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HomeMy WebLinkAboutContract 20045e � STA'�� OF TEXAS § COIINTY aF' TARRANT $ �?I'`r i,;�`� �'�::v.�r €"��[/i/SF•� � t. -..�� i..t f _ l i �l� i,;\� � _�l �, d; -. KNOW ALL BY THESE PR�SENTS: CONTRACT FOR PRQF�SSIONAL SERVICES Thia agreement is made by the City af Fort Worth ("City"), a home-rule municipali�y in Tarrant County, Texas and Mediaal and 5urgical Clinic, P. A. d/b/a Advanced Occupational Heal.�h Care ("AOFiC"j, a Texas Professional Association, both parties acting through their authorized representatives: 1. Services tq be Provided. ��`� . a. AOHC agrees to provide to City, in accordance with medically necessary or appropriate professional standards, a full range of occupatianal health care serviaee, a� outlined in AOHC�s propoaal in response to City, attached hereafter, labelled Attaahment "A" and incorporated in its entirety, including all �xhibits, as re].e- vant. Both partiea recognize, acknowledge and agree that �hose partions of AOHC`s propoeal conatituting deseriptians of services� �o ]�e rendared and �epresentations oi aspeots of contraetual undertakings to be performed in the event of agreement are hereby converted into the terms and conditiona of this agreement unless atherwise specifically abrogated or modified in this agreement. City �and AOHC both recognize and acknowledge the professianal nature of this agreement. Befng cognizant that iseueg of interpretation and performance wiil inevitably arise, both parties agree to coneult with each other and covenant to negotiate in the utmoat good faith in order to as�ure perfarmanc� of �his agreement without hinderance. b. Services under thie agreement will be provided at AOfiC's current facilitiss, at suhcontractor's facilitfes appraved by the city, and ati such City faciiities and o�her lacations as roay be mutually agreeable to AOHC and City. c. To the extent �hat the services to be p�rformed under this agreement conati�ute aervices compensable under the Texas Workera Compensation Act, as from time ta time in effect, or are aervicea � perfarmed by p�rsons other than AOHC and covered by the Palice and Fire Departments' Contracts (hereafter defined), both parties rec- agnize the nan-exclusive nature of this agreement. However, for any servicee to be performed by AOHC under this agreement that, under the circumstancea perfarmed, are no� compensable services under the Texas Workers Campensation Act, thi� agreemen,� shall cans�itute the City's exclusive contract for such servicea during the term of this agreemen�. The Police and Fire Departments' Contracts conaist �f (a} those cer�ain pre-existing contracts �ntered into by the City far the performance of post-offer physicale for persons affered jabs in the City's police or iire departments, and such other ma�ters as are cantained in such contracta, and (b) any renewals thereof that do nat expand the scope of services ta be performed thereunder. 2. Compensation. The parties agree that Sec�ion 9.0 and Exhibit "D" to Attachment "A", the AOHC progosal as modifi�d by AOHC's attached and incorparated let�er of 3 August 1993 concerning audiometric testing, ig acc�ptable as the compensation to AOHC for services delivered gursuant to thie agreement. The partie� acknowledge that an expansion of services to City by AOHC may become desirable and agree to conduct negotiatians on same in gaad faith to arrive at mutually agreeable performance and campensation. Same will be evidenced by wri�.�en amendmen� or attachment hereto. Payment will be due on or beiore thirty (30) days after the date of the invoice for such servip��. Any payments not timely made will be sUbject to interest at the ra�e of ten percent (1Q� } per annum, which ahall be payabl� upon demand. 3. Term. Thia agreement shall commes�ce on the date of execution and shall terminate 30 September 1994. As per Section 8.0 of the ADHC proposal (Attachmen� "A"} the City ehall have thereafter renewal aptions for faur consecutive one year periads. � 0 4. Records and Records Manaaement. This section supersedes section 4.0 of AOHC's Proposal to the extent af any conflict therewith. a. Cit�y will tzas�sfer phy9ioal cuatody o� i.ts pre-exieting medical recorda of i�s employees and ex-employees (�he "Pre--exieti.ng Medical R�cords"j to AOHC as necessary to facili�a�e performance of this agreement. It ie recognized and understood that any such records a�e de�med to remain in City'� legal custody and aUtha� ri.zed City pereorinel will be granted aacees to and uee of them as eity requires. Upon termination of this agreement, AOE3C agreeg to return all Pre-exis�ing Medical Reonrds back inta the physical custody of City, or to transfer them to such ather agent of the City as City may deaignate. CJpon receipt of autharization from �he affected City employees ar their regresentatives for AOHC to view and use the Pre-existing Medical Records (which authorization� may be given a� any time so long as it is in accordance with applicable law concezning aonfider�tiality of znadical recordsj, AOHC may keep COF11�9 thereof at its sole copying expense, or may subsequently request copies thereof and shall reimburse City for its reasonable copying charge� oi such records as AOHC requeeta. b. It ie additionally reoognized that additional medical records created by AOHC, in the �erformance flf this agreement, regardless of form or medium af storage S"New Medical Records"j shall be and remain the property af AOHC and shall not be removed or trane�erred from AOHC, exaept in a�coxdance with applicable law and AOHC policiea. Before requesting New Medical Recorde from ADHC, City shall obtain from Ci.ty's employee or a legal representative authorization to release copies of inedical records in accordance with applicable s�ate and federal law concerning �he confidentiality of inedical records. Provided� hawever, AOHC agrees to use all reasonable e�fox�e to nbtain the consent of each pa�ient aeen by AOE3C unde� this agreement, w�ich consent would authorize AOHC ta release capies of such New Medical Recorde to 3 the City upan xts reqUest therefor. Upon termination of this aqreement, AOHC shall retain the original� of ail New Medical Records in its poesession, and City ahall have the right to receive copies thereof in accordance with the faregoing, and ite reimburaement of fifty percent {50�) of AOHC's reasonable aopying aharges for such records as the City r8quests. c. AOHC agr�ee that no medical record covered by the terms of this agreement will be altered or deetroyed without express authoriza- �ian by city. City recognizes tha� medical recards will from time to time cease to have administrative, financial and/or leqal value to either City or A4HC, and City and AOHC agree to create appro- priate recard retention and deetruction schedules for the pu�pose of efficient recorde management. d. AOHC will exercise appropriate care in the management, uae, s�orage and retention of Gity records to preserve necessary- information and maintain confidentiality under the law. City hae examined ADHC'e record-keeping and management facilities and systeme and finds them eatisfactary for purpo�es of this agr- eement. Both parties recognize and agree that necessary and/ar useful modi£ications of the facilities and sy�tems used by AOHC tor recorde management may be indicated from time to time. AOHC will saliait City's input concerning any such modifications in order to ascertain if any issue� or cansequence�, legal, financial, ar practical, are �easonably foreseea�le because af facility or system modiiications. City and AOHC agree to negotiate in good faith to resolve any such ieeuea and consec�uences in a manner equitable to both partiea and consistent with the purpvsea of this agreement. 5. Terminatian. a. City may terminate this aqreement a� any time for any cause by 60- day no�ice in writing to AOHC. Upon the receip� of such notice, AOHC shall immediately discontinue all serviaes and work and the placing of all orders or the entering into con�za�ts for all 4 suppliea, assistance, faciiities and materials i� connection wi�h the performance of thie agreement and ahall proceed to cancel promptly all exiating contracts insofar aa they are chargeable to this.agreement. b. in the event no funds ar insufficient fundg are appropriated and budgeted by City in any fiscal period for any paymen�g due he•reunder, City wi11 notify AaHC of suah oocurrence and thia agreement shall terminate on the last day of the fiscal period for which appropriations wers rec�ived withou� penalty or expense to City of any kind whatsaever, except as to the portions of the paym�nts herein agreed upon For which funds shall have been appropriated and budgeted. City has iaformed AOHC that, concurrently with approval of this agre�ment, City will appropriate and budget sufficient funds ta finance anticipated serviaes describefl in this agreement, so that funds will be- appropriated and �udgeted priar to the commeneement date of this agreement. c. Upon te�mination af this agreement for anp reason, AOHC shall p�ovide the City with copies of a1i completed or partially completed documents prepared under �his agreement. d. AOHC may terminate this agreement as per its prop�sal, upon 60 day minimum written notice, subject to the terms and conditiona outlined above in this Section 5. e. If AOHC`s treatment of a City empZoyee is commenced before the termination date of this agreement and cantinue� beyond that dake, then City shall conti�ne to pay A4HC far medically appropriate services necessary to complete such treatmen� at AOHC's usual and customary rates untii such care ie completed, and the City also shall pay AOHC for services actually performed in accorda�ce herewith prior to auch termination, less suah payments as have been previously made, in accordance with a final state�ent submitted by AOHC documenting the performance of such work. 5 6. Tndemnification. a. To the extent wi�hin the limkts ❑£ AOHC•e policies of professional and general liabili�y insurance policies, ADHC aha1� indemnify and ho�d �he City�and its officers, agen�s and employees harmless from any loss, damage, liability or expenae for damage to property and injuries, including death, to any person, including but not limited to officers, agents or employees of AOHC or subcontractors, which may arise out of any negligent act, error or omission in the p�rformance of AOHC's profeseianal services. AOHC shaZi defend at its awn expense any suits or ather proceedinga braught againat the City, its officers, agents and employeea, ar any of them, reeul�ing from such negligent act, error or omission; and shali pay all expenses and satisfy all �udgmente which may be incurred by ar rendered agains� them or any of them in connection therewith resulting from such negligen� act. error or omiasion. I� is understood that the foregoing indemnification is not intended to cover matters to the extent to which City, ite afficers, emplayeeg, agenta or can�ractors are negligent. 