1. Agreement - Occupational Health Centers of California, dba Concentra Medical Centers — Anaheim City Council, February 7, 2023 (part 1 of 2)

12 EXHIBIT A

Request for Proposal

Medical Evaluation Services

September 19, 2022

Questions Due: September 26, 2022 at 5:00 P.M.

Proposals Due: October 7, 2022 at 5:00 P.M.

Projected Award Date: December 20, 2022

Submit bid questions online at:
http://anaheim.net/vendorportal

Human Resources Department
Anaheim West Tower, 5th Floor
201 South Anaheim Boulevard
Anaheim, California 92805

Bid Contacts:

Lisa Wirtz
[email protected]
Maggie West
[email protected]

2 Contents

1.01 Purpose of the Request for Proposal ................................................................................................ 3

1.02 Background .................................................................................................................................... 3

1.03 Scope of Services ............................................................................................................................ 3

1.04 General Requirements .................................................................................................................... 4

1.05 Certificate of Insurance/Indemnity Clause ........................................................................................ 6

1.06 Non-Collusion Clause ...................................................................................................................... 6

1.07 Questions and Communications ...................................................................................................... 6

1.08 City’s Requirement for Business License ........................................................................................... 6

2.01 Evaluation Factors for Award ........................................................................................................... 6

2.02 RFP Deadline .................................................................................................................................. 7

2.03 Submission of Proposal ................................................................................................................... 8

3.01 City of Anaheim General Conditions: Requests for Proposals ............................................................. 9 Appendix I:Standard Insurance Language ............................................................................................... 18 Appendix II: Standard Indemnification Provision ..................................................................................... 22 Appendix III: Non-Collusion Affidavit ...................................................................................................... 23 Appendix IV: References........................................................................................................................ 24

3 1.01 Purpose of the Request for Proposal (RFP)

The City of Anaheim Human Resources Department is seeking proposals from qualified professional occupational health providers to conduct pre-employment placement medical screenings, job analyses, fitness for duty tests, and related occupational health services. The City is committed to utilizing impartial medical reviews to objectively evaluate candidates’ and employees’ ability to perform job duties. The City encourages all prospective occupational health providers (herein referred to as “Proposer” or “Vendor”) to submit proposals. The City desires highly experienced occupational health providers with experience working with municipal government agencies, and who have an understanding of the unique requirements of public safety personnel.

The City currently uses the services of outside medical facilities and providers to conduct impartial medical reviews of City candidates and employees either seeking employment or currently employed with the City (hereinafter collectively referred to as “Employees”) to evaluate their ability to perform job duties.

The City encourages all prospective occupational health providers (herein referred to as “Proposer” or “Vendor”) to submit proposals. The City desires highly experienced occupational health providers with experience working with municipal government agencies and who have an understanding of the varying requirements of public safety personnel.

1.02 Background

The City of Anaheim, situated in the heart of Orange County, has a population of 350,000 residents within its 50 square mile city limits. It is the largest city in Orange County and the tenth largest city in California.

Anaheim features a mild year-round climate with easy access to a wide array of cultural, entertainment and recreational options. The City embraces a vibrant cultural arts community, and several museums and performing arts venues. Professional sports teams include the Angels Baseball team and the Anaheim Ducks Hockey team. Entertainment options include the Disneyland Resort, golf, boutique shopping, and a wide variety of restaurants. More than 40 million people visit Anaheim annually

Anaheim is a full- service city supporting more than 358,000 residents, 20,000 businesses, and 25 million annual visitors. The City provides public safety through the Anaheim Police Department and Anaheim Fire & Rescue, water and power service through Anaheim Public Utilities, parks, community centers, family services and libraries through Anaheim Community Services, neighborhood and transportation improvements through Anaheim Public Works, and community revitalization through Housing and Community Development. Business attraction and retention with Economic Development and the largest convention center in the West Coast. The City cur rently employs over 3,000 full and part -time employees using approximately 600 job classifications. Detailed job classifications are available online at:

https://www.governmentjobs.com/careers/anaheim/classspecs

1.03 Scope of Services

The City of Anaheim seeks to utilize the best combination of options available to implement a legally defensible medical evaluation program to improve program efficiency, effectiveness, and fiscal accountability. Additionally, the service provider must screen applicants and employees to properly evaluate and determine whether the physical capabilities and work-related safety requirements of the job, as well as 4 the essential job functions, can be performed by an individual. The Proposer must be familiar wit h requirements for fire and police public safety personnel, such as the California Commission on Peace Officer Standards and Training (POST).

The primary services required will include, but are not limited to, the following:

1. Conduct pre-placement medical evaluation of candidates for ability to perform the job function to include, but not limited to:
a. Evaluation of candidate’s physical ability to perform the essential functions of the job. i. As needed, facilitate an interactive process wit h candidate until the evaluation is complete/closed (i.e. follow-up assessment).
b. Drug testing
i. Provide options for multiple testing methods , including but not limited to urine, saliva, blood, and hair.
c. Tuberculosis testing
i. Provide options for multiple testing methods, including but not limited to skin PPD, chest x-ray, and blood.
d. Testing for immunizations, including but not limited to measles, mumps, rubella, varicella, hepatitis, etc.

2. Conduct an analysis and evaluation of the current pre -employment placement medical evaluation process and make recommendations for revising.

3. As needed, analyze current job classification specifications and make recommendations for the City’s use in the pre -employment medical examination and drug testing process , as well as occu pational injury medical examination for return-to-work/fitness for duty.

4. Provide a written outline of the administrative and procedural requirements and provide training to Human Resources personnel in administration procedures.

5. Communicate with Human Resources personnel regarding applicants or employees ’ progress throughout the medical evaluation process.

6. Communicate directly with applicants throughout the process , in regards to results and medical conditions. When necessary, obtain applicant confidential medical information that is needed for clearance for a particular job.

7. Provider shall have the ability to schedule pre -employment evaluations within five (5)) days of City’s referral.

8. Provider shall complete pre-employment evaluations within ten (10) business days after completing medical exams and tests.

9. Provider shall provide the City with status updates on any matter within two (2) business days of the City’s request.

10. Provider shall make every effort to limit a patient’s wait time to no greater than 30 minutes.

11. Conduct Fitness for Duty examinations (industrial and non -industrial), and provide reports and recommendations regarding the suitability of current employees to continue to perform their duties.

12. Establish and maintain a secure process for submitting final report s electronically, outlining each candidate’s pre-employment placement medical evaluation and results and provide results to the city within 48 hours of completion of evaluation.

13. Provide quarterly electronic activity reports in a format established by Human Resources in its sole discretion, on the nature and number of examinations conducted, including but not limited to results and final dispositions.

14. Provide consultation as needed to Human Resources personnel regarding medical services provided and outlined in this Agreement.

15. If the circumstances on a particular hearing and/or court proceeding warrants the presence of a competent and knowledgeabl e representative of the Proposer , the City will request and Proposer shall provide such representative, at no additional cost to the City. 5 16. Maintain records in accordance with State and Federal laws , or as otherwise reasonably required by the City and agree to permit agents and employees of the City to review such record s, as well as maintain all books, documents, papers, accounting records, and other evidence pertaining to the fees paid.

17. Provide, at a minimum, a quarterly itemization of charges incurred.

Additional services will include, but are not limited to, the following:

1. Maintain a network of qualified and trained medical providers and medical specialists for necessary exams.

2. Where applicable, interface with medical clinic and medical services provider to manage all aspects of medical review services.

3. Provide a separate op tion for p re-placement testing for tuberculosis and drug testing only, for specific part-time or seasonal occupations, and provide alternatives for mobile on-site testing.

4. Manage all bill review functions for the medical exams performed by clinics.

5. Provide access for City staff to Proposer’s tracking system.

Medical services to be provided:

Depending on job classification, pre-placement and pre-assignment medical examination processes may include, but are not limited to:

Job profile review; review of medical history; check vital signs; detailed vision exam; audiogram; chest x-ray; EKG or treadmill stress EKG; Spirometry; chem ical panel; CBC w/diff; dipstick UA, or UA w/Micro (to lab); venipuncture & collection.

Locations:

The primary clinic(s) location to provide the services above are preferred to be within Anaheim, California.

To ensure the City’s ability to efficiently schedu le candidates/employees, having multiple clinic locations in Southern California within reasonable proximity to Anaheim, California as an option is highly desired to ensure prompt scheduling available when the primary location is not reasonably available. The City may attract candidates from other regions in California and throughout the country; therefore the ability to test candidates or provide an alternative mechanism for testing in other locations is also desired.

While not required, having the op tion for onsite group pre -placement testing for tuberculosi s and drug testing is desirable for primary services #2 mentioned above. This would take place at City Hall, 200 S.

Anaheim Blvd, Anaheim, California and at the Anaheim Convention Center, 800 W. Ka tella Ave, Anaheim, California.

1.04 General Requirements

To be considered by the City, proposing occupational health providers should submit a comprehensive bid proposal, including summary provider and client service history, provided services and cost, clinician/staff qualifications, and references.

Sample cost estimates should be included, along with itemization of individual component costs to allow the possibility for ad-hoc services.

For pre -employment medical testing, please provide sam ple medical job profiles. While the City has 6 approximately 600 active job classifications, it is desired to utilize the absolute minimal medical job profiles for staff to utilize when scheduling candidates for pre -employment medical testing.

The estimated duration of the contract for services will include a not-to-exceed amount, for a duration of up to three years, with possible options to extend on a year-to-year basis

1.05 Certificate of Insurance/Indemnity Clause

The Agreement between Anaheim and the successful Proposer will contain Anaheim’s standard insurance provisions for Agreements of this type. This language is set forth in Section 3.01.

The Agreement between Anaheim and the successful Proposer will contain Anaheim’s stand ard indemnification provisions for Agreements of this type. This language is set forth in Appendix II.

1.06 Non-Collusion Clause

The Proposer agrees to sign a non-collusion affidavit to be executed by the bidder and submitted with the bid. The non-collusion affidavit will be included as part of the bid documents. See Appendix III.

1.07 Questions and Communications

All questions, concerns or comments regarding this RFP may only be submitted through the vendor portal (http://anaheim.net/vendorportal). Answers to such inquiries, as well as any revisions to the request for proposal, will be publicly posted on the vendor portal in the form of an addendum.

Anaheim’s policy is to provide fair and open competition and to ensure that accurate and complete information is communicated to all interested parties. Therefore, any verbal or written communications between any Proposer or its representativ es, agents or others acting on their behalf, and any other City employee, consultant, commission member, or elected official regarding this procurement are strictly prohibited from the time the RFP is issued until the date of execution of the contract. An y violation of the communication process set forth in this section may be grounds for disqualification of the offending firm from participation in this procurement.

1.08 City’s Requirement for Business License

During the term of the Agreement, the Proposer shall obtain and keep in full force and effect, all business licenses required by the City. For additional information regarding the applicability of the City’s business licenses, contact the Business License Division at (714) 765-5194.

2.01 Evaluation Factors for Award

Evaluation of proposals will be based on a fair, impartial, and competitive selection process in which the evaluation of proposals will not be limited to price alone. Proven expertise in occupational health services for municipal government agencies will be the primary consideration in the selection process. 7 The City reserves the right to select a vendor based solely on the information submitted in the proposal and to make a contract award without any further discussion with Proposers regarding the responses received.

Therefore, responses should be submitted initially on the most favorable terms available to the City from a price, contractual terms, and conditions.

The City also reserves the right to conduct discussions with Proposers who submit proposals.

Proposals shall be consistently evaluated based on the following competitive selection criteria:

Criteria Portion
Experience 30%
Ability to Meet Scope of Services 30%
Costs 30%
References 10%
Total 100%

Notification. Any Proposer(s) submitting proposals judged as being "most qualified" by the selection committee may be contacted and asked to provide additional information to supplement their initial proposal. Staff will negotiate a professional services agreement with the selected applicant and the final agreement will be presented to the City Council for approval.

2.02 RFP Deadline

Please submit the final response/proposal in the format specified in Section 2.03 by 5:00 P.M. Pacific Standard Time, on October 7, 2022.

Proposals received after the required time and date specified will be considered late and non-responsive and will not be evaluated for award.

Proposals that are incomplete or non-responsive may not be considered during the evaluation process.

All questions regarding this RFP must be submitted through the vendor portal noted above and must be submitted no later than September 26, 2022 by 5:00 P.M. Pacific Standard Time. Answers, if any, prepared by the City will be delivered via e-mail to all known proposal holders and/or posted on the vendor portal.

Timeline:

Below is the timeline for the selection of a Proposer; however, the City reserves the right to modify or reschedule procurement milestones as necessary.

Activity Date
Release of Request for Proposal September 22, 2022
Vendor Questions Final Submittal September 29, 2022
Vendor Questions – Answers Returned and Posted October 4, 2022 Proposals Due October 10, 2022
Selection of Finalist (Possible Vendor Interviews) October 17 – October 21, 2022 Contract Negotiations October 24 – November 4, 2022
8 Finalize Contract (internal process – obtaining
signatures, prepare staff report, etc.)
November 4, 2022 – November 21,
2022
Award Contract December 20, 2022
Estimated Implementation Start Date December 20, 2022

2.03 Proposal Requirements

Please submit the final response/proposal electronically by 5:00 P.M. Pacific Standard Time, on Friday, October 7, 2022, via the Department’s vendor portal website, located at http://anaheim.net/vendorportal.

Submission of a proposal shall constitute acknowledgment and acceptance of all terms and conditions contained in this RFP and all exhibits and attachments hereto.

Proposal Response Format. In order to assist in the fair and equitable evaluation of all responses, Proposers are being asked to adhere to the specific response format set forth below. Responses that deviate from the requested format may be classified as “non -responsive” at the discretion of the City and may be subject to disqualification. Marketing information will not be accepted in lieu of direct response to all requirements and questions.

Proposals should be organized in a bo okmarked PDF document that include s the following sections and content:

Section Description

1. Executive Summary A letter of introduction signed by an authorized representative of the Firm that provides an executive summary of the Firm’s experience relevant to the scope of work described in this RFP.

2. Experience Explain your organization’s capability to achieve the objectives of this project with reference to prior experience, ability to meet specified timelines, available resources, and the qualifications of your team.

Please include copies of your business license and certifications.

3. Firm Background Describe the organization, date founded and ownership of your firm.

Specify the number of years your organization has been developing and administering examinations for public safety agencies.

4. Personnel

1) Identify the number of professionals employed by your firm, by classification.
2) Describe the proposed project team, including role they will play, title and years at firm. Include relevant work experience. 3) Identify key personnel responsible for accomplishing all phases of the contract.

Consultant is free to comment on any other medical services review- related activities or initiatives your organization would recommend and assist in implementing.
9 6. Reporting Describe the frequency and format of reports you would provide to City staff. Please attach sample reports.

7. References Using the forms provided in Appendix IV provide five (5) customer references that are similar in size and project scope to the City. Three (3) of the 5 references must include agencies with public safety classifications.

8. Contract
Performance
Indicate if at any time during the past five years Proposer has had a contract terminated for convenience, non-performance, or any other reason, or has entered into legal action with a customer. Describe the situation(s) including name and address of contracting party and circumstances.

9. EXHIBIT A – Fee
Statement and
Proposed Pricing
The proposal shall include a fee schedule for the services to be performed, which shall be based on the Proposer’s best pricing.

– End of Proposal Format Section –

3.01 City of Anaheim General Conditions: Requests for Proposals

ACCEPTANCE PERIOD Unless otherwise specified herein, proposals are firm for a period of ninety (90) days.

ADDENDA ACKNOWLEDGMENT Each proposal shall include specific acknowledgment of receipt of all addenda issued during the solicitation period. Failure to so acknowledge may result in the proposal being rejected as not responsive. In electronic proposals, such acknowledgement is done online; in paper proposals, there is a space on the signature page for such acknowledgement.

AFFIRMATIVE ACTION AND NON-DISCRIMINATION If the total price exceeds $50,000, the successful bidder must certify prior to award that they have a written affirmative action program and that they comply with all Federal, State, and municipal laws and regulations pertaining to affirmative action and non -discrimination.

This certification may be made on the Special Provisions form provided.

ASSIGNMENT OF RIGHTS OR OBLIGATIONS Except as noted hereunder, the successful Proposer may not assign, transfer, or sell any rights or obligations resulting from this solicitation without first obtaining the specific written consent of the City.

AUTHORIZED SIGNATURES Every proposal must be signed by the person or persons legally authorized to bind the Proposer to a contract for the execution of the work. Upon request of the City of Anaheim, any agent submitting a proposal on behalf of a Proposer shall provide a current power of attorney certifying the agent’s authority to bind the Proposer.

AWARD OF PROPOSAL An evaluation committee will be established by the City. The committee will evaluate all proposals received in accordance with the selection criteria. The criteria are not listed in any order of preference. Award will be made to the Proposer offering the most advantageous proposal aft er consideration of all selection criteria set forth herein. 10 The evaluation committee reserves the right to contact and evaluate the Proposer's and (if applicable) subcontractor's references; contact any Proposer to clarify any response; contact any current users of a Proposer’s services; solicit information from any available source concerning any aspect of a proposal; and seek and review any other information deemed pertinent to the evaluation process. The City shall not be obligated to accept the lowest priced proposal, but will make an award in the best interests of the City after all factors have been evaluated.

Oral interviews may, at the City's sole option, be conducted with responsible Proposers who submit proposals determined to be most likely to best meet the needs of the City. Discussions may be for the purpose of clarification to assure full understanding of, and responsiveness to, the solicitation requirements. Proposers shall be accorded fair and equal treatment with respect to any opportunity for discussion and written revision of proposals. Unless otherwise indicated, revisions may be permitted after submissions and before award for obtaining best and final proposals. In conducting discussions, the City will not disclose information derived from proposals submitted by competing Proposers.

A notification of intent to award may be sent to any Proposer selected. Award is contingent upon the successful negotiation of final contract terms and the approval of the Anaheim City Council. Neg otiations shall be confidential and not subject to disclosure to competing Proposers unless an agreement is reached.

If contract negotiations cannot be concluded successfully, the City may negotiate a contract with another Proposer or withdraw the RFP. In the event the City Council does not approve the recommendation to award, the RFP may be cancelled without any cost or obligation of the City.

ADDITION/DELETION OF SERVICES The City of Anaheim reserves the right to add and/or delete services to be provided for in the contract. Should a service requirement be deleted, payment to the Successful Proposer will be reduced proportionally, to the amount of service reduced in accordance with the bid price. Should additional services be required from this cont ract, prices for such additions shall be in accordance with this Request for Proposal and Proposer’s response thereto.

