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HomeMy Public PortalAbout005-2011 - MEDICAL QUALIFICATION POLICYBOARD OF PUBLIC WORKS AND SAFETY RESOLUTION NO. 5 -2011 A RESOLUTION ADOPTING THE MEDICAL QUALIFICATION POLICY AND PROGRAM AND MEDICAL DETERMINATION OFFICER SERVICES CONTRACT FOR ROSE VIEW TRANSIT DEPARTMENT WHEREAS, From time to time the State of Indiana and the Federal Transit Administration (FTA) update the Medical Qualifications Policy and related supplemental policies for prescription (Rx) and over - the - counter (OTC) medications (hereinafter "Medical Qualification Policy and Program "), which updated policies are attached hereto as Exhibit A and incorporated by reference; and WHEREAS, A Services Contract for a Medical Determination Officer (MDO) in relation to the Medical Qualifications Policy, attached hereto as Exhibit B and incorporated by reference, and designated as Contract Number 111 -2011, outlines the services and responsibilities of the Medical Determination Officer Vendor, Public Safety Medical, to provide medical examinations and other related services to RVT as part of the Indiana Rural Transit Systems to support the Medical Qualification Policy and Program; and WHEREAS, An Itemization and Scope of Services addendum outlines the fee schedules associated with the medical testing services to be provided in connection with the MDO Services Contract, as well as the medical information reporting policies and confidentiality policies, which addendum is attached hereto as Exhibit C and incorporated herein by reference; and WHEREAS, It is in the best interest of the City of Richmond that the updated policies be adopted for the Rose View Transit Department and that the Medical Determination Officer services contract and its Addendum be approved by the Board of Public Works and Safety in order that the RVT Department can remain in compliance with the federal mandates set forth by the FTA. NOW THEREFORE, BE IT RESOLVED by the Board of Public Works and Safety of the City of Richmond, Indiana, that said Board hereby adopts the Medical Qualification Policy and Program as required by the State of Indiana and the FTA, which Policy and related documents are attached hereto as Exhibit A. NOW THEREFORE, BE IT ALSO RESOLVED by the Board of Public Works and Safety of the City of Richmond, Indiana, that said Board hereby approves Contract Number 111- 2011 with Public Safety Medical for the Medical Determination Officer Services in connection with the Medical Qualification Policy and Program, which Contract is attached hereto as Exhibit B. NOW THEREFORE, BE IT ALSO RESOLVED by the Board of Public Works and Safety of the City of Richmond, Indiana, that said Board hereby approves Addendum A to Contract Number 111 -2011, which outlines the fee schedules associated with the medical testing services as well as the medical information reporting policies and confidentiality policies, which Addendum is attached hereto as Exhibit C. Passed and adopted this _ 11 th day of _ August _____, 2011, by the Board of Public Works and Safety of the City of Richmond, Indiana. BOARD OF PUBLIC WORKS AND SAFETY S/S Vicki Robinson Vicki Robinson, President Dian Lawson, Member S/S Anthony L. Foster, II Anthony L. Foster, 11, Member Approved: S/S Sally Hutton Sally Hutton, Mayor Medical Qualification Policy For Rose View Transit I. Overview: Rose View Transit System is committed to providing a safe working environment and to protect the health and safety of customers, public, staff, visitors, and transit property. Indiana transit drivers must report for their safety- sensitive job duties "fit for duty," or for the purposes of this policy, "medically qualified." This policy provides a mechanism for identifying and intervening when individuals are believed to pose a threat to themselves as well as the safety of others and property and assessing an individual's "medical qualification" as it applies to the safe performance of safety- sensitive job functions. II. Definitions: Medical Qualification: The physical and mental health status that facilitates the performance of essential job duties in an effective manner and protects the health and safety of oneself, others, and property. Medical Qualification Assessment: A physical examination performed by Rose View Transit System's Medical Determination Officer (MDO), including but not limited to a health history, physical and /or psychological examination, and any medically indicated diagnostic studies, including blood tests. Medical Qualification Determination: A determination made by the MDO attesting to an employee's medical qualification in any of the situations described following an extended medical absence or management- required medical qualification assessment. Allowable costs to obtain the certification may be paid by Workers' Compensation for work - related injuries by the employee's health insurance, the employee, or the employer depending on the circumstances that led up to the medical qualification assessment and the outcome of the assessment. Medical Determination Officer (MDO): A medical professional under contract to Rose View Transit that performs a variety of medical services including, but not limited to, physical examination services /medical qualification assessments for all safety- sensitive transit positions in accordance with Indiana Code 20- 9.1 -3- 1 and applicable transit system policies including Medical Qualification, RX /OTC and Substance Abuse Policies. As such, the MDO provides a written recommendation for an applicant's ability to perform the essential duties of a safety- sensitive job. Reliable Report: Observations by a manager /supervisor to assess an employee's medical qualification, taking into consideration such factors as direct observation of the employee's appearance, behavior, and work performance, interactions with other employees, and /or other verifiable reports of the employee's behavior or condition. Working Hours: Beginning with an employee's starting time and ending with the employee's quitting time as well as any time an employee is on -call or considered on duty. All work activities are included whether these activities occur on or off transit property. Medical Qualification Policy Rose View Transit System Page 1 (Form rev. 05111) III. Medical Qualification Responsibilities Transit employees and management share responsibilities for ensuring that individuals are medically qualified to perform and, therefore, ensure the safety of Rose View Transit's employees and passengers. Specific responsibilities for each are detailed below. A. Employee Responsibilities Employees of Rose View Transit are responsible for: • Being medically qualified to report to work; • Notifying the manager /supervisor when the employee him /herself does not meet the medical qualification requirement; • Notifying the manager /supervisor of any concerns in the workplace which may impact an employee's medical qualification. (Note: In cases where concerns involve the employee's manager, the employee should make