7. Insurance. a. AOHC shall riat commence work under this agreement until it has obtained all insurance required under this aection and such insurance has been approved by the City, nor shall AOHC allow any subcontractar ta aommence work on its subcontract until ail similar insuranoe of the subcontractor has been so obtained and approval given by the City. b. Workers' Compensation Insurance. AOHC shall take out and maintain during the life of this agreement statutory Workers` Compensation Insurance for all af its employees performing any of the .aervice� herau�der, and, in case any work is sublet, AOHC shall require the subcon�ractor similarly to provide Worker�' Compensation Insurance ior all of the latter's employees unleaa such employees are cavered by the protection afforded by AOHC'.e insurance. AOHC will 6 additionally acquire Employer`s Liability coverage in the follawing a�t�ounts: $500,D00 each accident 5Q0,000 dieeaee - policy limit 5�0�000 di�ease - each employee c. Cammercial General Liability Insurance. AOHC �hall take out and maintain during �he life of tizis agreement such commercial general liability insurance ae shall protect AOHC and any subcontractor performing work covered by this agreement from claims for personal injuries� including death, as well as from claims for property damages or lossea which may arise fram operations under this agreement, whether euch operations be by A08C or by any subcontractor or hy anyane directly or indirectly e[npZoyed by either of them. The amaunt of such insur�nce sh�ll be as follvws: (1j CSL (combined �ingle limitj per occurrence: $1,OOD,OOfl minimum (2} Aggregate: $2,40fl,000 minimum (3) Umbrella Policy. In an amount not leas than One Million Dollars ($1,400,Od0); d. Profegsional Liabi.lity. Profegsional liabiiity or medical malpractice insurance shall be re[,�uired in the minimum amount of $i,00a,ODQ per claim. e. Au�o Liabiiity. Automobile liabiii�y insurance in the minimum amounti of $1,000,000 CSL (combined single limit) per accident shall be required. f. Proof of Insurance Caverage. AOHC shall furniah the City with a certificate of insurance as pr�of that it has obtai.ned far the duration af this agreement the ineurance amounts required herein. AOHC's insurance policy shall provide that the insurer shall give �he City thirty (30) days' prfor wri�ten notice before altering, modifying or terminatirsq the insurance coverage. g. T�rms of insurance specified in paragraph 7 above shall be as ioliaws: 7 (1) The Ci�y of Fart Worth shall be an additional insured on all applicable insurance policieg providing coverage required her�in. {2} Insurers of the policiea eha11 be acceptable to the City. (3} Deductiblee on each oi the contract�r's policies �hal1 not exceed $5,q00. (�) The city of Fort Worth shal� receive minimum 30 days n�tice of cancellation or change in coverage under th� palicies. (5) Applicable insurance policies ehall have waiver(sj af subrogation in £avor of the City. 8. Independen� Gontractor. AOHC shall perform all work and servicee hereunder ae an independent contractor and not as an officer, agent or employee of the City. AOHC shaLl have exclusive con�rol of, and the exclusive right to control, the details of the work performed hereunder and all persans performing same and shall be� solely responsible for th� ac�a and omiasione of its offivers, agents, employeea and suhcon�ractors. Nathfng herein shaZl be construsd ae creating a partnership or jaint venture between the City and the AOHC, ite ofticers, agents, employees and subcontractors; and the doctrine af respondeat superior shall have no application as betweea the City and the �OHC. 9. Disclosure of Conflic�s. AQHC warrants to the City of Fort Worth that it has made full disclosure in writing of any known exi�ting or potential conflicts ot interest reZated to the services to be performed hereunder. AOHC further warrants that it will make prompt disclosure in writing of any known Conflic�s of intezeat which develop subsequent to the signing of this agreement. 10. Ripht to Audit. AOHC agrees �hat the City sha11, until the expiration of three (3) years after £inal payment under �his agreement, have acce�s to and the right ta examine any directly pertinent boaks, dacuments, pape�� and records of the AqHC involving transactions relating to thi� agreement. AOHC agrees that the City shall have access during normal working hours to all necessary AOHC facilities and shall be provided adequate and appropriate work apace in order 8 to conduct audits in compliance with the provisions of this section. The City shall give AOHC reasonable advance notice (not iess than 7 working days) of intended audits. AOHC further agrees �o include iri ail itis aubcontractor agreementa hereunder a provision to th� effecti thati the subcontractor agree� that the City shall, until the expiration of thres (3) years after final payment under �he subcontract, have access �o arid the right to examine any directly pertinent books, documenta, paper� and records of such subcontractor involving tiransaations �o the subcon�ract, and further that City ehall have access during normal working hours to all subcontraator facilities and shall be provided adequate and appropriate work space in order �o conduct audits in compliance with �he provisions of this paragraph. City shall give subcontractor reasonable advance no�ice of intended audits. � 11. Prahibition of As�iQ�ment. Nei�her party heret� shall assign, sublet or transfer its interest� herein without the prior written consent of the other party, and any attemp�ed aesignroant, sublease or transfer af all or any par� hereof without auch prior written coneent shall be vaid. 1Z. DBE Goals: Nondiscrimina�ion. a. AOHC acknowledgea its commi�ment to meet or make "good faith" effort to meet �he City of Fort Worth's goala for Disadvantaged Eusiness �nterprises (DBE) participation in city cnntracta. DBE participation wae part of the evaluation criteria used in the award af thie agreem�nt; therefore� failure to comply may result in AOHC being classified ae �anreaponsive and �eing barred from City work for a period of not le�s than six months. AOHC agrees to furnish documentation of DBE participation such as cancelled checks, etc., or such evidence aa may be deemed appLicable and proper by the City of Fort Worth. b. As a condition of this ag�eement, AOHC covenants that it will take a11 necessary actions �o insure that, in cannection �ith any work under this agreement, AOHC, its associates and subcontractors, will not diacriminate in the treatment or employment of any 9 individual or groups of indfviduais on the groundg of race, color, religion, national origin, age, sex or physical handicap unrelated to job performance, efther directly, indirectly or through contractual nr other arrangemente. 13. Choice of Law; Venue. a. This agreement aha11 be construed in accnrdance with the internal law of the 5tate af Texas. b. Shauld any action, whether reai or asserted, at law or in equity, arise out o� the terma af th�s agreement, venue for said action ahall be in Tarrant County, Texas. 14. Mul�iple Counternarts. This agreement may be executed in multiple counterparts, each to constitute an ariginal, but all in the aqgregate to canstitute one agreement as executed. E%ECUTED on this, the�� day af �Q.C°f� , 1993, but effective for all pur.poses as o� ��h�e, � day of ��(� , 1993. AT7Y� S T : , �� , �' I .��� .I�G � r� �„�-�/y'— �BY: ity Secre y � CITY OF FOitT WORTi3 c� �.�. � . harles Soswell Aseistant City Manager ,APPROVED AS TO F012M AND LEGA ITY: . ��9� As ie nt �y Attorne� � �. �ti � �/ � ��,� � . . ,:�� 5�� � . , � -/C� �- � � � ADVANCED aCCUPATIDNAL HEALTFi CARE �x : �,w.�iv_� �'.o TITT.E: l,s �� in ����5� ��� � ���1������� �+ �� �� �����ES ����� � � �� �� 0 � �° �4,.�� ��� I�J����1�� ��le� �1.� - � ��� �� � �� �� ���� ���� ��l�Y���TT'��l�i �"O� BII� ���� �� 2�, ���3 � Atitachment ",A," � ��� a� �� ����� Page 8n il � 8+�n��S/ 8 aV A\�N��\a���NN��wNNfNNMM���M�G��il�iM�M���OGOO�NNN�/�N�iN/1M�rNMM 8 � ��o�os�, i.a o���z°nvG ��tar��r... ..................................................... � �.a sCo�� o� s�xvzc�s ......................................................................... s 3.a z�oc�.�a�v�sr� o� cor�cro� s��vicEs ...................... � 4A R�CDI�S 11�NAG�II�N'� ............................................................. 9 S.Q �OR I Il�iG RE�U��viENTS .................................................:..10 6.0 IR�SU�.r�NC� F�Qi.JZREI'�v�NTS ....................................................12 7.0 COh�'I.IA�NGE ��T'I�3 I�AV�S Al�� DB� POLIC� ......................14 �.Q 'I�R1.VfS ��' C�I�7'1'RAGi ................................................................... ].� 9.4 FRiC� QiJO'I'E ...................................................._........,...................... lb 10.0 (�U�I�ICA'TIOI�S ...........................................».................................17 � ��` .... ..� � � � � s��r.ap�a��sa���Ni�K.aaa�n�aGNNN+����oMn�owa�aaGa�aGe�Nauu��M�������J �G .�8�� �7[1'll'E9lt �► �tSl�t�I1C� �'� 517��t3 ...................:................................................. �0 �isit � €'crfor�anr� �and .......................................................................... �1 ��i� � D�� �'olicy 5taf����t ..................».....................................,........... �� iL +���Y � b ��4RI ��VY� ����1�����������������������������Y�Y��������aw��M����������H������������������a��� � �`�it � Finana� St�i�mcnt ........................................................................ 2� � �`�i$ F° Or��i�atior��i G3��rt ..............................»................,...................... 26 �i`bit �a R�s��s ........................................................................................... ?� �u`bit I� NIDA Ce�cadan ......................................................................... 3� �h�iDii I Ab1�r�iat�d Cli��t L�ist .................................................................. 33 ExliibitJ�ai� o£ Custo� �orm ...... .......................................................:.... 34 �u'bit K Author�aYion �or '�rc����t Form .............................................. 35 ��'�it �, HCA �s�ita� Con���tior� L,�t��� .......................................,..... 36 F�ehi�it 11� A�F�� �ations l�ap ...............:..............................�:.�............... 3i Y�������� A�anc�ed O�:patioflal �icalt�ri Gar� (AO�iC) s1��r�s in t�� gr�owth of t�t� m�tra�Iex and c�Iel��at�s its in�usi�ial s�c,�ess. I�aving oQerated in the �cc�pation�I/Industrial ar ena for the past forr�y-sia years, A�FiC has dcvelop�d servi�s whic� p�aducee su�cessful r�sults for our patients, em�loyers and i�s�ranc� compar�i�s. Ou� clinics a�c convenient�y located i� cor� ifldust�i�l areas, with fre� pazking, and �ach is fially equipped and staffed iay full-tim� physiciafls, r�u�s, t�cl��ians �.rid bilir��ua:l aSsistaz�ts. Th� following p�oposal is su�rmitted to the Citry of �'ort Wortli pu�suant to th�e Soli�it�tion fo� �id op���d or� June �5,1993 conc..��iflg th� pu�cHase oi ou#side occup�tionai h��tt� car� s�rrvices. Ad�anred Occupational H��� Care (AO�iC} �.nderstarids t��t t�� City o� �o�t VVorth d�si�es to contraci to a.n outside provide�, s��+ices pr�viously p�rfa�mmed by tt:e Cify's Oc,cupation�I Healr.� �Ii�� lo�ated at 700 W. Ros�dale. AO�iC is p��}��°ed to prQvide a�onsvlidatior� of o�cugational healti� serrric�s £o�e City of �'ori W�rth emplay��s as outiin��i in ti�is �ropasal, � �'ox tlie pu�pose o£ coasisteaey arid to �o�e ciea�ly coramunicate the services A�I3C zs p�epaY°�d to p�ovid� fo� t�C� �ity oi �a�t �or�li, this do�u�ent is divided into th� same ten {10) crttegori�s cov�fed �y t�re Sal�atation far �id Each cate�orr� contains t�� �ollowi�� two subsections: O"��VI�i� A�r�rnary of t.�� ssrr+ices o� information pequest�d by t�� City's Solicitatio� for �i�. Ii�COR�AT'IOI�dSIB� � s�ma� of �4,Q�i�'s c�ent s��rices a�d/or r��thods ���sted by AOI�C to accorn�lis� t�� serr�i�s pe��st�d in t�t� Cit�r's Solic�tatior� £or �id Ir�tro�uctia� Ciry af Fart Worth Soiicitatior� far �id Page 1 �.o o�����v� ��or�� o��� ihe Ca�cy oi �'ort VVorth d�sip�s � Cont�actor to �erforrn o�up�tional �ealth caee s�rvi���. Services ���ormed u�der th� cont�act resuttir�� feotn ttiis Solicitatio� for �id wi]I b� administercd by the Cz�ry's Ris� Ma�ager or �SJii��° design�e. '�e goals for � providia�g th�s� s�r�+ices will in�lude: � fast�ring optimum �e�th fa� city ��nployees 4 assistin� i� compIiar�ce witli the A���icans with Disabilities A� (AUA) � obtair�ing �a�aally ���e�icial ��sults peg�rding costs associat�d with the �ork�rs' Compens�tion progeara ����l�t�,T`I�I�Si�ID . Sinc� occ�pado�al hea]t1� care ppo�ams havc � direct impact upon comp3iance with a myri�d of gav�rr�ment �c�atior�s, AQh�C p�cognizes th� Cit}�s d�i�e to cont�act thes� s���s to a�rovide� wl�o is ��e�i��ced iri o�r.p�tional r�edi�in�. AOHC has provided o�zpatio�al �i�alth car� s�rvic�s irl tl�e D�lilas/�'a� V�ior� metroplex for the past foriy- six y�ars. Oia� 9(1�� client papulation includes corrnpariies requiring compliance with the fol�owfng gavernme�t re�ulato�y ��ncies: OSI�A, b01", �E4C, �'ede�a! �Iighway �epartm�rnt, T�s ]]e�a�a�n� of Put�Iic Saf�ty, �'ederal Avi�tion Ad�.inistratio� and �'�der�l RaiIr�a�d Ad�ix�ist�aiion. O�pational h�alth ca�e s�r`+ic�s wiil b� o��r�d at t�ee t�OI�C Io�atiofls. �ach lo�t�on is staf�fed with lic�n�d physi�ians, �urs�s and pl�ysical �ri�rapists and provid�s access to th� fol�owing: 4 A L��1 I i�u�a Uflit 4 L.�abo�atory �4� �ha���y � Wo�k Iiarde�� 1.�1.1 �G� �OIT� U�' OFE�'�'I��i AOI�� p�ysi�iarts afl� professional sta.f� will prov�de �cupatioflal health se�vi�es 1Vlonday-F�s�ay, $:0� �.ln. � 5:�0 p.m. PYop�al--O�ratir�g En�ronment City of i�o�t Wori� 5mliaitatior� for �id Pag� 2 �`T��3 �IUL1�l1,+��'IC� CON�II�G�P1G'� P� 1��HC physicians will coordinat� treatni�nt oi rrnajor inju�ies or inju�i�s th�t ac� �te� re�ulac clir�ic h4urs witi� th� following hospitals: � k�iC�i 1�Y€�i�] �I� �Iospita� 9�0 �tl�i Av�nu� �ort V�oz�th, iexas 761Q4 $ HC.