; ❑intt3vla�arlleu4e Proprietor El Vim' �s r stun 0 Pa �Tr /eetat4 � exampt Pam 2 ® Pmitari rabttty cart fir.i3artfae teat a iltrn tGc ccrpOrsticn,d— +�rPcnniva.f`° c+Prhi). _ other OW irWh=6dn4 Ad& r(number,street.and*�Or ni°a Requartera ruurra auxs � # 1 Q11 North Macdill Avenue x x t ity,et ,W,and OF ode Tarn�ta. FL S36ii7 l Jot searsu A numbWO)rWO PPa O 'r lder ri"far atlon Humber(TI oams 9lvera ore the`Nerve'line 8 l�rwar►t er Enter yowr TIN to the appropriate box.The TIN provided must match the r to avoid backup i+a>�ar9•For" this IS ytutr 30OW secUrltyy,aacarttMW{ }•Hotiwevar,for a � resident fin.sale proprlator,or dlarrggerdW wWty.use the part I instructions on Far other entities.It Is Your erne number(CW).If you do not have a number,sett Now to lief a E1 77N an Pap 3• Note.if the a ccount is in mare than are name,use the chart on pagan 4 for gul lebnet an whose Mr" 0 tttrnber .to eater: - 3FSK370 T22 8 • Under penalties of perjury,I certify that: 1. The number shown on this form is my correct taxpayer r identification Ptw+rrber(or i am waidan9 for a ncanaber to be iSSued to►rre}®and cN Revenue2. 1 arty not subject to backup withholding because:(a)I am exempt from;backup wkhholliing.or(b)I Rave Post been notified by fie Internal Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has nodfled me that I can ry no ksnger subject to backup Withholding.end y 3. 1 am a U.S.citizen or other U.S.person(defined below). - Cartlfic atibin you must cram out Item 2 above#f you have been notified by the IRS that You are cr#Mtly subject to backup withholdIN because you have failed to arl interest am divide on yor.a'tax mtum.For real oatate transactions,item 2 doss not'apply.Far;mortgage irhterast paid acquisition or xa ,cancelliwon of debt.contributionsto an individual retirement aarergarnerat pfN,and tam,p�Other lrrtereat era not required to ai thou but you must provide Yore o0mect TIN.See the iretructlom on(saga 4. Sign r4palurs at HWO ua rne+son► tsea► General i!1�r1 C 70118 Note,ifs 91' a or#41 Font W-9 to request — your TIN,you must use the requeoWs harm a it is substantially similar Section references are to the Internal Revenue Code unless otherwise to this Farm W-9. - noted. Do"nitiars of a U.S.person.For tmderal tax pwrposes,you ere � PI,rpoSe of Firm ccs a U.S.person it you ec: •An IndIvkk l who is a U.S.citlnen or U.S.resident alien, rn o fain Y who Is required a fiirr rt Information tionw rota(with the IRS mist company.car won cnm ted or � obtain Your artnect taxpayer k#arhtlacadarn numttee('f`ihi)to report,for `A fp. example,Income paid to you,real estate era tav;do as.mwWpe Iritereat In the United Stag or under the laws of fha united States, you paid,acquisition or abandonment of samirrld property,cancellation r An estate(tithe there a toieIgn estate},or of debt,or contributions You shade to an lRk .A dornestic trrtaat(aaa defined In Regulations section 301.7701-7). Use Form W=9 only If you are a U.S.pawn including a resident pa"narstdits,partnerships that conduct a trade or - alien),to provide your corm TIN to the person requesting It( Special in ft United Stain arc generally rOWIn d to pay a withhaid requester}and.when applicable.to: tax on any fonftn partAwsshm of income from such business. 1.Certify chat the TIN you are giving is comact(or you are wasitktg for a Ftartlher,in cartsin nooses where a Form W-8 has not been received,a number to be issued), partnership is required to presume that a partner IS a foreign person, � 2.Car*that you are not subject to backup withholding.or and pay fins vrlthholding tax.Therefore.If You are a U.S.person that b it partner in a partnership caonduating a trade or business in the United 3.Claim exehp*m from backup withhoWY9 If You are a U-&atxempt Stain,Pam Form W-9 to the partnership to sslablith your U.S. payee.it apptcebis,you are also certifying that as a U.S.person,your status and avoid withholding on your share of partnership Income. allocable share of any partnership khcarne from a U.S..uWa or Wain s is not subject to the withholding tax on foreign partneW share of eff