the notification to the next higher level manager); and • Cooperating with a manager /supervisor's directive and /or referral for a medical qualification assessment. B. Manager /Supervisor Responsibilities Managers /Supervisors of Rose View Transit are responsible for: Observing the attendance, performance, and behavior of the employees they supervise; • Interviewing an employee who appears to the manager /supervisor as medically unqualified and, therefore unfit, for duty and referring that employee to the MDO for a medical qualification assessment, when appropriate; • Recording the reasons /observations that triggered a medical qualification assessment referral; • Following appropriate leave and disciplinary policies, when appropriate; and • Utilizing this policy in a fair and consistent manner, respecting the employee's privacy and the confidentiality of medical information. C. Medical Determination Officer (MDO) The Medical Determination Officer (MDO) is responsible for: • Conducting physical examination services /medical qualification assessments for all safety- sensitive transit applicants and employees, including the request and review of laboratory tests, in accordance with Indiana Code 20- 27 -8 -1 and applicable transit system policies including Medical Qualification, Substance Abuse, and Prescription and Over- the - Counter Medications; • Make medical qualification determinations, as applicable and provide written reports of all such assessments and determinations. • For new applicants, review each applicant for a safety- sensitive position and all safety sensitive employees' health histories to issue a determination about an operator's physical qualifications and ability to operate a small urban and rural (5311) public transit vehicle pursuant to Indiana Code 20- 27-8-1 and applicable transit system substance abuse and Rx /OTC policies. • Provide recommendation for an applicant's ability to perform the essential duties of a job based upon a review of a physical capabilities examination or assessment exercise. IV. Conducting Medical Qualification Assessments: Medical qualification assessments will be conducted for all safety- sensitive employees or applicants for safety- sensitive positions in the following circumstances: A. As a requirement of the hiring process; Medical Qualification Policy Rose View Transit System Page 2 (Form rev. 05111) B. As part of the annual medical qualification assessment; C. Returning from absences as defined below; D. Following a triggering event, as defined by this Policy and other applicable Rose View Transit System policies; E. In special circumstances, as may be required. A. Hiring: Driver Qualifications: Because drivers work without direct supervision and have full responsibility for their vehicle and passengers, they must possess strong customer service skills, including communication skills and the ability to manage large groups of people with varying needs. Applicants and existing employees must meet the following qualifications in order to be considered for and /or maintain a driver's position with Rose Veiw Transit System. At a minimum, drivers must: Be at least 21 years of age; Be in good health and physically able to perform all duties of a driver including, but not limited to, providing passenger assistance; Speak and read English well enough to converse with the general public, understand highway traffic and signals, respond to official questions, and able to make legible entries on reports and records; Be able to conduct pre -trip vehicle inspections; Be able to drive the vehicle safely in accordance with Rose View Transit's policies and procedures; Have an annual physical (Note: There is no upper age limit set by the U.S. Department of Transportation (DOT), but as drivers age, their reflexes, vision, and stamina all decline. Therefore, it is recommended that drivers over the age of 65 be required to undergo an annual physical rather than the bi- annual requirement set by the DOT); and Submit to physical examinations as determined necessary by the management of Rose View Transit in accordance with this policy. Annual Medical Qualification Assessments All safety- sensitive transit employees are expected to continue to meet all of the requirements established at the time of their hire (see Section A above) and to undergo an annual medical qualification assessment, and at other times as established by this policy. C. Return to Active Status Employees will undergo a medical qualification assessment by the MDO following return to active status in the following situations: • Before returning to work from a non - occupational medical leave of 30 calendar days or longer; • Before returning to work from a serious non - occupational injury or illness requiring hospitalization; • Before returning to work if employee experienced a medical episode that suggests serious safety risk such as chest pains, loss of consciousness, dizziness, blurry vision, temporary paralysis, extremely elevated blood pressure, suspected heart attack, etc. Medical Qualification Policy Rose View Transit System Page 3 (Form rev. 05111) The MDO may consult with the treating physician to obtain additional information, as necessary. The company's MDO will be the ultimate determining factor in an employee's medical qualification and return to active status. The MDO also determines whether or not the employee can perform essential functions of the job with or without reasonable accommodations. The manager /supervisor provides, and the employee utilizes, reasonable accommodations, if applicable. If none apply and the employee is not approved to return to active status, the manager /supervisor will then inform the employee of his or her options in accordance with the company's medical leave policy. Accommodations that result in an undue financial burden to the transit system will not be approved. D. Triggering Events A triggering event will require that an employee undergo a medical qualification assessment by the MDO. Triggering events include 1. a qualifying accident (see definition below), 2. self - referral, and 3. observations (reliable reports). 1. For purposes of this policy, a qualifying accident is one which meets the National Transit Database definition of a "reportable accident." Qualifying accidents will be investigated and documented in accordance with Rose View Transit's Post Accident Investigation Procedures (see Exhibit C). 2. Employees have a responsibility to request a medical qualification assessment any time they believe their performance of safety- sensitive job functions may be compromised, either from a medical condition, as a result of taking Prescription or Over- the - Counter Medications (Rx /OTC), or any other condition or event that has the potential to impact the safe conduct of their job duties. 