�, l�io�h I�lls I�I�dicc�ll Centee �1 �ootti �al3oway �oad No� Richlaz�d I�ills, T�xas 76180�'i371 1.2 [� DRL1C�'T��G Ana�ysis of tb� u�ir�e spe�imefl eo€le�ccted for dr�� t�stir7g will be pe�formed by PharmChem, � Pd�A ceriifed I�borato�►. 1.� SA�i�t/�A 3iJR�ILL�C�/OSIit� CO1V�Y�LI,�C� AQFiC's 4c��ational k�eaIth Co�suitant and Cert�ed Safety Engineer will be availabl�, upon r�qu�s�, to coordina�e o�cupatiar�al haza�� s�arveillance t�sting a�d ass�ist #.�ie Cit�s s��ty of�c�� in complyin� with gov�r�meat stafldarc�. 1.� CARDIUPIJ�41�i�Y �IJSCTTATIQI�i Cardiapuimana�y ��s�itation (CP�) coc�rs�s will b� provided upon Y�quest by a c��tif�� CT�R inst�ctor. I� PRU�SIQPi,�I� S��%� AOHC will p�ovide lic�esed o�apational I�ealtlr� physi�ians who will pe�ozm th� following �►ices: �'r Post-off�� cota����ter�siv� phys�ic� assessm��ts � cyo�plianc� wit� th� AD1� � �'i�st aidlrt�ino�` i�jurry tr�at�.cnt �} �Ifloci�orne pathogen �posu�e initial ass�ssr�en� cot�s�iin�, tr�atme�t and �%llaw-up� isi addi�iofl to th� r���ss�ry r�fe�� t1r��ough the City's �rnploy�e Assistan+� �°o�n %r outside pro%ssion�l cot�s�Ii�rg ��ou�selin� rel�� to U�� D�vg S��c��ir�$ and HI�i t�sting � �valuation of all test r�sul�s Lic�flsed �ocatioflal R�urses oP R�Icc3ical Assistants train�d in occupational health wilI ��ovid� the �ollov�ing s��ices: � da�sr�ationl;�a�Iatiorn (i�cludi�g tri�garitis �) 4 Initial �1ood P`��ss�.�ee, �ision and kica�in� S�re�ns a�d Pulrnor�ary �unctiarz T'esting � � Drug Screea Cou�fiions fo�Iowing t�ie DOi 23 Step P�acess outlined foP NID� collectior�s Peagasal--(7�eatsng �t�vi�o���tt City of Fort Warth Salicitation for �id �'a&� � 1.3.1 ��`� �CO�O� �TIlYG AOHC's Oc�upaYioaal �ealt7� Consul�arit wiI] c�ordiflate el�e a�inistr�atior� o£ the ���ath Alcohol Tes�ig perfar�n�d by �o�ensic Cofls�Itiri� Ser�rices.. 1.4 �IL,LII�� A�kiC will p�ovid� a detail�d 1�ill fop a11 first aid �� �patioflal hea�th se�vices to the City ofl � rnonthIy s�hedul�. '�he s�h�dule an� components o£ the billing wi111�e d�t��rnin�d by ttie Ci�s Di�ecta�e of Risk 1i�aaa��meni upon t1�e acceptanc� of tl�is p�a�as�I. Detailed �iIlirig fa� iflj�► car� and woxker's co��e�don s�rnices will be %rvva.�ded to th� Citry's thirc� pariy adtnir�istrator. PPoFasal--O��ating Environmetat Ci�r of Fort Worth �licitadon for �id p��� .� �.� SCO�� �F S�RViCES o��� 'I�e City oi F'os°t Worth d�su°es a contractar to �eovide a£�ll ra�g� o� c�cu�ational he�Ith care sernices. 'I�h�t�e� t�e �onteactor c�oos�s tQ p�ovide t�es� se�c�s ai �OQ� W. �osedale or at tHe Cont�actvr's facilities (s�e I ocatiaz�/Sit� og Co�tractoP Se�vices}, a d�dicate� sta£� is to be provided to p�rr�orm o�cupatio�al h�alth ca.�e s�rvices. 1�COR�1�A'I'IO1�S/�� 2.1 E.IST OF S��IC� AO�C ��rpas�s to provi�� t�i� followin� servi+�s £or th� City o¢ �or� Vdoeth (comp�hensive pricing and rate �for�n�tia� is pr�vided urcder° Sectiar� 9.0). I. �T�a�th Assessme�ts a. �o�t Qi%� b. �a�atio�al �. Audiometriclfrlea�in� wit& o� without �Hysicals d. �'oliow�up Assess�ents � II. U�n�ll�rug Sc��e�ings a. 'Tests {fap Rar�dom, P�romotior�af and H�a�th Assessm�nt) 1. 1�� colie�#ion 2. l�on�NID�+I cyoll�ctioa an� t�s�$ b, T,7rin� Sc���ss (dipsti� u�i�alysis) fo� promotioflal ar�d h�alth assessrnent �. IriitiaI cou�selirz� III. I�boratory 'T�s�g a. T�ii b. I.ead I�v�ls �. I�Iis�cll�n�ous iesYs I�i. A�ino� I�j�ri�irs� Aid a Initial visit b. �oilow-up v�sit �. Hcaltlri �� Saf�ty �u�atio� a C�R b. ��ood�orn� �attlaog�ns c. �'iPs� Ai� d. Safety Class�s Pta�sal--Scop� af Secwices City oi Fart Wo� Solicitatiar� foe �id Page 5 �iI. Inac�laYions and T°ii�rs a. H�patitis � b. H���tids � Zit�r c. �abies Inje�ions d Rabi�s Tit�� �. "Tctanus/�ipht��ria f. I�ucziza g. PP�s (FI�3 si�n test) `TII. �Iearin,� a. �uai�o�ram b. � c. Co�s��� �JiII. Mis�ellan�ous a. �1ood pP�ssua°� ch�ck �. G1urAs� ch�k (fu�gc� stick} c. Vi�iofl s�r�en I�. �e%�als a. �AA Coordir�ato� b, Sp�iatist �.� �O�'giO1�S1�Qi� OF" 0����'TOI�i A�n��d O�.�ational �e�1tFi Caz� p�o�as�s tv�o �'�te�i�s %r ppovidin� o�p�tiaea� health �rvi�s far th� City as follows: � 1. Oc.�u�atior��l h�alt}a s�ices v�ill b� provid�d c�u�in� regular bouxs {Ii�ianday - F`riday, �:Om �m. � S:il� p.r�.) �t th� ti��� (3)•�r��t AQHC lo�ations (s�� L,o��ior�ISit� of �ofl���ior Se�ic,es). �, -��� r��lax ciifli� �o�ars, ��ePgen�y injur�y r�e wil� b� coo�di�at�d by t�OI�C physiaa�s at eithc� Fr�CA lY��dic,al PI� Hospital o� I�C�r l�orth f�ills 1R�[��icai C.�flte� �y c��d�atin� t3�� �eea�e�t oi irijuries o� erner��n�ies t�iat a�t.�r aft�r �e�al�r cliriic hou�s with the abc3v� hospitals, t1�� Cit�y oi �o�t wo�th will re�ei�e a 209�e di�ouft� or� em�rge�c�► room �ar� rela�iv� to t3i� medical fec guidelx�es�a�opt�d foe oVork��s' �o��ens�tion iri th� Sta#e of T�xas. (Please refcr 10 ca�f �ai�� 1�1te� ��r�ibit L) Proposal--5ctape of Ser�ces Ci�y af Fort WortJg Solicitatio� fnr �id Page 5 ��i DEDIC��D S�� A�dvari�eed Oc�ap�4ion�1 I-�ealt}� C�e is a f�Il�se�ir� fa�ilitry so1�Ip devot�d to th� praciic� of o��ational rnedici.nc. �� staf� af lir�e�sed physi�i�s, nupses a�d medical as.sistants is spe,�sally t��ined in a��atio�al medi�in� and is p�epar�ed to p�ovide I��alth care s�rvvi�s to t�e em�Zoyces of t�� City o� F'ort Riorth. �.4 �NI]ERGEPIC'�' �'IaA� .�►s t�� select�� provide�, AO�IC will elect to p��oen� tl�e services �equested by th� Ci�'s solicitatio� %r bi� ai the cu�er�t AOHC Iacatio�s (s�� Tda�a.tio�lSit� of Co�t�actor Seflri�es). �.� STI�CO�Ci'OR(s) AOHC wi]11�e so1�Iy ��s�aonsibi� Eof p�rfopming th� s�r�vic,�s outlined in this p�opos�l. T7�e fallowirlg e�dti�s �e s�.bcoflte�ct�d by AOI�C: ¢ PHa�°mCh��nn Lai�orato�ies e} Aamo� Iaboratories �oposal--Scape of 5�c� Cit�r of Fo�t Worth Saticitadan for Bid � �a8� � 300 ����►'�"��1�f5IT"� 4F C����'�R SE��dI��S O'�I�'V�i�J T%e Cit�s Solicitatior� £o� �id offers tl�e Ca�tr�cto� th� opportunity to prvvide the requested servic�s at any of th� foilawin� lacations: 4 t�e sit� o� th� Cit�s �msting Qr,cup�tianal ��a1t?ri Cliflic-�70U VV. Ros�dal� 4 t�� Gont�acto�s o� facility; or +4 a svl�cor�teacted facili�}►. �'he �ast two options wiIl Y�quir� t�� City's �pQroval. 'I�� Ci�y rnay i�spect the site during th� t�rm of t.�� contr�ct p�riad It�C0�1`1D�i'IO1�i/�IID 3.0 a 3.3 �O�A.'TIQ►T�/�I7'� � Ifl th� past, at�cupational inju�r c�r� i�as t�een p�ovided foP many Gity empioy��s by the ��ysicians a�� staff of A�I�C at AOF�C fa�ities. Relevant to this soUcitatiofl, at is th� desir�e of AO�iC to p�ov�i�� detiicated occuparional h�alth se�vic�s to City �mp�oyees at tlz� ia�ations Ust�d below: � Cea�l �s�ili�.y 1651 Rt. Ro�cial�, Suit� 2� F'ort �ii��tb, 'i� 7�14� � P1o� �'aAlih► �300 N.�. I,00p �20 �'ort 1�o�h, '1'� 7�1a6 � �ut1� ]��dlity 4i15 S. ����ay at �'elu �ort �o�i, "i� 76115 TI�� r�afl�g�m�nt t�ar� af �►OHC wou�d welcom� the opportunity to provid� a g�Zid�d to�° of t�� fa�iliti�s to t1�e Cit�s co�4�act directo�, his/Fier designee, st.�if aat�lo� a�y oth�p Cirry p���el wit}a intcP�st in t�is p�oposal. � Proposa]—Lorationl5ite of ConYractop S�ic�s Citry af �'ort Wort� Smlicitatia� fQr �id �a�� g �oo �c��� �v����r� o��� AII recort�s developed du�ing this contract, wh�th�r they �� medical pecards o� other+,fris€, wi11 be maintained to th� specifications o� t1ri� City. Ihe� r�cords wilI be k�pt cor�'ide�tia� ar�d made a�ailaial� to the City upon ��quest. Re�o�ds will be compute�ized a�d the softwa�e used %r t�is �rocess will be comgah'bl� with t�a� of the City. R�COR�1lrl]A'1'�O�dS/BIIi �.1 R�FCAL RECOR�AS All rn�dical ���o�ds aze maintaifl�d at .�Q�-iC by a R��st�r�d Recapds A�mmirlist�atop. Recogrii�in� t1�a# � br�ach in confidet�ii�lity could cause hartn to both the • emp�oyee az�dlo� ��ploy�r, p►Q�IC �eat�s a sepa�ate pecor� for each n�w injuz� an� physical. 'I"�uis �ror�ss prevents a 1�reach af co�'identiality when records ape Peqnest�d fo� � pa�Yi�ulaz date o� se�ice. Strict guide�ines have b�en established by the'�e�s ldledic� }�ecords A�oc�ation ca�c��sing t�ie rel�as� of inedical reco�ds. Currx�t�y AO�C r�Yaifls �acH m�dical �ecoPd fo� � period of five (5) years. At th� en� of t}iis tim� ���od, tlrie employ�� is off�r�d ttie opport�ity ta assume custo� of th� r�c;apd p�iap to its d�str��ion. AOfr�C's c�rr�nt m�thod a� �ecoxdkeeping may difg�� fror� tha� of the Cit�r; tl�e��fa��, in recogniz�ing the need fa� �� Citey to r�tain bott� �st�lish�d ar�� near �edic�l re�ords � r�qui�ed unde� stat� an� �ov�rnm��4 Pegulatior�s, AQ�� would lilc� to irlvit� iurtl��r diss�ssion Coflcefliillg t�ii3 #D�iC to ei�sur� that t17� fl�ds Of th� City �� ffi�t. �.� AiJT01�'� �GB�S AO€�C doe� noi c��ntly provide an auto�atc� �et�riod of m�di�al �e�vr��pin�. Should t�e Cit� d�ssir� t�at AO�C p�ovi�� t�is s�rrrir� tl�e cu��nt �fopo�l r�oraid e��d to �� a�nendcd. Pra¢n�al—��c:ords Ma.r�ageme�t Cit�► of Fort Worth Salicstado� for Bid page 9 �.m ��a���iQ� ������r�►� o��� �etails of all t�st r�sults w�'ll be p�avided to tli� City on a rnonthly basis accordi�ng to �� City's requi�ements. In addition, tl�� resul�s of Post-0�£er �xarns and �pomotiofl�l H[�alt� Assessments will b� provid�d to t%e hi�� at�tlzo�itry and Per�nnel dcpa�mei�t witi�in �4 hours. All Pos�-(�ff�r exarzxs t��Y ir:�lude ar�co�aoc�ation r�cornrrnendadons will also 1�� repo�te� to t1�� AAA Caordi�ator vai#hiri �4 �ours. ��O�1�iAEY�01�5l�Ib 5.1 1�riON��' ��(}�tZ'IPfiG A4HC p�oposes io p�avide thc o�i�irial do�m�n#ation of a11 test results and e�arrns pe�o�m�d at AOE�C lacatio�s to the Ci� on a monthly basis no Iate� t�ian t�� last wo��� day of �ach �ont�. � ��cagnizin� that the �ity desires a detailed bi�Iirgg sum�nary outli�ing the numbe�r arid types of inciden�s occ�i°ir�� �ach mont� a�ong witi� t1�� autcoYne ofr each incide�t, AOI�C will work wit.�i the City to develop such � repo�ting �yst�m at r�o additinnal cc�st to the City. �.1.1 PO�'I' ��T �0�3"I'II4��C AOHC will u�iliz� the Czt�s "Sup�lem�ntal 1'�edicai l�valuadon �'o�m" to recaPd �� �e�1t� of �ll e�s. �e r�sralp,s oi tb� folIowin� will �e teleghoned within �4 �io�rs ta thc individual �esi�at�d �y th� �i�► to r�eiv� t�i� results: �} �osfi-�ff�r (�t�iin � hour�s) � ���lth �ss�nenfi (a�t�i� � hours) � Sur�cill�n� (v�irhi� rti�� (3) warki�g a�ys} . Q t7iiti� Dii1�'�'�S�S (ifle�al negatiru'e r�lY� �v�ithi� 24 ��s; posit�ve GC'l11+IS pesults aaitf�in '� houea) � P`ost-Iniurny �v�lu�dor�s (witi�i� � �icn�rs) �.�.� U�IP� D�iTG SC� COI.I�G�Olob � �R�� Utilisrig a D4T�A appro�ed Cixaia oi Custoc�y do�ment and t�� DO'�' Z1 step coIl�ctio� m��o� AiOHC �wilZ coll�cr �rtd ship t�� s�e�im�ns to a c�rti�ied i�iII�A 3aborato�y �or initial an� �+o�atorr� testirig. Pro�sal--Rcportir�g Requi��m�nts City of �rort Wor� Salicitatiaa for Bid Page 10 T�i� 1�A �ug s�r��� paneI inc�ud�s t�c followiag five �t�go�► oi drugs: � Coc�� � Marijuat�a � a�iates 4 Araph�ta�ines � Ph�ncy�3idi�� N��ativ� �esv]ts o� th� initial ���a perFo�ned on th� u�ine s�arnplc wiil b� t��ep�az��d to the �itr�s designat�d pe�n within 24 �iou�s. A11 positive drug tests ar�d (��IS v�ill b� Pepo�tcd withsn 'i� hou�s. Co��ation oi positive z esults t�r t3�i� I�IDA lalaoratvr� vvi]7 be co��uct�d usiri� G�s C�omato�raphy Mass Spect�°a�etry �GC/lislS). AOK[C rcco�rrnends tiiat a SEGLI�`.E faxin� system be ��velop�d so that tl� PesuIts of th� �g c�ing ca� bc fa�d to on� pe�son desi�nat�d by t�e.�ity ta ��ive thes� r��zlts. Th� Cit�s d�signated ge�son will �cc.�ive a"hard copy�� af t�i� driig t�s� �csults witi�in scven ('ij workin� days. �.I� �t3S'T IRi.��' �U�'I'II�tC � In addition to tt�e aboee ��po�ting s��vices, AOHC wilI pravide a"Durry Status" stat���nt v�hich can �i��r b� f��d, rrn�iI�ti, or hand carri�� to t�e empioyee's super�ris�r ar ta t�ie ���r� desi�nat�d by t�� City �o ��yve t�iis ir�ormatior�. �uniflation ��sults a�d a g�vpvs�d t�eatrnn�nt plax for ea�� injur� care episod� will bc t��ep�ia��d to tl�e emplaye�'s s�pe�wisor o� t�i� Cit,�s desig�ated p�son within �4 hours of �� employ�e's visi�. Praposal--Re�nrti�g Reqcsi��me�ts City o;f Fort Wortii Salicitatio� for Bita Fage 11 �.� ������� ��������y ������� G�]�� � II��1VIl��AiI�1� ��3 t3�R� � '�'he City r�qu�pes th� Cantractor� ta mainta,in specific i�su��c� coverage which shall include subrogation waiver(s} �d to com�aunicat� wit.