AWARD SELECTION PROCESS Selection of qualified Proposer will generally be based on the quality and completeness of submitted proposal; understanding of project objectives; project approach; product offering; experience and expertise; references; costs; and any other criteria identified in the specific RFP.

Additional questions may be asked of Proposer and interviews may be conducted. Proposer will be notified of any additional required information or interviews after the written proposals have been evaluated.

Interviews will be held only with the most qualified respondents. The recommended proposals and resulting Agreement may require a pproval by the City Council for award. The Proposer selected will enter into a written contract with the City.

BUSINESS LICENSES Any person, including but not limited to, an individual, corporation, or sole proprietor who wishes to conduct any business w ithin the City of Anaheim, must secure a business license. City law states that no person shall engage in business or transact and carry on a business, trade, profession, calling or occupation without first having procured a license from the City to do so , or without complying with any and all applicable provisions of Title 3 of the City Ordinance relating to business license. A City of Anaheim business license is not required for submitting a proposal, but must be obtained when awarded a contract, prior to commencing services or selling merchandise to the City.

CANCELLATION OF SOLICITATION The City may cancel this solicitation at any time, without obligation.

COMPLIANCE WITH LAWS The Contractor shall adhere to all applicable federal, state, and local laws, codes and ordinances, including, but not limited to, those promulgated by CAL-OSHA, FED-OSHA, EPA, the California State Department of Health Services, and City of Anaheim regulations. Proposer shall conform to the 11 Immigration Reform and Control Act of 1986, as amended, including, but not limited to, the verification of the employment eligibility of Proposer’s employees working in the City, and the Workers’ Compensation laws of the State of California.

CONTRACT DOCUMENTS, EXAMINATION OF It is the responsibility of the Proposer to thoroughly examine and be familiar with legal and procedural documents, general conditions, all forms, specifications, scope of work, drawings, plans, and addenda (if any), hereinafter referred to as Contract Documents. Proposer shall satisfy himself as to the nature, quantity, and quality of work to be performed and materials, labor, supervision, equipment and permits necessary to perform the work as specified by the Contract Documents.

The failure or neglect of the Proposer to examine the Contract Documents shall in no way relieve him from any obligations with respect to the solicitation or contract. The submission of a proposal shall constitute an acknowledgment upon which the City of Anaheim may rely that the Proposer has thoroughly examined and is familiar with the contract documents. No claim will be allowed for additional compensation that is based upon a lack of knowledge of any solicitation document.

DEFINITION OF TERMS For the purposes of this RFP, the following definitions will be used:

Contractor - Same as Proposer, may be used interchangeably with "Supplier," “Bidder,” or "Vendor." Evaluation Committee -. A committee established by the City to review, evaluate, and score the proposals, and to recommend award to the Proposer that submitted the proposal determined by the committee to be in the best interest of the City.

May - Indicates something that is not mandatory but permissible.

Must/Shall - Indicates a mandatory requirement. A proposal that fails to meet a mandatory requirement will be deemed non-responsive and may not be considered for award.

Proposer - The person or firm making the offer. May be used interchangeably with the word “Bidder.” Proposal - The offer presented by the Proposer.

RFP -. Acronym for Request for Proposals.

Should - Indicates something that is recommended but not mandatory. Failure to do what "should" be done will not result in rejection of your proposal.

Submission Deadline - The date and time on or before which all proposals must be submitted.

Successful Proposer - The person, contractor, or firm to whom the award is made.

DISQUALIFICATION OF PROPOSER If there is reason to believe that collusion exists among the Proposers, the City may refuse to consider proposals from participants in such collusion. No person, firm, or corporation under the same or different name, shall make, file, or be interested in more than one proposal for the same work unless alternate proposals are called for. Reasonable ground for believing that any Proposer is interested in more than one Proposal for the same work will cause the rejection of all Proposals for the work in which a Proposer is interested. A p erson, firm, or corporation who has submitted a sub -Proposal to a Proposer, or who has quoted prices on materials to a Proposer, is not thereby disqualified from submitting a sub-Proposal or quoting prices to other Proposers. Proposers shall submit as part of their Proposal documents the completed Non-Collusion Affidavit provided herein.

DOCUMENTS TO BE RETURNED WITH PROPOSAL Failure to completely execute and submit the required documents before the Submission Deadline may render a proposal non -responsive. The documents that must be returned by the Submission Deadline are indicated on the specific Request for Proposal Documents.

EXECUTION OF CONTRACT Time is of the essence for this contract. The Successful Proposer will be expected to execute the contra ct, including but not limited to signing all necessary documents and submitting all required bonds and evidences of insurance, within ten (10) days after notification of award. One copy of the contract will be returned to the Contractor after the City of Anaheim executes the contract. In case of failure of the Contractor to execute and return the contract and all required documents within the time allowed, the City of Anaheim may, at its option, consider that the Proposer has abandoned the contract. After the 12 contract has been executed, including the insurance documents, certificates, and any applicable bonds, notice to proceed will be issued. Unless otherwise specified, Proposer agrees to commence work within ten (10) working days after the date of the n otice to proceed and fully complete the project within the time specified in the contract.

FIRM PRICE PERIOD Unless specified otherwise herein, Proposers’ offer shall remain valid and firm for a period of not less than ninety (90) calendar days from the Submission Deadline.

HOLD HARMLESS AND INDEMNIFICATION The successful bidder herby agrees to indemnify, defend, and hold harmless the City (including its officials, officers, agents, employees, and representatives) from and against any and all claims of any kind or nature presented against the City arising out of vendor’s (including vendor’s employees, representatives, and subcontractors) performance under this agreement, excepting only such claims, costs or liability which may arise out of the sole negligence or willful misconduct of the City.

INDEPENDENT CONTRACTOR Contractor covenants that it presently has no interest, and shall not acquire any interest, direct or indirect, financial or otherwise, which would conflict in any manner or degree with the performance of the services hereunder. Contractor further covena nts that, in the performance of this contract, no subcontractor or person having such an interest shall be employed. Contractor certifies that to the best of his knowledge, no one who has or will have any financial interest under this contract is an officer or employee of City of Anaheim. It is expressly agreed by Contractor that in the performance of the services required under this contract, Contractor, and any of its subcontractors or employees, shall at times be considered independent contractors and not agents of City of Anaheim.

INFORMED PROPOSER Proposers are expected to fully inform themselves as to the conditions, requirements, and specifications before submitting proposals. Failure to do so will be at Proposers’ own risk and they cannot secure relief on the plea of error.

INK OR TYPEWRITTEN For proposals submitted in hard copy (paper) format, all information, prices, notations, signatures, and corrections must be in ink or typewritten. Mistakes may be crossed out and corrections typed or printed adjacent to the mistake and initialed in ink by the person signing the proposal.

INSURANCE REQUIREMENTS Within ten (10) consecutive calendar days of award of contract, Successful Proposer must furnish the City with the Certificates of Insurance proving coverage as specified in the specifications and naming the City of Anaheim, its officers and agents, Additional Insured by endorsement.

Failure to furnish the required certificates within the time allowed may result breach of the contract. Unless different requirements are called out elsewhere in the RFP, the City's general insurance requirements are:

1. Comprehensive General Liability Insurance: (include products liability coverage, when applicable); $1,000,000 per occurrence.

2. Auto Liability Insurance: $1,000,000 per occurrence, combined single limit (CSL).

3. Workers' Compensation Insurance: as required by State statutes.

4. City of Anaheim to be named as an Additional Insured on the above-captioned insurance coverages as respects the City's interests under this agreement. This is to be complied with by presenting an appropriate insurance certificate to the City prior to commencement of work under this agreement; and by presenting to the City an endorsement to the policy signed by an officer of the insurance company within ten (10) days of the inception date of this agreement.

5. All policies of insurance shall provide for a minimum of thirty (30) days written notice of any change or cancellation of the policy.

6. Insurance policies are to be in a form and written through companies acceptable to the City, and shall include those endorsements which are necessary to extend coverage which is 13 appropriate to the nature of the agreement.

INTERPRETATION OF CONTRACT DOCUMENTS; ADDENDA If any person is in doubt as to the true meaning of any part of the specifications or other contract documents, or finds discrepancies or omissions in the specifications, he may submit to the City of Anaheim a written request for an int erpretation or correction.

Requests for interpretations shall be made in writing and delivered to the City of Anaheim by email, or facsimile to the person identified herein at least ten (10) days before the Submission Deadline, unless a different date is stated in the specific RFP. The requesting party is responsible for prompt delivery of any requests. When the City of Anaheim considers interpretations necessary, interpretations will be in the form of a written addendum to the contract documents, which will be e-mailed to all parties recorded by the City of Anaheim as having received contract documents, or posted on the City's website at http://www.anaheim.net/vendorportal for all Proposers to reference. All such addenda shall become a part of the contract. Oral and other interpretations or clarifications shall be without legal or contractual effect.

It is the responsibility of each Proposer to ensure the City of Anah eim has their correct business name, address, phone number, and e -mail on file. Any prospective Proposer who obtained a set of contract documents from anyone other than the City of Anaheim is responsible for verifying the accuracy and completeness of the documents, and for registering as a Prospective Bidder with the City of Anaheim, in order to receive subsequent Addenda.

LIMITATION OF LIABILITY Unless otherwise expressly set forth herein, (a) each Party’s maximum liability for loss or damage arising out of the performance or non -performance under this Agreement shall be proven direct, actual damages and (b) each Party’s sole remedy against the other for loss or damage arising out of the performance or non-performance under this Agreement shall be proven direct, actual damages. Neither party shall be liable to the other for any indirect, punitive, incidental, reliance, special or consequential damages arising out of its performance or non-performance under this Agreement, whether or not such party had been advised of the possibility of such damages.

MINORITY OWNED BUSINESSES The City of Anaheim encourages minority -owned business firms to submit proposals. Opportunity to identify your firm is contained within the Special Provisions forms.

NOMENCLATURES The terms Successful Proposer, Successful Contractor, Contractor, Supplie r and/or Vendor may be used interchangeably in these specifications and documents and shall refer exclusively to the firm with whom the City enters into a contract because of this solicitation.

NONDISCLOSURE Until such time that the City Council awards th e contract, the Proposer agrees that its proposal shall not be made available to any individual or organization without the prior written approval of the City of Anaheim. The master copy of each proposal shall be retained for official files and will becom e public record after the award of a contract, unless the City of Anaheim determines, in its sole discretion, that the proposal or specific parts of the proposal are exempt from disclosure under California law.

NON-COLLUSION AFFIDAVIT Proposers are required to submit a Non-Collusion Affidavit with their Proposals.

See enclosed Affidavit.

OFFERS OF MORE THAN ONE PRICE Unless otherwise specified within these RFP documents, Proposers are not allowed to submit more than one proposal.

OPENING OF PROPOSALS The City of Anaheim reserves the right to postpone the Submission Deadline and opening of proposals any time before the date and time announced in the Request for Proposals or subsequent addenda.

PRE-PROPOSAL CONFERENCE When applicable, a pre -proposal co nference may be scheduled to allow 14 Proposer’s to view the jobsite and/or ask questions concerning the specifications or proposal content. If a pre-proposal conference is to be held, the date, time, and location will be indicated on the RFP documents, and the conference will be designated to be either optional or mandatory. Proposals will not be considered from suppliers who failed to attend a mandatory pre-proposal conference.

PRICE DISCREPANCIES In the event that there are unit price items in a proposal schedule and the "amount" indicated for the extended price of an item does not equal the product of the unit price and quantity listed, the unit price shall govern and the extended price amount will be corrected accordingly. If there is more than one item in a proposal schedule, and the total indicated for the schedule does not agree with the sum of prices of the individual items, the prices given for the individual items shall govern and the total for the schedule will be corrected accordingly. The Proposer will be bound by said corrections.

PRICES All Proposals shall give the prices proposed, and all other information requested herein, and shall be signed by the Proposer’s authorized representative. Proposal prices shall include everything necessary for the completion and fulfillment of the contract in accordance with the contract documents, except as may be provided otherwise in the contract documents. Any items shown on the plans or details or described in the specifications that are not specifically listed in the proposal item are to be considered included in the proposal item and no additional or special compensation will be allowed. In the event that there is more than one proposal item in the proposal schedule, the Proposer shall furnish a pric e for all proposal items in the schedule, and failure to do so may render the proposal as non -responsive and may cause its rejection. The total amount of the proposal will be the sum of the total prices of all items in the proposal schedule. The total price of unit price items will be the product of the unit price and estimated quantity of the item. In case of discrepancy between the unit price and total price of an item, the unit price shall prevail. If the unit price is ambiguous, unintelligible, or un certain for any cause, or is omitted, it shall be the amount obtained by dividing the amount set forth as the total price by the estimated quantity of the item.

PROPOSAL CONTENT Proposer must describe in detail how he will meet the requirements of this RF P, and may provide additional related information with his proposal. The proposal must be presented in a format that corresponds to, and references, the sections outlined in the Specification or Scope of Work, and must be presented in the same order. Res ponses to each section and subsection should be labeled to indicate which item is being addressed. Proposals should be straightforward and concise and provide "layman" explanations of technical terms that are used. Emphasis should be concentrated on conf orming to the RFP instructions, responding to the RFP requirements, and on providing a complete and clear description of the offer. If a complete response cannot be provided without referencing supporting documentation, you must provide such documentation with the proposal indicating where the supplemental information can be found.

Proposals must include all proposed terms and conditions, including, without limitation, written warranties, maintenance/service agreements, license agreements, lease purchase agreements (if applicable), and the Proposer’s standard contract language.

PROPOSAL COSTS The City is not liable for any costs incurred by Proposers before entering into a formal contract. Costs of developing the proposals or any other such expenses incurred by the Proposer in responding to the RFP, are entirely the responsibility of the Proposer, and shall not be reimbursed in any manner by the City.

PROPOSAL DEADLINE Proposals may be submitted any time before the Submission Deadline. Proposals that do not arrive by the Submission Deadline will be late and will not be considered. Paper proposals delivered before the Submission Deadline but to the wrong City office will be considered non -responsive unless re - delivery is made to the office specified before the Submission Deadline. It is the responsibility of Proposers to allow sufficient time for their proposals to be received by the Purchasing Office before the Submission Deadline. The City will not be held responsible for paper proposals mishandled as a result of the envelope 15 not being properly labeled and delivered, or in the case of an electronic submission, for failure of a Proposer to allow adequate time to fully upload their electronic submission before the Submission Deadline.

PROPOSAL FORMS Proposals must be submitted on the forms supplied, or in the format requested, by the Purchasing Division. If the proposal is submitted in paper format, one original and the requested number of copies must be submitted on or before the Submission Deadline. Proposers shall submit one (1) original proposal marked “MASTER” and the requeste d number of identical copies, clearly marked "COPY".

Envelopes containing the original and the copies should be marked in accordance with the directions found elsewhere in these instructions. If discrepancies are found between the copies, or between the original and any copies, the original "MASTER" will provide the basis for resolving such discrepancies. If one document is not clearly marked “MASTER", the City reserves the right to use the original as the Master. If no document can be identified as an o riginal, bearing original signatures, Proposer's proposal may be rejected at the discretion of the City. For proposals submitted electronically, all required forms must be uploaded in the area provided in the vendor portal.

PROPOSAL MODIFICATIONS Any Proposer who wishes to make modifications to a proposal already received by the City of Anaheim must withdraw his proposal in order to make the modifications. Withdrawals must be made in accordance with the terms and conditions of this solicitation (see Withd rawal of Proposal). For proposals submitted in paper form, all modifications must be made in ink, properly initialed by Proposer’s authorized representative, executed, and resubmitted in accordance with the terms and conditions of this solicitation. Electronic submissions may be withdrawn and resubmitted online. It is the responsibility of the Proposer to ensure that modified or withdrawn proposals are resubmitted before the Submission Deadline.

PROPOSAL OPENING AND RESULTS Only the names of the Proposer s submitting proposals will be posted after opening. After an award is made, proposals received will become public record and made available upon request to the City Clerk.

PROPOSER IS SOLE POINT OF CONTACT The Successful Proposer will be the sole p oint of contact for any resulting contract. The City will look solely to the Successful Proposer for the performance of all contractual obligations that may result from an award based on this RFP, and the awarded Proposer shall not be relieved for the non-performance of any or all subcontractors.

PROPOSER'S BACKGROUND Proposer must provide a company profile. Information required is shown on the enclosed Request for Proposal. If so requested, Proposer must include in their proposal a complete disclosure of any alleged significant prior or ongoing contract failures, any civil or criminal litigation or investigation pending which involves the Proposer or in which the Proposer has been judged guilty or liable.

Failure to comply with the terms of this provision will disqualify any proposal. The City reserves the right to reject any proposal based upon the Proposer’s prior history with the City or with any other party, which documents, without limitation, unsatisfactory performance, adversarial or contentious demeanor, significant failure(s) to meet contract milestones or other contractual failures.

PROPOSER'S REFERENCES Proposers may be required to provide references from similar projects performed for any other clients. Information required is shown on the enclosed Request for Proposal.

QUALIFICATION OF PROPOSERS Each Proposer shall be skilled and regularly engaged in the general class or type of work called for under the contract. The Proposer's experience shall be set forth and submitted in the Proposal. It is the intention of the City to award a contract to a Proposer who furnishes satisfactory evidence that the Proposer has the requisite experience, ability, sufficient capital, facilities, and resources to enable the Proposer to perform the work successfully and properly, and to complete it within the time specified in the contract. To determine the qualifications of the Proposer, the City will weigh any evidence that the Proposer has performed satisfactorily other contracts of like nature, magnitude and comparable difficulty 16 and comparable rates of progress. In selecting the Successful Proposer, consideration will be given not only to the financial standing but also to the general competency of the Proposer for the performance of the work covered and/or specified in the contract documents.

QUESTIONS AND COMMENTS Questions and comments regarding this solicitation must be submitted electronically through the vendor portal no later than ten (10) days before the Submission Deadline, unless a different date is stated in the specific RFP. The questioner's company name, phone, email address, and contact person must be included with the questions or comments. Answers made by the City will be posted electronically in the vendor portal. Attempting to obtain information from anyone other than the named point of contact for this RFP is strictly prohibited. Communications about this RFP with other City staff or elected officials, or other efforts to influence the outcome of the RFP process may result in disqualification or rejection of the offending company’s proposal.