3. Observations (reliable reports) may address issues including, but not limited to, an employee's manual dexterity, coordination, alertness, speech, vision acuity, concentration, response to criticism, interactions with co- workers and supervisors, suicidal or threatening statements, change in personal hygiene, presence of condition likely to lead to foodborne disease transmission, memory and /or odor of alcohol, marijuana, or other substance of concern. Observations must be made by a manager /supervisor, or if by another employee, verified by a manager /supervisor. In cases of triggering events the following steps must be followed: The manager /supervisor immediately assesses the risk and, if applicable, removes the employee from safety- sensitive duty; The employee is sent to the MDO for a medical qualification assessment; and In the event of a qualifying accident, the employee will be immediately subject to a medical qualification assessment and FTA substance abuse testing, including an expanded opiates panel under the transit system's own authority, as identified in Rose View Transit's substance abuse policy and /or Rx /OTC medication policy. Special Circumstances Rose View Transit reserves the right to request a medical qualification assessment as a result of special circumstances, to be determined on a case by case basis. V. Documenting Risk Assessments In the cases of qualifying accidents, the employee is immediately referred to the MDO for a medical qualification assessment. In other triggering events, Managers /Supervisors must assess the risk and document each individual triggering event. Medical Qualification Policy Rose View Transit System Page 4 (Form rev. 05111) No risk: Keep notes of the event. Minor risk: Remove the employee from safety- sensitive duty, and encourage the employee to seek medical treatment or use Employee Assistance Program;; document the event. Significant risk: • Remove the employee from safety- sensitive duty and refer to the MDO for immediate medical qualification assessment, and as applicable, place the employee on paid leave of absence (sick leave or paid administrative leave depending on the situation); • Arrange for the employee's safe transportation home or to a medical facility, as the situation warrants; • Refer the employee for medical qualification assessment or Employee Assistance Program; and • Implement discipline, as appropriate; • Contact local law enforcement, as appropriate. VI. Medical Qualification Referrals Medical qualification referrals are either self - referrals by the employee or referrals made by the manager /supervisor. Employees voluntarily seeking assistance (i.e., self - referral) for physical (including controlled substance, drug and alcohol abuse /addictions, side effects or impairments resulting from legally prescribed or purchased Rx /OTC medications), mental, and /or emotional problems before their work performance or attendance is adversely impacted will not have their employment status jeopardized for seeking assistance. Self- referral, however, does not exempt an employee from disciplinary action for work performance or safety infractions, if such action is warranted. In instances where management makes a mandatory medical qualification assessment referral, employees must cooperate with the assessment. Failure to cooperate will result in immediate medical disqualification and discipline in accordance with Rose View Transit's progressive discipline policy. ■ Employees cooperating in a medical qualification assessment and determined to have successfully complied with recommendations for medical, psychological, and /or chemical dependence treatment may be returned to the job provided appropriate discipline, if warranted, has taken place. ■ Employees posing a significant safety risk may be medically disqualified from performing safety - sensitive duties and, as such, their employment may be medically disqualified indefinitely. This Medical Qualification Policy is effective as of September 30, 2011. Supplemental Policies: I. Prescription and Over- the - Counter (Rx /OTC) Medications Policy Exhibits A- Prescription and Over- the - Counter Medication Information Form B -Post Accident Investigation Procedures and Forms C -State of Indiana Requirements for Section 5311 Public Transit Operators Medical Qualification Policy Rose View Transit System Page 5 (Form rev. 05111) Indiana Model Post Accident Documentation Procedures for Determining Rx /OTC Involvement In the interest of safety and protecting employees and the public, Rose View Transit has adopted the following procedures to investigate Prescription and Over- the - Counter (Rx /OTC) Medication use after accidents. These procedures are not intended to obstruct law enforcement from performing their investigation or from the employee seeking medical treatment. Post Accident Investigation - Required Forms As part of the post accident investigation process a Rose View Transit manager /supervisor will complete a Post Accident Drug and Alcohol Testing Determination Form. The investigating supervisor will make a general fitness - for -duty determination and ask them if they have taken any prescription or over - the - counter medications. If the employee indicates that they have taken an Rx /OTC medication the investigating supervisor will ask the employee to complete a second form. The second form, Prescription and Over- the - Counter Medication Post - Accident Investigation Form, will be kept confidential, is considered a medical report, and is afforded the same protections. This form has two parts. The first part is used to list all the medications taken by the employee during the 7 days immediately preceding the accident. The second part contains questions concerning dosage, frequency, last time taken, prescribing physician, discussions with the medical practitioner or pharmacist, side effects experienced by the employee, etc. It also has a space to list the exact information provided on the label of the medication. A separate second part should be completed for each of the medications listed on the first part. This information will be used, along with the opinion of the FFDO, by management to determine whether the medication could have contributed to the accident. Non FTA Post - Accident Drug Testing In the event of a qualifying accident, the employee will be immediately subject to a fitness for duty evaluation and a non -FTA NIDA 10 +2 (synthetic opiates) drug test under Rose View Transit's own authority. A qualifying accident is defined as a National Transit Database (NTD) reportable accident. Post Accident Investigation - Findings and Actions The information obtained from the Rx /OTC accident investigation will be used by the Fitness for Duty Officer (FFDO) to compare with the employee's Medication Information Forms on file and to determine causal or contributing factors. This information, together with the results of the non -FTA post accident NIDA 10 +2 (synthetic opiates) drug test, will determine if the employee informed management of all medications as required by the Rx /OTC Medication Policy. If it is found that a safety- sensitive employee was taking a restricted medication that had not been reported and /or reviewed by the FFDO, the employee will face disciplinary