�iri 30 days a�y �celI�tions o� c�an��s in �ri� fal�owin� cove�ag�: � Co��ne�ial Li�6iIity �¢ F�o�°essional Li�il3ty/A��dical liRalgractice $I,OOO,U� CSI. per o�cuNe�ce �1,0�,0� $�,O�,O�DO Ag,,��$ate 4 Wo�sers' Ca ,��nsa�tloa � �utoffiobil� I.iahilit3► S5(30,O�il eaeh acxides� S1,O�,�D GS� eacl� accider�t SS�O,f3�Q disea� - pali� limii SS�U,O� disease - eac1� employee Th� Co�tracio� will a�5o maiatain a Perforsnanc� �or�d of $150,Q�00. �'li� co�t�act deve3oped between the �it� and t�� s�r�vic� p�ovid�r will i�ciude a hold �iarml�ss cIause artd � ind��ificatiorn cl�use. 1�CO�l�A�T�1�t�l�ID 6.0 � B.� �SYJ�1�C� CO�G� A�F�C r�aintaifls th� follo�.firig ir�s�u°ance coy���� and limits with dedu�l�s �ot ���ir�g $S,QO�; . � Cor�me�cl�l Y�iabilf� 4 Peo%ss#ua�l if�billiy/RRedic�l 1'�Y�l�arr�actice . �1,O�O,UO�D �b per a�rr�enc�e S1,UO�,Q�DU , . S2,OQ�U,O[lm �e�a4� 4 �'or�r�' Com��s�iio�t � �to�aT�il� %iai�il�tx �50m,0�0 eac� ao�ide�t �1,0�0,(i�D C�v eac�i accident S.SCJ�U,0�0 diseas� a polic,y lir�it �SQQ,Q�Dm dis�� - eacf� er�ployee Insvrance fa� s�ee� a�r� provid�� an ��it �. Propasal--Insurance Roq�ir�er�ts, Pcsformaric� Guapa�tce and �d�mnification ierms City of gort Wo�tF� Salicitatio� foP �id Page 12 b.� iypan �oti��ation oi having suc�essgully r�ceiv�d the �or�t�a� for the s�rvices �eqraested in ttrie Ci�s solicitation for bid„ ,�4HC will: 6.2.1 additiQnally ir�suxe th� City of �o�t V�orth aa its g���pal liability and autemabile i�s�u aric,� polzci�s. 6.3 provid� t�e City wit�ri a contract whicl� will include boti� a ho�d harmless claus� and � iridernni�cation claus�. 6.4 obtain a pe�o�mance bofld vvitl�in 3� days of tl�� acceptar�ce of this p�opos�l in th� arnaunt of $].50,OU�0 wit�in 30 days. Propmsa3--Insurance R�quiremer�ts, Perfor:naac� Guazantee a�d rndemnification T'erms City of �'orc Woeth So3icitation fa� Bid Page 13 7.m �0��,�YC� �7l'�I I,��� � D�� ��,�� Q��� � �� et�► P�9u���5 �,� �o����to� zo ����y ��n �i i�, stat� and fed�r�l Iaws in�luding the p�avision of � Dis�dva�ta��d �usin�ss Enterp�is� poli� (DBI�). ��Q�1�A.iIOI�iSi�� 7.1 AOHC �u��r�tly corn�lie�s wit�, all city, stat� and f�aeral l�ws �p�licable to ope�ation as ari oc�up��onal t���l�t clinic. i.� CO�.CT �i]P��fl �JTT�OU1' D�E P�TYC�A'TiOl�i AO�iC acicriowl�d��s tt��t it is tii� Ci�s pali�r ta involv� DBEs iri its p�oc�rem��t of pro£essional se�rices. ��co�izin� tha# � D�� poIic�+ or � st�teru�nt of "Good F'ait}i" must l�e provided in cQ�junction wit}� this Bid, A�HC h�s completed t�i� D�E camp�ia�ce statement attached as �bit H. FYoposal—Compliance witl� Laws and D�� �aIicy City o� Fort Wort� Solicicaao� for Bid Pagc 14 �90 �� �� ���V 8 a��� "�e City p�oposes tY�at t�� i�sitial caatr�cfi ��riod b�gi� Augvst 1,1993 and condnue for a period of fourteen (14) z�onths until Scpt�rrn�er 3D,1994. At tha� timc, t�ie Ciry (at i�s sol� dis�etzon) ��y ex�rcis� a r�ew�l opdon fo� fo�r ca�ssec,udve on� y�ar pefloc�s. � Termir�adon of tlze contract �y �ither pa� rnust be submitted ifl wr�itin� at least 6� days �riar ta t.�e dats fox dis�o�tinuation of �rvices. Iat�rirn ser�►ic,�s v� Pate changes may be rnad� vditJ� th� p�ior app�aval oi t}ie City''s i�i�ecto� o£ �tisk Irriazaa��mc�t. �CO�I�r�.1'iO1�dS1�ID �.1 AUHC will �in p�ovidin� se�i�s on AuEgust 1,1�3. _ Since AOHC h�.s proposed to pravide th� �eguested a�cuQation�l health c�e �rvi�s at its �ent Io�ation, a�°ar�sitio� p��iod may 1�e requs�ed to assist the �mployees in adjusting to tFie new lozatian�, as w�ll as to any n�w p��edupes requir�d to assure prap�P implemcnt�ti.on of tl�e �r+ric.�s req�ested It is �ecotnmended that AOFriC's O�patior�a� kiealtt� Caflsulta�t a�d th� Cit�s i]i�e,cto� of �isk 1i�ana�ement �eet to outlin� t�°g�t dates and ident'�Cy employees requiriag annuaI se�ic�s sucl� as �ar►dom testin�, audio�ram�, lcac� e��ms and He�tth e�lu�tians. Fasy acc.�ss to all a�p�tional ��alih �e s�rvic�s �s a�tanda�d r�aintain�d by .�O�C. City �gIoy�es will �e s�en at ar�y of ou� Io�atior�s 1V.[ar�day tt�ough Friday, �:t�} a.m. Yo 5:00 p.rn. wiYliout ax �ppoiat��n� '�e Au�ori�ation for 'Tr�atrnc�t Fo�, �'bit K, s�ould be cvmpI�t�d foP �ach ernployc� on each visit as a�e�s of ide�tifyiri� �� se�vice to b� provid�d. �.� Shou�d t.��r� b� a rea�n to c�ange or �lt�r the rat�s for s�rvices prov�d�d on �Z'�xt �, AO�� w�l �oti�r tl�e City fo� �provaI 9� days p�io� to tli� expect�d change. $3 A�I�C �nd�rs�a�ds and a�cepts tf�at t�� �or�tra�t rnay be termiflated by eithe� Pa�ry wit19 a ffiinim� bQ�c�ay writtefl �oeicc�. , Peo�sal--Terms of Canteact Cilj► O� FO�i WOT�1 SOZICIi8t10� �OP B1d Pag� 15 9.0 PRiC� �QJ�1� O�]�� 'Ihe Cit�y requi�es t1�at ti�� Contractor s�bnut com�Peh�nsive prir,� a�d rat� iriformation, including tl�e serr�rices �isted on Attaclr�n�nt � of the Cit�y's Solic�tatioa for �i�. '�ie Yat�s must be �uaranteed for t}9,� i�aitial fourt�efl {14) r�o�t.�i term. F'rices will b� revjiewed-siac�iy {f�} days �rior to t1�e contr°a�t �niver�sary d�te. �CO�F�A�TT"gOi�SI�� 9.1 All rates a,nd o� c�a��es for ser�ri�es propos�d by AOHC to t.�e City faY a�cup�tional ���th seiwsc�s �e outtu�ed in �Z�it �. 9,2 AOHC agrees �o �aarite� to th� Ciiy that it will not exce�d the rates andJor c%aP��s as out�ir�ed in �u1�it � du�g tli� ir�itia114 mofl� tenn. � Rates pres�nt�d ir� �xlu`biC D, year-to-ciate fro� 10�1-94 tti�ough 9-30-97, ir�clude at�uai incr�as�s of appro�urn�tely 9%a. 'These estiz�at�s re��� andcipat�d i�c�eas�s in A�HC's du°e� operatir�� casts. A�HC vr,�'ll comply with Section �.2 wh�n arstieipatin� a r�te �����. Proposal—Pric� Qr�ot� City of Fart Worth Solicitatiorr foP �id Page Ifi ��a� �������� � � 11���i�" 8����1 \ � O�L'�•�►i Althou�i th� p:eo�ement tea�a, for t�ie City may el�ct to int��view certain �i�ns, the fol2awing info�matioft s&all �e peovided witi� tt�e propas�l: 1`r Stat�ments identifyi�,� th� ca�abili�y of t�� contractar to assume respor�s�bility �o� adniinistratioz�, rnana�eme�t of a�cu�ational Health s�r�ri��s �ontract by August 1, 1�3. �} Cant��ctors' A�zdit�d F'inancial� Stat�ment ����nizationaE cha�tt �d resur��s of �e�cal pro�cssional p�rso�el assign�d to d�3ivcr th� o�upational health s�ivic�s outli��d in the Cit�y's Solicitation £or Bid � List o� ��f�reaces to rjrham tlrie �ont�acta� ��s provid�� tike serrvic�s from Tarivax� 1,1�1 to preseni � �GO��1�A�"IO1��/EIl) 10.1.1 Il�1'�'IAZ'IUI�i O� S��IC� AO�IC v�ill begin provid�rri� s�rvices as outline� in t1g� City's Solicitatian for F3id on Augu.si 1,1�3. AOFi� s�r�s ��re�utly ia �Iac� ifl�ciud� tii� p�ompt, �c�tuate �iiagnosis of injurie�, uriri� d�� scre��� ar�d �ollections, pha�mauy and r�diolog� sciwi� ��re1.I'Trauma U�i� ����ral Su�g�, physiCal therapy, �nd an ex�e�i�n�d V�ork �°derjin� �eograffi. AOI�C also of�ers assistance i� sti,zcturi�� �omp�y m�di�l poli�� wor4� �I�s, uniofl ��latians, OSHA compIiar�� arid �ecord���ing. �aF�� prof�ianals a� pr�pa�d to �ee� with thc g�re��fl� t�arn op t�te �i�ecior oi �isk m�ag�m�nt to det�rii�� i� addc�don� proc,�du�es n��d to 1�e i�plerrn��ted p�ior �o t�e.�ug� 1,1993 de�+d]iri� to e��rc a�elairvel}► s�anoth tra�sition. At��IC is d��icat�d 4o t�e �a�ce�t that auY best inier�sts are s��ed whefl tHe best iflt�r�s o� in� �°� s�rvec�. R�� th�pe�ore pl�d�e our �ontin�ed eiFo�ts.to provid� yo� rr.+iti� ti�ely, ecor�omica� �� skilled �ealth �e servic�s in . stat��o� t�ic-�rrt iac�iti�s wi�otat ti�� constrai�ts oi appoi��ents. Proposal--0rga�ization a�d I�alificatia�s Cit�► of Ffl�# Wo� Soiicitation for Hid Pa�e 17 �a.�.� ���c� Since oc�patio�al ��aIth c�e pro�arr�s h�ve a d.iP�ct smpaci u�ofl co�nplia�cce wit� a�nyriad of �overn��nt ��gt�lations, AQFriC �°eco�i�es t1i� Gi�'s aesit°e to cor�tract th�se s�rvices to a p�ovid�r who is e�g�ri�nr�d i� oc�zpa�onal n�edicine. Advanced Occupatia�al I�e�l� Care �as g�ovided a�cupa�ional �ealt�i ca�e services in the Dall�o�t V[iort� metrq�lex foe the past foYty-si� yea�s. Ot� 906}� clicnt populatior� inciudes comparYies requiring compliance witb t�e followifl� gove�ent re�u3atc�ry �ger�cies: OSI-�A, DO'i', ]��OC, Fed��al �ii�way �e�aa�rn�n�, 'T�a.s Depa�trn�xi of Pu�ii� Sa£�ty, F�dcral Aviation Ad�iflistration and F'ed��al Ra.ilraad Adnunistratio�. ��I�C's ex�erie� witlz gav�r�ent anc3 municipal�itjr carat�a�ts in�ludes clients s�ch as the City o£ RTort3� R.icl�la�d HilIs, th� Unit�d States Post Offic�, t�� T'arr�t Ct��ty She�if�s Dega�rrn�nt, an� tlie Ta�eant Cou�t�y �et�sonnel Depa�trneai, in addition to th� list oi satisfied cli�nts inc�icat�d iri �xhi`bit I of this p�opc�sa.I, . 10.1.3 AiJDTI'3�D �Pd�tCIAI., STAi�h�EP�'T Attac��d as �bit � AQHC sub�its its curr�nt �'uian�i�I Stat�ment fo� tlze period ending May 3�,1493. Upon �otifiradon t�at t}ae Ci�y of �o�t Worth has ac�c�pte� this Propos�i submitted by AOHC, arid upon r�c�uest by th� Ci�►, AO�C vaill provid� a�opy o� tl�� Audited �'inancial Statenient. ia.�.a �ula�/o�tG��.,��o�� C�� AOI�� prof�ssionals �epres�r�t a cor�l�iried total of ov�r SU years o� OccupatiQnal Healtl� and Safet}� �eri��ce. T�e Quali�c�tions og th� ghysiciafts, sta� and consult�fi� of �O�C �irectIy related to this project are p�es�nted ir� �bit G. 'I`�e o��ar�i��iona� �iart ��pr�s�nts th� �aemb��s partici�atin� in tlr�is p�oj�ct a�d is att�ch�d as �`�it �. 1Q.i� �►4HC h�s pro�� ocx�patiofl� �t�dicirl� se�+i�s to rrn�y corrapanies in th� rn�tevplc� An �b�r�ated list of s�tis5ed cii�nt com�ar�i�s is attach�d as �iYbit I.� Prop�sal--Organizat�on and Q�aa�ificadons City oE Fort Wart�t Solicitatior� for �id Pag� 18 SU�� Advanced Oc�upadaaal ��altf� Care a��r�eciates t�e oppaptu�it� to bi� for �� Cit�s �ccu�ationa! I�e�th S��ic�s and �roposes to ��ovid� t1�� City wiY.� co�pr�h�nsirv� �ccupa#ional �i�a]th ca�� at iis conveni��tly lo�ated clini�s ti�ou�hout �ort Wor�. Sinr.e its incepdon iri f 946, Adv�nc�d ���ador�al H�altli CaPe (AQI-€C) l�a� si�ared � t�� g�owtlx of tl�� M�tr�plex arid celeb�at�d its ixldus#rial suocess. With physicians and �Fofessianal sta� experie�ce� iri th� v�ious iac�t� af �patioflal z�nnedi�ine �O€�C has �fne�ged as the x��on�l l�der by develapirig se�vic.es whicl� praduc� �uccessful results fo� p�tients, �mpioy�rs and ifls�ranc� car�a.�arii�s. In �dditian to this bid., AOHC off�� t�e followin� s�rvi�€s fo� City cmployees in canjunction with inju�r ca�6 or czne�g�n�y �r�: 4 �harma� (past-inju.rY PP�s�iptivns orily) �} Radiolog,� <} Physic�[ Tn�rapy (post-injury only} � Aft��-�iours mcdical cofltirr���n� plar�ing wit� HC�4 f�Iospitals AOHC r�ogni��s t}ia� t�� acx,�ptaflc� of �his ppo�as�l vyill s}iift th� pPovision of s�pvices fpor� 7(3�} `M. Rosedale to �40gIC locations. 'ii�is s�iift i� services will c�'e�t� a tra.r�sition pe�io� durir�� w1�ic� .�OHC's �i�ec�or� of Cli�r�t Se�vic�s, alang wit3� xnembers of th� p�oj� t�am, Rrill �e ava�abi� tu a�sw�r ariy qu�iat�s or add�ess ar�y con�rns i� an ef�o�t to str�amline th� a�apatio��! ��a�tk� s�rvic�s �favid�d for th� Ci�y. As t�� s�c�ssful bi�de� A��� v+�ill pravid� a�y �ddit�or�al do�r�n�ntatior� at thc Cit�s �eqiacst. 5��� P e 19 City of Fn�t Wott�i Soticitaboa for Bid � ���� � Y�S���� �L�� ►���� Exhibit A Ci�+ of �'ari Worth Salicita�ion #or �ed Page �0 :���:��e�w� :;H��: -�- TPI�� I„�. h7efl�r��dgf� �mp���ee� lfl�uP�hne� �i4�� ���fet�+iera Dri1��, �9�� a�n Aw�+�r� i � , �'x 7�2�� �10�7�4�9��� .• yau�w --- _ ��b�f9��� ����G3�f � �P9� i H�� I �F� C�r� (M�dieal & ��ar�ie�i crr�;�, ��� ��� z �o, �e���� � � g�P� Y�ortF� rx i� tQa�i���--- - �s� . � �� ������� � ��� R� R � ., . �.�:. ae.+rr� iF�� .� �"«�.`f-. �,� . 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I i�a��-r�r�. �r� �� � 0,�� 1 I��Ia�Y��� Y+� ! 1 I 1a�����c. �a�. �50�, ��� �.�a' ooaoaaaa�o���ammaoa���oao�aa.oaoo...�..�.��00000.`oao�s�avooadoaa�oo�a4m�_ao��o_��no_.000�_°aoaoo�o_o__aoo.�000.00. 1 1��� I I f I I I E i I � I ! . � f I � - � � f���ab�s����o�6Oo�o��oo�mo�pa����p�o�oa�aa�o0op�i�o�O�+�e0000�o�oo��nfoo�OO�oa00o0o��mi060GOdo���pnos�a�v�c��rroo����n�od��000aG�� � B���i�p� �% �ii�d�l i��/�=������� ii�� � I � f f> C�'��Bed' d`� i��� t�o�M�ao�urr�vt���c����s��.o��a�sa �'C.��-T-Je.'�,"�OL�1 s�.r�s�ar�ow����s:�r��o����r��o��.s�o�o����w��oo�s���� � � � �1i� A8 � A� �I�S�� gBFaeC�'S�l �� �a.}iT� B�C]fL�' i7R� �' � � �x�Zeti �E si��l� � ss� �ros�Y l�YL,ia ��v�a � xs.=L �A � �7f� id�l3�S� 1�£� T� � C���C-8'� ���li MA}C� 'ia :!� F�. 8� I ei�y �� Fe��� Ho�'� 9 r�x�s x� es�� ��s r�rxc� �rr� �s�� � gn�a�°sarr � Lxa��s�r o� D� ��°t��u� ��� 1��� T����3�r��� �°��� �a��. � 'i�l�� _beo�ee �s-o ��/90� . a�e xtr� �R � ce���. �gs ��� a� A�r�i Bs�s�. �o..000_..o�oo.o.m�ao......----__._.