connected Income. U..No.t94"3fit FrMrn1N- lP " t2 ate++) Packet Pg. 1562 H.1.c TAD 10: CONFIL1ENTUL ADDITIONAL INFORMATION 0 Our standard testing on Page One and additional testing on Page Two. c Life Scan Firefighter Physical: $395.00 QuantiFeron Gold: $ 60.00 Hazmat Tests: $ 127.00 0 Testosterone: $ 20.00 Heml t s_C: $ 55.00 ca CD Total: $ 657.00 N CD Ch N x LU Polk County RFP 17-601 Firefighter Annual Physicals Packet Pg. 1563 H.1.c EXHIBIT 461311 RATES Life Scan Wellness Centers 2018 Polk County Comprehensive Physical Exam Physical Exam(NFPA 1582 Compliant) included 0 Vision (Titmus) included Hearing Exam included Skin cancer assessment included Personal Consultation with review of testing results included Cardio Pulmonary Assessment Echocardiogram (Heart Ultrasound) included Resting EKG included tJ Treadmill Stress Test with EKG included Carotid Arteries Ultrasound included o Aortic Aneurysm Ultrasound included Pulmonary Function Test included Cancer and Disease Assessment ca Thyroid Ultrasound included CD N Liver, Pancreas, Gall Bladder, Spleen, & Kidney Ultrasounds included Bladder Ultrasound "9 included Pelvic Ultrasound for Women (external, Ovaries and � Uterus included x Testicular Ultrasound for Men included Prostate Ultrasound for Men Included E Blood and Laboratory Tests QuantiFeron Gold (TB Blood Test) included Hepatitis C Test included Hemoccult Test included Urinalysis _ included Lipid Panel o included Diabetes Tests(Hemoglobin A1C and Glucose) included Complete Blood Count included N Comprehensive Metabolic Panel included x Thyroid Panel included w PSA(men) included CA-125(women) included m 0 Packet Pg. 1564 H.1.c QuantiFeron Gold included - Testosterone(Men) NEW for this RFP (added $20.00) included Fitness Program (NFPA 1582 Guidelines) 0 Fitness and,Agility Evaluation - - included Body Composition Analysis included StretchingfFlexabilitylEndurance Analysis included 0 0 Nutrition and Diet Recommendations included 0 Personal Fitness Recommendations included Medical Clearances OSHA Respirator Medical Clearance included Firefighter Medical Clearance -included TOTA,<. 0 Palk County 2018 Additional Tests - HAZMAT Tests(Cholinestrese and Heavy Metals) $1 20 CO _ Chest X-Ray with Radiologist review - $65 CD CD Hepatitis A Test $55 cv Hepatitis B Test $ 55 r9 Hepatitis A Titer $30 Hepatitis B Titer $30 0 x Hepatitis A Vaccines each shot(2 series) Each$60 Hepatitis B Vaccines each shot(3 per series) Each$60 E PPD °' 15 OSHA Respirator Mask Fit Testing (Pcrtacount) $35 0 .E 0 0 x 0 m 0 Packet Pg. 1565 H.1.c Exhibit 2 Life Scan Wellness Centers MONROE COUNTY 2018 Comprehensive Physical Exam $ 395.00 Physical Exam NFPA 1582 compliant) included Comprehensive Hands-on Physical with Vital Signs Vision (Titmus) included c Audiometry included Skin Cancer assessment included Mental and Behavioral Health Questionnaire included c Sleep Disorder Questionnaire included Personal Consultation with review of testing results included Cardio Pulmonary Assessment Echocardio ram Heart Ultrasound included _ Resting EKG included Treadmill Stress Test with EKG included Carotid Arteries Ultrasound included Aortic Aneurysm Ultrasound included Pulmonary Function Test s iromet included 0 Cancer and Disease Assessment Thyroid Ultrasound included Liver, Pancreas, Gall Bladder, Spleen, & Kidney Ultrasounds included Bladder Ultrasound included Pelvic Ultrasound for Women Ovaries and Uterus included Testicular Ultrasound for Men included Prostate Ultrasound for Men Included Blood and Laboratory Tests Hemoccult Test included Urinalysis included r9 Lipid Panel included Diabetes Tests (Hemoglobin Al C and Glucose) included Complete Blood Count included Comprehensive Metabolic Panel included Thyroid Panel included PSA(men) included Testosterone (Men) included CA-125 women included Fitness Evaluation NFPA 1583 Guidelines Aerobic Capacity Evaluation included Body Composition Analysis included Muscular Strength Evaluation Muscular Endurance Evaluation Flexibility Test included Nutrition and Diet Recommendations included Personal Fitness Recommendations