action. This information will also be used in the post accident investigation to determine causal or contributing factors. Disciplinary action, if any, will be determined in accordance with the appropriate Transit System's policies and procedures, including its Rx /OTC Medication Policy. Medical Qualification Policy Rose View Transit System Page 6 (Form rev. 05111) Indiana Medical Qualification (MQ) Program Medical Determination Officer (MDO) Services Contract This agreement, is made between Rose View Transit located at 401 South "Q" St., Richmond, IN hereinafter referred to as the "System," and, Public Safety Medical located at 324 E. New York Street, Indianapolis, IN hereinafter referred to as the "Vendor." This agreement outlines the services and responsibilities of the Vendor, acting as the Medical Determination Officer, to provide medical examination and other related services to Indiana Rural Transit Systems, including the System named above. Said services are to support Indiana's Medical Qualification Policy and Program, and other applicable programs, and to ensure the safety of Indiana's safety- sensitive transit employees and the traveling public. In addition, this agreement acknowledges that the System has a policy for Medical Qualification of applicants for safety - sensitive functions and /or existing safety- sensitive employees and requires medical examination and other related services from the Vendor. In consideration of the mutual covenants and promises set forth, the parties hereby enter into this agreement, the terms and conditions of which shall apply from the execution date of this agreement. The Vendor shall provide services pursuant to the United States Department of Transportation's "Physical Qualifications for Drivers" 49 CFR part 391; the Americans with Disabilities Act (ADA); Indiana Code 20- 27 -8 -1; and the Indiana Medical Qualification (MQ) Policy and Program, and the Indiana Rx /OTC Medication Policy, all of which apply to all Indiana Rural Transit Systems. Furthermore, the Vendor must allow regulating agencies (Federal Transit Administration, Indiana Department of Transportation, its authorized representatives and the System as a part of its Vendor oversight) to interview Vendor employees and review files necessary to complete program audits and ensure compliance. In consideration of the premises and the mutual promises, covenants, and agreements contained herein, the parties agree as follows. SCOPE OF SERVICES Services shall include the following outlined items. A. Evaluating job Positions 1. Conduct evaluations of safety- sensitive transit job descriptions and develop standards for each position that include physical and health demands required to perform the essential job functions in accordance with ADA regulations. 2. Review and update job standards biennially. Contract No. 111 -2011 B. Conducting Physical Examinations 1. Perform physical examination services at the request of the System(s); provide a complete written report using the Medical Examination Report for Operator Medical Qualification Determination (Indiana Code 20- 27 -8 -1). Additional reporting may be required, as necessary. Physical examinations will, at a minimum, be conducted for all safety- sensitive transit positions in the following circumstances: a. New hires; b. Return to active status (as defined in the Indiana MQ Policy); c. Following a qualifying accident (as defined in the Indiana Medical Qualification Policy); d. As required to comply with the Indiana Prescription and Over- the - Counter (Rx /OTC) Medication Policy and Procedures; and e. On a case -by -case basis as requested by the individual purchasers and /or required in accordance with other applicable Indiana policies and procedures. 2. Review all applicants' and all safety- sensitive employees' health histories to issue a determination about an operator's physical qualifications and ability to operate a small urban and rural (5311) public transit vehicle pursuant to Indiana Code 20- 9.1 -3 -1 and applicable transit system substance abuse and Rx /OTC policies. 3. Assess applicants' ability to perform the essential duties of a job based upon a review of his or her physical capabilities examination or assessment exercise. 4. Request and evaluate laboratory tests sufficient to render a medical decision regarding an applicant's or employee's health as it relates to the position for which he or she is being examined. S. Following all physical examinations as specified in #1 above, render a decision as to the applicant's ability to fully perform the essential functions of his or her assigned job duties. DOT and non -DOT physical examinations shall at a minimum contain the following: a. Completion of a comprehensive health and occupational history questionnaire, including inquiries into an applicant's on- and - off -job injury history as related to the job duties. b. Measurement of job - related work activities such as lifting, pushing, turning, etc., against the load, according to proper physical and occupational therapy procedures. c. A complete examination by a licensed physician. d. Urine sample analysis including dipstick evaluation test to include a minimum of specific gravity, PH, protein, and sugar and other as deemed necessary. For all examinations except for pre - employment, a urine specimen must be collected to perform an expanded opiates (10 +2) drug test. Chain of custody must be maintained at all times and follow standard industry protocols at qualified laboratories. If a DOT drug test is also required under 49CFR Parts 40 and 655, the DOT Collection must be performed first. A separate void should be collected for the MQ test unless the DOT specimen exceeds 45mL. In that case the remaining specimen can be used for the MQ evaluation. In all cases, the DOT drug testing regulation (49CFR Part 40) must be followed and preempts the MQ procedures outlined herein. e. X -rays, if deemed necessary by the physician and approved by the transit system's designated contact person. f. Other tests as deemed necessary by the physician and approved by the transit system's designated contact person. Note: Required medical examinations, including non -DOT drug and alcohol testing, may be required to determine an employee's physical and /or mental fitness for duty. The results should, therefore, include an evaluation of the issues and recommended action for the transit system. C. Assessing and Determining Medical Qualifications 1. Consult with an employee's treating physician to obtain additional information about an employee's medical qualification following an extended medical absence or transit system management required MQ assessment. 