__.00___--�--'�-�---------------------- • �t�¢x�� R�p�B�s�svo � d C�h��7� ��s3c� _ ....—� - — -- ���1lI. � �������� ���� As the successful bidderAQfrIC will p�ovide �ny additio,aal docurrrentation �t the City's r�ques� Exi�slsit � Ci�r of F'ort Wo� Solicita�on for �id Page �1 ���� � ��� �L�� S'�A"�i�� E�r�y��c c City of Fort Worth Sa�icitatio� for Brd Page 2,� Attachment lA DSE COMPLIANCE STATEMENT The undersigned bidder hereby ce�ifies that they will �omply with the DBE Policy in the following manner. {check 1, �, ar 3) PLEASE READ INSTRUCTIONS: DBE GOAL. Section t. Para�ranh �. Pa�e 1 I. ENTIRE CONTRACT SUPPLIED BY DBE, (check ceRificatioa status) Certifie� by t�e City of Fort Worti� In th� process of being cer�ified by the City o£Fort Worth NOTE:FAILURE TO SUBMIT THIS iNFORMATION WII,L RESULT IN BID BEING CONSIDEREb NQN�RESPONSNE TO SPECIFICATiONS. � 3. X CONTRACT SUPPLIED �JITH DBE PARTICIPATION If DBE participation meets or exceeds the City's goal, cnmp�ete Attachment 2B. CONTRACT 5UPPLIED WITHOUT DBE PARTICIPATiON Compl�te the "Gaod Faith Ei%rt" Documentation Form, Attachment 1 C Authorized SignatuYe Presider�t Title Advanced Occunatioi�al Health Care Name af Company Julv 14_ 1993 Date The bidder fii�her a�reEs ta p�ovi�e, di�ectly to the City upon requ�st, complete and accurate information regardi�g actual woek perfarmed by the DBE on t�e cor�tYact, the payment therefare an� a�ny �roposed changes to th� original DBE arrangements submitted witla t19is bidlproposal. Ti�e �idder also agrees to allow an audit a�dJoc examination af aary books, records, a�nd fdes held by their company that will subst�.ntiate the act�al work perfor��d 1�y tHe D�E on tt�is contract, by a�a authorized officer or em�loyee of th� City. Any material misrepresentatian will b� grounds for terminatin� the contract and far initiatir�g actio� under �ederal, State ternii�ati�g tl�e contract and for ir�itiati�g action u�dep Federal, State or Local laws concernir�g false statements. (ALL DBEs MUS'T BE CER.TI�IED BY THE CITY BEFORF COI�ITRACT AWARD) Attachment 1 C Fa�re 1 of 4 Occub�iana� Health Ser�rices Pro�ect Piame N/A Praject Number "G�OD FAITH EFFORT" DOCUMENTATION FORM If you have failed to secure DBE fit�mms or if your DBE participatian is less than the City's goal, vou must aompl�t� t�is farm. FAILU�E '�O COA�PLET'E Ti� �tEQUIRED DBE PARTICIPATION FORMS IS GROUNDS FQR REJECTI��V OF THE �ID. "ALL OUESTIONS ON THIS FQRM MUST �E AN'SWERED 4R THE BID W1LL � BE, CONSIDERED NOl�i-R.ESPONSIVE '�U SPECi�'ICATjONS", . I: Did yo� obtain a list of DBE firms from the Gity's DBE Uffice? Yes X No 2. Did you eontact any of the orgatizatia�s that arc avaiIab[e to assist DBEs, to obtain a list af �otential subaontractorslsuppliers? Yes � No X 3. Please Iist each �nd e�ery subco�tracting/supplieP opgortunity wlvch will be used in the completio� oi'tt�is praject. . PHanmchem Laboratories Damon Laboratv�ies If none, ple�s� explaui in d�#ail. 4. Did you send written notice to DBE firms soliciting their bids on this ppoject? yes IVo X If yes, attach copy S. Did you salicit bids from DSE firms by telephone7 Yes No X If yes, list £rms and�the results of tHese effocts on page 3 af 1C. 6. If DBE firms w�r� reje�cted on tHe basis of quotation being ta h��h or qualifications, attach documentatio�r ta support yuotation bein� too high and/or reasons for rejectian based upan qualifications; i.e. Ietters, �eemos of telephone ca(Is, meetings,etc. 9. Did you solicit bids frflrn DBE firma �y Ad�ertisemer�t in the Newspaper? Y�s No X If yes, a�tach copy of advertisement. $. If you propose to perForm the eaiire contract without subcontractors or suppliers, please p�ovide a detailed explanation beiow that pro�es, based an the siz� and scope of the project, tl�is is youY norma] business practice. N/A 9. P�ease provide ar�y additior�al informatio� you feel will fiu�h�r eacplain your good faith effarts to solicst bids f�os� D�Es o� the groject. T'�e compasition of your work forces is nat a car�sid��atian. N/A Attachtnent 1 Page 4 of 4 Th,e undersigned �ertifies that the in.farmation provided and the DBE(s) listed wasl�uvere contacte� i� �ood faith. It is unc�erstood that the DBE(s) o� the attac€�ed list wiil E�e contact�d and.the reasons far not using them will be aerified by t�e City's DBE Office. The misrepresentation Of facts is �rounds iar cocasideratio or disqualification and �nay result in a bidder bein� classified as an irresponsible bidder acfd bein� barred from the City of Fort Worth wor4� for a periad of not less than six months. Authnrized Si�r►atur� President �'itie Contact Perso� Nam� and Titl� {if dif%rent from authorized signature) Advanced �ccunationa� Health Care Compa�y Name I65 Z i�{i. Ros�da�e, Suite ioa.l�t. �JVorth.TX �6104 Address 81?133��4Q44 Phane Number(s} 7u[�u 14. 1443 Date � � !� l� �I�-� 11 � �l, ��, 4� �� ���� ���l�l �"�'�E�S� �IJ�Li� ,�U�X �2,19�3 ����� I HeaI� Elssess��nts: A. Post off�� B. PYD�IOtIOfl� C. �i[e�rlin� 'I ests wlexa� D. F'ollow-up Ass�ssments 48JOi 10/01/94 101 1193 1�0/95 ��� s z�. � z�.00 $ 22.(1a $ 24.(�l $12.O+U � 13.O�U � 22.t1m $ 24.IX} io�o��s� XOIQl/9b 09/30/96 09/�0/� $ ��.00 $ �9.(31} $ 26.00 $ �9.Q0 $14.�U $15.p0 � 2�.OQ} $ 29.(i0 � II ilri�� A�ag �ning, {P�IDA}; (���iudes lab, call�tor�, & 1l�O se�ic�s) A,, '��s�s 1. Randor� $ 30.t�1 $ 33.0(} $ 3fi.00 � 39.Di1 �. �om'vtional � 3�.0� S 33.(�l � 3Fi.{�} $ 39.00 3. w1I-i�alt� Ass�ssmen4 $ 30.(3� $ 33.OQ1 � 3G.0� � 39.01} �. Co�rzs�ling l�a Cf�r�e--in�luded iri M�LO servic�s ffi Ot}ier La�'Tes&s/Co�tseii$�: A. �I�T T'�sti�ig T� Counseliflg B. L,�ad Lcv�ls C. 1l�ellan�ous T°ests � P �' � � ZQ.00 S �.{l� S �4.tlQ? $ �fi.00 S �0.00 S �.Om $ �4.Q0 S �b.E�} S �9.OU $ 3�.()0 $ 35.00 $ 3�.0� '�o b� �et�rmin�d u�on requ�st by Ci�y � atq. � T� 11l�II�no� �iari�ss: A. I�itia� i�isit �AOHc ��,c� �r��y ao� oa c� �t�woc � F� ���) 1. ��i�ilFirst e�i� Only � 7�.{� . �. Lirnit�d � 33.U� 3. In����i�te � 44.00 4. ��z�de� $ 66.00 B. �`ollov�-u� �isits T�CC Cur�ent F°e� Sch�dule rd H�I� � S�ii�;�► ���t3a� A. G'PR Tr.aini��'estir�� "'�'ii5� Al� '��31ood�orne Pa�o�ens '�Safe�► Classes Exfribit D City of Fart Worth Soiicitatio� for Bid S �5.00 � � ZS.OQ $ 31.� � � 34.UQ} per pe� p�r �:sas per pe�n per pecsan � �3.� �r��� � 45.00 �� ia b� �etersni�ed u�or� r�qu�st by City Pag� �3 City a� �ort �Vort�ri �'r�i� Quot�, J�ly 1� 1�3 �'I � �� � � � � �JIII ��acetlations � T'it.��°s: A. He�. � Injectians $ 4U.(m $ 4�.00 $ 4�.fxD $ 5�.[�l eaefa eac� eacf� eac� $ 30.0� $ 33.00 $ 36.0� $ 39.f3�] f:(3St + IQ� (� cisternnin�d t�r the State of Te�) Same as Rabies Ifljec�ions above $13.411 S 14.�U � IS.fm $16.00 $ $.00 $ 9.00 $10.0U $ l�.tl� � 9.� S 10.00 $ z�.00 $12.00 . ��p. � 'I°it�iS B. Ra�res Injectians Ral�ies T'it�rs C. '�'et�n�ighr�ieria l�nj�t. �. Ir�iuenze Inj�cizons E. P�T�sfi� �i �rir�g {,�udio��): J�. Checksfl� Cli�ic S 1�.� $13.00 $14.OU $15.D�1 �. Aru�ual A�dio�z�tric Chl�� $1�.00 $13.0� � 14.IX1 $15.Q� C. Counse�in� $12.�? $13.DQ $14.Q�U $15.00 1�Iisc�llan�aius �oc.�du�s: �►. �lood ��ss�e (au� only) iX �tefer�ls to �� Co��di��tor $ 8.OQ1 � 9.00 $10.{m $11.00 Pdo C�� *'�iese �epr�s�nt additiorial servic�s �vaila�l� fipam pi(7�iC u�on the City's Pequ�st, Extribit D Ci�► of Fort Worth Solicitatios� far Bid Pag� ��b ���� � �1�'L'al1��t�e �A��ti'.�F�l\J. Exh�bit E City o# Fort Wnrt}� Salicitatio� foP Bic� F��� � ���� � ���au������t� ��� AO�C sub�zts tlriie fol�owin� o�ganizationa� ci�afi wtii�� depi�ts ttge pl�cement of t�� team membePs respvnsble for administ�rifl� or su�pord�� th� �r�ric,�s r�quest�d in rhe Ci�s Solicitation fo� �id to procur� cat taifl o�up�tional �iea�th se�ic�s. �i� p�ojec� t�am desi�ned to pe�#orm the s�rwices P�c��st�d by tl�e Citry wi1� be di�ected by A�friC's Medir,al Director. PHysici�ns at e��h Io�atiofl wilI p�avid� t%� t°equest�d �rni�adons ar�d trea#ment a� �ar ir�juri�s. '�e physici�s vvill � ca�ns�l tYrie ��ploye�s �s request�d an� wh�n n�cessary in conjur�ction with t�s� and examinatior� r�s�2ts. Ifljuries r�quirin� the services of a specia�ist will be �eferred aft�r car�sultation wit� the Ci�s I7i��ctor of �isk 1Vi�na�ement. Nupsing staff will perfoem s�°eening test�, adrninist�r i�nocuIations and provide collectian s�rvice %p �ri.ne dr�.� #�siin�. During the perfor�nan� af 5ervic.�s pres�at�d by AOI�C iri ti�is prop4�, the Gity may �iav� qu�stio�s o�° �onc��s �bout t�os� s��rwi�s. AQI��'s Di�ecior of Cli�r�t S�iwices, Oc�pational HeaIth Cofl�alta�t and IrrternaI Services R�presentative ar� available ta add�cs� afly co��nis o� qu�stians that tfrie City may �r�couflteP with tl�e se�ic�s pe�orm�� 1�y A8I-iC. . A4l�IC �knawl�d��s t1�� �:i�r's d�si�e to �air�ttai� c,omplia�� v�ifh stat� and f�de�a.l lavvs, s�andar�ds �rtd �e�lador�s. �e th�r�forc har►e ag pa� oi ou� proj�ct team � C�rti�ied Safe�ry �ri��er a�� O�patior�a� H�alt.�i Co�s�2t�� '�'t�e s��rices �vailal�le f�or� �Fi� cAnsulta$� ar� acce�'�1� upor� ��quest af th�� Cit� ar�d will b� �Harged �t n��otiated p�t�s ag���d u�an by ttrie Git�r �d t1�c Con�lta�t at �� tirBe servi�s axe rcquest�d.� Fxh��it F City af Fa�t Worth Sali�itation foe �id Pagc Z� ���anced O��up�t�on�l �e�I�H +���e �oj�t Tea� O�ani�a�ion n PRO,T]�Cf DIRELTDR Roy G. Kr�usel, M.D. �VS��1C� DlP�Oi 6 AdRC PAYSICIAFdS Rvy G. Kreuael, M.D. Da�riel Tort�mTM MD. Nar�ass MeCaq, HLD. Henry Birdeaell, A�LD. c I CLI� S�RVICES Bn ��a 1� �A+�T�S � • — - ___. � � _. �ii�I'E�AI. �Q�LCUPATIOI'�AL SE��VICES H�lx.�'R �PR�S�Fi`I'AT1YE COEYSULTA�T $d�'Pare�, LV.N. [.a�a Fre�mam4 R.N. f � ������� SAk`�T� EPFGIl�iEER Joe Shepheid P.E, CSP � ��ija��t Dir�ctor--p�fls��fe far iitqui�ies conce�ni�g tHe treatment prov�dE,d to City �splayee� aftd/or �adional iss�. �r. F�ru�l v�] ais� fruic�o� as tfae Mcdical ���w O�ceY. �. Pl�ysici.�s—ees��sit�le ioe cand�cti�g e�i�a�o�,s/ewaluatioas as w�l� as dei�ie�� breatrnest astd wunseli�g a[t�at�� b�4 s�ited far t}« patiesat (i,e., �e�ripdons, wheth� �1�y�ical t1�eYapy wouId ls� i�e�cia], when a s�i��st slioul� be oo�sult� etc.). c. Clie�t �#ce�P�a�sibl� for in[�t�i�iEs £rorc� c�i�� ooc�c�in� clinic o�ratiot�s aC a�y of t}t� ti���e l�atiana as ti�ey ee�si� s�ifiea�+ to ti�at e1i�L d. I�te�l Se�wic� Re$r�t�tiv�-p�nas�'bl� foe a�y i�idal ir��ui�ie� wncer�ring patieat ca*e, �iltin�, radioiog�r, and�og tf�� pha��r. e. Qccup�tEo�i Iie�eltt� Co�esui�tmavar'EaHI� ta assist client compaft's�s in pian�iag and imn�lcmenting ac�pauanal hcalth c�� �ra�ra�s dc�i�ed to �eet th� ��cd� of bnth i��stry a�d c��layee� r�i�il� itist�i�� camplia�t� witla OSfr�,ey bOT� ��� a�cf '! W�C. i Certitt�i S�fety ����availa�l� ta �eov�d� �id�oe for car��lia�ce vrith ��ilatory safety standards througFt writt� s�£erry ���a�ns tau'loYed for thc client which rr�ay in�clude t�e �arfantyanc� of t�e Eoltowing: r�ork practie� ara� co�ditia�rs s�+c�. ind�s�ial hy��ne testi�g far airboefl� corztami�atc�„ noise ]cw�l surv�s a�d esgo�omic evalu�Cio�s Frach�biC � Cirry af �ort Warct� Solicitation far Bid �agc 2i ����� � ����� Fxitbit G Ciry of �art Worth Solicita�o� for Hid Page 28 It�� �. �S�L� 1VI��� ADV�CED OCCiTP�1I'IORTr��L ��'I°Bf CAI� 1651 W. k�ose�sle, Sui�� ZDO �'or� i�oYi�, ���a� 7�104 (819) 33�04� �TIUCATION � Aoctor oiMedicinc 'Texas A & I University 19'i5 1979 1979-80 198(�8� 198� �992 1993 Univ�rsity of T'exas M�dica� Sc�ool at I�ouston Inter�sl�ig David D. �iser�riower Arrrty Me�ic�l Ce�ter Augusta, �'ieargia R�sidency navid D. �isenlriow�r Axmy Medical Ce�ter Augusta, Geargia Certification �neeican Academy of �amily Practice M�dic� Review Offic�r� ComgleteQl �asi� Car�iculum i,za, Occupadon�l Medicifle PR0�5SIO1�i.61L E�ERIf�1�C'� _. . �„� 1985—Prese€�t A�v�ced 4c�patior� Healt� C�e { I 990—Pres��t M�dical �ir�ctor} { 199�-Pr�se�t FYesider�t of Bo�rd of I}i�ectoPs� 19$�-1985 St�ff Physicia� �'ort Polk, Louisiana �RO�'E�SIOl�lAL O�GA�A`ITOI`iS Amer�caz� Colleg� of Occup�tior� &c ��vi�nr�rnental Medicine 'Texas 11�edical Associatian T°arrarrt County Medic�i Associ�tio� e:IwirtvuordVrtaricetldorarey.6l 1 dvanced ccupational �ealth �are �1"��1JL�� JL ����1`'9 �.�. ����c�� o�e���o��, �a.� ��� 16�f W. �os�d���, S�ite �40 F�� �orri�, 'Te�aas ��104 (�19} 33�4044 �DUC�,I`I�l"1 � Graduate Wpfk Doctor of Medicinc Intemship University af Illinois Urbana, llli�ois U�iversity of Ar�arxsas �'ayetteville, Arkansas University of'��nnessee Colle�e af Medicine Mem��is, 'Te�esse� IV�id—State Ba�tist Hospital Nashville, '�en��ssce 1950 1953-55 1959 i959--64 �'RO�'ES�IOi�T�►L EI�PFRI�EI�TC']� 1977�-Preseat Adv�nc�d Occu�atior�al Health Ca�e 1968-19ii Prriv�te Pra�tice G��lOc�a�ationa� Med�ci�e Marr►ell, ArkA�cs+c p�o�ss�o��L o�c���rox� �'arra�t County Me.