REJECTION OF PROPOSALS, WAIVER OF INFORMALITIES The City reserves the right to reject any or all proposals, or any part of a proposal. The City reserves the right to reject the propo sal of any Proposer who previously failed to perform adequately for the City or any other client. The City expressly reserves the right to reject the proposal of any Proposer who is in default on the payment of taxes, licenses, or other monies due the City of Anaheim.

SIGNATURES An individual who is authorized to bind the Proposer must sign the proposal.

SPECIAL PROVISIONS ATTACHMENT The special provisions attachment contains requirements that are hereby incorporated into this request for proposal and w ill become binding contract documents. Please enclose the signed special provisions form and any affidavits, bonds or other required documents with your proposal.

SPECIFICATIONS, DEFINITION The term "specification" as used in this solicitation shall be interpreted to mean all the pages that make up this solicitation, including but not limited to; the Request For Proposals, Instructions To Proposers, Terms and Conditions, Detailed Specifications or Scope of Work, Proposal form(s), Special Provisions, , Subcontractor's List, and Insurance Certificates.

SUBCONTRACTOR’S COMPETENCY In the event subcontractors are allowed, the Successful Proposer will be required to establish to the satisfaction of the City of Anaheim the competency, reliability and responsibility of the subcontractors proposed to furnish or perform 10 % or more of the work described in the contract documents. Before the award of the contract, the City of Anaheim will notify the Proposer in writing if, after due investigation, the City of Anaheim has reasonable objection to any proposed subcontractor. If the City of Anaheim has reasonable objection to any subcontractor the Proposer shall submit an acceptable substitute to the City. Persons and entities proposed by the Proposer to be used as subcontractors, and to whom the City of Anaheim has made no reasonable objection, must be used on the work for which they were proposed and shall not be changed except with the written consent of the City of Anaheim.

SUBMISSION METHOD The City issues and receives most solicitations electronically through the Bid Management Vendor Portal. However, in the event paper proposals are requested, such proposals must be submitted in sealed envelopes a nd should be properly identified with the Proposal number and the Submission Deadline. Telephone, facsimile, or late Proposals will not be accepted or considered.

TAXES Successful Proposer shall pay all federal, state and taxes, levies, duties and ass essments of every nature due in connection with any work under the contract and shall indemnify and hold harmless the City of Anaheim from any liability on account of any and all such taxes, levies, duties, assessments and deductions.

Proposal prices shall include allowance for said taxes.

17 TERMS OF THE OFFER The City reserves the right to negotiate final contract terms with any Proposer selected.

The contract between the parties will consist of the RFP together with any modifications thereto, the awarded Proposer’s proposal, and all modifications and clarifications that are submitted at the request of the City during the evaluation and negotiation process. In the event of any conflict or contradiction between or among these documents, the documents shall control in the following order of precedence: the final executed contract, the RFP, any modifications and clarifications to the awarded Proposer’s proposal, and the awarded Proposer’s proposal. Specific exceptions to this general rule may be noted in th e final executed contract. Proposer understands and acknowledges that the representations above are material and important, and will be relied on by the City in evaluation of the proposal. Proposer misrepresentation shall be treated as fraudulent concealment from the City of the facts relating to the proposal.

WITHDRAWAL OF PROPOSAL Proposers’ authorized representative may withdraw Proposals only before the Proposal Submission Deadline. After that time, Proposers may not withdraw their Proposals for a period of ninety (90) days from the date of opening, unless a different time limit is identified in the specifications of this solicitation. At no time may the successful Proposer withdraw his Proposal.

18 Appendix I – Standard Insurance Language

Note: The following represents ANAHEIM’S standard language for the insurance provisions in its professional services contracts. With few exceptions, the language in the final Agreement will be as shown here. If a proposer has any specific concerns regarding any of the ANAHEIM’s insurance language or requirements, which would render the proposer unable or unwilling to e nter into an Agreement with the City, the proposer shall identify these concerns in its proposal. Deviations from the ANAHEIM’S standard language may be considered by the City in its evaluation of the responsiveness of a proposal.

INSURANCE

Without limiting ANAHEIM’ S right to indemnification, it is agreed that CONSULTANT shall secure, prior to commencing any activities under this Agreement, and maintain, during the term of this Agreement, insurance coverage as follows:

Workers’ Compensation Insurance as required by California law and Employers Liability Insurance in an amount not less than $1,000,000 per occurrence.

Commercial General Liability Insurance , including coverage for Premises and Operations, Contractual Liability, Personal Injury Liability, Products/Completed Operations Liability, and Sexual Abuse and Molestation and Independent CONSULTANT ’S Liability where determined appropriate by ANAHEIM’S R isk Manager, in an amount not less than $2 ,000,000 per occurrence, $4,000,000 annual aggregate, written on an occurrence form. Such insurance shall be written on a primary basis, but may include a deductible or self- insurance retention (SIR) of more than $10,000 per occurrence, provided that such deductible or SIR is disclosed to ANAHEIM in writing, at the inception of this Agreement and approved by the Risk Manager for ANAHEIM.

Comprehensive Automobile Liability Coverage including—as applicable —owned, non-owned, and hired autos, in an amount not less than $2,000,000 per occurrence, combined single limit, as required by California law.

Professional Liability Insurance in an amount not less than $2 ,000,000 per occurrence, and CONSULTANT shall maintain such coverage for at least one (1) year from the termination of this Agreement.

This coverage must include Cyber Liability Insurance where determined by ANAHEIM’s Risk Manager. Such insurance shall be written on a primary basis, but may include a deductible or self-insurance retention (SIR) of more than $10,000 per occurrence, provided that such deductible or SIR is disclosed to ANAHEIM in writing, at the inception of this Agreement and approved by the Risk Manager for ANAHEIM.

Each insurance policy required by this Agreement shall contain the following clause or shall otherwise provide for the following conditions:

“This insurance shall not be cancelled, or limited in scope or coverage, until after thirty (30) days prior written notice has been given to the City Clerk, City of Anaheim, 200 S. Anaheim Blvd., Anaheim, CA 19 92805, except in the event of cancellation for non-payment of premium that shall provide for not less than ten (10) days’ notice.”

20 Each insurance policy required by this Agreement, except policies for Professional Liability and Workers’ Compensation, shall contain the following clauses or shall otherwise provide for the fo llowing conditions:

“It is agreed that any insurance maintained by CONSULTANT pursuant to this Agreement shall be primary to, and not contribute with, any insurance or self- insurance maintained by the City of Anaheim.”

“The City of Anaheim, its officers , agents, employees, representatives and ANAHEIM designated volunteers are added as additional insured as respects the acts, omissions, operations and activities of, or on behalf of, the named insured, in regard to products supplied to, or work or services performed for, or related to, the City of Anaheim.”

Prior to commencing any work under this Agreement, CONSULTANT shall deliver to ANAHEIM insurance certificates confirming the existence of the insurance required under this Agreement, and including the applicable clauses referenced above. Also, within thirty (30) days of the execution date of this Agreement, CONSULTANT shall provide ANAHEIM (i) endorsements to the insurance policies that add to these policies the applicable clauses referenced above, or (ii) in lieu of said endorsements, documentation acceptable to ANAHEIM evidencing that the coverage, terms, and conditions set forth in the above- referenced clauses are otherwise included in said insurance policies. Insurance required hereunder shall be placed with insurers (i) admitted to write insurance in California, (ii) possessing an A. M. Best’s rating of A VII or higher, or (iii) otherwise acceptable to ANAHEIM, with prior written permission from ANAHEIM.

In the event that a claim or other legal action is filed against ANAHEIM, and if ANAHEIM, in its good faith opinion, believes it may have coverage under any of the insurance required herein, then ANAHEIM has the right to demand, and to receive within a reasonable time period, copies of the insurance policies related to such required insurance; provided, however, that this provision shall not apply if the parties agree that CONSULTANT shall fully defend, hold harmless, and indemnify ANAHEIM against any such claim or other legal action.

In addition to other remedies ANAHEIM may have if CONSULTANT fails to provide or maintain any insurance policies or policy endorsements to the extent and within the time herein required, ANAHEIM may, at its sole option:

Order CONSULTANT to stop work under this Agreement and/or withhold any payment(s) that become due to CONSULTANT hereunder until CONSULTANT demonstrates compliance with the requirements hereof:

Terminate this Agreement.

Exercise of any of the above remedies, however, is an alternative to other remedies ANAHEIM may have and is not the exclusive remedy for CONSULTANT ’S failure to maintain insurance or secure appropriate endorsements.

21 Nothing herein contained shall be construed in any way as limiting the extent that an CONSULTANT may be held responsible for payments of damages to persons or property resulting from CONSULTANT’S, (or CONSULTANT’S AGENT or SUB-AGENT, if any) performance of the work covered under this Agreement.

In the event CONSULTANT hires other persons or firms to perform some of the work related to this Agreement, CONSULTANT shall ensure (i) that the acts or omissions of such persons or firms are covered under the above-referenced liability insurance, or (ii) that such firms maintain insurance equal to or better than, and subject to the same limits, terms and conditions as, the insurance required of CONSULTANT under this Agreement (except for firms that are not performing professional services —such firms shall not be required to carry the above -referenced professional liability insurance); and in either instance, CONSULTANT shall provide, or cause to be provided, evidence of such insurance coverage, reasonably acceptable to ANAHEIM.

ANAHEIM’S Risk Manager is hereby authorized to amend the requirements set forth herein in the event that such reduction is in ANAHEIM’S best interest.

22 Appendix II – Standard Indemnification Provision

The following represents the City’s standard language for the indemnification, defense and hold harmless provisions in its contracts. With very few exceptions, the language in the final Agreement will be as shown here. If a proposer has any specific concerns regarding any of the City’s indemnification language that would render the proposer unable or unwilling to enter into an Agreement with the City, proposer shall identify these concerns in their proposal. Deviations from the City’s standard language may be considered by City in its evaluation of the responsiveness of a proposal.

[Note: Proposer should also be aware it is the City’s practice not to enter into Agreements that contain restrictive limitation of liabi lity language or provisions. This includes language and provisions seeking to limit or restrict liability based on cost of services performed or goods provided.]

INDEMNIFICATION

As respects acts, errors or omissions in the performance of professional services, CONSULTANT agrees to indemnify and hold harmless ANAHEIM, its officials, officers, and employees from and against any and all claims, losses, damages, defense costs, or liability, of any kind or nature, arising directly out of the negligent acts, er rors or omissions of the CONSULTANT or any SUB -AGENT in the performance of professional services under this Agreement

As respects all acts, errors or omissions that do not arise directly out of the performance of professional services, including but not limited to those acts, errors or omissions typically covered by general and automobile liability insurance, CONSULTANT agrees to indemnify, defend (at ANAHEIM' S option), and hold harmless ANAHEIM, its officials, officers, employees , agents, and representatives from and against any and all claims, losses, damages, defense costs, or liability, of any kind or nature (collectively referred to hereinafter as “Claims”), arising out of or in connection with CONSULTANT’S (or CONSULTANT'S AGENT or SUB-AGENT, if any) acts, errors, omissions, or work, relative to this Agreement; except for those Claims that arise out of the sole negligence or willful misconduct of ANAHEIM.

The obligations set forth in this indemnification provision (i) shall be in effect without regard to whether or not ANAHEIM, CONSULTANT, or any other person maintains, or fails to maintain, insurance coverage, or a self-insurance program, for any such Claims; and (ii) shall survive the termination of this Agreement.

23 Appendix III – Non-Collusion Affidavit

Note: To be executed by Proposer and submitted with proposal. STATE OF CALIFORNIA County of

, being first duly sworn deposes and says that
he/she is of
, the party making the foregoing bid that such bid is not made in the interest of or on the behalf of any undisclosed person, partnership, company, association, organization or corporation; that such bid is ge nuine and not collusive or sham; that said bidder has not directly or indirectly induced or solicited any other bidder to put in a false or sham bid and has not directly or indirectly colluded, conspired, connived, or agreed with any bidder or anyone else to put in a sham bid, or that anyone shall refrain from bidding; that said bidder has not in any manner directly or indirectly sought by agreement, communication, or conference with anyone to fix the bid price of said bidder or of any other bidder or to fix any overhead profit, or cost element of such bid price, or of that of any other bidder, or to secure any advantage against the public body awarding the contract of anyone interested in the proposed contract; that all statements contained in such bid are true, and further, that said bidder has not directly or indirectly submitted his bid price or any breakdown thereof, or the contents thereof, or divulged information or data relative thereto, or paid and will not pay any fee in connection therewith, to any corporation, partnership, company, association, organization, bid depository, or to any member or agent thereof, or to any other individual except to any person or persons as have a partnership or other financial interest with said bidder in the general business.

Subscribed and sworn to before me this

day of , 20

Notary Public in and for said County and State

24 Appendix IV – References

Using the format below, provide five (5) customer references that are similar in size and project scope to the City. Three of the five references must include agencies with public safety classifications.

Client Reference
Item Vendor Response
Name
Project Description
Contact Name
Contact Telephone Number
Contact E-mail Address
Business Initiation Date

Business End Date
Rationale for Inclusion as a Reference

13 EXHIBIT B

Proposal / Scope of Services

Concentra's Proposal for
Medical Evaluation Services

PRESENTED TO
The City of Anaheim

PRESENTED BY

Dori Haubner
Director of Key Accounts

1101 S. Anaheim Blvd.

Anaheim, CA 92805

Mobile: 949.233.9641
Email: [email protected]

concentra.com 5080 Spectrum Drive, 1200 West Tower, Addison, Texas 75001 • 800.232.3550 October 10, 2022

The City of Anaheim
Human Resources Department
201 South Anaheim Boulevard
Anaheim, California 92805

RE: Medical Evaluation Services

Concentra® is pleased to present to The City of Anaheim (the City) our proposal to provide Medical Evaluation Services, which adheres to all specifications and includes all relevant attachments.

As the City’s incumbent provider for the scope of services and as the nation’s leader in occupational healthcare, Concentra is highly qualified and well positioned to continue performing the services the City is seeking. Our national footprint, strong infrastructure, health care expertise, and commitment to service excellence would provide ongoing tangible benefits for the City – supporting you in your efforts to meet your program objectives.

Concentra draws from a pool of experienced professionals to serve our clients’ needs. We assign an initial point of contact during the procurement and contracting phases and designate operational resources to provide ongoing account management and program support. The operations director would monitor contract deliverables and program expectations to help ensure we achieve successful ou tcomes that effectively meet the program objectives. In addition, the account management team would help ensure the services rendered under the contract remain compliant with all applicable local, state, and federal regulations.

Should you have any questions or concerns regarding our response, please contact Dori Haubner, Director of Key Accounts, via phone: 949.233.9641 or by email: [email protected].

Concentra affirms that:
▪ All information contained herein is current, complete, accurate, and remains valid for 90 days following the due date, October 10, 2022
▪ The City anticipates a contract term of up to three years, with possible options to extend on a year -to- year basis

Concentra values the City’s consideration of our response. We are confident that when our experience and capabilities, geographic footprint, and account management strategy are taken into account, Concentra will emerge as your ideal partner for the requested services. We look forward to the opportunity to continue serving as the preferred Medical Evaluation Services partner with The City of Anaheim and its employees.

Respectfully submitted,

Kathy T. Le, MD, MPH
President and Treasurer
Occupational Health Centers of California, a Medical Corporation dba Concentra Medical Centers DocuSign Envelope ID: BD862BFC-393F-4ADE-8D2E-C0364E8948E8

The City of Anaheim ♦ Medical Evaluation Services

1. Executive Summary ................................................................................................... 3

2. Experience ................................................................................................................. 5

3. Firm Background ........................................................................................................ 9

4. Personnel ................................................................................................................. 10

5. Work Plan ................................................................................................................ 13

6. Reporting ................................................................................................................. 34

7. References .............................................................................................................. 36

8. Contract Performance .............................................................................................. 38

9. Exhibit A – Fee Statement and Proposed Pricing .................................................... 39

10. Attachments ............................................................................................................. 40

The City of Anaheim ♦ Medical Evaluation Services

1. Executive Summary
A letter of introduction signed by an authorized representative of the Firm that provides an executive summary of the Firm’s experience relevant to the scope of work described in this RFP.

The City has unique service specifications and Concentra can deliver customized clinical solutions to help you achieve your program goals and objectives. We treat one in every five work-related injuries/illnesses, more than 18 million since 1979. We maintain policies and procedures to ensure ongoing compliance with standard regulating bodies, including the Occupational Safety and Health Administration (OSHA), the U.S. Department of Transportation (DOT), the Americans with Disabilities Act (ADA), the Family and Medical Leave Act (FMLA), the National Fire Protection Association (NFPA), police officer standards, and many others. Our approach successfully combines evidence-based medicine with our clinical expertise and superior service discipline to deliver convenient access to quality care and measurable cost savings.

A Best-in-Class Occupational Health Model
With a clear and compelling vision and a notable record of accomplishments, we offer our best -in-class solution and a health care experience that is second to none. As clients come to know us, they discover Concentra’s value in everything we do.

Clinical Foundation
Concentra was founded by physicians as a medical practice and the delivery of high -quality medical care continues to be our core competency to this day. We hire and retain some of the finest clinicians in the industry and have established a model for workplace health unequalled in the industry. Concentra’s Medical Expert Panels work to identify health trends, research new treatment approaches, monitor regulatory changes and develop clinical practice guidelines and best practices.

Examples include, but are not limited to:
▪ Developed the FReSH program (Functional Restoration/Status of Healing Scale), a new approach to pain management, which focuses on functional movement and improvements in the healing process.

This program encourages patients to take a more active role in their recovery which means injured employees return to work faster, making your company more productive.

Developed a Sleep Evaluation Worksheet (SEW) used by our clinicians to evaluate individuals in safety sensitive positions for the presence of sleep disorders that may pose a hazard to themselves and their workplace. This was created due to the lack of guidelines in the FMCSA’s Medical Examiner Handbook and to provide consistency and direction for our medical examiners. The SEW incorporates recommendations from the FMCSA’s Medical Expert Panel and the Medical Review Board .

Concentra has also built the clinical infrastructure to keep us at the forefront in workplace health and our Enterprise Quality Improvement Program Committee monitors key quality measures and oversees improvement initiatives.