included Medical Clearances OSHA Respirator Medical Clearance included w Firefighter Medical Clearance included TOTAL $395.00 Packet Pg. 1566 H.1.c Exhibit 2 c Additional Tests Available U Chest X-Raywith Radiologist review 65.00 0) Lumbar X-Raywith Radiologist review 65.00 Hepatitis A Test(antigen) 55.00 Hepatitis B Test(antigen) 55.00 Hepatitis C Test(antigen) 55.00 Hepatitis A Titer(antibody) 30.00 Hepatitis B Titer(antibody) 30.00 Hepatitis A Vaccine 2 Series 60.00 Each c Hepatitis B Vaccine 3 Series 60.00 Each HIV Test 40.00 ABO Blood Type 22.00 OSHA Respirator Mask Fit Testing (Portacount) 35.00 Cholinestrese and Heavy Metals (Hazmat) 120.00 CO QuantiFeron Gold (TBlood Test for TB 60.00 '✓ PPD Test 15.00 The Life Scan Pricing is based on Location being provided by the City, County, or Union. A surcharge will be added based on the operational cost for Life Scan to provide space or increased cost of on-site locations. x .E x Packet Pg. 1567 CERTIFICATE OF LIABILITY INSURANCE °ATE( H.1 A �. 02/25/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THI: CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIE! BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZE[ REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject tt 0) the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to th, certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Cinda Groves >- NAME: 0.E.Wilson Insurance,Inc. PHONE (727)535-0524 aC No):(727)536-9828 1475 Belcher Rd S E-MAIL ADDRESS: cinda@oewilson.com Largo FL 33771 INSURERS AFFORDING COVERAGE NAIC# INSURER A: Auto-Owners Insurance Company 18988 INSURED INSURER B: Admiral Insurance Company 24856 Life Extension Clinics,lnc.dba Life Scan Wellness Centers INSURER C: Transportation Insurance Company 12408 1011 N.Macdill Ave INSURER D: Q Tampa FL 33607 INSURER E: INSURER F: L, COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: Q THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIO[ INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THI; CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS Ch EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBTYPE OF INSURANCE INSD WVD POLICY NUMBER /Y POLICYPOLICY EFF LTR MM/DDYYY /Y M /DDYYY LIMITS uJ X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 A CLAIMS-MADE OCCUR DAMAGE TO RENTED $100,000 X X 062312-20690745 11/10/2020 11/10/2021 MED EXP(Any oneperson) $10,000 Approved L.skk Manag m nt PERSONAL&ADV INJURY $1,000,000 () GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 PRO- X POLICY El JJECT 1:1LOC 3-2-2021 PRODUCTS-COMP/OP AGG $2,000,000 ) OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000 A X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS X X 4159162800 09/18/2020 09/18/2021 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS $ $ r X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $1,000,000 A EXCESS LIAB CLAIMS-MADE X X 41-591-628-01 11/10/2020 11/10/2021 AGGREGATE $1,000,000 N DED RETENTION$ $ WORKERS COMPENSATION X PER LITE OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 CCD V C OFFICER/MEMBER EXCLUDED? N/A X WC 6 56600287 11/29/2020 11/29/2021 CV (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under LO DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 CV B Medical Professional Liability E0000037691-04 05/31/2020 05/31/2021 2,000,000 Aggregate CD Retroactive Date:5/31/2001 2,000,000 Each Claim DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate holder is additional insured on the general liability and auto liability with respect to work performed by insured. CJ Medical Professional Liability Additional Coverages: Sexual Abuse $1,000,000 Each Claim/$1,000,000 Aggregate Network Security&Data Privacy Liability$1,000,000 Each Claim/$1,000,000 Aggregate CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORI Monroe County BOCC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED II E ACCORDANCE WITH THE POLICY PROVISIONS. 1100 Simonton St Key West,FL 33040 AUTHORIZED REPRESENTATIVE � � r/� <SK> ¢° ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Packet Pg. 1568