�i��l Soei�ty �e�s Medical Associatior� American I1+i�dical Associatio�t American Academy of Family Physiciat�s �:�������.sii �dvanced �ccupational �ealth �are ��i�l��.� �� �.vJL��1���y �o�.� ����o �b�.�NG'�D �CCU�Ai'IOI��, �AL,i°� CA� 1300 �t.E. �uop ��Q Fo�t Wor�h, T°�a�s ��lOb {$19} 6���1gi �DUCA'�OP1 1�I. S. Physics Ph.A. As#rophysics Doctor of Medicine Internship Residency University of '�exas Ut�iversity of �'exas Ur�ive�sity of Texas 11�iedicai �ranch G�lves#on Tucsor� h�ospitals Medical �ducatia� PYogram Urniversity af Wasi�in�ton PRU��SIOI�,�L E�ERIEPIC� 198�-199� Ar�►erican Airlines St�ff Physician, F�i�at Su�ge�on, Medicai Review O�i�er an� Scnior FAA Aviatioa Med�c�l �xaminer 198�-1984 1979-198� l�mePgency Medaci�e P�iysiciar� Snlo Fatnily Pr�ctice aad �cc�p�tior�al Mediciae �1 Paso, T°ex�s; - 1964 � 197� 19i6 1978—�9 Sole p�ysician for �I Pasw��sed 'i�caco, I��., refi�e�y ��sor�rael �d �'hotan Power, ar� �t�atior�al firm i�volved ia �eesearc�, develo��ent �nd production af solar �evic�s. EX I'E1��I� ]�I�ERYERiC� �I'iH: i) �) 3) Chemical intoxicatiora, ca��mi�r� lead, ch�orianated i�ydrocarboas, berue�e, os�anic eompour�ds, peteoleum distil�at�s, bis�ut�, antimony, �ercu�y s�lts ari� siiv�r. Burns (chemieai d� fire), laser arid �en�ral tra�ma. OSHe� TTIOSH regulatiorhs ar�d tl�eir int�rpretation 4) Genera[ Interz�al Medicine �:� � '. � . . ,.., � �'�K+aoc�ea.bl� . t�dvanced �ccupational �ealth �are ���� • � ������� �� �o�• �t/ Y t'�� 4.+�s,V LCL V 1Ct'� E LUl,�J.e �C�i� 4�fAd�.C� ' 1��1 �. �OS��.S�� �LLI�� ��� �'ar� �Vo�t}�, Tesax i5104 ($!9} 33�U44 �nuc��o� B.S. Doctor of M�dici�e Intemshi� '�exas A & M t3�iversity University of Tex�s Medical �ranc3� Galvestan A�my � Nar�+ Hospn�l Hot Sprirngs, Arkaflsas �tesidency Scott 8� WHite Clinic & Sentt Sherwood �c �rin��ey Faundatio� '�'�mPle, T'e°x�s Ce�ification A�ericart Board of Surge�}+ P�t4�S�I01�1AL E%�'�R.IE�CE 1959--Pres�nt A�vanced Oc�u�ational tiealt� Car� Sec�et�i'ireasur�e o£�oarci oiDuecto�s I9?9--I984 'Tata�t C�i�ic�l Instructor Surgery �t Southwest Medic� Sc�ool D�llas, 'Tex�s PROF�S�IO1v�I14RG��T°IOP�3 �. , .�� _� T$xas Medica� Associatidr� Tarrant Couaty Adedi�al Society. '�exas 5urgi�a�l Society American College of Surgeo�s Internatianal CoII�g� of Sufgeo�s A:neric� 1Viedical Associatio� 5outl�west Su�rgica� Co�gr�ss Society of Ameeic� G�stroi�testinal �ndosco�ic Surgeo�s American Academy of Dis�bility �valuatirig Physiciar�s 19�48 195� 195�-53 1956--59' r.lwiinward�r�e[1c�ttidocar�.611 1�dvanced �ccupational �ealth �are ���a �Pe���an�9 �.��T� �c�up��io��� ���1�� ��n����t ������ ����JP���Iv�o �'� C� �.651 �4 Ros��l� S�ait� �0� �ort �or�h9 'I'�xa� 76].�04 {��7)33���44 EAiTCAT'IQI�1 I��d HO��PTr� �hooi of da�catioaai Nvrsi�g HOU5TOPt ��'1TST UiYi�dERSiTY, Sc1�ool of Nu�ing �fltU�����fl1�dt�I. E��I�NG� 194�U to �rese�t �►ptiI 19�9 to D��mbe� �989 19�� to 1989 19�ii to I985 1979 �9�5 �v�c� Occiap�tiar��l He�lt� C�, Occupatior�al Healtlri Co�nsultant I�els�y-5eyi3ald C'Iirii� P.�, Supervisor, Corrporate Der+elopment R�edi�al agd 5��i G'lialc, P.�, Di�ector, �i0 Sesvices �e�S�y�Bey�a�d Csiaic, ��, �4,t�iaist�adve t�ssistant ��o��s�o�� c������o�vs 4 � � � 4 � � � �'�'/CT�irie �g Collectia�s NIaSIi/Spirorr�etry . ADA/�acilii� Ac�essi'�ili�y CAOCI�/Atadia�etry �onQ�aic�GhNAW OS%i��fovd.�o�e Patlxa�e� 'Tr�a�n� Weli�ess'�rai�ePlYol�ns�� & Joh�so� �v� for L�ife iDS�lCflR & �'ir�C Aid ����� ��U�'E�SaQ1�t�I. �riE11�ERS�S i� Araerir.� �atio� of �c�upa�onal I°�oalt� Nufscs � Plaiional As,so�ia�aa of Q�pa�or�al HIealt� �ofess�iona�s i� �'o� Worth Q�ct�pational l�ea�t� Pl�se� � Amer�can Sc�i�ty of Safetry �Sgi��er� �} `�exas P�so�at�a� of Busifle� Each�bit G City c�f Fort Wortir Saiicitadoft for Bid �agc 29 ��� �� Sheph���9 �0�04 �o�o�o aaf�t� �ftgin�r�n� �or��ul��� - ��A1�dCE� S�'� ��i�S�]I�'�"ill�i� ���3'�iI�ES A. �ivi�ion� of Adva�c�� O�cupation�i �ealt� �C�� 165� �. �tos��l�, �ui�e 26Qi For� �or��,'�e� '�614'� (��9)3320'�2�3 �DT1CA'1'IOIv '�loi� U�ider�ity of Tea�s a� A�stin, �.�. i� Architec�ural ��ir�eering May 19�5 Su��temental Courses in Flectrical Safety, �i�e Safery, FYgoeomics and �eet Safety PI�O�S�IONA:.I. ����NC� 1� ta �se�t Adt�aced Safety Cu�sulting Servic�s, � 131� ajr�dv�aac� n�•� �.:��i 1y� C�, �afe�j► E�ginee�ing Go�xsultant 19�9 ta 199� Er�ployer� Ca�tty Car�pany, Special Accvuflts Safety Er�ginee� 1�� to 19�9 ��ployees Cas�ait�► Co�p�y� Field Safery► �epreseatative P�U���IOi�1,�I. ��1'IF']fCA�01�� 4 P�OF'E,SSIUi�«A� E�iGIN��ING �GIST�,4'�IOA1 as ati I�de�sfrial Engineer in'�exa� -1'� � G�R'T�'� SAF�'� FR(7�SSIOP�A�. (Compre�e�sive Practice) -19SI1 4 TF,XAS � S� �A�S�N'I°fi►I'�V'.� re�i�red b�r �e T°exas Aepa�trnent of Inst3Farece ¢ P�QF�SSIOI�AIa 5� SOURG� approved by �e 'Tcaeas Wo�kers' Campensation �or�issia� C.�a� sHai�ofi� up� �a�t PIt4� � S I4 �t�.i.1�1�EItS�S � ��ICAPd SOCI�I"Y OF' SA�Ii �P+IGIN��S Prnfe�iaaal Membe� aa� For� Wox�ti� C�apter'%r �} T1�X� S�l ASSOCiATIOI� Mer�l�x �r �,�Tro�r�. �� ��v�c�oN assoc�ar�or� MeffibeY � �►i�it G City of Fort Wor�t}� Solicita�on for Bid �'ag� 30 �� L��.a ����i �o���o � t` ���lJ �LC �J �t'���1 �'t�1.� SjlJallo e .1 d� �t�E�a ���� �. �OS����� ��1� �� F'O� �a�$� ��7�5 7�1Q� {�1'�)338�044 �DIJCA"rlUlid Californi� L�sfitut� of llRedic�l Stadies �ud ni�ocatlo�ai l�d�e aad �s�c�.faikr�c `�e��nic3a8 State af Pdc�v Yori� Lice�se� �cdce l�d�s� �oarrd 19'�i 1�'� 19� �RO�SSIO�i� ��E1���E � - 19�9 to �sent �d�nce� 4cc�ap�eo��l H�ltt� C�, Internal Se�ices Reppesentative ��o�s��or��x. c���c��or�s 4 CP�tiFi�st A�d Ce�ficatian � S�iromel�ic'Teci�nicia� �e�ifcation �} �g Enforce�eat a8d Progra� Cornpliatice � 'Te�s �op��rrs' Corsgerisatioa , � �actical ]�gonomics'Tr�ining � OSi�A �laod�or�e �atho�ea T°rairii�� 1977 to present 19�8 1991 I991 1�1'l 199� PliQ�S�IOI�d� 1�Y�1�L��� ��.IC�NS� �iOCA'I`lOPI�. PNRS� ASSOCIATIOI� O� �►S 19�U to ppesest Fxh��it G City of Foet W�rt�t Solicitatiofl for �id �age 31 ���� � ��l� ����C���� F�ch�'�ait �i City vf Fart Warth Salicitatio� far �id Page 3� �f��ll.��'��`//�� . c����,������ f�r� .�`'`.,J1�/�� 'rAl. 't�`ii�iR� � l'� .`�P.�i� e::W � SS.::'tn�Lr% �:�5 ; �' : u d .._.: r; 7'�iv `� �, iP+� • :�.5 :'� � 'ax 4C I �; L��ei�� - f� q� �}� G� ,«.o`A� �x wr ' d .s � � �1 .w ry� i• i �� �q ^ � ig/� � � .�V /„�� �/�iL4�' T'��'LA/4 � �7 V + Vw�1 �/ V..i•. bZ� d !`Z.�F. rdi� s�Gh7.�� 7.`ii56�d � :tW �1.%.. . !�Yl1 1�1 �� : ��i� � 1� ���rm+�h�em i� ��ertifi�� by �1[ tt�r�e �a�i+��l �Adie� th�� e��ifiy �rug e�stir�� l�bo��rt�ri�� lr� th� �fr�it�d� �t����, t�e tV��l���! ���ti�cct� �n ���g A���� tiVIDA�}, ��vd �t��� xr�� �u������ �,���� �n� M����i a���t� ���r�c�� �dr�ir�is�c��i�r, (���r�5�f� �h� ���1�g� �f ���ri�n P��F�eE��ist� ��.��} �r�� tt�� U.a. ��p�rtr���� �f ��f���� i���1. ���rm�H�� i� �l�o ��r�i�i�� �� li��r���d �y �It �� �f�� s����s ��� 10��� jt��i�di�'i'ti��� �+�i�h r�q�air� �ee�i�i6��i�� �r li��r���r� �� drtag ���ti�� {�b�e�t��i��. Th� ���ht�t�J ��id �r�p�wis�t� ��rs�nn�t r�q�i��d by �i��s� �e�rei�i�at� �nd li��r����, in�i��i�g � q��li�i�d ����i��l �ir��t�r, �r� or� st�ff ��d �erre� routi��ly t� ���c��s an� �v�l��� dr�ag t�t re�ut��, Ph�rrr�t��rn ��� n�+�er lo� �r ��� �u�p�nd�� ar�y Q� it� ���ific�t� �nd fi������. ���r�Cl�+�rfl t��ld� ��� ��[f��ving ii��n��3. 6��eiii��t�s, �n� ���r�v�l�: �r�it�i at��as ���arttr���Y �� �+��H �fld i���n�n ��rvi�es, t���'iorrai tr��;�ut� or� �r�g ,�,bu�� �il�j�A►}. ���i�r�! L.�bar�tor� ��rtif���ti��t �r��r�� ���ifie�t�, i��a �d� ��a'! ���7�;� - �a�l�g� of �r��r��n P��h����i�t� tC�P�, For��si� ��in� ��up `�esti�g l�b�f�ia�j! ��liif',C�t�, a�'�3iC�'i �� t3�it�d �t�t�� ��p��m�rtt �f ��f�r�� (D��1. �ru�� �f A��s� i�b�rat�ry �1��r�d�i U�i��d St���s �?���rtr��nY nf be�IY� ��� Hu��� �r�rvie��, Ctinic�� ��ar�tgry I��r�v�n�ent ��t {��1Rj 6i�����, #����86� Unite� 5���� D����rn�n� ,o� �u�tic�� Dru�.�ni�r��r��nt �►d�inistr�eio�, C�n�r�)1�� ��a���n��� R��t�t���ian ��rti����t�. �`P��B�i� � ���� � � ������ ���� �� ������� ����� .4lbertsons I�istrfbutian C��tcr �o� Moox� Constructio� �v.�li��ton l�iorth�rn Rail�oad C}i�znical I)ynan�ics Citry of F°ort V�a� City o� North RichIar�d I�ills Ca�a-Cola Dalwoi°fil' T°r�c�iag Dr. Pep�er Fori Wartlri '1 �a�sit Authority F'�T', I��. ta�ne�� llr�oto�s - Parts �ivision Ev�'%x� HCA �ospital I.�i� L,it�s A�%n�i�� R�diatio� Z°a�rant Corarity S�e�ifPs De��ent ���nt Cowr�� P�rso��l '��nol %s ��ricarx F°ood LSr�ior� 1'�� ��iI�°oad Llnit�d Staies �osf Offic� V�d�rvovr�s F.aci�u�it I City af �ort Wo�tF� Solicitatio� foe �id �'age 33 � � �� ��� �� ������� ���� �athibit J City of �'o�t Wort}� Solicitatia� fa� �id Page 34 ~/�- ��f��`�!lI1�Nbl�lir� I,�OS A Bn"en Dr euuAH�ENa 7� ��e 0'mo. LABORATORIES !NC Menb PazM, CA 94025��i35 Fort WGrth, TX 78115 ��UG iESiIPiG CU�TODY �Pl� �aNi��� ���l�i R���y � E cod� v�..ically on hottle Medical Raview Qfficar Name ana Address �'. ��� �f`�l,i��� ��+�r►�e� t?�cu��t l��+a�l �7����h ��w� b�! �d. i��s�d���, ii �s4 t. W��th. �'� ��104 Collection Sita and Address Collecfor Code (If managed by PCLj � � � � :. ,a .. � � � � �� �id'� ��4A' Y� � � ���, i -- �a�AGi��� I. �.�: �d � � !d e3 � � � � ����I�f�l� �+i0. ��4'�1 D�iJ 1 TEsr ir�srRucTio�us ❑ Only THC and Cpcaine ,� tHC Coeaine, PCP, Opia�aa, aee amphefammas ❑ Qlher (speairy�• W i�l I��I�III IIII��IIII����I�� II � ���6 ��F �fd9 Pl�AG� Old �PE�1�E3� �bG �� � � ��� $ �S�i��i�� Cu�t��y ���1 P�armC��rn La��r�t��i��, I�c.� @mpipyeel.O pr Sac�al Setuniy No. 5�gnature oi Caliector � I�I����I IN� I III I�I�� �I I II, � S�CURITY ��1�� S�� �V�R �!'4 � 5pecimen I.�. No. �� C}ala i �nor's Inilials Rh�r�Ch�r� La��rat�r��s, fn�. � F@EL ��� A�d� PLkG� dN SPEC1�I�i� �A� ��•'3�$� � S�ip�ing Custo�� S��I Pf��p���9��11 L���P�t�PIE�, 1F��. EmplOy9e I_0- Or $qC�81 59Cunly Np. � ����R� Specimen I.O. No. � ��aL PLACE ���I� �V�� ���� I Oate oonnr's in+t�ais j �9 I Signa�ure of Collector ��r ���P���e� l��bop�t��ies, �ri�. I�st��a�tiAn� �o Golf�cior o COM���T� ail pin�C shad� sectian of �LY 2. � A�F� donor to comple#e the. 9onor Cer�i#ication section of PLY 4 aft�r tf�e spec�men E�as been coll€�ted. *����IX barcode and security seal to sp�imer� bottle tn dar�or's presence. •��i� donor to enter employe� I.D, or social securi�y, dat� and danor's initials an the sec�rity seal. � 51GI� security s�a! and enter specimen I.D. number on E�t� security seal and sp�cimen bag s�al, � P�C� specime� in specimen �nclosure bag, seal bag artd plac� shipping custody seal over bag. � K��P specimen in s�ure storage until shipp�d to �harmC�em. T � � �IS�A�� P�Y i AFTE� �EMOVIN� �ARC���S AN� S�A�S �' �j�(1��lf.111lr1li�.�'y��lL�/,fL•� GOPPORAf£HEA�pUAF�TER5 TE%ASOIViSION �i Rr7�i�r.a i�a�e���7 15135 A 0'6rren Umre. 7908 P6bINB �rrve. LA6Qf�ATOR/ES. INC. �e"� Park, CA 9tU25.1435 �on worM+. nc �ei ie JFr3[!G i���IPI�a �11S�0�Y dPd� COfViROL ��F�h9 � � � � � � � � � � � � � Sp�ci�en L �.#+: � � � � � Medlcai Fieview Off�cer Name and Address , • �; "_ . �, ��y xR��s��1 ���n��� d����aa�YA�$1 F�eal4�r ���e � u�9 i�. Ra�ce��l�. � ?fl0 �:, t . W���� i:� �r6; 0� Collection Siie and Address � ������� ��. �G.4� 1��� 1 � , TEST IIVSTRUGTIONS �� + . ±4' ' ❑ Only 7}iC uid Cacaine �, �] THC. Coc�lna. FCP. Opiatea, antl Amphe�aminea C]om.r�sae�tp�: --- --. -- -- - �� Collect6r Cad� {If managed Gy PCLj :r� Reason for 7est (oheck anej: Post Periodic �easanable Dther ~�a ❑ �1 Preemplayment ❑ 02 Random ❑ 03 Accldent ❑ 04 Medical ❑ 05 Cause ❑ Q8 ($pecityj: , . -- • Employee I.�. No. or Social Securi;y No. � Time Goilected I Date of Collection .. . . . _1 . . _ _ _ ' �����AL R�GIJLA�I�N� P��Fil�li �IS�LOSU�� �� �'H� D�f��R'S � 1��NiI�Y �'O �H� LI���R�i�RY. � �-----------�-�--- ._.....----�----�---- --�..._._ . . � � ��N�� S�iA�� �Of��L��� IN����A�I��I If� ih11S ��C�ION �� �LY 4����'. �- �EMPERATURE 0� SPECIMEiV � I TEMPERATl1RE IS Wf7FiIN �ANG� n . _ . _ . _ !�� .ilas hawn roarl WI�FIIrl d mlmdPa n Vqq LUa et 32_5�.37 7�f.Mi!! S�AC ooG n [Un.1FAfAT_rarnr.f �nit��! �_-.,,�• -- , Remarks Cflncerning ColleCtivn SpIR sample collected in accardance � , with appllaahle Federal requirements. ❑ Yes ❑ No ` CQLLECTpR GERTIFICATIdIV: f cartify Uiat Ihe specimen i�enlified on this [orm ia the specimen preserned to ma by Ehe donar providing t�a certifrcatian on py 4 of V�ia farm, that iS hears the seme identlfic�6ion numper as that sat (orth abwe, end thst it has been mlls�t�, la6eled end sea�ed es in accordance with appficable Federal , requirements. I'ROVIDE'SR£CIM�1�[ FOR T�STING �ft D���� — - ����Fu coRaclor �nr �� �� d� � �..