Expertise and Innovation
Concentra played a significant role in creating the workplace health industry model that exists today. We apply our proven methodologies to occupational medicine and workers’ compensation and have developed evidence-based clinical guidelines to help improve treatment and overall outcomes. We established the Concentra Occupational Health Research Institute (COHRI) in 2000 to promote scientific research and continuing medical education in occupational health.

The City of Anaheim ♦ Medical Evaluation Services

Unmatched Access
With Concentra, your employees have access to our extensive network of nearly 520 Concentra medical centers nationwide. In addition, Concentra Telemed® and Concentra Telerehab® extend access to care beyond the centers’ walls and standard working hours. Our integrated approach ensures continuity of care by leveraging the same electronic medical record and practice model regardless of access point.

Concentra’s Transportation Solution provides injured employees with scheduled and real-time rides to and from Concentra medical centers. Available nationwide, our transportation solution is provided free of cost for employee transportation after initial injury, for follow-up appointments, and for scheduled physical therapy visits. After an employee reports an injury to his/her supervisor, the supervisor calls the local Concentra medical center to request a ride. A few minutes later, a driver sends a text message notifying the employee of the estimated time of arrival for pickup. After the visit, center team members arrange for the employee’s ride back to the workplace or home, depending on the severity of the injury and the treating clinician’s recommended treatment plan. the City’s employees would have prompt access to expert care, convenient rides with no smartphone app or tip required, and reduced time away from work.

Our Mission
Our company mission is to improve the health of America’s workforce, one patient at a time. We take a customized approach that enables us to meet the diverse needs of our customers across the U.S. We attribute our success to our commitment to put our customers’ people first, delivering personalized attention that optimizes employee health and productivity.

The City of Anaheim ♦ Medical Evaluation Services

2. Experience
Explain your organization’s capability to achieve the objectives of this project with reference to prior experience, ability to meet specified timelines, available resources, and the qualifications of your team.

Please include copies of your business license and certifications.

Clinical Experience
Injury Experience
Concentra's injury treatment experience gave rise to our process management approach. We monitor and direct the processes and events that make up the structure and flow of an individual case, all with the focus of achieving the optimal outcome. These processes and events include many variables, such as frequency and timing of injured employee visits, communication with the employer, and referral patterns for consultations and diagnostic testing.

This analysis of comprehensive outcomes data proves that the following factors have a considerable impact on the clinical and cost outcomes:

▪ Treating the injured employee at frequent intervals in the initial period following an injury ▪ Communicating with the employer about the activity/duty status of the injured employee ▪ Monitoring referrals to ensure that the injured employee is evaluated in a timely manner ▪ Paying attention to case closure following release to full-duty activity

Non-injury Experience
Concentra has been performing physical examinations, conducting drug and alcohol testing, and administering immunizations and vaccinations since our inception more than four decades ago. We maintain written guidelines on all relevant regulatory standards and create client -specific service packages tailored to meet the unique needs of each client’s program requirements. Furthermore, we assure that only qualified individuals perform the requested services, in accordance with all local, state, and federal guidelines.

Department of Transportation Experience
Annually, Concentra performs more than 800,000 DOT examinations, making us the nation’s largest provider of screening services for drivers of commercial motor vehicles. We provide DOT physical examinations for employers who operate in various industries, including:

▪ Aviation (FAA)
▪ Trucking (FMCSA)
▪ Railways (FRA)
▪ Public Transit (FTA)
▪ Maritime (MARAD)
▪ Pipelines and Hazmat (PHMSA), and more

Concentra maintains current, comprehensive knowledge of DOT rules and regulations. We require all Concentra physicians to be Federal Motor Carriers Safety Administration (FMCSA) National Registry certified to complete DOT examinations. In addition, Concentra offers the FMCSA curriculum as part of our training program to educate medical examiners on multiple topics within 13 different training modules on FMCSA regulations. Concentra’s participants who complete the program are prepared to:

▪ Apply knowledge of FMCSA’s driver physical qualification standards and advisory criteria to findings gathered during the driver’s medical examination
▪ Make sound determination of the driver’s medical and physical qualifications for safely operating a commercial motor vehicle (CMV) in interstate commerce
▪ Accurately complete the Medical Examination Report Form

The City of Anaheim ♦ Medical Evaluation Services

October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Page 6 As a recognized expert in DOT, Concentra also provides a suite of DOT-related services to keep employers and their drivers safe and compliant, including:

▪ DOT Drug Testing – DOT drug screenings test for the presence of illegal drugs, alcohol, and other substances
▪ Concentra’s Sleep Evaluation Program – Objective and consistent evaluation of drivers who are at a risk of collision due to excessive sleepiness
▪ Concentra is proud of its experience and attributes much of our success to our residen t experts.

Former Concentra physician, Ellison Wittels, MD, FACP, was the former senior consultant to the FMCSA. Dr. Wittels chaired the 2002 Cardiac Advisory Panel, which was empowered to provide cardiac interpretive guidelines to all physicians performing DOT medical examinations. ▪ Due to our vast experience and relationship with the FMCSA, Concentra published a book, “Concentra Guide to Medical Certification of Commercial Drivers,” to create consistent medical interpretations for Concentra physicians. The Concentra Guide integrates and defines the federal standards, medical guidelines, recent literature, and opinion, thus, providing a consistent framework for the medical examiner’s assessment of the DOT-covered participant and determination of fitness.

This led to Concentra physicians creating a training and certification course for non -Concentra physicians regarding DOT examination procedures and interpretations.

The City would benefit from Concentra’s vast experience maintaining the health and safety of commercial drivers.

Firefighter and Police Officers Examination Experience
For nearly 45 years, Concentra has performed examinations for firefighters, police officers, and other safety sensitive positions through our network of freestanding medical centers and employer onsite clinics. Today we provide services to more than 1,500 fire, rescue, and police departments nationwide .

We maintain written guidelines on all firefighter and police officer standards and the regulations specified by the Occupational Safety and Health Administration (OSHA), National Fire Protection Agency (NFPA) Standard 1582, the Americans with Disabilities Act (ADA), and other applicable laws. Our clinicians delivering services have the appropriate certifications to perform the neces sary clinical evaluations.

Firefighter Examination Experience
Evaluating firefighter candidates to determine if they are physically capable of performing the essential functions requires special expertise. Candidates must be evaluated in conjunction wit h NFPA Standard 1582 guidelines — a standard established by individuals with fire safety expertise and approved by the American National Standards Institute. The inherent on-the-job requirements of a firefighter necessitate that candidates have the strength and fitness to crawl or walk extensively, climb stairs/ladders while lifting and carrying heavy objects, wear a self-contained breathing apparatus, ventilate roofs or walls using power tools and/or hand tools, and advance water-filled hoses. Understanding this, Concentra has created physical conditioning procedures and performed job site analyses, physical fitness testing, and more for hundreds of fire departments nationwide. We follow local, state, and federal guidelines, including NFPA and International Association of Fire Fighters / International Association of Fire Chiefs (IAFF/IAFC) standards, to ensure individuals in these positions are fit to perform their essential job functions.

Police Officer Examination Experience
In performing their duties, police officers frequently face strenuous physical situations. They can be involved in combative incidents, including handcuffing, use of restraining devices, batons, locks, grips, holds, self-defense, and body force. As emergency responders, they can be required to run, jump, climb, crawl, walk extensively, lift, carry, drag, pull, balance, and push. In addition, police officers are often subjected to extreme psychological and emotional stress when dealing with aggression, violence, and cruelty, and must intervene in high-pressure, human crisis situations frequently. As such, it is imperative to provide thorough candidate evaluations and pre-screenings, and access to ongoing medical and psychological support for officers, to ensure the overall health and safety of these individuals. Concentra has extensive experience working with hundreds of police departments and other law enforcement The City of Anaheim ♦ Medical Evaluation Services

We adhere to all local, state, and federal guidelines, as well as each agency’s unique standards.

Medical Expertise
Concentra's Clinical Advisory Board (CAB) directs and oversees overall company clinical operations in all Concentra medical centers and onsite clinics. The Board’s goal is to develop and disseminate guidance and policies for all Concentra clinicians in the various areas of patient care to continually improve the quality of health care Concentra provides, remaining relevant and forward-thinking in an evolving health care environment.

In addition, Concentra has developed national Medical Expert Panels to serve as resources to clinicians, clients, and patients. The clinicians on these panels work to identify health trends; research the latest developments; and develop policies, procedures, clinical guidance documents, and processes to ensure Concentra’s treatment and service philosophy adhere to established industry best practices. These clinical experts research the latest medical literature and recommendations of national industry groups.

Information is combined and integrated, then forwarded to our Clinical Advisory Board for review and approval. Once approved, the information is disseminated via continuing medical education courses, clinical bulletins, and direct review with the clinician’s supervisor depending on the topic and relevance to the practice. The City and its employees would benefit from this process which helps to ensure continual clinical program improvement.

Business License and Certifications
We have included our business license in Attachment D – Concentra Business License.

Concentra’s Solution
Concentra has extensive experience performing the requested services and we are confident our expertise and best practices approach to medical evaluation services make us the right company to assist the City in meeting its program objectives.

Concentra would successfully perform the requested scope of services proficiently and in the most cost-effective manner through our extensive network of medical centers, our skilled clinicians and account management team staff, and our operational efficiency.

Concentra assures the City that we would:
▪ Leverage our decades of experience and use company best practices that are compliant with the Department of Transportation (DOT), Occupational Safety and Health Administration (OSHA), and other regulated examinations
▪ Maintain policies and procedures to ensure ongoing compliance with the Americans with Disabilit ies Act (ADA), the Family and Medical Leave Act (FMLA), the National Fire Protection Association (NFPA), California Commission on Peace Officer Standards and Training (POST) , police officer standards, and many others
[Concentra’s longevity in
health care and our
experience serving clients like
the City would prove valuable
during our engagement.]
The City of Anaheim ♦ Medical Evaluation Services

October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Page 8 ▪ Conduct drug screenings in accordance with DOT standard, 49 CFR Part 40 ▪ Utilize a Substance Abuse and Mental Health Services Administration (SAMHSA) -certified, College of American Pathologists-Forensic Drug Testing (CAP-FDT) accredited, and Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory for specimen analysis ▪ Utilize our Anaheim-Orange medical center as the main service site ▪ Employ only properly certified and trained staff to perform the scope of work ▪ Assign a designated team of qualified professionals to oversee [the] the City’s program and ensure continued compliance
▪ Document patient visits and generate meaningful reports ▪ Maintain records securely to ensure confidentiality of personal health information in accordance with the guidelines outlined by the Health Insurance Portability and Accountability Act (HIPAA)

We have the experience and resources, and qualified personnel, and are readily able to serve the City efficiently and professionally.

The City of Anaheim ♦ Medical Evaluation Services

3. Firm Background
Describe the organization, date founded and ownership of your firm. Specify the number of years your organization has been developing and administering examinations for public safety agencies.

History and Background
Concentra was founded by physicians in 1979. Since then, we have grown to be the largest provider of occupational health services in the country. Our footprint includes nearly 520 medical centers in the United States with unmatched occupational health expertise and clinicians. We know how to deliver care that works for companies and their employees.

Operating as a division of Select Medical, Concentra is a leading health care company focused on improving the health of America’s workforce, one patient at a time. Through its affiliated clinicians, the company currently provides occupational medicine, urgent care, physical therapy, and wellness services from nearly 520 medical centers nationwide. In addition to these medical center locations, Concentra currently serves employers by providing a broad range of health advisory services and operating nearly 140 onsite clinics.

▪ One in every five workplace injuries in the United States is treated at Concentra ▪ Concentra treated more than 18 million injured workers since 1979 ▪ Largest urgent care and occupational health care provider in the United States ▪ Concentra performs more than 2 million physicals and 3.1 million drug screens annually ▪ 60,000 patients seen at Concentra onsite clinics and medical centers each day ▪ Concentra has 239,000 clients and nearly 520 medical centers nationwide in markets representing 60 percent of the nation's workforce
▪ Concentra treats more than 500,000 initial injuries each year ▪ Concentra partners with 85 percent of Fortune 500 companies and all the Fortune 100

Organizational Structure
Concentra is wholly owned by Select Medical Corporation, a subsidiary of Select Medical Holdings Corporation, a publicly held corporation and leading operator of specialty hospitals and outpatient clinics in the U.S.

Concentra structures all transactions, physician
compensation models, and agreements to comply
with the requirements set forth in the Stark Law.

Several states have a corporate practice of medicine
restriction and we are structured throughout the
country to comply with such restrictions.

Specifically, Concentra Health Services, Inc.
(Concentra) acts as an administrative manager to
more than 40 professional associations (PA) and/or
professional corporations (PC) affiliated with
Concentra. Medical professionals (physicians,
physical therapists, and mid-levels) employed by
professional associations/corporations provide all
professional services. Concentra, pursuant to a
Management Services Agreement entered into
between Concentra and the applicable professional association/corporation, provides a ll non-medical services necessary for the operation of a medical practice.

For the City’s program, we would provide services as Occupational Health Centers of California, a Medical Corporation dba Concentra Medical Centers, to provide occupational health care services within the state.

The City of Anaheim ♦ Medical Evaluation Services

4. Personnel
1) Identify the number of professionals employed by your firm, by classification. 2) Describe the proposed project team, including role they will play, title and years at firm. Include relevant work experience.
3) Identify key personnel responsible for accomplishing all phases of the contract .

Key Personnel
Concentra carefully considers each project and its unique goals when assigning an account management team. We take a collaborative approach that combines local operational and clinical support to ensure quality and service excellence. The individuals we select bring valuable, relevant experience to the program and provide ongoing support within their respective areas of expertise.

Initial Contact
Dori Haubner, Director of Key Accounts, would be responsible for ensuring Concentra colleagues know and understand your program requirements and would be available to answer your questions throughout the solicitation and initial phase of engagement.

Operational Oversight
Jennifer Nunez, center operations director, would serve as the day-to-day contact for program operations. This individual regularly monitors processes and procedures to ensure ongoing compliance with applicable regulations and guidelines, as well as program specifications. The Center Operations Director (COD) is invaluable to the success of the program and is available to answer questions, address issues, and ensure the program continues to operate efficiently.

▪ Serves as the liaison between Concentra and the City
▪ Oversees day-to-day medical center operations
▪ Implements and ensures ongoing compliance with operational policies, procedures, and training programs within the center
▪ Manages patient care issues and other center issues requiring resolutions ▪ Establishes a clear understanding of contract objectives and deliverables to ensure successful execution of programs and projects
▪ Collaborates with center, area, and regional leadership teams to ensure we effectively deliver the stipulated scope of work, monitors program outcomes, and maintains the City’s account

Medical Oversight
Siena Ona, center medical director, would provide primary oversight for clinical practices, ensuring continued compliance. The Center Medical Director (CMD) ensures that medical interpretations and associated clearances comply with the most recent medical standards and guidelines and adhere to applicable regulations. The CMD’s expertise relevant to the desired scope of work is instrumental in the provision of services.

▪ Reviews medical history and performs medical physical examinations ▪ Reviews medical evaluations conducted by other center clinicians Credentials
▪ 2 years 10 months with Concentra
▪ 35 years of experience

Credentials
▪ 5 years with Concentra
▪ 3 years of experience
▪ MBA – University of Redlands
Credentials
▪ 10 years with Concentra
▪ 11 years of experience
▪ Doctor of Medicine (MD)
The City of Anaheim ♦ Medical Evaluation Services

October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Page 11 ▪ Understands all medical surveillance requirements of the Occupational Safety and Health Administration (OSHA), the U.S. Department of Transportation (DOT), the National Fire Protection Association (NFPA), police officer standards, the Americans with Disabilities Act (ADA), the Family and Medical Leave Act (FMLA), and other regulated examinations ▪ Reports the results of the medical evaluation to the employee, including any medical condition(s) identified during the evaluation
▪ Provides the recommendation as to whether the employee is medically certified to safely perform the essential job tasks
▪ Forwards copies of any abnormal results, along with instructions regarding primary care follow -up, to individuals who are instructed to seek medical follow-up to address any medical conditions or abnormal laboratory results identified during an evaluation ▪ Provides or arranges for a prescriptive rehabilitation and/or fitness program, when indicated, to aid in an employee’s recovery from illness or injury and enhance his/her ability to safely perform essential job tasks
▪ Reviews individual medical evaluations and aggregate data to detect evidence of occupational exposure(s) or clusters of occupational disease

Physical Therapy and Functional Testing Oversight
Eric Sato, PT, center therapy director, would provide oversight for the physical therapy and functional testing services rendered as part of the program. The Center Therapy Director (CTD) is an expert in this field and possesses a wide breadth of knowledge overseeing physical therapy and functional testing services for other area clients. Using this expertise, the CTD delivers services that objectively assess an employee’s functional abilities and expedite the return -to-work process.

▪ Conducts an initial evaluation on clinician referrals and develops appropriate treatment plans ▪ Ensures treating clinicians have the necessary information to appropriately evaluate an employee’s functional ability
▪ Communicates with all clinicians and with the employer regarding an employee’s diagnoses, sets expectations for return-to-work, emphasizes education and motivation, and discusses specific rehabilitation issues and early intervention opportunities ▪ Utilizes knowledge of best demonstrated practices and quality indicators to evaluate and measure program effectiveness, and implements methods to improve processes and outcomes ▪ Ensures compliance with guidelines and regulations established by the Americans with Disabilities Act (ADA) and by the relevant licensing, certification, and accrediting bodies

Center Staff
Concentra employs skilled and experienced health care professionals to deliver services relevant to our offering. Center staff includes an appropriate combination of physicians, mid-levels, nurses, physical therapists, radiology technicians, and medical assistants.

Clinical Professionals
Concentra utilizes qualified and appropriately licensed and credentialed clinical professionals to serve the occupational health needs of a client's workforce. These professionals are skilled in their respective areas of expertise and undergo extensive annual training in addition to continuing education classes.

Furthermore, our clinical professionals are vigilant in applying their knowledge to recognize and diagnose potential exposures and resulting health issues. They regularly monitor OSHA, DOT, NFPA, police officer standards, ADA, and other applicable federal and state regulations to ensure all associated services remain in compliance and adhere to best practice guidelines.

Credentials
▪ 20years with Concentra
▪ 24 years of experience
▪ DPT - CSULB
The City of Anaheim ♦ Medical Evaluation Services

October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Page 12 Support Staff
Concentra employs qualified support personnel whom we train and fully certify to perform their associated tasks. Specifically, our center support staff includes drug specimen collectors certified to perform DOT collections, certified breath alcohol technicians, National Institute for Occupational Safety and Health (NIOSH)-certified pulmonary function testers, Council for Accreditation in Occupational Hearing Conservation (CAOHC)-certified personnel to perform audiometric testing, certified radiologic technologists, certified medical assistants, and certified phlebotomists.