2. Consult with transit system management to provide the ultimate and final determining recommendation for transit system management regarding an employee's medical qualification. This may include overruling a prescribing medical practitioner's determination. The decision may, in some cases, medically disqualify the employee from performing his or her safety- sensitive function(s). The ultimate decision will be made by the transit system management, based on the Medical Determination Officer's recommendation. D. Developing Policy Statements Provide technical expertise on the United States Department of Transportation's "Physical Qualifications for Drivers" 49 CFR Part 391.41, relevant guidelines pertaining to Rx /OTC medication use as developed by the Federal Motor Carrier Safety Administration (FMCSA), and Federal Transit Administration (FTA), as appropriate, to assist systems with policy modification or updates. Describe the company's ability, preparedness, and strategy for informing systems of Medical Qualification requirements while using Prescription and Over- the - Counter (Rx /OTC) medications. E. Provide Training and Education 1. Provide new employee training at up to three locations within the state (north, central, south) to explain the precautions of using Rx /OTC medications and how they could impair a driver's ability to operate a vehicle. 2. Educate transit operators about common prescriptions and over - the - counter medications relative to the side effects and hazards of these medications while driving. Include instructions on how to read and understand warning labels on all medications. F. Perform Required Recordkeeping and Reporting 1. Maintain all necessary records of services provided and appropriate procedures to assure confidentiality of records and reporting. 2. Maintain documentation of medical evaluations for a minimum of four (4) years or longer as determined necessary by transit system management. 3. Report on the results of each evaluation to the transit system's designated contact person by telephone within 24 hours of the physical. Provide complete written, quantified test results to the transit system's Human Resources Department within three (3) days of the examination in a format acceptable to the INDOT. 4. Prepare and submit monthly progress reports along with a monthly invoice as described in Section H of this Contract. G. Expert Testimony Provide expert testimony, including explanation of tests and examination results, as needed. H. Invoices Payment shall be net thirty (30) days upon receipt of a satisfactory monthly progress report. Proposers should note any discounts for payment before thirty (30) days. Invoices should be sent to the attention of the Accounts Payable Department of each respective Purchaser. Invoices shall reflect the following: purchase order number, description of service, and total amount of payment due. OTHER CONDITIONS 1. PROVIDER RESPONSIBILITIES The Vendor will maintain facilities and personnel adequate to the performance of services outlined in this agreement to System. In particular, the Vendor will maintain personnel with the proper professional licensure of all physicians, medical personnel and administrative personnel who will be providing direct services to the System. The Vendor will maintain, in a secure location with controlled access, all dated records, information, and notifications, identified by individual for specific information and records for the minimum time period of four (4) years and as applicable to the services provided by the Vendor to the System. The Vendor will not release individual evaluation results to any person, without first obtaining specific written authorization from the individual. Nothing in this paragraph shall prohibit the Vendor from releasing, to the System, its agents or to officials of the Federal Transit Administration or the Indiana Department of Transportation or its designated representative with regulatory authority over the testing program, individual evaluation results or related information to comply with requests resulting from a legal action and on the behalf of the employee. The Vendor will make available to the System, at location(s) of the System's choosing, and at reasonable expense to the System for copying and shipping charges, all records related to medical examination services performed by the Vendor for the System, except records containing confidential medical information, within two business days of notification by the System of such request. Evaluation results are sent directly to the System from the Vendor. Furthermore, the Vendor shall not hold hostage any records relating to this program or its compliance for purposes of collecting outstanding payments from the System. Quarterly reporting of specified information to the Indiana Department of Transportations Safety and Security Program Manager and annual reporting to the System will be by facsimile transmission, electronic transmission, or U.S. mail. 2. SYSTEM RESPONSIBILITIES The System will provide the Vendor with the most recent applicable Medical Qualification and Rx /OTC policies of the System. The System will designate a primary representative and an alternate representative to whom the Vendor will report evaluation results and discuss or report other necessary information. A password will be established for each representative to ensure confidentiality of information passed between the Vendor and the System. The means of obtaining results from the Vendor, (including, but not limited to, electronic or computer transmission, facsimile transmission (fax), or written communication) with password protection will assure that the results and other information remain secure and confidential with distribution of or access to such information to System officials with a business need for the information only. The System authorizes the Vendor to request specific information or to order additional tests as necessary for System to comply with the United States Department of Transportation's "Physical Qualifications for Drivers" 49 CFR Part 391; the Americans with Disabilities Act (ADA); Indiana Code 20- 27 -8 -1; and the Indiana Medical Qualification Policy and Program, and the Indiana Rx /OTC Medication Policy. The System agrees to pay for additional costs and charges related to such information requests or additional testing performed. The System acknowledges that performance of necessary verification procedures may be dependent upon cooperation by System representatives, evaluated individuals, and /or personal physicians and /or health care providers that may possess vital medical history information. 3. TERM This contract shall be in effect from the date of execution and continuing for a period not to exceed twenty -four (24) months. The responsibilities and obligations and liabilities shall survive the term of this contract. This contract can be renewed on an annual basis for up to two (2) additional one year periods, subject to the approval of the System unless either party has given written notice of intent to change the terms of the contract no less than sixty (60) days prior to the renewal date. The total length of the contract including extensions cannot exceed four (4) years. 