� � .�. �� �� �..� ��� .�� �� �_ ��� ��� ��� �� �� .r.r� ��� �� � � ' laboretary . Laboratory Name and Address . Seal IntacS IjLabels Match Batch Nq. Accession No, PharmChem Laborataries, Ina. ❑ Yes ❑ No I❑ Yes ❑ na 150SA a'Brien Orlve Remarks Manlo Park, CA 9a025 • I certify that the specimen identi�igd by this aCcessian number IS the same speCiman tltat bears the idantifiCatian number sai fDrth above, tfiat tha spacimen has heen examined upon receipt, handled and gnalyzed in accordanca with applicable Fedaral requiramenFs and Ih�l the resulEs set lorth helow, are far that specimert. � . �Certifying Scientist's Name-Prin� (First, Middle, l.ast} Certiiviny 5cientisYs 5iqnature �ate � THE RESlILFS FOR ThEE A80VE IDE�ITIFIE� 5PEC�MEN ARE IN ACCOR�ANCE WITH THE APPLICABLE SCFiEENING AND CONFIRMATION CUTOFF " LEVELS E5TA8L1SHE0 8Y THE HHS MANARTORY GUIDELIN�ES FOA FEDERAL WORI4PLACF DRUO TESTINQ PROQIiAHlS. r ❑ NEGATIVE ❑ P05�71VE, far the foHowing: ❑ Cannabinoids as Carhoxy—THC ❑ Amphelaminea ❑ Cocaine Metabalites as 8enzaylecgonine ❑ Amphelamine q Phencyclidine p Methampl�etamine r ❑ Opiales �, d Codeine ❑ Marphine � - --- �� I ha�e reviewed the laboratary results 1or the specimen idenlified by this lorm In accordance wilh applicahte Federal requirements. ikAy tinal determinatianl '' veritication is: (Check oneJ L1 N6GATIVE C7 POSlTlVE I tuledical Raview Officer's Name-Print fFirst, Middle, Last1 fUfedical Review qffiCer:s Sianature __ Date ^ _ C � Q �`II�1lLI���� ��/d/!Y/�r/�l C5p5 0'Brenp QUARTEiiS 7909PeWflastiriva. � L.�46DRATOFI�ES. ING Menlo ParN, CA 94025�1435 Fan N�arth.l7f 7B4�B �R�lC TESiIfV(3 �U�TODY A[V[� ��R�i��6 �OI�� Medical Review Officer Name and Address 1° f�@�! �E � €�l.:$� �� �var�e�� ��c��:9atia�,�I c���ii�► •`saI '�d �.::.da�I�, �P ��73 . iJ �] : s ; . � ; '_ � ; �j � CollecSian Site and Address � �� � Calleetor Catlq p1 managetl by PCLj i.� J • • Reasan far Test (check pne): �r o ❑ fl1 PraemplaymenS ❑ 02 �andom ❑ `� �mp�ayas I.D. Na. or Social Security No. I ��sP� �� �� �� � � � � ���� �p�ci��r� I.�.�: �'� � � � � � � � A��e�nf R�a. ��� t 4� � t -- TEST INSTRUC710iVS . ❑ only ThIC and Caealne i�7 THC. Cocalna. PCP, Oplates, and Amphstaminsa f] Olher f9P6dhll' . — .�� � � �.� �� �� � �� �� �� �� ��� �� ��� �� Past Periodic Reasanable Othar 03 Acofdent ❑ 04 Madical ❑ 05 Caus� ❑ OB (Specify): _ _ _ _ _ _ � Tlme Cailected � Daie of Collecilon ����i��►L ����I�AifOiVS ���F;��IT D�����SU�� �I� ib� ��fVO�'S 0 I��NiITI� i0 ��i� L�l��R�TORY. � Q�d ��� q�ilO i6�i�1LN • 4�IfF1 �� ��IVOR �bALL C��IY�L�i� If��OR�,4�'IO�V IN TbIS S�Ci1�f� �N ��Y 4�NLY. TEMPERATURE OF S�ECIM�N ! TEMPERATUR�:IS WIiHIN RANQ� Has heen re�� yy�xhia4minute�; n Yasc n N e e o, o Remarks Concerning CoUectfon Split eample r.rollected in accordance . w4th applica6le Federal req�iramenEs. ❑ Yas ❑ No COLLECTOR CERTIFlCATIdN: I certify that 1he spacimen iden'bfied on thia torm is the spe�imers pre�anted po ma try the donar provlding the ceAificatian on py 4 of thiS fo►m, thai it beais the same identfflcatlon number as thaf sel forth above� arid that it haa heen colLact9d, IaHeled a�d sea�led as in aocardance with applicable Fedaral rayuirementa. t+..s...sr a �-= . I�I�OVIdE SPECIMEN F�R TESTiEVG , r9[�_ Eo�B� �,��� i ; I - callectar ea�aator I I . , . 1;'i la6ontory e� Lahoratory Name and Address Seal Intact Labels Match Batch Np. Accession Na. PharmChem Laboratories, lnc, I Q Yea ❑ No ❑ Yes ❑ no � 15d5A O'Brien Drive I Remarks Menio Park, CA 94025 I oertiry thal !he specimen identilled h�r this accession number is tha same spacimert Ihat bears the identltication num6er set forth aGove, that the specimen has been examined upon receipS, handled and analyzed in accordance with applicable Federa! requirements and thal Ihe results set farEh belaw, ara }or that specimen. � � I � CerEifying Scienlisl's Name-Print (Firsi, Midtfle, Last) Certi(ying 5cientist's Signatura Date • THE RESULTS FOp THE ABQVE IOENTIFIED SPECIMEN ARE IN ACCOR�ANCE WITH TF4E APPLlCABLE SCREENINO AN� CONFIRMATION GUTOFF '�� LEVELS �S7A8LISHED HY TH� HHS MAIVDATORY GUIDELlfUES �OR FE�FRAL WOAKPL4CE ORUG TE5TIN(3 PAOCiRAMS. �. Q NEGATIVE ❑ POSIT]VE, far the following: I'^�IC. Q Cannabinoids as Carboxy—THC � Q Amphetamines '� E7 Cocaine Mstabolkes as Benzoylecgonina ❑ Amphetamine ' ❑ PhenCyClidine ❑ Methamphet&mine ❑ Dpiates ❑ Codeine q Marphine � I have reviewed the lahoratory resulls for the speciman identifled by this form in accardance wilh applicable Faderal requiremenls. My linal determination/ veriticatlon is: (CheCk pneJ L7 NEGAi�VE ❑ PpSITlVE luEedical Review Olticer's Name-Print (First, Midd4a, Lastj Madlcai Review Ofticer's Signature .__ _ Dale _ y � � � � � S � � � � � � C'r � � 'f�l�/�����/�(/ """�' CARPQRATE HEApOURATEFiS TE%AS DIVI510N F �1� ,sas � a�sr�«, orw�, 7eaa p�o� oriw, �Li�BORAT(�R/ES INC. "�'0"b P"'`� �'` ��',� Fo� wo�a,, nc re„a �I�� Tl��i1�1G C�I�iODY Ai�L� CON'��06 �B�RN Medicai Revlew Officer Name and Address �. ���p 5����s��l �v�n��� A�eu��� i�v°z�l I���a ti� G�rr� , a�t �d. �e����3�, I� ��14 � . �d����, �'� T514� Callectfon Site and Address • Cailecror Code (p managed by PCL) . ' ' � � � � � � � � � � � � � �������� �.�.�: a�� a 3 s 3 a s � �����t id€�. �v'��'t aw� t r�sraucriaNs ❑ only THc and Caoa+na � itiC. CocWno. PCP, Opiet�a. aM AmphNeminaf ❑ anw csva�M� � Reason tor Test (check one): Post Repiodic Fieasnnable �ther ' o❑ 01 Preamployment ❑ 02 Random ❑ 03 Accident ❑ 04 Medicai ❑ 45 Cause ❑ 06 {Specity): . Em�loyee I.D. No. or Social Security No. . Time Collecied ' Date of CoNection Name of �anor (Last, First, Middle} � , �MYTf � PHQNE NiJMB�R DATE OF BIRTH DQNpR CERTIFICATION: I certify lhat I prnvidsd my urine sp9cimen to the callector; Ihat th� specimen bottle was sealed with a tamperproof saal in my presence; and that the information providad on th�s fprm 8nd an the label aftixed lo the specimen boKle is correct. • . �ONOR'S SIGNATURE: � �� DATE: . &hould the results of tfie laboratary tests ipr Ihe spac�mert identified by this torm be conflrmed paslUve, the Medical Feview OBicar will contact you to ask about prescriptions and over-t3ie-courtter medications yau mag have taken. Therefars, you may want to maka a Iist ot those medications as a"memdry jogger." THI5 I5 NpT NECES5AHY. If you choase to make a list, dn ao aither on a separate piece of paper or on tha back o} your (piy � of this torm—QO NOT LIST ON TWE BACK OF AMY OTHER COPY OF 7HE FORM. TAKE YOUR COPY WI7i1 YOU. . TEMPERATURE O� SP�CIM�CN TEMPERA7URE:IS WIiFiIN RANGE within 4 minu#�s f1 Y$� f7 N e e e. .gep f� 1(aa n u�.r� un�' rnMrri ac�r,a! temn� Remarks Concerntng Callectian I SpEit aampIB callected En accordenee with applEsabla Federal requlrements. q Yes ❑ No . COLLECTOFI CERTiFiCATION: I CartifY thaot iha spe�timan Idestlfied an this hxm 19 tl�a spedmer� pr�erned lo me bY tha ddtiar providing tlte cert'�ication on ply 4 � of Ihis' twm� that R 6ears the same ider�tiflcatfon number as that set farth abnve, and that it hae bean callected. labeiad and seaEed aa In eccordance with applicable Federal �uiremanls. CalNclar's Nama-F'rintlFirst. Mld P .� � F r �� PROVI�� SPECfMEN �'OR 'f�STINC3 ` ht h �. . � -- I I � "� .. � ��� .. � �r 4 � � 1 I ' I � � � � �� s s , � colkclar � Cpll6�pr IiC6fID10Iy ��j A��rlf ����� t503�0'Bri:n DmV, �AFITERS 7608 P Rimbfo Orivo. 61 � LA80HATt1Rl�'S. INC. �0 �'�'� �" �'"� Fon w�", rx �a, ia RUG i�SiIR1G CUSiB�Y Afd� �ONi�O� �0�� Medical Review ptficer Nam� and Address 's^, R��j +k��ti��� eva��ed �����a��i���l ��a3t�> ��,r� �,r� +� �7c����i�� # ?$�i : . i�1Cii �' � a , i � � �i:: I�� Collection 5ite and Address � b.1� � 5�s i�� �.J � F�e i d i�O 1 i i �p�i��� I.�.�: � �r � �� �7 � � � � �CC011f1� �V�. ��4� � ��� � TESTINSTRUCTION3 ❑ pNy THC sJM Cotalna �J THG, CocslnC. PCP. �Watas. u�d Amphalunina ❑ o�h�r {8p�N1: - - - Collactor Cod� (If manaqstl 6y PCLj Reasan tnr Test (check one}: Post 0 01 Preemployment [� 8� Plandom � 03 /�ccident �mplqyee I.�. No. or 5ocial SecuNty No. Name of Danar (Last, First, hAiddle) I�erfa�ic Rea�nabl� Dthet � Q4 MediCal [� 05 Caus� [] 06 (Specity): _ . T'ime Gollected . �ate of Collection � �AYTI E PH013E iVUMBER DATE �F BIRTN _� � � ��� �...e �� � �.� � � .��� .��.-.- �� ��� � ��� �� � ��� a� � DONOR CERTIFICATIpN: ! certify that I pravided my urkne speeimsn to the calfector; that the specimen bottle was sealed with a tamperpraof seal In my presence; and that the inforrr�akion pro�ided on this fq►m and on the label afHxed to tha specimsn baBle ia cflrrect. �ONOFi'S SIi3NATURE: DATE: , Shauld the results of the laboratory testa for tha specimen IdentlfEed by thia form be conSrmed positivs, !ha Madical Review Ofticer will cantact you to ask abaut presCriptions and aver•the-counter medicalions you may have tak9n. Therefore, you may want to make a list of thvse medications as a"memory jogger." THIS IS NOT NECE5SARY. li you choosa to make a list, do so either on a separate pieca of paper or ort Ihe back af your (ply 5} af this form—�Q NOT LIST ON THE BACK OF ANY pTHER CpPY OF i'HE FORM, TAKE YOUR COPY WfTH YOII. 7FMP�RA�UR� 4� S��CIMEI� I T�MPFRATUR�;IS WI�F�iN FIANG� � ^ Has been re�y,iithin 4 rninut�s f't Yes ❑ Na oT 32.5°�7.7'�C190� °•99.�°F f1 _ Aemarks Concern�ng Collsctfan SpiK aample cullected rn accordance . with spplicable Fsderal requirements. p Yea O No (�LEL"TOk9 CERTIFICATIQN: I oa�ly h`rst .in� apscimeer id�e�tlRed on this Tam is 1� �Cirnen pieaentett DD m9 Fiy Ihe dormr pmuiding tlie certifieatlort an p!y 4 OT this (arm, that it tiesrs Iha earn� {derNiflcs�or� nunnbsr aq 1l9m s�i fi0rtlt eb0�a� and Ihak � F�aa � collaclad, la6eled artd �ealed Ss In a000rdarx� rvitli aipplk�6le ged�aPal requhsrriattb. - � - c:awerw�a [Vamo-ahin tFuet. M�uuta Lr�n ca�eemrs str,nsw� . na�■ � ti . . • • . . . ����� ' ' ' ,+ _ ' . _ PROVID� SPECIM�N �OR T�5�1N0 ' � `�. ` � ���,1��' -�'9�.I�P�' . � � . . - ' cdtsstoe , - I � � J l � � � � " eaUsstar Irs�ararory � � � � � � � � � � � � r -- Qe C� I7lI,II'7Al� ,�`fI1L7Il1'+r:�rd4e'�'N : f CSQS R 0'& -�+� � �ARTEAS 7908 Prhif Oriw, , L,�60RATG'RiES. INC;. ""°"'° pe''°� °A "�'� Fat worth, T1f 78118 -�R�IC T��iING �IJ�iODY AAE[� ��Ni�@� �O�i�P I� Medical Review Offlcer Name and Address �� ��•r •••��.r�?�: :x , �:" . c:`'d 3+' ti� 7 CT . : . � e C ', :� !7 i '� � ii . . "• ': .. . • _ _ - �-'� . : . . _. . . • . . . �. . -�r'. . � � . � . - . Cnklection Site and Addrsss I �f� r- r'-� Y �r , ' CaIlBctor Code (If managed by PCLj ` + �,. � '"P. - �" Y� �. � � �� � "i vr� E.. ,��. i� l,�� �. t,.� �'"'€ !v �., � S�e�1rn�R [.�.�: � � a i •,� ` � � � �1 ] �:i Qlb�f�l�1Ci� i�0. �.3 �! �'� ? '7 �: �� i - --- - - �ss i�vsr�ucrioNs ❑ 4nly THC antl Caaina ;{� 7HC, Cxainc. PCP, Opiales, and Amph�lamFnea � aner �spec�N►: —. �� � Reason }or Test (check one): ppgt Periodic Reasonable Other :❑ 01 Presmployment ❑ 02 Random ❑ 43 Accident ❑ 04 Medicai ❑ OB Cause ❑ O6 (5pecify): .�mployee 1.D. No. or Sooial Security No. Time Callected Date of Gollection Name ol Donar (Last, Rrst, Middlej ��. . � _ DONOfi CERTiFICATIOiV: I cenify that I provided my urina specimen to the couector; t a e speciman -o a was seale wrt a laniperproo sea n I. my presence; and that the informatcon provided on th{s form and an th6 label aHixed to Ihe specimen hottle is correct ' �' DONOR'S 51GNATURE: DATE: TEMPERATUR� O� SPECIM�fV � TEMP�RATURE IS WITFkIN �ANG� Has he�� within 4 mir�gs ❑ Yes ❑ Nn af e o e, a �temarks Co�cerning Cflllection Splic sampia calfecfad In accardance � wiEh appiicable Federal requirements. ❑ Yes Q No COLLECTOR CERI7FlCATION: I certity that ttie specimen identiHed an th�s hxm is the spacimen prBsenied ta ma by tha dOnor prqvfding the certification on ply 4 af this-torrtt� that it bears 1he� same idantlBcaatf�on number as ffiat set forth ebave, and that It has bean collected, labeled and sealsd as in accordance with applicatyle Federa! tequlrements. Collector's Namo-Pnn� fFlrsl. PROVIDE SPECIMEN FOR T�5TING . . ; . _- �ro co��scmr coll6clor Isboretory � � 1 J I� 1- _� E , �����n�cncr.vVVnMicn� Icu50UIVIMl1N ��fi��ifr'�'�� ;sos r� o�aria, ar�a. �eon a.t� or�,�,, LA80RAT�7RIES, INC. �b P�� �" �''*'s �„ wonh. rit rea �e ��f� ��SilidG CUS'�O�Y AND COidi��L ���IW Medical R�view Offlcer Nam� and Address <<�. ��y ���ti��� +�s��n��� � �C�.i�%Y bOi'i�Z i�taa�s �� ��rr� �a�' �. �G��:r���, � u;iZ :j - . LYs.ti �: i . }•C : .: ! j�i � Callectfon Site and Address ������� ��� ��i� ` ��������, �.