Credentialing Practices
All Concentra clinicians undergo a stringent credentialing process. Once the Credentials Committee Chair/Medical Advisor clears the candidate for hire/credentialing, we follow National Committee for Quality Assurance (NCQA) guidelines for credentialing, which require primary source verification of licensure, education and training, board certifications, and any provider sanctions. In addition, we perform a System for Award Management (SAM) query to identify if a candidate is barred from contracting with the federal government and use secondary sources (copies of documentation) to verify Drug Enforcement Administration (DEA) and state-controlled substance certifications. Finally, we check the National Practitioner Databank for malpractice history and the Office of Inspector General (OIG) for Medicare/Medicaid sanctions. We re-credential our clinicians every three years and, in the interim, we monitor clinicians’ licensures to ensure that they remain active and current.

All Concentra personnel, regardless of position, are required to have a background check consisting of a felony/misdemeanor check, Social Security validation and trace, national sex offender check (for staff rendering patient care), national criminal search, drug screen, and a check against the Office of Foreign Assets Control list.

The City of Anaheim ♦ Medical Evaluation Services

5. Work Plan
Provide a detailed description of how your organization intends to provide the services outlined in this RFP. The descriptions should be formatted to enable the City to evaluate the Proposer’s capability to effectively coordinate and manage medical services review. Consultant is free to comment on any other medical services review-related activities or initiatives your organization would recommend and assist in implementing.

Approach to Performing the Scope of Work
In the following pages, we provide service descriptions for providing the City’s requested scope of work.

While these service descriptions highlight our standard approach, we have the expertise and resource to render all services per the City’s specifications and in full compliance with all applicable regulatory requirements.

Facility Overview
Concentra medical centers offer a full complement of health care services including, but not limited to, substance abuse testing, physical examinations, clinical services, vaccinations, injury care, physical therapy, and wellness screenings. Our centers offer convenient weekday operational hours, and many locations also offer evening and weekend hours.

We continually evaluate the layout of our centers to accommodate patient flow and volume. Therefore, the physical dimensions, layout, and staffing of each center vary depending on the location and overall scope of services. Our centers average between 3,100 and 9,000 square feet in size. The centers maintain security services, and most offer free parking on the center property or adjacent to the center. All facilities are accessible (ADA-compliant) and conform to all applicable federal, state, and local safety and disability laws.

As described in the following table, each center’s layout consists of support/common areas and clinical areas.

Support/Common Areas
▪ Waiting room – seating for
patients with a television and
magazine/coffee bar
▪ Business office – work area for
clerical staff
▪ Manager office
▪ Break room
▪ Marketing office
▪ Restroom
▪ Records storage area
▪ Telephone/electrical area
Clinical Areas
▪ Procedure rooms (for minor
procedures)
▪ Examination rooms
▪ Lab area – separate restrooms
(ADA-compliant) for drug and
alcohol collections
▪ Breath analysis/exam room – to
maximize privacy for federally
mandated testing
▪ Audio testing room – a single-
person booth
▪ Physician office
▪ Physician station – with X-ray
viewing areas and privacy to
enter patient data into
computer system
▪ X-ray facilities – a full-service
X-ray room and digital file
storage
▪ Storage area – for patient
charts
▪ Physical therapy area with
whirlpool, treatment areas,
strength and flexibility
equipment,
hydrocollator/freezer, and a
wide variety of therapy
modalities

Service Sites
Concentra proposes that our center closest to the City, the Anaheim-Orange center, serve as the primary site for employees to obtain medical evaluation services. While the Anaheim-Orange center is fully capable of providing all required services in one facility, all Concentra medical centers are available as convenience necessitates. All Concentra medical centers maintain the essential staffing resources, The City of Anaheim ♦ Medical Evaluation Services

October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Page 14 required equipment, and licensed and credentialed clinicians to perform your requested scope of services. Please note that hours are subject to change.

Concentra Medical Centers the City area

Multilingual Support
Through our nationwide network of Concentra Medical Centers and employer onsite clinics, Concentra has acquired extensive experience with multilingual populations. To accommodate multiple language requirements, we use remote translation services through our preferred provider, Voiance. This 24/7 service supports more than 200 languages and dialects, including American Sign Language. Also, many Concentra centers are staffed with clinician’s and office staff who are bilingual, and recruiting bilingual staff is another option, where a specific engagement requires.

In addition, our marketing department can translate promotional material and center messaging into other languages. Additional fees may apply for translation services.

Telemedicine
Concentra Telemed is the first telemedicine platform designed for the treatment of work-related injuries and illnesses. Since its launch in 2017, thousands of employees nationwide have trusted Concentra Telemed clinicians to provide the right care at the right time — no need to leave work or home. Using a smartphone or computer, an employee can connect with a licensed Concentra clinician and receive immediate attention to minor medical issues, work injury care rechecks, physical therapy, and more.

In addition, Concentra has recently expanded its offering. If you and/or your employees have an existing relationship with a center and want to continue working with the team you know and trust, telemedicine visits can be arranged by calling the center directly. Contact information for all Concentra medical centers is available on Concentra.com. Services will be provided during current hours of operation and include:

▪ Initial treatment of minor, work-related injuries and illnesses ▪ Rechecks for employees who were previously seen at a Concentra medical center ▪ Concentra Telerehab® for employees who were previously seen at a Concentra medical center and want to continue physical therapy regimens at home
▪ Return-to-work evaluations for asymptomatic employees with possible exposure to COV ID-19

Concentra Telemed and Concentra medical centers use the same patient management system and electronic medical record allowing employees to experience a continuity of care regardless of the access point of care. In addition, utilizing the same patient management system that holds the employer’s existing account and service instructions, allows for the expedited exchange of information for accurate and timely reporting, claim management, and billing.

Occupational Health Services
Physical Examinations
Concentra has comprehensive policies and procedures outlining examination requirements in accordance with DOT, OSHA, ADA, and general occupational health. We assure the City that a trained and Anaheim-Orange Concentra Medical Center
Address
1101 S. Anaheim Blvd.

Anaheim, CA 92805
Located 1.1 miles from the City
Contact Information
T 714.937.1919  F 714.937.1095

Hours of Operation*:
24 hours 7 days a week
The City of Anaheim ♦ Medical Evaluation Services

October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Page 15 appropriately licensed medical professional would perform the required examinations and adhere to all applicable regulations and guidelines specific to the examination.

Medical and Work History Questionnaire
Prior to any physical examination, an employee completes a thorough medical history questionnair e that includes personal, occupational, family, and medication history. Our comprehensive medical and work history questionnaires ensure your employees are compliant with all federal, state, and local mandates specific to their job category.

After reviewing the questionnaire, Concentra’s clinician performs a comprehensive physical examination and reviews the questionnaire in conjunction with the employee’s test results to make the appropriate medical recommendations. Concentra immediately addresses any findings that pose immediate danger to the life or health of the employee.

FormFox Electronic Forms
Concentra uses the FormFox system to electronically capture the employee’s medical history and questionnaire. The employee completes the form online before coming to the clinic/medical center, or upon arrival, thus ensuring legibility and completeness (the system prevents skipping sections).

For DOT physicals, if the driver is certified, the medical examiner's certificate (MEC) is provided in the center post-visit. All determinations are reported to the National Registry of Certified Medical Examiners (NRCME) per regulations.

Custom and Spanish Forms
Concentra has custom medical and work history questionnaires in both English and Spanish and can provide an array of comprehensive and mandated questionnaires necessary to maintain compliance.

Types of Physical Examinations
Standard Examination Components
Concentra would provide physical examinations according to the City’s requirements. However, it is customary for the standard examination to include the following components:
▪ Medical history
▪ Occupational history
▪ Vital signs
▪ Vision acuity (far distance)
▪ Examination of head, eyes, ears, nose, and throat
▪ Evaluation of the cardiovascular system
▪ Evaluation of the respiratory system
▪ Gastrointestinal examination
▪ Musculoskeletal examination
▪ Neurological evaluation
▪ Skin and lymphatic examination

We would also perform other ancillary testing as requested and/or indicated, upon the City’s approval and consistent with evidence-based medical standards and regulatory requirements.

Pre-placement/Post-offer Physical Examinations
Concentra realizes that any medical examination must be “job-related and consistent with business necessity” (29 CFR 1630.14(b)). Pre-placement/post-offer physical examinations help ensure employees or prospective employees do not have a medical condition that:

▪ Prevents safe performance of the essential job duties ▪ Can be exacerbated by the job duties
▪ Affects the safety of the employee, co-workers, or others in the workplace

Fitness-for-Duty Examinations
Fitness-for-duty examinations help ensure that employees can safely perform their job functions.

Concentra therapists and clinicians are specifically trained to assess fitness for duty for injured The City of Anaheim ♦ Medical Evaluation Services

October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Page 16 employees and for employees who have medical conditions that could limit their ability to perform essential job functions.

A fitness-for-duty examination is performed when an employee:
▪ Has observable difficulty performing work duties in a manner that is safe for the employee, his/her coworkers, the employer, or the public, as determined by the employee’s supervisor ▪ Poses an imminent and serious safety threat to self or others ▪ Returns to work from a non-work-related illness or injury

When an employee meeting the above conditions is referred to Concentra, our clinicians begin to implement our well-coordinated evaluation to identify issues that may be affecting performance. This begins with a comprehensive evaluation and communication with the employer to determine if the employee can return to his/her normal job or if a limited-duty arrangement is indicated. Our clinicians apply a three-phase methodology:

▪ Phase 1: Our clinicians work to understand the various jobs in the workplace and perform evaluations to ensure the employee can meet the essential job functions. We educate the employee on how to enhance function and encourage support from his/her supervisor. ▪ Phase 2: The employee undergoes a clinical examination to determine if he/she is medically able to perform his/her job; this may include a job-specific functional test. Once the medical evaluation is complete, Concentra’s physical therapist conducts functional testing. In cases where the employee has other medical conditions (e.g. recent surgery or a cardiac condition), we seek clearance from the employee’s primary care physician to proceed.
▪ Phase 3: Upon completion of the functional testing, our physical therapist provides the results to our physician, who combines the medical and functional test results and renders an overall “able to" or "not able to” return-to-work decision. If our clinicians believe additional testing is required to render a proper medical decision, we would seek the City’s authorization to proceed.

Return-to-work Examinations
Concentra’s longstanding methodology and practices expedite employees’ safe and sustainable return to work. Our process includes immediate communication with the employer, careful job analysis, and a focus on avoiding or limiting an employee’s lost time from work.

During a return-to-work physical examination, in addition to a review of the employee’s medical history and existing documentation, the clinician performs a basic medical examination. The clinician determines if the employee is medically able to proceed with the functional performance evaluation. If the employee has a medical condition that precludes participation in a functional performance evaluation (e.g., recent back/knee/shoulder surgery, an active hernia, a cardiac condition), we require clearance from the employee’s personal physician prior to the functional evaluation.

Once the employee has completed the required functional tests, the Concentra therapist documents a “pass/fail” result and the results are given to the clinician. The clinician then combines the medical results with the functional test results to render an overall “pass/fail” result for the employee. In some cases, our examining clinician may require additional testing to render a medical decision. However, we do not conduct any additional testing without authorization by the designated employer contact.

Medical Surveillance Examinations
Concentra performs medical surveillance examinations for employees who may be exposed to potentially hazardous substances and conditions. Our medical surveillance services include Baseline Surveillance Examination, Baseline Follow Up, Periodic Surveillance Examination, Biologic Monitoring, and Exit Surveillance Examination. These exams vary by the type of exposure, as every kind of exposure has specific requirements defined by the Occupational Safety and Health Administration (OSHA). We maintain medical surveillance exam clinical guidelines for the most common exposure types and employ skilled personnel trained in examination components. Concentra assures that all exam components and results reposting are in accordance with current OSHA regulations.

The City of Anaheim ♦ Medical Evaluation Services

October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Page 17 Regarding medical surveillance examinations, Concentra:
▪ Renders medical services and abides by the reporting standards in accordance with OSHA requirements including, but not limited to, the following:
 1910.120. Hazardous waste operations and emergency response  1910.134. Respiratory protection
 1910.1001. Asbestos exposure
 1910.1024. Beryllium
 1910.1030. Bloodborne pathogens
 1910.1053. Respirable crystalline silica
▪ Follows the recommendations of the Centers for Disease Control and Prevention (CDC) ▪ Ensures all personnel who perform associated clinical testing maintain the appropriate certifications from National Institute for Occupational Safety and Health (NIOSH) and Council for Accreditation in Occupational Hearing Conservation (CAOHC) to perform such testing (e.g., audiograms, pulmonary function tests, etc.)

Department of Transportation (DOT) Physical Examinations Concentra has been performing Department of Transportation (DOT) physical examinations for employers for the past 40 years. Annually, we perform more than 800,000 DOT physicals. We maintain comprehensive policies and procedures for these examinations and thoroughly train our staff on each testing component. The Federal Motor Carrier Safety Administration (FMCSA) provides the physical requirements for commercial motor vehicle (CMV) drivers in 49 CFR 391.41. (Other DOT agencies may have prescribed different physical standards for their safety sensitive roles, such as pilots, rail conductors, etc.)

The purpose of the DOT examination is to detect the presence of physical, mental, or organic conditions of such a character and extent as to affect the driver’s ability to safely operate a commercial motor vehicle. The examination must be conducted carefully and include (at least) all information requested in the applicable form. A history of certain conditions may lead to a disqualification or indicate the need for further testing and/or an evaluation by a specialist.

Medical Examiner’s Certificate
The DOT physical exam is performed by a certified medical examiner listed on the National Registry of Certified Medical Examiners. The exam includes a review of the employee's medical history; a physical exam with vital signs, vision, and hearing testing; and a urine test for blood, protein, and sugar to look for conditions that may impact a driver's ability to safely operate a vehicle. Following the examination, the results are automatically reported to the National Registry and state motor vehicle agencies, as required.

If the driver passes, the ME provides the required Medical Examiner’s Certificate (MEC). The ce rtificate may be issued for up to 24 months; however, the Concentra ME may limit certification based on a driver's medical history.

Firefighter Physical Examinations
Concentra conducts comprehensive physical examinations of firefighters. To begin, we requ ire firefighters to complete a medical history questionnaire, which includes medical, personal, occupational, family, and medication history. A Concentra clinician reviews the questionnaire and performs a thorough physical examination, which focuses on the firefighter’s ability to meet the physical demands required to perform the essential job functions identified by the fire department. The clinician also performs a medical examination to reveal any health conditions that could adversely affect job perform ance.

Examples of essential functions tested include:
▪ Lifting/carrying – Simulates the height/weight of a fan, jaws of life, chain saw, or portable ladder ▪ Pushing/pulling – Simulates the pulling/carrying the hose off the truck to the scene/fire hydrant ▪ Upper body push/pull – Simulates coupling the hoses to the hydrant/truck, using hand tools, and opening doors
▪ Climbing – Simulates accessing the fire ladder to reach victims and climbing stairs in structures The City of Anaheim ♦ Medical Evaluation Services

In addition, clinicians assess the firefighter for aerobic capacity, muscular strength and flexibility, and cardiovascular endurance. Concentra offers a variety of assessment testing including, but not limited to, the following:
▪ Body fat composition
▪ Sit/reach flexibility test
▪ Maximum muscular upper and lower body strength (hand-grip strength, pushups, curl-up muscle endurance)

Please note, assessment testing components may not be included if the individual has already passed a physical abilities test.

NFPA Standard 1582
Concentra performs National Fire Protection Agency (NFPA) and International Association of Fire Fighters (IAFF) examinations for hundreds of municipalities across the United States. We maintain written protocols on all NFPA and IAFF standards and ensure that all personnel who deliver services have the appropriate certifications to perform audiograms, pulmonary function tests, and stress testing. Furthermore, we have physical conditioning protocols and perform job site analyses, physical fitness testing, and more to meet NFPA requirements for our clients.

Concentra recognizes that appropriate physical condition is essential to a firefighter’s safety, as well as the public’s safety. As such, we share the City’s responsibility to ensure firefighters have the requisite physical and cardiac fitness to perform the essential job functions. Understanding the environmental conditions (including required use of personal protective equipment) in which firefighters perform, we assess their cardiovascular and muscular fitness, and follow fitness guidelines that address the physiological and psychological demands they face on the job.

Our Clinicians’ NFPA Expertise
Concentra clinicians are experts in their field and go through extensive occupational health care training specific to firefighters, in accordance with National Fire Protection Agency (NFPA) gu idelines. They:

▪ Understand the physiological, psychological, and environmental demands placed on fire fighters ▪ Evaluate fire department candidates and employees to identify medical conditions that could affect their ability to safely respond to emergency operations ▪ Utilize the essential job task descriptions provided by the fire department to determine a candidate's or member’s medical certification
▪ Identify and report the presence of disqualifying medical conditions ▪ Inform the fire department chief or designee if/when a candidate or current member is assessed as medically fit to safely perform the essential job functions

Confidentiality
Concentra maintains the confidentiality of all medical data. Information firefighters provide to our clinician would not be inappropriately shared. No fire department supervisor or manager shall have access to medical records without the express written consent of the employee. There are occasions, however, when specific medical information is required to make decisions regarding placement, return to work, and so forth. In these cases, written consent shall be obtained from the employee prior to release of specific medical information.

Police Officer Physical Examinations
Concentra conducts police officer examinations according to the employing agency’s examination requirements. In addition, for identified safety-sensitive positions, Concentra performs a medical history [Concentra maintains written
protocols on all NFPA
standards and ensures that
our personnel have the
appropriate certifications to
perform audiograms and
pulmonary function tests.]
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October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Page 19 and physical examination designed to detect any of the following outlined conditions that may affect th e individual’s job function:

▪ Angina pectoris
▪ Asthma
▪ Cancer-metastatic or leukemia
▪ Cardiac arrhythmias or murmurs
▪ Cerebral vascular accident
▪ Chest pains of unknown origin
▪ Contagious hepatitis
▪ Contagious tuberculosis
▪ Chronic respiratory disease
▪ Diabetes, insulin-dependent or ketosis-prone
▪ Fixation of major joint
▪ Hearing
▪ Herniated lumbar disc
▪ Hypertension, uncontrolled
▪ Inguinal hernia
▪ Liver or renal dysfunction
▪ Migraine headache
▪ Myocardial infarction, history of
▪ Paralysis
▪ Prosthetic device, e.g., limbs, hearing aid,
colostomy
▪ Recurrent dislocation of a major joint
▪ Schizophrenia or manic-depressive psychosis
▪ Scoliosis greater than 15 degrees
▪ Seizure disorders
▪ Current substance abuse
▪ Valvular heart disease, uncorrected
▪ Vision
▪ Wasting disease, chronic, such as multiple
sclerosis, myasthenia gravis, or amyotrophic
lateral sclerosis

The examining physician records the findings of the medical examination on the prescribed form, and indicates whether a limiting medical, physical, or mental circumstance exists – describing how the circumstance affects the officer’s ability to perform his/her duties and specifying the type and duration of treatment required. Infectious disease screenings and immunizations are completed, as needed, based on the individual’s health history.