4. INDEPENDENT CONTRACTORS Both parties to this contract are independent contractors, and nothing contained herein shall be construed to place the parties in the relationship of partners, joint venture, or employer - employee, and neither party shall have the power to obligate or blind the other whatsoever beyond the terms of this contract. 5. RESPONSIBILITY FOR COMPANY POLICY AND PROGRAM The parties understand and agree that the Vendor does not make any employee decisions for the System such as hiring of applicants, termination, discipline or retention of any employee or former employee and that the System has sole responsibility for all such decisions. The Vendor shall not be responsible for any damages resulting from acts or omissions of the System under the System's substance abuse policy. 6. DEBARMENT The Vendor will be required to certify that it is not included on the U.S. Comptroller General's Consolidated List of Persons or Firms Currently Debarred for Violations of Various Contracts Incorporating Labor Standards Provisions. 7. NON - COLLUSION The Vendor guarantees that this contract is not a product of collusion with any other proposer. An affidavit of non - collusion form is included and must be signed and submitted with the contract. 8. INTEREST OF MEMBERS OF, OR DELEGATES TO, CONGRESS In accordance with 18 U. S. C. 431, no member of, or delegates to, the Congress of the United States shall be admitted to a share of part of this contract or to any benefit arising there from. 9. CONFLICT OF INTEREST No employee, officer, or agent of the grantee shall participate in the selection or in the award of administration of a contract if a conflict of interest, real or apparent, would be involved. Such a conflict would arise when: The employee, officer or agent, any member of his immediate family, his or her partner, or any organization which employs, or is about to employ, has a financial or other interest in the firm selected for award. The grantee's officers, employees, or agents shall neither solicit nor accept gratuities, favors, or anything of monetary value from contractors, potential contractors, or parties of sub - agreement. 10. SEVERABILITY If any provision of this contract is held to be illegal, invalid, or unenforceable by a court of competent jurisdiction, the parties shall, if possible, agree on a legal, valid, and enforceable substitute provision, which is as similar in effect to the deleted provision as possible. The remaining portion of the contract not declared illegal, invalid, or enforceable shall, in any event, remain valid and effective for the term remaining unless the provision found illegal, invalid or unenforceable goes to the essence of this contract. Either party has the right to terminate this contract, for any reason whatsoever, upon 60 days notice by the terminating party. In no event shall the Vendor have any responsibility or liability to the System for any failure or delay in performance by the Vendor, which results from or is due to, directly or indirectly and in whole or in part, any cause or circumstances beyond the reasonable control of the Vendor. Such causes and circumstances shall include but are not limited to acts of God, acts of the System, rules or regulations or orders of any governmental authority or agency thereof (whether civil, military, executive, legislative, judicial, or otherwise), strikes or other concerted actions of workers, lockouts, or other labor disputes or disasters, accidents, wars, riots, rebellion, sabotage, insurrection or civil disturbances, difficulties or delays in private or public transportation, or any other cause beyond the Vendor's reasonable control. INDEMNIFICATION The System shall indemnify, defend, and hold harmless the Vendor, the Vendor's directors, officers, agents and employees, and each one of them, from and against any and all claims, suits, and damages of whatever nature made or asserted by a present or former employee or agent or applicant for employment of the System, of its parent, subsidiaries or affiliate companies, arising out of or in any way related to services provided by the Vendor under this agreement, related to negligent, fraudulent, or illegal action or omission of the System or the System's employees, agents, or related personnel. The System agrees to indemnify and hold harmless the Vendor, its parent companies, subsidiaries, and affiliates from any loss, or damage, or claim brought by third parties (including the System's evaluated individuals) resulting from any negligent act or omission on the part of the System or System's representatives. The Vendor shall indemnify, defend, and hold harmless the System, System's directors, officers, agents and employees, and each one of them, from and against any and all claims, suits, and damages of whatever nature made or asserted by a present or former employee or agent of Vendor, of its parent, subsidiaries or affiliate companies, arising out of or in any way related to services provided by the Vendor under this Agreement, related to negligent, fraudulent, or illegal action or omission of the Vendor, or the Vendor's employees agents, or related personnel. The Vendor agrees to indemnify company from and against any and all claims arising out of its submission of data or analytical results which are false or incorrect as a result of willful, intentional, or negligent acts or omissions by the Vendor personnel. REQUIRED FEDERAL CLAUSES The Vendor and System must comply with all required Federal clauses as outlined in the Federal Transit Administration's (FTA) Master Agreement which is incorporated herein by reference. FEDERAL AND STATE STANDARD ASSURANCES AND CERTIFICATIONS The Vendor and System must comply with all applicable Federal and State standard assurances and certifications which are applicable both at the time of this agreement and any which may become applicable during the contract period, including the initial period and any renewals. REQUIRED STATE CLAUSES A. Pursuant to Indiana Code 22- 9 -1 -10, Vendor, any sub - contractor, or any person acting on behalf of Vendor or any sub - contractor shall not discriminate against any employee or applicant for employment to be employed in the performance of this Agreement, with respect to hire, tenure, terms, conditions or privileges of employment or any matter directly or indirectly related to employment, because of race, religion, color, sex, disability, national origin, or ancestry. B. Pursuant to Indiana Code 5- 16 -6 -1, the Vendor agrees: 1. That in the hiring of employees for the performance of work under this Agreement of any subcontract hereunder, Vendor, any subcontractor, or any person acting on behalf of Vendor or any sub - contractor, shall not discriminate by reason of race, religion, color, sex, national origin or ancestry against any citizen of the State of Indiana who is qualified and available to perform the work to which the employment relates; 2. That Vendor, any sub - contractor, or any person acting on behalf of Vendor or any sub - contractor shall in no manner discriminate against or intimidate any employee hired for the performance of work under this Agreement on account of race, religion, color, sex, national