�.�: � f � � �9� � � � � � ' 1���0l�f1���. ��4�tQa�,41 TE5TIN3TRUCTIONS � ony rkC sna cacae�ro xl THC� Cocat�, PCP, Opi�lee, and Amphstamino� 0 OMa ISpa¢ayj• - — - -- �� �.� ;� � � � �� or� i�a�i � �� � ��� � ��� CW�ia Codo (li m�neq�tl by PCI.j � . r�s�rs, Reasan tor Yest (check one): .� � Post �ariodlc Reasonabfe �ther ❑ 01 Rreempinyment ❑ 02 Random ❑ 03 Aacident ❑ 04 Medicai � 05 Caus� � 06 {5peciiy): �.� Employae I.�. No. or 5oclaE Security No: � -. �im� Coilected ,. i Date af Collecttan �E Nams of Donor (Last, First, Mtddlej �� � � r 4� ��� . � �ONOR CfRTI�iCATIQN: I certif�r that I provided my urine specimen to the aollector; t a the specimen -o e was seal wi s 3artiperproa ses in my presence; and that the Informatian provided an this form and on tha lat�e! affixed Io tha specimen boqle ia correct. DONQR'S SIGNATUFI�: DATE: ' a�y�.■l��:rr� �� --, � � II � � Has,�Rn re� witllLn d�in�+tws n]CaSt-- - O Na � ot 32.a�'•:j7,Z(fl9a.�i°-99.�°F - Y� ❑ Nc�.fGNO_Y_ � actu�l �emA• Remarks Co�ceming Collection � • 5pIk �rple cauected In aawrdance , � • wEth appl�ca6le Fadaral ras;uirernenta, ❑ Yes ❑ No COLL�CTD�t CERT]F{CATiON: i C6rti1y ahat tlsa speamsn fdentlNed on Ihis form fs tha �eekn�r� preasntod fo �a hy !ha dortor prori�ng iha certification an p[y 4 ol thts Torm. Iftat R Bae�s the sama kiantlficadan numt�er as Ihet set farth a6we� end that [t has bsan �� labeled and sesled aa v� a�cordance with ap�ilicabla fe�eral reqUiie�rnarrts. _ . . . �:':�`�° KP'^O'P�i"t.�Flf� ��ddw �t�__ _ SAIIF�', s�aturo ue�s ' •, � . �d��� ` � F'ROVIQE S�ECfM�i�I FOR T�Si"�NG � � �_ ��1�� .���� . ' calsc�r eWE�clor . . � " . ' • , . ' ' le6oretory ' � � � � � � � � � L � � C e � r ? � ��i�/"f������,� 1505A �'Bri~n rivV��r,�u,a �cn„au�,im�n Q e D a 7806 P�46fe Orive, LAB4RATt]RlE,S /NC. �°b park, CA 94025�1435 � wonn, rx ra„ e Fil�� T��iING C��i�DY �tVD �AN�i��L ��F�� Medical Review Qtflcer Name and Addres5 . • "� �� Y � . Z ��`y . . � , _L;.�.".i , -. �iC... •G'a �i'. �. . ... . _ . , •.� 'r•. . � . ? �� . •' • .. .' CoNactinn Sita and Address CoRvxb]f Codr (It manfQed hy PCL) �esisn� tar Taat {ch�k one}: ppg� � 01 �reer�plqyr�ent � a� �dandom � 0:3 Accid�nt �mplaye� F.�. M1�n. ar Soaial Srac�rity No. � i �.� ��*� wr �r .� W�� � ,.. � lb.,. � �"`i S{���im�n I.�.�: i�l }�: `�' 1.� j�'�'� �, 1������� F�Eo. �����oes�? TE$T lNSTRUC710NS ❑ ONy T�t� aeid c,omfnn . , ;�3 TFiC. Caor:ria. PCi+� Opinr.�, iuW Ampwlon�`nA .. C7 Oui�r I�P�Yi � � �eriadio R�f� @tFr�r � 04 Medicsi � E3� Ca� � 0� (.S�e�Ph1�- - iime Gol�cte� .� D�t� oi Collectio�►. . _ • , � � . . � _ . _ .:n�� , . . . / Fi�a heeri read Woithln 4 eninute9 _ ❑ Yes ❑ Na v€ 32.5°�'f.7°CI90.5°•99.5°� fl Ye� R NtrlF�1V0� �ar�d xttr�i l�rfln� -- . . , Ram�►�Cs Gancerning ColEectEon � Spi�t samp� cdta� �n accordanc� � - . � . , ,. . � witit applfcabi� �r�lesal rs�ulrement�. � ; �C7 Yes C1 No C�fi.LEC'roF! cE€�TlFF4Ai1�N: � ae�r tt�t tlrs spscirtisn fd�Fa� on hiie farm is t�ie spar�rt� presa�ad t+a ma #Yy tNa donor p� u,� c�licalfon, ae p+y. 4 ct 1F�a i�tn, tllet EP t�s tiFs aeune iden�fla�fnn nut�ar as tl9mt a eh 4orth above, and tltet k I�aa ha� mlle�led. Ieb�:ed emd aeal� as �! ��nce v�itl� applk� Fe�sl iequlrea��aads. . . . • . , : .. M[ddlo. L�sIS PROWL�� SPECIM�i�i �OR 'C�SiIh1G 1;i11, ,� •., �� �, \ ' 9'aK�6,�R � �',, , �. '., '. �C# P�T SI�P+� . ca[�tEor � � � . s�ea� � � � �Y Laboratory Nama and Address Seal Intact Lahals Match Batch No. Accessian l�o. PharmChem Laboratories, Inc. ❑ Yes � iVo ❑ Yes C] no 1505A O'Brian Orive RemSrks Menlc ?aric, CA 94tl25 I certify Ihat the speciman identified by this accession number is the same apeciman that Ceare the identi}ication number set farth above, that the speclmen has bean examined upon receipt, handled and analyzed in accordance with applicabla FederaY requirements and that the results set forth belavy, a�e for Ihat specimen. Cartiiy;ng Scientisl's Name-Print (Firsl, Middls, Last) Certifying Scientist's Signature Date 71iE RE5UL75 FbFi FHE ABOVE I��NTIFI�D SPECIMEN ARE IN ACCOR�ANCE WfTH THE APPLICABLE SCREElVING A�kD CONFIRMATION CUiOFF LEVELS ESTABLISHED BY THE HHS MANDATORY GU�DEZINES FOR FEDERAL WORKPLAC� ORUG TES77NG PROGrAAMS. ❑ NEQATIVE ❑ POSITIVE, tor the fallowing: ❑ Cannabinaids as Carboxy—THC C1 Cocaine Metabolites as Benzoylecgonine R Phencyclidine ❑ Opiates ❑ Cadeine ❑ Morphine ❑ Amphetamines ❑ Amphetamine C7 Methamphetamine n 1 ha�e reviewed the laboratory resu4t9 tor the specimen identified by this [orm in acCDrdanCe wilh applicable Federal raquiraments. l4IEy 1in31 dstermination! veri#icatlon is: (Check onel ❑ NFCATlVE Q Pp51T1VE Medical Review pfliCer'S Name•Print (Firsl, 14Aiddle, LastJ Medical I�eview Officer'S Signawra Oate — _ —� . _ ._ . . �� OC } � ���� � ��������� ��� ���� ��� t�dvanced �ecupa�ional � � AI.IT'H�Fil�i1��1 F�� iR�AiAAER�Y � eal�h are Serr�ing 8usiness f� Industry 5iRce 2946 �1651 W. Rosedale 13�11 l�.E. L4op 820 4775 50. Fre�way at Felix Pfi���17 33�-4044� � Ph�B1 624-2 g 78106 � PhrtB� 24-8 0rB115 Mstro @17! 429-565fi Fsx: 817/ 740-1725 Fax: B17! 92b-9534 Fa�c: �1 i/ 336-T310 Oa1e Nama- For PleeSe SBnd addltiOnel forms Company Author�ration by Pnona Number Fxhxbit K City of �'ort Worth Solicitatioa fae �id Pa�� 35 ��� � ��A ����B��L ���li����1 �����;� ���c � City of �'ort Wort� SmG�itatin� for �id Page 3S M��ie�l �!�$� � � #�e���t�l July b4, �993 Ftoy �. Kr�eu��l, M. �. M�d�.�al �irector �idv��c�d o�cupational Hea�t� Cax� ���� w@�� �����a��, sui�e aoa �°��t w�r�r�, �x � � � o a �ear ��. ���se�: T�i� le��e� i� �o ���v� a� co�g�.xma���fl �o �he �bty oi� �°o�� �d���& �ha� I��di�al P�a�a Hospita� wor)c� �lo�eZy witlx Advanc�d �ccu�ation�l Fi�al��i Ca�e (AOFiCj �o pgov�d� quali�y c��to ef��ec�bv� ��n�r�g���y cage �4 ���ars a �ay. � M�d���l �la��' � �m��gency D�pa�tr�ent �� �x��pax°�d t�o �reat� injug�,�� t�ia� ��cur a��er-�i�urs a� w�l]� as t�io�� ���w��s ��.m. and �p.m. w�i�r� �hey a�� de�e�m��ed by P�OHC p�ysic�an� to ���aixe n�o�� �x��r��bv� �age ���r� ��� ho�g$tal. �n �ddbt�or�, compani�� usingi ADI�C s��vice� age aut�ma�ica�3y �x°eogegisi����d w�ti� M�di��,� Pla�a's ��rgency ��om �a �Y�e �R �ia� �i� �omp��y �� s�a��if i� �e��ing a�d reper�in� g�quireme�t� �o� t��ix° r�o�k��r�� �fl adv�nce. �'his x��da�y avai�.ab�� �n�aa��tion a���r�� �� p���onne� �o x°ev��w c�t�pany ins��uct,��r�� ���c�ia�e�y ar�d de�bv�r �im��y �a�� to �Y�e inju�ed ��pl�yee. Finally, sp��ial p���ing �.� availab�� �� �h� cliente �ompan�e� �g Adv�need Occupa��.�fl�b �ealth Cax°e. M��b�al �la�� w���, �X$�fl�, � �Q� �2.���t1I1� ( ��� � a �. '�`W� �L1j7�^C�bb�� �Z13� �� �� �fl ADHC c�b�fl�) �o t�� �i�y of Far� Wo�-�h fox ��� �c�upa�iona�. Heal�ix cag� �ela��d �xpens��. �in��r�ly ��� � �ill �'ox � �ix�c�o�° �� Market�r�g 90D E�qnln Are Ft ��l;,s� �=xas '�it0a ..�n. �� o ai .', ;7R- � . �� � ��p�o ,���j+� ��,,���'�`��l�d� ly� ��� �� �,�it �+t �licitasic�n fa� �id Ci�► of Fort Worth ■� ��������� � ����■ .� ;� I�I C�� �'ACILIT� 1b�1 �. Ro�edale Fort �Porth, 'I'e.�as 7�i10� 81'7/33�Q� IlTO�t�°�I �'�►CII.�I`� 1300 NE I,�op 820 Fort Worth, Texa� '76106 817/624-2161 SO�]'i"gI FACI� 4775 �. Free�ay at Felisc Fort Woreh, Texa� 7611� 8�7/92�00 � � BLLTE MO ��� i I �.�' I . --- � ' —� - MEACHAM I�35 ��30 � � � ._ � � ROSEDAL� � FOR�STPAR� �iH AYENUE � F'EI�IX � i�dvanced �ccupational �ealth �are Suite 2Q0 � I6S1 W. Rosedale � Fort Worth, TX 7510-� � 817I 338-40-}�} � All devi�iio�s f�om th� propos�l r�uiremer�ts h�v� beea add� i� writin� as �ar� oi my �espons�. T'1�is r�s�Qns� will be i�co�orat�d as �a� of th� contr�ct b�tw�r� the p�ies alor�g wit�i any deviations �e�otiated and a�eed ta in writit�g by �ot� parties. 'Th� ut�d�psign�l has the aut�aority to 1�ind t#�� proposer. . � ;-�� �c Aut�orr�� Sig�rat�re � � P��sid�nt Juiy_ I4_ 1993 Da#e � �'itle Advanced Occu�ational Health C�r� Campa�y l�ame I651 West Rosedale_ Suit� �OO.Ft. Worih TX 76104 Address � 17/33 �-4044 -- - �hofle I�um��r ��c�. c��� /�- -- � '" �� �'i�� o�`' �o� �o�h� �"eac�.s .�I�c���� �c� �o��� �'"����a�c��io� �AT� REI�L1i�NC� ?d11E���R I,O� HAb3E PA�E �������� � �#�-����� I ������ I � O� � s�s��c� CONTRA�I' V1lITF# ,4DV�►[�1��D ���UP�T�O�IAL I-��ALTH �ARE TO PRD1f�D� O��UPATIOf�AL 1-IE�1L�`H ���iVl��� F�R C171f OF ��RT 1N�I�T�-I �tV1PL0Y��� ���V1EN�AT10�l= 1t rs re�arr}R�te�nd�d ��at �he �k#� �oun�il authof�•r.e �:he �}ty fl+lansger tc� �xecu�e a co�t�'�ct wi�#� an ini�i�l l�r� oi f�u�t�en � 141 mar�l�� �r�d v�i[h an t�ption t� rt�neu►+ ��r thre� a�ditivnaC �ne-ye2�r periods �.+irh A�va���� Oc��,p�tior��E H�alrh �a�a �AOF#�� iar the fallo�nring ���ts# r�at to be exce�ded; �, � 24,�00.00 for th� peric�d fr�m August 1, 1993 #o Oct�bar X, 1�93. and �. $ ���.�0�,0� ior C�e ar�nual per�od �rorr� O�tober 1. ���'� �� Qctobe� 1, 1�94. DI��I.��S1Q�l: Certain �cc��#��tia�al he2�l�17 s�r�ri�es �re currer�#ly prvvfded t� �ity ��p�oyees ti�r��g#� rt�e F�is�c f1+1an��err��nt Departm�n#'s ��cupati�r��l He�lt#� �lir�ic lac�ted a# 7D0 ►Nest ��ser#��e �lreoz. �ue xo th� re�irel��nt a� Ice� p���o��tiel, etf�ctiva August 1, � 88�, ar�d the ct�ranic un�er�taffin� expe��enced 4n tl�a �li��c d��rin� th� ���t two years, a l��qu�st f�r �r��o�al� {RFI�i wa� �r�pare�i t� solicit provisi�r� of cer�ain o�c�t���i�nal he�lth ��rvic�s fr��n sn ��stside �rend�r. 1-he R�� v�r�s ��r�ail�d �to sixt�en � y 61 ven�or� �r� t#te �r���er F��t 1No�t�� are� wl�o �re ���cia�isi� iR, �ccu�{ztEonal N1adi�:i�e. �n .i�iG� 15, 7�9�, nine re��onsiv� pr��osals were rec�ived. Qn� ��r�pos�r eiecxed tv "no��id" �II �erv�ces axc�pt I�b�ratory sr�a4�sis service�. �1n ev�ivaX��n team compa�ed �f cmplaye�s fram F�ksk M�na��mer�t. Fiscal �ervic��, the Pu�cha�ing bi�i�ior� a��d �he 1N�i�r D�par�me�t p�r�ticipa#e� ir� evalWatio� o# t��c� proposals ac�:�rclin� io �rit�ria outEined in tlie RFP. �w� far�alis�� wer� in�ri�ed t� make �resent�ti�r�s �nc� 2� d�cision was mad� �a s�l�c;� A�v�nr.�tJ �c�u��tianal I-lealth �are as th� recomrn�ntled �e��ric� pra�+ide� b���d �rn #�� qu2�liiic��io��s �f th� �ers�n� providing s�r�ices. �I�e c�mp�c�y'� I�n�-t�rm, ctr�nproherti�ive cornn�it�rr�rtit #� Occup�tion�� hl��di�in�, the �v��l�bili�y of thre� cMir�ic l�cati�ns ir� �ll�e �ort 1Nor�h ar�� �nd pric�n�. All pro�����rrs compliec# wwt�t th� �it�l's DB� policy. �er�ric�� �nr�re pr��ed �n � per un�t iaasis. 1# 's� �ntic:ip�ted #h�t ane�u�ia�ed seruice� will cosf �ppro�c�mately �150,00�. Fun�is are t�udg�ted kn th� Oc��pa#io�a�l I-��al�h �Eir�ic bu��et f�r �Y ��l��m9� t� ��y ior pre-incident servi��s #hro��gh th� baian�o of t�e c�+rr�r�t iiscak y��r ar�d are knr.iud�d in cl�e bud�et rec�ue�t a� the �k�k AlEa�ag���r�t ��p�rt��nt �or F1� ��J9�-��. Th� cast a# s�r�ri��s r�l�tt�d t� occu�r��io�a! injury or ilJness as compc�n�a#a�� �hraugh the 1+11�rkers' �or�ti�er�s�ti�r� Insurance Pr�gr�rr� foe w�ich mon�� is b�d���eci in #h� 1N�rke�'s �ornpensa#i�r� Ft�n�l. Acfual ex�eR�dilur�� wfll �#��end upor� C�� d�mand for se�vG�e� includi�� tl���� 1ist�d �law: � Hn�aud oh reC4titd p��* G'��lr �,� .�'�� ���., �'e�c� .�����' �� �'���i� ���2�a��?��i�� 1}AT� Ii�FEAErIC}5 N4J�73EG1 LU{3 N]�Fx& Pi1{i� 08l1019� I •"�- �-���4� I ��A�H� 2 of � sx�,����r �OfVTfi��T U1I'li�-I A�1IA�VC�� 4���PA���NAL H���TH �AR� T'0 ���1flD� O��UP�ATI�T�AL H�AL71-I ���i111��� ��f# �ITY �� F�RT WORTH �M�L�1fEE� ,— I � • injury c�re �, - p��t-�ffe� N}h�y��cal assessr��r�t in��udin� �ri�� drug s�re�r� - r�ndom drug scteens • "�or ca�s�" dru� ss:re��� - nr.�u���tior�a� e�posure testin�. txe��r�ne�#, foll�w-up antl ��unsefling - �re-ex�osure v��cin�tr�r� it� is a��ti�i�a��d t�at serv�ce� t� er���inye�s and riepartmen�s will b� �x�redi#e� thr��,g� the re��m�r���dod cor�t�act. I� S�#'�l, I�lF�Rh+�ATIOi����RTI������Ni TF�e Directnr of �iscal �er���es certi#ie� tl��t t#�e f�nds r�q�ired f�r tinis ex��ndixure are avai�able i�ti �Ire ��rrerkt op�ratirt� I�ut�get, a� ��pro�riated, o� th� �ae�eral ��xnd and tFte 1Nork�rs" �orra�k�ns�zion F�i3d. CF�;b ��wCi�i�ilikYl f.Gr C�ily I�swuy�p�''� U r�ee �ry: �'lahrlas Huhwcll (]�i@i�nliu�; D����n:teunut ]lend: S��anu Ii,>>Ic i'or �1ddiUol�ol =uformuli,w Coul arl: `.�,�Rn�o l3u]a� � e�ur�o ��c�our��r � c�r��r��t � �n,n�u� {�o} @S(}[i � d5]! (Crs�u4} �� C�GO� i39124 T U151006 $ 9.R37[I.i1�7 FE73 53�120 0lS7��4 �14.70Q.00 8513 CITY S�C�$7'A3lY ��,I'f'I;�: �.k,�� �� �_'I�i 1' ���.1�,1�€k.. ���1�� �� �� �, { �=fi�.�s�f�4� ff � 3� �:,Ily� ;4cxnlMryaf kh• ;�'i I;, ��i �.'c�; k �''f+�F!]t,'Cil,t�5� � Pnrniul pn r��}�Iptl R��