ADA-compliant ADApt®
Concentra developed ADApt®, a pre-placement and return-to-work process, in response to our clients’ needs to make objective employment decisions, retain healthy and physically adept employees, and maintain compliance with the Americans with Disabilities Act (ADA).

The ADA does not prevent employers from obtaining medical and related information necessary to evaluate the ability of an applicant or employee to perform essential job functions or to promote health and safety on the job. However, to protect individuals with disabilities from employment actions based on information that is not job-related and consistent with business necessity, the ADA imposes specific obligations on the employer at the following three stages of the employment process:

▪ Prior to making a job offer, an employer may not make any medical inquiry or conduct any medical examination.
▪ Following a job offer, an employer may make unrestricted medical inquiries, but may not refuse to hire an individual with a disability based on results of such inquiries, unless the reason for rejection is job-related and justified by business necessity.
▪ After employment, any medical examination or inquiry required of an employee must be job -related and justified by business necessity; exceptions are voluntary examinations conducted as part of employee health programs and examinations required by other federal laws.

Challenges of ADA compliance for the employer and occupational medicine provider include:
▪ The essential functions of each job must be determined. ▪ Any examination performed to provide recommendations regarding employment must be job-related and consistent with business necessity.
▪ All recommendations and resulting employment decisions must be consistent for all job applicants. ▪ The confidentiality of medical information must be maintained.

The ADApt program:
▪ Ensures the pre-placement medical examination tests for the essential job functions The City of Anaheim ♦ Medical Evaluation Services

October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Page 20 ▪ Provides documentation of readiness of an applicant being placed in the appropriate job (and/or an injured employee being able to return to work)
▪ Furnishes the medical provider and employer with definitive information regarding essential functions of each job with measured criteria
▪ Assists in the reduction of workers’ compensation costs by identifying employees who can safely perform the essential functions of the job

Together, the human performance evaluation (HPE) and medical exam allow the clinician to determine a person’s ability to perform essential job functions, which is critical to the client when making objective employment decisions.

ADApt consists of the following components:

Component Purpose
Job-site Evaluation Assist the employer in defining the physical abilities necessary to perform essential functions of specific jobs
Pre-placement/
Return-to-work Evaluation
Correlate the worksite evaluation information with a clinical evaluation that is “job related and consistent with business necessity” This evaluation allows the employer to medically determine a person’s ability to perform the essential job functions and objectively assess risk or direct threat
Education and Installation Establish the ADApt compliance program for the employer Analysis and Compliance Provide the employer with the necessary consistency of employment actions resulting from medical recommendations, and ensure confidentiality of medical information

Job-site Evaluation
When performing the job-site evaluation, the physical therapist:

▪ Defines the physical abilities necessary to perform essential functions of the job with the employer supervisor
▪ Measures all physical abilities necessary to perform essential functions of the job ▪ Verifies with employees that the functions are essential ▪ Submits the job-site evaluation to the employer supervisor for confirmation

The job-site evaluation results in the following:

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October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Page 21 Task Description Human Performance Evaluation (HPE)
The task description is a detailed listing of the
functional and non-functional requirements and
associated tasks involved in job performance. Task
descriptions can be created in approximately 14 to 21
days, depending on the volume of jobs to be
constructed. Task descriptions are reviewed and
approved by client management.

The HPE is the job-related functional test used in the
pre-placement or return-to-work exam process. The
physical therapist requires seven to 10 days to create
the HPE. Testing can commence within one week of
the client’s approval of the task description.

Human Performance Evaluation/Job-specific Functional Testing Following the job-site evaluation, our specialist develops an ADA-compliant, job-specific functional test that we refer to as a human performance evaluation (HPE). The HPE assesses individuals on the ability to perform the essential job functions (EJFs) and can be used for pre-employment and return-to-work testing.

The Concentra physical therapist begins by defining each physically distinguishable task involved in the job (i.e., lifting, carrying, pushing, pulling, etc.), including those tasks that have a definitive starting and ending point, occur with regularity, and require a level of quantifiable physical exertion. For each qualified biomechanical functional requirement, the physical therapist uses a force gauge to measure external weights, starting and ending heights, task frequencies, forces produced or overcome , climbing requirements, and more. This process adheres strictly to evaluation techniques that have a direct correlation to the functional requirements.

HPE Components
Once the therapist has measured the EJFs, an HPE is developed to recreate the exact p hysical demands of the job as measured in the biomechanical evaluation. The job-specific functional test may include assessing any combination of the tasks listed below. However, this is not an all-inclusive list.

▪ Lift/Carry: "Vertically translating" or moving an object from a definitive starting height to a definitive ending height; start/end heights are measured at location of hands ▪ Push/Pull: Total body push/pull; manual or using assistive device (i.e. pallet jack) ▪ UE PU/PL: Upper extremity push/pull; no lower extremity involvement; manual or using assistive device
▪ Couple: True "grip" force required to perform action (e.g., activate power tool) ▪ CLIMBL: Accessing a ladder to perform job task
▪ CLIMBS: Accessing stairs/steps to perform job task
▪ Walk: Distance traveled during shift
▪ Confined Access (Con Acc): Dimensions of a space to be accessed (e.g., manhole) ▪ Repetitive Posture Assumption (Rep Pos): To access specified distance from ground ▪ Limited Headroom (Lim Hdr): Dimensions of a space that does not permit standing to perform task ▪ Height Tolerance (Ht Tol): The highest vertical distance from the ground (e.g., putting shingles on a roof)
▪ Sit: Amount of continuous time sitting
▪ Stand: Amount of continuous time standing
▪ Vision: Type of vision required to perform the essential tasks of the job ▪ Temperature: The environmental conditions present while performing the job

Validation of Testing Methodology
Our methods of validation and examination techniques follow ADA requirements for pre - employment/post-offer testing and are the most defensible under ADA guidelines. Standard 29 CFR 1630.10 states, “The Uniform Guidelines on Employee Selection Procedures do not apply to the Rehabilitation Act and are similarly inapplicable to this part.” However, 29 CFR 1630.15 h olds the defenses of such screening techniques to the same means as other claims under Title VII. When there is The City of Anaheim ♦ Medical Evaluation Services

October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Page 22 a need for screening techniques to be adapted to a disabled population, Concentra uses techniques that are “job-related and consistent with business necessity,” in accordance with ADA guidelines.

We evaluate tasks that:
▪ Meet the definition of “essential function”
▪ Are sufficiently quantifiable to be functionally tested by trained individuals

HPE Testing Process
The physical therapist instructs the applicant of the goals of each testing service package included in the HPE and allows the applicant to perform one trial of a specific task as he/she deems most appropriate. If the applicant demonstrates poor knowledge of proper body mechanics and lifting technique during the first trial, the physical therapist instructs the individual by demonstrating good body mechanics and technique prior to proceeding with test.

The test is terminated if the applicant:
▪ Represents a significant threat or risk to self
▪ Requests to discontinue for any reason

HPE Results Reporting
Once the individual has completed the required functional tests, the physical therapist documents the “pass/fail” results and gives them to the clinician. If the individual fails, the physical therapist documents the reason and records observations on the testing form. The clinician combines the medical results with the functional test results to render an overall “pass/fail” result for the individual.

Concentra has direct experience serving as the City’s preferred occupational health provider and we are prepared to leverage our existing insight to develop a physical ability testing program that exceeds program expectations. We are confident that our current relationship, expertise, and best practice approach make us the right company to assist the City in meeting its physical ability testing needs and objectives.

Drug and Alcohol Testing
DOT-Compliant Urine Drug Screens
Concentra conducts urine drug testing in full compliance with Department of Transportation (DOT) rule 49 CFR Part 40 (Procedures for Transportation Workplace Drug and Alcohol Testing) and adheres to all Substance Abuse and Mental Health Services Administration (SAMHSA) policies and procedures to ensure appropriate chain of custody. By following these procedures in both federal and non -federal testing, Concentra simplifies the collection process, offers the most defensible procedures for our collectors and clients, and provides the optimal level of confidentiality for the donors.

Our typical process includes:
▪ Certified staff to perform collections
▪ Use of split specimen collection method as required by DOT ▪ Use of the proper custody and control forms (CCF) for regulated and non-regulated testing, using electronic CCFs when possible
▪ Proper specimen containment
▪ Shipment of specimen, within 24 hours, to a SAMHSA-certified laboratory for analysis ▪ Involvement of a Medical Review Officer (MRO) for follow-up review, as appropriate

Concentra Collectors
Concentra’s collector certification course meets and exceeds the DOT training model. To help ensure consistency among all Concentra markets in adhering to DOT regulations, we developed a three -phase Collector Certification Program. Our policy is that all collectors (new hires and existing) successfully complete each phase of the program prior to Concentra certifying the individual to perform drug screen collections. Concentra’s intention is to maintain high standards and quality throughout the collection The City of Anaheim ♦ Medical Evaluation Services

October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Page 23 process. To that end, although DOT regulations require refresher training to occur within five years, Concentra requires refresher training for all collectors every 2.5 years. If the collector does not complete refresher training within the designated timeframe, we do not allow him/her to perform DOT collections.

We summarize each phase of our Collector Certification Program in the following table.

Phase One: Study Guide and Quiz
Intranet study guide and quiz (required prior to attending Phase Two) Phase Two: Classroom Instruction
Interactive instruction
Hands-on collection training
▪ Written examination (85 percent pass rate required
for certification)
▪ Completion of Collector Acknowledgement Form
Phase Three: Proficiency Examination
Five consecutive, error-free mock collections
Two uneventful collection scenarios
One “insufficient quantity of urine” scenario
▪ One “temperature out-of-range” scenario
▪ One scenario in which the donor refuses to sign the
CCF and initial the specimen bottle’s tamper-evident
seal

Collection Process
Concentra uses the DOT-required split specimen collection method, when possible. DOT collection specimens are tested for substances outlined in the most recent regulations. The certified collector and appropriate laboratory adhere to the following guidelines:
▪ Collect a minimum of 45 milliliters (ml.) of urine
▪ Divide the specimen into two bottles, 30 ml. in one and 15 ml. into a second bottle ▪ Seals the specimen appropriately
▪ Transport each specimen to the laboratory within 24 hours ▪ Once received, the lab analyzes the primary 30 ml. bottle while the second bottle is held pending a request from the employee for a second test in the event of a verified positive of the primary te st result

Observed Collections
We acknowledge that in certain instances, direct observation may be required, and Concentra can meet this requirement.

Chain of Custody
When collecting urine specimens, Concentra adheres to all SAMHSA policies and procedure s to ensure appropriate chain of custody to document the integrity and security of the specimen from the time of collection until receipt by the laboratory. For DOT collections, we use the federal chain of custody and control form (CCF); for non-regulated drug screens, we use the non-federal CCF.

Specific to DOT testing, Concentra completes the federal CCF in accordance with SAMHSA guidelines, as we outline below:

▪ Collector ensures that the name and address of the drug testing laboratory appears on the to p of the CCF and that the specimen ID number on the top of the CCF matches the specimen ID number on the labels/seals
▪ Collector provides the required information in step 1 on the CCF and provides a remark in step 2 if the donor refuses to provide his/her Social Security or employee ID number ▪ Collector gives a collection container to the donor to provide specimen ▪ After the donor gives the specimen to the collector, the collector checks the temperature of the specimen within four minutes, marks the appropriate temperature box in step 2 on the CCF, and provides a remark if the temperature is outside the acceptable range ▪ Collector checks the split or single specimen collection box:

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October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Page 24  If no specimen is collected, the collector checks that box, provides a remark, d iscards Copy 1, and distributes the remaining copies as required
 If it is an observed collection, the collector checks that box and provides a remark ▪ Donor watches as the collector pours the specimen from the collection container into the specimen bottle(s), places the cap(s) on the specimen bottle(s), and affixes the label(s)/seal(s) on the specimen bottle(s)
▪ After affixing the labels/seals, the collector dates the specimen bottle label(s) ▪ Donor initials affixed and dated specimen bottle label(s) ▪ Collector turns to Copy 2 (MRO Copy) and instructs the donor to (1) read the certification statement in step 5 and (2) sign, print name, date, provide phone numbers, and date of birth; if the donor refuses to sign the certification statement, the collector provides a remark in step 2 on Copy 1 ▪ Collector completes step 4 (i.e., provides signature, printed name, date, time of collection, and name of delivery service), immediately places the sealed specimen bottle(s) and Copy 1 of the CCF in a leak-proof plastic bag, releases specimen package to the delivery service, and distributes the other copies as required

Specimen Transport
Once the specimen is sealed, a courier picks up the specimen from the collection site via automobile. The collector or collection site must ensure that each specimen collected is shipped to a laboratory as quickly as possible, but in every case, within 24 hours. Specimens are picked up one to two times per day depending on the volume of drug tests being administered at the center location.

Laboratory Urine Drug Screening
Initial Screening Test
A high-sensitivity enzyme immunoassay (EIA) screens for the presence of commonly abused drugs. At this stage, test results equal to or greater than a calibrated immunoassay cutoff concentration identify presumptively positive specimens. Each batch contains both negative and positive quality control samples along with one blind quality control sample that is inserted into the batch in a random position.

Laboratory Urine Screen Confirmation Test
For specimens that do not screen negative initially, confirmatory drug testing is performed by gas chromatography/mass spectrometry (GC/MS), liquid chromatography/mass spectrometry (LC/MS), or any other technique recognized by the U.S. Department of Health and Human Services (DHHS) and Substance Abuse and Mental Health Services Administration (SAMHSA).

The concentration of drug or drug metabolite in each donor specimen is determined by comparison of the response of the specimen to the response of calibrators of known concentration. As with the screening test, each batch contains both negative and positive quality control samples along with one blind quality control sample that is inserted into the batch in a random position. If required, confirmation testing for specimen validity is performed by the same or, if available, a second definitive method that can be utilized to identify specimens as adulterated, substituted, or invalid. Each confirmation test is performed on a second aliquot that is obtained from the original specimen container and all confirmation batches contain appropriate quality control samples to verify the performance of the procedure.

▪ If a donor specimen has a concentration of drug that is less than the employer -specific cutoff, the specimen is determined to be negative for the confirmation test. ▪ If a donor specimen has a concentration of drug that is greater than or equal to the employer-specific cutoff, the specimen is determined to be positive for the specific test.

Laboratory positives are transmitted to the Medical Review Officer (MRO.) The MRO gathers all test data, interviews the donor, and confirms the result as positive or negative. The result is posted only after MRO verification.

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October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Page 25 Breath Alcohol Testing
Concentra conducts breath alcohol testing using an evidential breath testing (EBT) device selected from the National Highway Traffic Safety Administration (NHTSA) Conforming Products List for both screening and confirmation testing. To ensure quality results, we calibrate each EBT device daily and after every positive result, without exception. Records of the calibration are filed with a retention per iod of five years.

In addition, personnel performing breath alcohol testing are trained and certified as breath alcohol technicians (BAT) in accordance with Department of Transportation (DOT) guidelines.

Initial Test
Typically, breath alcohol tests that register less than 0.02 g/210 L are reported as negative (for the purposes of DOT) and no additional testing is required. Breath alcohol tests that register 0.02 g/210 L or greater require a second confirmatory test.

Breath Alcohol Confirmation Test
If the confirmatory test is less than 0.02 g/210 L, the results are reported as negative. Breath alcohol results that register 0.04 g/210 L or greater on the confirmation test are immediately reported to the employer. A result that registers 0.04 g/210 L or greater is considered a DOT positive result.

Medical Review Officer (MRO) Services
When the laboratory confirms a non-negative result, Concentra enlists a Medical Review Officer (MRO) through our preferred vendor for review of the result. An MRO assistant ensures the MRO copy and the laboratory copy of the chain of custody and control form (CCF) are transmitted timely, as the MRO does not initiate a donor interview until receiving the MRO copy of the CCF and does not t ransmit verified results until receiving the laboratory copy. If the MRO is unable to obtain either copy, the MRO reports a “canceled” test.

The MRO makes three or more attempts in a three-day period to reach the donor (barring unforeseen circumstances, such as donor’s phone disconnected). The MRO interviews the donor to determine if there is a legitimate medical explanation for the non-negative result. The MRO can ask medically related questions (which the donor’s employer cannot ask under the Americans w ith Disabilities Act) to validate or invalidate a non-negative laboratory result.

The MRO’s standard responsibilities include:
▪ Conform to DOT Regulation 49 CFR Part 40 in the performance of all services and data transmissions for DOT and non-DOT drug tests
▪ Provide an MRO assistant to review all test results and CCFs under the MRO’s direct supervision ▪ Receive appropriate copies of the CCF within 24 hours of the collection; if collection sites do not adhere to this requirement, Concentra provides appropriate follow up and training ▪ Store MRO records within regulatory requirements and best practices to maintain confidentiality ▪ Facilitate blind sampling for all laboratories, per DOT regulations ▪ Adhere to federal guidelines when coordinating the collection site process ▪ Transmit results via a secured network; SAMHSA-certified laboratories produce an export file from their information management system and send it across their internal network in an encrypted file, restricting access

Clinical Screenings
A range of clinical screening services are offered at Concentra centers. We perform screenings on equipment that has been thoroughly examined and calibrated so that results are as timely and accurate as possible.