origin or ancestry; 3. That there may be deducted from the amount payable to Vendor by the City under this Agreement, a penalty of five dollars ($5.00) for each person for each calendar day during which such person was discriminated against or intimidated in violation of the provisions of the Agreement; and 4. That this Agreement may be canceled or terminated by the City and all money due or to become due hereunder may be forfeited, for a second or any subsequent violation of the terms or conditions of this section of the Agreement. C. Violation of the terms or conditions of this Agreement relating to discrimination or intimidation shall be considered a material breach of this Agreement. D. Pursuant to Indiana Code 22- 5 -1.7, Vendor is required to enroll in and verify the work eligibility status of all newly hired employees of the contractor through the Indiana E- Verify program. Vendor is not required to verify the work eligibility status of all newly hired employees of the Vendor through the Indiana E- Verify program if the Indiana E- Verify program no longer exists. Prior to the performance of this Agreement, Vendor shall provide to the City its signed Affidavit affirming that Vendor does not knowingly employ an unauthorized alien in accordance with IC 22- 5- 1.7 -11 (a) (2). In the event Vendor violates IC 22 -5 -1.7 the Vendor shall be required to remedy the violation not later than thirty (30) days after the City notifies the Vendor of the violation. If Vendor fails to remedy the violation within the thirty (30) day period provided above, the City shall consider the Vendor to be in breach of this Agreement and this Agreement will be terminated. If the City determines that terminating this Agreement would be detrimental to the public interest or public property, the City may allow this Agreement to remain in effect until the City procures a new contractor. If this Agreement is terminated under this section, then pursuant to IC 22- 5- 1.7 -13 (c) the Vendor will remain liable to the City for actual damages. GOVERNING LAW The provisions of the Agreement shall be construed, interpreted and governed by the substantive laws of the State of Indiana, including all matters of construction, validity and performance but without giving effect to Indiana choice -of -law or conflict -of -law principles. ENTIRE AGREEMENT This agreement represents the entire agreement between the Vendor and the System. This agreement supersedes all prior agreements, understandings, negotiations and discussions, written or oral, and may be modified only by a written document signed by both the Vendor and the System. IN WITNESS WHEREOF, the parties hereto have caused this agreement to be executed as of the day and year executed below: SYSTEM "CITY" THE CITY OF RICHMOND, INDIANA by and through its Board of Public Works and Safety VENDOR "CONTRACTOR" PUBLIC SAFETY MEDICAL Vicki Robinson, President Printed: Title: Dian Lawson, Member Anthony L. Foster, II, Member Date: APPROVED: Sarah L. Hutton, Mayor Date: Date: Addendum A Scope of Services /Itemization Transit Medical Qualification Program 324 E. New York Street, Ste 300 Indianapolis, IN 46204 317.972.1180 Phone 317.972.1190 FAX Grantee Richmond Transit System: Rose View Transit & Paratransit System Annual Physicals PSM agrees to provide the following services: ADDITIONAL SERVICES DESCRIPTION' Code Cost rn Physical Demands Test" 2159 $65 each 3' SERVICE DESCRIPTION Code Cost o Chest X -Ray (PA/LAT) (Offsite) 4010 $61.20 m TB Skin Test 6153 $7,.14 0 Med. Testing: 1121 $250 Vital Signs 6000 $0 X Medical Testing Vision - Acuity 6050 $26.52 X Audiometry 6090 $14.28 X Urinalysis — Dipstick 6020 $4.06 X Physical Exam' INDOT - Medical Review (Annual) 20050 $25.18 X INDOT —Annual Physical (NP) 20005 $48.96 X Web -Based OnMed Program 8135 $25 X Services Injection Fee j 6170 j $10.20 Administrative Fee (Your Site) 3206 $ 40 X SUBTOTAL Annual Physical (seeing an' IP) Subtotal: $184 ADDITIONAL SERVICES DESCRIPTION' Code Cost Check All That Apply Physical Demands Test" 2159 $65 each X— If Indicated' Chest X -Ray (PA/LAT) 4000 $61.20 Chest X -Ray (PA/LAT) (Offsite) 4010 $61.20 TB Skin Test 6153 $7,.14 Tb Read Class 1121 $250 Venpuncture 3000 Included Quantiferon' -Tb (Blood) 3545 $51 Blood Type'(ABO group+ RH type) 3110 $22.44 Drug Screen (5)-(DOT) 3090 $71.40 Hep B Titer'SAb — Quantitative 3119 $35.70 Hep -B Vacc (3 -shot series)' 6161- 63 $71.40 each Influenza Vacc 6167 $11.22 Injection Fee j 6170 j $10.20 Td Vacc (tetanus, diphtheria) 6168 $20.40 Injection Fee 6170 $10.20 * *Physical Demands Test will consist of confirmation of an employee or applicant's ability to perform the essential physical demands of their position per Public Safety Medical's recommendation. F: market ing /Goldmine templates 1 of 5 New Hires PSM agrees to provide the followinq services: Return to Active Status PSM agrees to provide the followinq services: z 3 SERVICE DESCRIPTION Code Cost _ SERVICE DESCRIPTION Code ' Cost m N Med. Testing: M Vital Signs 6000 $0 X Medical Testing Drug Screen (5) -(DOT) (New Hire) 20062 $25 X Vision - Acuity 6050 $26.52 X Audiometry 6090 $14.28 X Urinalysis — Dipstick 6020 1 $4.06 X Physical Exam' INDOT - Medical Review (New Hire) 20052 $25.18 X INDOT — New Hire Physical (MD) 20010 $99.96 X SUBTOTAL INDOT — New Hire Physical (NP) 20015 $60.96 X SUBTOTAL $60 $195 SUBTOTAL New Hire (seeing an MD) Subtotal'.: $60 $156 SUBTOTAL New Hire (seeing an NP Subtotal`: Return to Active Status PSM agrees to provide the followinq services: Post Accident PSM agrees to provide the followinq services: rn 3 v SERVICE DESCRIPTION Code ' Cost o M N Vital Signs 6000 $0 X INDOT - Medical Review (RTAS) 20054 $25.18 X INDOT — Return -to- Active Status 20020 $49.82 X Physical (MD 20030 $49.82 X INDOT — Return -to- Active Status 20025 $34.82 X Physical (NP) 20035 $34.82 X SUBTOTAL Return to Work (seeing an MD) Subtotal: $75 SUBTOTAL Return to Work (seeing an NP) Subtotal`: $60 Post Accident PSM agrees to provide the followinq services: F: market ing /Goldmine templates 2 of 5 M 3 SERVICE DESCRIPTION' Code Cost .0 m N Vital Sig ns 6000 $0 X INDOT - Medical Review 20056 $25.18 X (Post Accident) INDOT— Post Accident Physical 20030 $49.82 X (MD) INDOT— Post Accident Physical 20035 $34.82 X (NP) SUBTOTAL Post Accident Evaluations (seeing an MD) Subtotal: $75 SUBTOTAL Post Accident Evaluations (seeing an NP) Subtotal: $60 F: market ing /Goldmine templates 2 of 5 Special Circumstances Evaluation PSM agrees to provide the followinq services: Rx /OTC Compliance & Review PSM agrees to provide the following services: Code Cost Transit System M Development 3 $2,500 Billed to IRTAP' (Master/Template) SERVICE DESCRIPTION Code Cost o Customization 20071 $275 Billed to Rose View Transit & m Paratransit System System) m 0 Vital Signs 6000 $0 X Billed to IRTAP' INDOT - Medical Review 20058 $50.04 X SUBTOTAL (Special Circumstance) $35 Billed to Rose View Transit & (Per Rose View Transit & Paratransit 20073 INDOT — Special Circumstance 20040 $99.96 X Physical (MD) INDOT - Training & Education 20074 $250 per SUBTOTAL I Special Circumstances Evaluation Subtotal $150 Rx /OTC Compliance & Review PSM agrees to provide the following services: Miscellaneous Services PSM agrees to provide the followina services: DESCRIPTION Code Cost Transit System M Development 3 $2,500 Billed to IRTAP' (Master/Template) SERVICE DESCRIPTION Code Cost Customization 20071 $275 Billed to Rose View Transit & m m Paratransit System System) y INDOT - Medical Review 20060 $35.00 X Billed to IRTAP' Rx /OTC Compliance SUBTOTAL Rx /OTC Compliance & Review 'Subtotal: $35 Miscellaneous Services PSM agrees to provide the followina services: DESCRIPTION Code Cost Transit System INDOT — Policy Statement Development 20070 $2,500 Billed to IRTAP' (Master/Template) INDOT — Policy Statement Customization 20071 $275 Billed to Rose View Transit & (Per Rose View Transit & Paratransit Paratransit System System) INDOT -.Job Position Evaluation 20072 $1,850' Billed to IRTAP' (Master/Template) INDOT —Job Position Customization Billed to Rose View Transit & (Per Rose View Transit & Paratransit 20073 $100 Paratransit System System) INDOT - Training & Education 20074 $250 per 'Billed to IRTAP' Session INDOT - Expert Testimony 20 ©75' $350 per Billed to Rose View Transit & Hour Paratransit System Administrative Fee —Travel Costs Not to (Presentation or Consulting) 3206 exceed ;.Billed to IRTAP' $8,000 Billing Bills are generated weekly. Net 30 days. Invoices will be sent to: Terri Quinter, Rose View Transit & Paratransit System, 401 South Q Street, Richmond, IN 47374. F: market ing /Goldmine templates 3 of 5 Policy on Additional Testing In the event that PSM finds it necessary to perform additional testing at Rose View Transit & Paratransit System expense and at the request of the medical director, the Rose View Transit & Paratransit System representative will be notified in advance. Policy on Repeat Testing In the event that PSM finds it necessary to retest a patient due to a positive test result or the recommendation of the PSM medical director, the cost incurred will be billed to Rose View Transit & Paratransit System if the retest was not based upon an error on the original test. The Rose View Transit & Paratransit System representative will be notified in advance. If the retest is due to an error by PSM or a contracted laboratory or other representative, PSM will absorb any additional retest costs. No recommended actions will be made to Rose View Transit & Paratransit System until PSM has received accurate retest information. Policy on Reporting Results PSM will provide a medical clearance /fitness - for -duty letter for every patient. The letter will state whether or not the employee is medically cleared for duty. No specific medical test results for any patient are provided to any representative without the written consent of the patient unless required by law (i.e. OSHA) If during the medical evaluation, findings are such that the patient cannot be medically - cleared for duty, the patient will be counseled as to the medical concerns and the need to limit duty assignment. The designated Rose View Transit & Paratransit System representative will be notified, in general terms, of the need for duty restriction and any safety- sensitive responsibilities. It will also be recommended that the patient be re- evaluated by PSM, after appropriate medical treatment, to provide final clearance of return to full duty after a release is first made by the patient's treating physician. PSM will assist the employee with providing related medical information and their job requirements to the treating physician to assist in their care. OnMed Permissions PSM will provide access to our proprietary online medical information system for the following individuals: Name: Vicky Warner Title: RTAP Manager Access Level: All access Name: Terri Quinter Title: Access Level: All access Dates and Location of Services On -Site Examinations Dates: TBD Location: (Regional Training Site) Rose View Transit & Paratransit System Information Contact person: Name: Terri Quinter Phone: 765 - 983 -7227 E -mail: tquinter @richmondindianna.gov Address: 401 South Q Street, Richmond', IN 47374 Number of personnel: Total: 22 Exam Arrival Time To optimize the service provided to Rose View Transit & Paratransit System personnel, we request that you send your personnel 15 minutes prior to their appointment time Liability and Indemnification PSM shall have no liability whatsoever to Rose View Transit & Paratransit System for any error, act or omission in connection with the services to be rendered by PSM to Rose View Transit & Paratransit System hereunder unless any such error, act or omission derives from willful misconduct or gross negligence. Insurance PSM maintains insurance to protect it and Rose View Transit & Paratransit System from the claims set forth below which may arise out of or result from PSM operations under this Agreement, whether such operations be by F: market ing /Goldmine templates 4 of 5 PSM or by its subcontractors or by anyone directly or indirectly employed by any of them, or by anyone directly for whose acts any of them may be liable: 1. Claims under Workers' Compensation and Occupational Disease Acts, and any other employee benefits acts applicable to the performance of the work; 2. Claims for damages because of bodily injury and personal injury, including death, and; 3. Claims for damages to property PSM insurance shall be not less than the acceptable industry standards for the performance of medical and occupational health - related services. Confidentiality PSM agrees to hold in strict confidence, and to use reasonable efforts to cause its employees and representatives to hold in strict confidence, all confidential information concerning Rose View Transit & Paratransit System furnished to or obtained by PSM in the course of providing the agreed -upon services. PSM will not disclose or release any such confidential information to any person, except its employees, representatives and agents who have a need to know such information in connection with PSM performance under this Agreement or by the express written consent of a Rose View Transit & Paratransit System employee. Proprietary Information PSM asks that all information provided within this document be held confidentially and not shared with any related providers, those organizations who could be considered competition to PSM, other fire or law enforcement organizations, or unnecessary personnel within the Rose View Transit & Paratransit System. Term of Agreement This agreement and pricing is valid through March 29, 2013. Questions regarding this Agreement may be directed to the Client Manager below at 317.972.1180. Public Safety Medical Rose View Transit & Paratransit System Representative Lora L. Lex Name Printed a Name Signed Client Manager Title July 28, 2011 Date Name Printed Name Signed Title Date Your Public Safety Medical Contact Client Manager: Lora Lex Office: 317.972.1180, ext. 345 Mobile: 317.331.6806 F: market ing /Goldmine templates 5 of 5