The following table summarizes our clinical screening capabilities:

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October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Page 26 Type of Test Details
Audiometric
Screening
All audiometric screening conforms to the Occupational Safety and Health Administration (OSHA) standard 29 CFR 1910.95. We have Council for Accreditation in Occupational Hearing Conservation (CAOHC)-certified technicians to perform the tests, and we would provide all certifications upon request. Concentra’s services specific to audiometric screening include:
▪ Audiometers that pause screening if ambient sound levels temporarily exceed OSHA levels
▪ Immediate Standard Threshold Shift (STS) identification and retest capability ▪ CAOHC-certified hearing specialists
▪ Acoustic Systems audio booth professionally designed and installed in each clinic ▪ Daily equipment calibration
▪ Microprocessor audiometers
▪ Please note: Concentra cannot test hearing in people who wear hearing aids as this requires specialized equipment. People with hearing aids need to be tested by an audiologist and then submit the results.

EKG (resting) Concentra performs a 12-lead EKG that measures the electrical activity of the heart, read by a center clinician.

Pulmonary
Function
Testing
A technician performs all pulmonary function testing that allows real-time graphic and numeric data to verify the test validity. Data returns of VC, FEVI, PEFR, FEF 25 percent-75 percent, and FEVI/FVC are required.

Vision A trained technician performs a vision test that meets OSHA standards for visual acuity. The technician screens for visual acuity with corrective lenses, lateral and vertical phorias, stereo depth perception, and color discrimination.

For visual acuity testing, we utilize the Snellen chart for distance vision, and the Ishihara book to assess color vision.

Vitals A trained technician records resting pulse rates and blood pressure using a hospital grade sphygmomanometer and stethoscope. Any person who does not meet normal pulse rate or blood pressure criteria is re-tested.

X-rays All posterior-anterior X-rays are performed by registered X-ray technicians and certified B- readers review selected chest X-rays in accordance with OSHA regulations.

Vaccination Services and Infectious Disease Screenings
Concentra offers vaccination services and screening/testing for infectious disease to assist employers in maintaining a healthy workforce. We administer vaccinations and infectious disease screenings per regulatory requirements and recommendations from leading health organizations, including the Occupational Safety and Health Administration (OSHA), Centers for Disease Control and Prevention (CDC), and the World Health Organization (WHO).

Vaccinations / Immunization
The following table describes common vaccinations we administer for immunization. It also describes specialty vaccinations, such as those required and/or recommended for a traveling workforce, which are offered at selected Concentra locations.

Vaccine Comments
Hepatitis A Vaccine The hepatitis A vaccine should be offered when a high occupational risk for infection is present (e.g., travel to a developing country or working with hepatitis A in a research laboratory). Consideration may be given to vaccination of employees who work in areas where community-wide outbreaks are occurring, sewage workers, and workforces where state and local health authorities or private employers determine that such vaccination is cost-effective or desired. The hepatitis A vaccine is also indicated for post-exposure prophylaxis.

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October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Page 27 Vaccine Comments
Hepatitis B Vaccine OSHA requires the hepatitis B vaccine be offered to employees at risk for bloodborne pathogen (BBP) exposures through contact with blood or other potentially infectious material (OPIM) (e.g., health care personnel, emergency responders, first-aid personnel, correctional officers, laundry workers in hospitals, and morticians). The vaccination must be offered post-exposure if the employee is not already immune. Within 15 days of the completed evaluation, the clinician completes a health care professional’s written opinion for the employer indicating whether the hepatitis B vaccine is indicated for an employee and if the employee has received the vaccination. The hepatitis B vaccine is also recommended for many international travelers.

In addition to the three-dose hepatitis B vaccine (Engerix-B or Recombivax), we offer the new hepatitis B vaccine, Heplisav-B, which is a two-dose series over one month, instead of three doses over four to six months.

Hepatitis A and B
combined
For individuals who need immunity to both hepatitis A and hepatitis B, Concentra offers the Twinrix vaccine, which is a combined hepatitis A and hepatitis B vaccine.

Hepatitis B Immune
Globulin
HBIG is recommended after certain exposures to blood or other potentially infectious material (OPIM) if the source is unknown (e.g., needle stick from a sharps container) or is positive for hepatitis B and the exposed employee is not immune.

Influenza Vaccine The influenza vaccine is recommended annually for all individuals age six months and older as it is the best way to prevent the flu. The flu can significantly affect productivity and increase absenteeism among workers. As appropriate, Concentra discusses with the employer the specifics regarding administering the shots and anticipated volumes.

Japanese
Encephalitis Vaccine
The Japanese encephalitis vaccine is recommended for certain travelers to endemic areas of Asia.

Measles, Mumps,
Rubella (MMR)
Vaccine
Per CDC recommendations, all health care personnel should have presumptive evidence of immunity to measles, mumps, and rubella. Those without presumptive evidence (i.e., documentation of receiving the vaccine or laboratory evidence of disease or immunity) should be vaccinated. Screening bloodwork (titers) prior to vaccination may be cost- effective but is not required. Other indications for MMR vaccine include international travel.

Meningococcal
Vaccine
This vaccine is recommended or required for certain international travelers and laboratory personnel who are routinely exposed to meningococcal bacteria. College freshman living in dormitories, military recruits, and people with certain medical conditions are also recommended for vaccination. There are two types of meningitis vaccines: the quadrivalent meningococcal ACWY and the meningitis B vaccine. The latter is not routinely indicated for international travel.

Polio Vaccine The polio vaccine may be recommended or required for certain international travelers.

Rabies Vaccine People at high risk of exposure to rabies (e.g., veterinarians, animal handlers, rabies laboratory workers, spelunkers, and rabies biologics production workers) should be offered pre-exposure rabies vaccine. Rabies vaccine is also recommended for pre- exposure for certain international travelers. The rabies vaccine may also be recommended after being bitten or scratched by an animal or otherwise exposed to rabies. In the case of post-exposure, rabies immune globulin (RIG) is also recommended if the person had not completed the rabies vaccine series for pre-exposure.

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October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Page 28 Vaccine Comments
Tetanus, Diphtheria,
Pertussis (Tdap)
Vaccine
A one-time dose of Tdap is recommended for all adults and adolescents. The CDC recommends all health care personnel receive a single dose of Tdap as soon as feasible if they have not previously received Tdap, regardless of the time since their most recent Tetanus/diphtheria (Td) vaccination. Tdap is also recommended for women during every pregnancy.

Typhoid Vaccine Typhoid vaccine is often recommended for international travelers to the developing world.

Typhoid fever is spread by the fecal-oral route, such as ingesting contaminated food or water. There are two forms of the vaccine: an injectable vaccine that lasts for two years and an oral vaccine that lasts for five years.

Varicella
(chickenpox)
Vaccine
Per CDC recommendations, all health care personnel without evidence of immunity (e.g., written documentation of two doses of vaccine or laboratory evidence of immunity) should be vaccinated. Screening bloodwork (titers) prior to vaccination may be cost-effective but is not required.

Other Vaccines Other vaccinations, including but not limited to vaccines to prevent shingles, human papillomavirus (HPV), cholera, pneumococcal disease, and immune globulin may be administered at Concentra facilities upon request and clinical approval.

Infectious Disease Screenings
Infectious disease screening includes testing for disease and/or for immunity. The following table describes infectious disease screenings we offer.

Screening Comments
COVID-19 Return-
to-Work Clearance
Following a suspected or confirmed COVID-19 illness or exposure; includes return-to-work evaluation, screening, and testing for active COVID-19 infection. COVID-19 test-based return-to-work option is available to meet state requirements or employer protocol.

Your employees’ COVID-19 status will be assessed by qualified experienced workers’ compensation clinicians who can apply their medical knowledge and experience to evaluate the risk of each individual employees and the risk of your workforce at large. With Concentra, you have the added assurance that services will be delivered consistently from nearly 520 Concentra medical centers across your employee population.

Hepatitis B Virus Hepatitis B antibody screening is recommended for health care personnel one to two months after completing a hepatitis B vaccine series to confirm immunity. For new hires who have completed the hepatitis B vaccine series but have no evidence of immunity, an employer may decide to test for vaccine-induced immunity or test after a possible bloodborne pathogens (BBP) exposure. An individual is considered immune once he/she has a positive hepatitis B titer after one month of completing the hepatitis B vaccine series.

No further hepatitis B testing is required even if the individual is exposed to hepatitis B because of BBP exposure. According to the CDC, testing for hepatitis B surface antibody on an individual who has not completed the hepatitis B vaccine series should not be performed, as the results could be misleading. Health care personnel who are tested before receiving a documented completion of hepatitis B vaccine series should not be considered immune because a positive hepatitis B titer is a known correlate of protection only when testing follows a documented hepatitis B vaccine series.

Hepatitis C Virus Hepatitis C testing is recommended after an employee has an exposure to blood or other potentially infectious material (OPIM). Testing for hepatitis C disease may be also indicated in the source person.

HIV Testing for HIV is indicated after an employee is exposed to blood or OPIM. Testing is indicated in both the exposed and source person. Some countries require HIV testing for business visas. There are other indications for HIV testing. Concentra offers rapid HIV tests and the newer, fourth-generation HIV test.

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October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Page 29 Screening Comments
Influenza Testing for influenza as part of an acute care visit could be performed to help guide clinical decisions.

Measles, Mumps,
Rubella
Testing for immunity to measles, mumps, and/or rubella is an option instead of vaccination for employees (e.g., health care personal) when immunity to these diseases is recommended or required and proof of vaccination or disease is not available.

Tuberculosis (TB) TB is a disease spread through the air from one person to another. It is recommended and/or required that all health care personnel be screened for TB prior to employment and patient interaction. Some health care personnel are recommended or required to be screened for TB annually (varies by state). TB screening may be recommended and/or required for correctional facility workers, first responders, teachers, daycare workers, homeless shelter staff, and others. Employers may choose to screen employees prior to starting employment.

Screening for TB can be performed by skin testing or blood test such as the T-spot. A chest X-ray should be performed if the blood or skin test is positive or if there are symptoms consistent with TB disease.

Tuberculin Skin Test (TST) – The skin test requires that the employee return in 48-72 hours after its administration to have it read. Two-step skin testing (i.e., administering and reading the TST twice within a three-week period) is recommended for the initial skin testing of adults who will be retested periodically, such as health care workers or nursing home residents.

T-Spot (Blood Test) – This blood test is preferred for foreign-born persons who have received the Bacille Calmette-Guérin (BCG) vaccine or employees who may have difficulty returning to have the test read. Two-step testing is not indicated with the blood test. The T- spot is blood work and can only be collected Monday through Thursday. It may take five to seven days to obtain results.

Varicella (chicken
pox)
Testing for immunity to varicella is an option instead of vaccination for employees (e.g., health care personnel) when immunity to these diseases are recommended or required and proof of vaccination or disease is not available. For individuals born before 1980, when natural infection provided immunity to most people, checking a varicella titer instead of vaccinating may be cost effective.

Other Many other tests for infectious diseases are available upon request and clinical approval.

This includes tests for screening and treating infectious diseases as part of acute care visits.

Laboratory Services Vendor
Concentra would utilize our preferred vendor, Quest Diagnostics Incorporated (Quest) for laboratory analyses.

Established in 1990, Quest possesses more than 30 years of experience providing exceptions services in the field of laboratory testing. Quest Diagnostics Clinical Laboratories, Inc., a subsidiar y of the parent company, has four forensic drug testing laboratories certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and accredited by the College of American Pathologists -Forensic Drug Testing (CAP-FDT); three of the labs are also Clinical Laboratory Improvement Amendments (CLIA)-certified.

Each of Quest’s forensic toxicology laboratories is certified by the Department of Health and Human Services (DHHS)/SAMHSA to perform urine drug testing under the federal program. The four SAMHSA certified laboratories are compliant with SAMHSA guidelines as detailed in the Federal Register 73 (228):
71858-71907 (11-25-2008) and the DOT’s 49 CFR Part 40 rules, detailed in Federal Register 65 (244):
79462-79579 (12-19-2000), and any subsequent revisions. The DOT, Nuclear Regulatory Commission (NRC), Federal Railroad Administration (FRA), Pipeline and Hazardous Materials Safety Administration (PHMSA), and the FMCSA all require this certification.

The City of Anaheim ♦ Medical Evaluation Services

Each laboratory is licensed by the state where the laboratory is located. Quest’s drug testing procedures and laboratories are also fully certified and accredited by federal government agencies, and professional organizations such as the Agency for Health Care Administration (AHCA) Florida and CLIA.

Of relevance, Quest:
▪ Performs services in all 50 states and the District of Columbia (DC), Puerto Rico, Mexico, and the United Kingdom
▪ Performs more than 11 million drug and alcohol tests annually ▪ Performs more than 300 million clinical tests each year ▪ Is trusted by more than two-thirds of the nation’s hospitals ▪ Is the preferred laboratory of choice for more than 200,000 physicians ▪ Impacts more than 70 percent of the health care decisions made by physicians today

We outline Quest’s capabilities in the following table.

Substance Abuse Testing Clinical Testing
▪ A comprehensive menu of both standard and
customized panels
▪ Specialized test panels and adulterant testing,
including expanded opiate and DOT and HHS
panels
▪ A range of specimen options, including urine, oral
fluid, hair testing, and breath alcohol testing
▪ A national network of laboratories with locations in
or near all major cities, so there is always a lab
nearby
▪ Two full-service, bicoastal, esoteric testing
laboratories for fast turnaround on specialized
testing
▪ Additional clinical laboratory testing options
including, but not limited to: OSHA, industrial,
heavy metals, esoteric testing, and executive
health panels

Technology
Allscripts TouchWorks® Electronic Health Record (EMR) enables our clinicians to access patient records from any Concentra medical center, onsite clinic, Concentra Telemed, or Concentra TeleRehab site in the country. Our EMR integrates with practice management systems and supports continuity of patient care and an exceptional customer experience. Allscripts provides:

▪ Computerized order entry and management with electronic integration with laboratory and X -ray vendors
▪ Supports both onsite dispensing and pharmacy e-prescribing ▪ Customized clinical documentation templates to support clinical operations ▪ Best practice, evidence based, diagnosis specific care guides ▪ Integrated tasking and communication function

Allscripts supports all clinical operations, improves clinical quality, and streamlines the information exchange process to afford our clinicians the ability to quickly and accurately communicate information to the City and your employees. The system also provides data-driven insights, allowing us to apply population management principles for measurable trend management. Our ability to capture member data in real time from multiple sources helps us learn the health and social behavior patterns unique to each individual and the City’s population in the aggregate.

The following illustration depicts the various features of an APM/Touchworks technology solution:

The City of Anaheim ♦ Medical Evaluation Services

Concentra HUB
Concentra offers a self-service, online tool for the City’s convenient access to account information, test results, and reporting. Concentra HUB uses advanced security software to ensure privacy and the protection of employee information.

▪ Online account management
 Access to make edits to your company and location addresses and contacts  View capabilities of all service packages, components, and payors, third-party administrators, and medical review officers (MROs)
▪ Timely updates to your employees' non-injury and injury visit results and work restrictions  Full integration of existing employer reports for easy access  Search, export and print functionality for all accessible reports ▪ Ability to create, manage, and review employee authorizations online  Electronic creation and transmission of authorization and associated forms  Saving the authorization sends it to Concentra automatically; no need for empl oyee to bring form  Option to print and email authorization to employee is available, but not required  Search, edit and copy authorization functions
▪ Enhanced security features protect your information
 Access control
 Database monitoring
▪ Malware and virus protection
▪ Intrusion detection and prevention
.

Administrative and Support Services
Appointment Scheduling
Concentra would provide the City's employees with prompt service. Although our medical centers are primarily “first come, first serve,” Concentra can accommodate scheduled appointments if requested, with 24 hours’ advance notice. In addition, our medical centers implement “fast track” drug/alcohol testing services where employees experience a 30-minute-or-less wait time for drug specimen collection and/or breath alcohol testing.

Billing and Invoicing
Concentra’s Central Business Offices (CBO) maintain responsibility for all aspects of revenue billing and collection within their designated regions, including bill production, cash receipt, payment posting , and account receivable management services. We outline our standard billing process in the following table.

The City of Anaheim ♦ Medical Evaluation Services

October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Page 32 Service Type Billing/Invoicing Details
Injury Care ▪ Invoices generated the following business day by the market ▪ Utilize standard first report of injury to bill injury care services ▪ Term is net 45 days
Non-Injury Care ▪ Invoices generated weekly by market
▪ Includes a minimum of the following for each line item: patient name, date of service, employee’s department location (if provided), complete list of services performed ▪ Term is net 30 days

Patient Confidentiality
Concentra takes the privacy, security, and protection of confidential and personal information very seriously and we have enterprise-wide strategies and industry leading technologies to maintain compliance with the HIPAA Privacy and Security Regulations.

Concentra’s Compliance department incorporates all aspects of HIPAA, information security, privacy, and compliance into our initial colleague training upon hire and annually thereafter. New privacy and security laws and challenges including high profile topics such as phishing, social engineering, and data handling procedures are communicated through corporate communications (e.g., Concentra intranet, internal newsletters, and face-to-face educational programs) on a quarterly basis. We have HIPAA policies and procedures in place to ensure on-going compliance with the HIPAA Privacy and Security Regulations.

We also employ:
▪ A HIPAA-compliant Business Associate Agreement (BAA) with any third-party whose services provided, and data shared, are subject to the HIPAA regulations ▪ Concentra-owned, internal documentation systems on our servers, all of which are protected by firewalls and anti-virus technologies that are monitored daily ▪ A secured intranet for all internal documents and a secured virtual private network (VPN) for authorized remote access
▪ HIPAA policies and procedures that outline the required privacy and security requirements for handling, maintaining, and disposing of personal health information (PHI) ▪ Contracted service with a bonded (HIPAA-compliant) vendor to manage the shredding and recycling of paper documents located internally in locked cabinets within our office space (as per the HIPAA guidelines). Our vendor provides an approved form of identification, picks up and removes all materials from our offices, and obtains required signatures from our bonded workers ▪ Password protected access to all sensitive client files and access only to those staff members with a need to know, who require the files to support direct client services ▪ Acknowledgement of our HIPAA compliance for all employees within new hire and annual training ▪ HIPAA regulations regarding proper consent prior to sharing individual PHI with any party, i.e., client (employer), insurance company, or other provider(s), as required

Commitment to Service Excellence
Concentra’s customer service philosophy is focused on going above and beyond to deliver a superior patient experience. This philosophy is at the root of our core values and motivates Concentra team members in their ongoing pursuit of excellence.

Concentra has a long and distinguished history and we are proud of our role in shaping the occupational health care consumer experience. We recognized that the people we served were expecting more and better services from their health care providers. As a result, Concentra took steps that would revolutionize care delivery and shift the paradigm to create a best-in-class occupational health care approach. We worked with leading consulting firms specializing in customer satisfaction t o build and refine our methodology. We benchmarked our approach against other consumer-driven organizations (i.e.

Southwest Airlines, Starbucks and Nordstrom), meeting with their executive teams and incorporating their best practices. In addition, Concentra worked directly with Fred Reichheld, a Fellow at Bain & Company The City of Anaheim ♦ Medical Evaluation Services

October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Page 33 and the bestselling author of “The Loyalty Effect” and “The Ultimate Question 2.0” (see page 240 for Concentra reference) to create and shape our program. What started as a good business exe rcise became a virtual movement at Concentra. We:

▪ Redesigned our medical centers for a more customer-friendly layout and look ▪ Redefined our mission/vision/values
▪ Developed our award-winning “Orange Book” – a ‘how to’ guide for Concentra team members with specific, common-sense actions that create great service ▪ Established the Concentra Hall of Fame, recognizing colleagues who embody outstanding service and exemplify our core values

The impact of this effort and our commitment to delivering a superior experience is evident in our patient and customer satisfaction scores even today.

The City of Anaheim ♦ Medical Evaluation Services

6. Reporting
Describe the frequency and format of reports you would provide to City staff. Please attach sample reports.

Standard Reporting
Individual patient encounters provide the basis for the reporting system. Our system would create a report for each employee seen at Concentra and would make it available to the City via the Concentra HUB.

Concentra can set up notification for multiple contacts, if desired. The following table outlines examples of our standard visit-based report output. We have provided sample reports in Attachment C – Sample Reports.

Sample Reports and Communications
Activity Status
Report
▪ Generated after each injury visit
▪ Includes the employee’s name, company department, date of visit, check- in/check-out time, diagnosis, treating provider, restrictions on duty, next scheduled appointment
Non-Injury Status
Report
▪ Generated after each non-injury visit
▪ Includes the employee's name and demographics, date seen, time checked in and out of the center, results, and remarks
Patient Referral ▪ Generated when a referral to a specialist takes place ▪ Includes basic demographics, billing information, specialist information, and referrals details (i.e., type of referral, recommendations, priority, notes)

Utilization Reporting
Concentra also offers utilization reports that share key injury information. This report captures all injuries treated at Concentra for each employer, and provides detailed information specific to injury care services, including but not limited to the following:
▪ Number of employees treated
▪ Distribution of body category injured
▪ Number and percentage of cases closed
▪ Average visits per case
▪ Percentage of cases referred to a
specialist provider
▪ Percentage of cases referred to physical
therapy
▪ Average days to discharge
▪ Percentage of cases with off-duty and limited-
duty days
▪ Average number of off-duty and limited-duty
days
▪ Average cost per case
▪ Comparisons of the project data to the entire
client market for the same period

Results Reporting
Physical Examinations
Concentra evaluates and reports all medical information back to an employer’s designated representative within 24 hours of receiving all relevant data. The report provides a recommendation based on the results, and any recommended referrals and/or restrictions. The clinician notes if additional testing is necessary and advises of the clearance status for job placement. If the results require supplemental testing, Concentra would notify the City’s designated representative prior to performing any additional testing. Depending on the specific components tested for (i.e., blood or urine analysis), results may take up to five days to report.

Drug and Alcohol Testing
Concentra’s average turnaround time for a negative drug screen result is 24-48 hours upon receipt at the laboratory. Turnaround time for a non-negative drug screen result, including Medical Review Office’s (MRO) review, varies for non-DOT and DOT tests, and may take 48 to 72 hours depending on the MRO verifications.

The City of Anaheim ♦ Medical Evaluation Services

October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Page 35 ▪ For a non-DOT non-negative drug test, MRO review is at the employer’s discretion and results can take 48 to 72 hours once received at the lab.
▪ MRO review is required for all DOT non-negative drug tests. While we can report a non-negative result to the MRO within 48 hours, the average turnaround time for a non-negative DOT drug screen review by the MRO varies. Per DOT guidelines the donor has up to five days to contact the MRO before the MRO reports a result.

Breath alcohol test results are reported the same day the specimen is obtained.

Injury Care
For injury care, we provide employers an activity status report immediately upon employee checkout that includes:

▪ General employee demographics
▪ Basic employer information
▪ Visit information, including name of treating provider and diagnosis ▪ Employees' status, including any restrictions, and return-to-work status ▪ Name of treating provider
▪ Date, time, and provider for next scheduled appointment

We also notify the employer of any issues or concerns regarding return-to-work status The City of Anaheim ♦ Medical Evaluation Services

7. References
Using the forms provided in Appendix IV provide five (5) customer references that are similar in size and project scope to the City.

Client Reference
Item Vendor Response
Name County of San Diego
Project Description
New Hire physicals/police and fire
physicals/Hazmat physicals and Injury care
Contact Name Suzann Charney
Contact Telephone Number 858-694-3756
Contact E-mail Address [email protected] Business Initiation Date 10+ years
Business End Date Current
Rationale for Inclusion as a Reference
Client Reference
Item Vendor Response
Name
San Diego County Schools- JPA (multiple
districts)
Project Description
Physicals / Workers Compensation /
Respiratory Physicals
Contact Name Felicia Amenta
Contact Telephone Number 858-5717221
Contact E-mail Address [email protected]
Business Initiation Date 10+ years
Business End Date Current
Rationale for Inclusion as a Reference

Three (3) of the 5 references must include agencies with public safety classifications.

Client Reference
Item Vendor Response
Name City of San Diego
Project Description
Injury Care with additional Respiratory
Physical components
Contact Name Joseph Sousa
Contact Telephone Number 619-235-5748
Contact E-mail Address [email protected]
Business Initiation Date 10+ years
Business End Date Current
Rationale for Inclusion as a Reference
Client Reference
Item Vendor Response

The City of Anaheim ♦ Medical Evaluation Services

October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Page 37 Name Newport Mesa UDS
Project Description
New hire/Pre-employee/physicals/Injury
Care/UDS
Contact Name Jonathan Wilby
Contact Telephone Number 714-424-7535
Contact E-mail Address [email protected]
Business Initiation Date 2/2019
Business End Date current
Rationale for Inclusion as a Reference
Client Reference
Item Vendor Response
Name Edwards Life Sciences
Project Description
Pre-employment physicals/Resp fit
testing/UDS
Contact Name Vicky Lucio
Contact Telephone Number 949-250-5155
Contact E-mail Address [email protected]
Business Initiation Date 01/2007
Business End Date Current
Rationale for Inclusion as a Reference

The City of Anaheim ♦ Medical Evaluation Services

8. Contract Performance
Indicate if at any time during the past five years Proposer has had a contract terminated for convenience, non-performance, or any other reason, or has entered into legal action with a customer. Describe the situation(s) including name and address of contracting party and circumstances.

Contract Termination
Breach of Contract Disclaimer
Occupational Health Centers of California, A Medical Corporation, maintains contractual relationships with many public and private entities throughout the State of California. No contract previously held by Occupational Health Centers of California, A Medical Corporation, has been terminated by the customer prior to the expiration date for breach of contract.

Notice to Cure Disclaimer
Occupational Health Centers of California, A Medical Corporation, maintains contractual relationships with many public and private entities throughout the State of California. At this time, we are unable to identify any specific instances where a Notice to Cure message was received. Howe ver, no customer has terminated its contract with Occupational Health Centers of California, A Medical Corporation, for breach of contract.

The City of Anaheim ♦ Medical Evaluation Services

9. Exhibit A – Fee Statement and Proposed Pricing
The proposal shall include a fee schedule for the services to be performed, which shall be based on the Proposer’s best pricing.

Concentra appreciates the opportunity to present our proposed fee schedule. We affirm all information contained herein is current, complete, accurate, and remains valid for 90 days following the date of our submittal. Pricing sheet attached.

Note regarding any applicable immunization services: After the first twelve months of this Agreement, if the current market price for the above Services change due to market conditions, demand(s) and/or shortage(s), the City will be billed the then current market rate.

The City of Anaheim ♦ Medical Evaluation Services

10. Attachments
In this section, Concentra includes the following information for the City’s review:

▪ Attachment A - Required Forms and Documents
▪ Attachment B - Key Employee Qualifications
▪ Attachment C – Sample Reports
▪ Attachment D – Concentra Business License
▪ Attachment E - Legal and Risk
The City of Anaheim ♦ Medical Evaluation Services

October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Attachment Attachment A
Required Forms and Documents

23 Appendix III – Non-Collusion Affidavit

Note: To be executed by Proposer and submitted with proposal. STATE OF CALIFORNIA County of

Subscribed and sworn to before me this

day of , 20

Notary Public in and for said County and State

22 October
10th
Tanisha Thompson
Kathy T. Le, MD, MPH
Occupational Health Centers of California, a Medical Corporation dba Concentra Medical Centers President and Treasurer
Kathy T. Le, MD, MPH
DALLAS

XXXXXXXX TEXAS
DocuSign Envelope ID: BD862BFC-393F-4ADE-8D2E-C0364E8948E8

The City of Anaheim ♦ Medical Evaluation Services

October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Attachment Attachment B
Key Employee Qualifications

Jennifer Nunez
Anaheim, CA Cell Phone: (310) 847-0816 Email: [email protected]

Education
Master of Business Administration 8/2020- 8/2022 University of Redlands

Bachelor of Science in Health Care Administration 8/2010 – 5/2015 California State University, Long Beach

Professional Experience
Concentra, Anaheim, CA- Center Operations Director 06/2022-present • Overseeing and creating an environment of team building, integrity, patient/colleague safety, quality care, continuous improvement, reward and recognition.
• Responsible for monitoring and driving key business and clinical metrics. • Assessing center processes, work flows and staffing to continuously improve the patient experience. • Maintaining and establishing relationships with employers, payers, referral sources, networks, local communities to drive market growth.
• Developing colleague success through all aspects of the talent life cycle including recruiting, hiring, onboarding, orientation, mentoring / development, engagement, retention, performance management and succession planning.

Family Health Care Centers of Greater Los Angeles, Bell Gardens, CA 08/2019- 05/2022 Clinic Operations Manager
• Responsible for the day-to-day operations of three health care centers by overseeing business, operations, and compliance.
• Coordinated administrative and clinical staff work schedule. • Review projects and reports on a weekly basis with Executive and Management staff. • Plan, schedule and supervise the daily activities of direct reports. • Responsible for hiring, orientation, training, evaluation, and counseling of all site staff.

Executive Assistant to C.E.O.
• Coordinated day-to-day activities for CEO and Executive leadership including CFO, CMO and COO. • Developed meeting agendas and maintained minutes of Quarterly Staff Meetings, Board of Directors, Executive Committee and Finance Committee meetings.
• Organized workflow, handled multiple projects and diffused work conflicts on behalf of C.E.O. • Provided support to Executive leadership, middle management, and supervised administrative staff. • Coordinated high-level conference calls and meetings.

California Cryobank, West LA, CA- Donor Program Coordinator 07/2015 – 05/31/2019 • Managed several projects and company initiatives while operating the largest donor program and reached breaking record high number of donors.
• Assisted with front office clerical tasks for main headquarters office. • Coordinated donor recruitment, developed marketing strategies which increased number of targeted applicants and exceeded company’s profit and production goals. • Performed as a support auditor to conduct internal audits to ensure compliance requirement of the FDA, Department of Health, and American Association of Tissue Banks. • Responsible of onboarding and training new donor team members.

Ninety-Nine Cents Plus City- Long Beach, CA- Customer Service Manager 9/2012 – 07/2014 • Drove a 20% revenue increase, outperforming sales target for three consecutive quarters. • Formulated pricing policies and studied trends which created 35% more in sales in 2013. • Analyzed operating and financial statements for profitability ratios.

Professional Development
• Strong attention to detail with superb organizational, project management and creative problem solving skills with impeccable multi-tasking and prioritization abilities in a fast-paced work environment.
• Knowledge of administrative procedures and software applications- Asana, Access, Excel, Microsoft Word, Microsoft Dynamic NAV, NextGen, Outlook, PowerPoint, and SharePoint. • High level of interpersonal skills with strong verbal and written communication skills, fluent in Spanish.

Siena Ona M.D.

Biographical
Phone: +1-917-292-6046
Email: [email protected]
Present Posi9on
Center Medical Director. Concentra - Los Angeles, California Dec 2021 - present Medical Training
Spinal Cord Injury Fellowship. Virginia Commonwealth University and Hunter Holmes McGuire VA Medical Center. Richmond, VA. July 2017- June 2018
Physical Medicine and Rehabilita9on Residency (Combined Program with Internship).

East Carolina University-Vidant Medical Center. Greenville, NC, USA. July 2013- June 2017 Educa9on
Postgraduate. Doctor of Medicine. University of the Philippines, Manila, Philippines. Jun 2005- Apr 2010 (5 year medical program including internship)
Undergraduate. B.S. Biology. University of the Philippines, Manila, Philippines. Cum laude Jun 2001-Mar 2005 Board Cer9ﬁca9ons
Spinal Cord Injury Medicine- American Board of Physical Medicine and Rehabilita9on. July 2018-present Diplomate, American Board of Physical Medicine and Rehabilita9on. Dec 2018-present Licensure
Current acYve licenses:

State of California Medical License. A172213.

State of Illinois Medical License. 036.14537
DEA license. F07731210

Professional Experience
Interim Medical Director. Herrin, IL Jan 2021-Nov 2021 Southern Illinois Healthcare-Shirley Ryan Ability Lab(formerly RehabilitaYon InsYtute of Chicago). •Directed and coordinated the involvement of providers, nursing and therapists to resolve medical and rehabilitaYon problems of paYents in the 29 bed acute rehab unit and outpaYent clinic •Directed program strategy, service development, clinical protocols and policies •Acted as supervising physician for 2 midlevel providers AMending Physician. Consult Service . Herrin and Carbondale, IL. Nov 2018-Nov 2021 Southern Illinois Healthcare – Shirley Ryan Ability Lab (formerly RehabilitaYon InsYtute of Chicago). •Increased consult numbers 4 Ymes the prior census
AMending Physician OutpaYent Clinic. Herrin, IL Nov 2018-Nov 2021 Southern Illinois Healthcare – Shirley Ryan Ability Lab (formerly RehabilitaYon InsYtute of Chicago). •Spearheaded an interdisciplinary pain program aside from performing general rehabilitaYon services, worker’s comp cases and outpaYent procedures including MSK and ultrasound guided injecYons, spasYcity intervenYons (Botox injecYons, Baclofen pump) and EMG.

Physician. P & O Cruises-Australia. Sydney, Australia/Manila Philippines Feb 2012 – Oct 2012 Junior Assistant Professor. San Beda College of Medicine. Manila, Philippines Nov 2011 – Feb 2012 Physician. Princess Cruises. USA /Manila Philippines Apr 2011 – Oct 2011 Research Assistant. Department of Epidemiology, UP College of Medicine. Manila, Philippines Feb 2011 – Apr 2011
Physician. Lifeline Clinic. Rockwell, MakaY, Philippines Jan 2011- Mar 2011 Physician. Paranaque Doctors Hospital. Manila, Philippines Oct 2010-Mar 2011 Physician. PTC Health Metrics. MakaY City, Philippines Sept 2010-Mar 2011 Academic Posi9ons
Adjunct Assistant Professor. Southern Illinois University School of Medicine. Carbondale, IL. Dec 2020-present Health System Clinician. Physical Medicine and RehabilitaYon. Feinberg School of Medicine. Northwestern University. Dec 2020-present
Observerships
Physical Medicine and RehabilitaYon Department, East Carolina University. Greenville, NC . Nov-Dec 2012 Physical Medicine and RehabilitaYon Department, Thomas Jeﬀerson University. Philadelphia, PA . Jan-Feb2013 Awards, Honors and Membership in Honorary Socie9es
2016 - Annual Research Award, Department of Physical Medicine and RehabilitaYon, East Carolina University, Greenville, North Carolina
2005 - cum laude, Department of Biology, University of the Philippines. Manila, Philippines 2005 - Phi Sigma Biological Sciences Honor Society
2005 - Phi Kappa Phi Honor Society
Research Experience, Abstracts and Poster Presenta9ons
Poster. Ewing’s Sarcoma Causing Epidural Spinal Cord Compression and Posterior Cord Syndrome -Presented by co-author at the AAPMR MeeYng 2018. Orlando, Florida.

Poster PresentaYon. October 2017. Beyond Saturday Night: A Case Series of Radial Neuropathy in the Arm Diagnosed by Ultrasound in ConjuncYon with Electrodiagnosis. -Presented by co-author at the AAPMR MeeYng 2017, Denver, Colorado.

Poster PresentaYon. February 2017. Diagnosis of a rare case of spontaneous plantar fascia rupture, A Case Report. -Presented at the AAP MeeYng 2017, Las Vegas, Nevada Poster PresentaYon. October 2016. Cauda Equina Syndrome aher Lumbar Disc HerniaYon, A Case Report -Presented at the AAPM&R MeeYng 2016, New Orleans, LA
-Presented by co-author at the ASIA MeeYng 2016, Philadelphia PA Poster PresentaYon. October 2016. Diagnosis of an ulnar nerve foreign body by ultrasound: A Case Report -Presented at the AAPM&R MeeYng 2016, New Orleans, LA
Poster PresentaYon. October 2015. Spinal arteriovenous malformaYon resulYng in sudden paraplegia in an elderly paYent, A Case Report
-Presented at the AAPM&R Conference 2015, Boston, MA and ASIA MeeYng 2016, Philadelphia PA Poster PresentaYon. October 2015. RehabilitaYon course of a long term survivor of Glioblastoma mulYforme aher a poliovirus trial, A Case Report.
-Presented at the North Carolina Medical Society Conference 2014, Greensboro, NC -1st place- VigneMe category, North Carolina Medical Society's (NCMS) Third Annual ScienYﬁc Poster Session Poster PresentaYon. October 2014. Locked in Syndrome aher ruptured Basilar Artery aneurysm in a Pediatric PaYent, A Case Report.
-Presented at the North Carolina Medical Society Conference 2014, Greensboro, NC -Accepted for PresentaYon for AssociaYon of Academic Physiatrist 2015, San Antonio, Texas Publica9ons
Herring, C., Navarro, J., Ona S. Living with your Spinal Cord Injury. EducaYonal Book for SCI paYents at Vidant medical Center, Greenville, NC
Ona, S., Millan, R., Spinal arteriovenous malformaYon resulYng in sudden paraplegia in an elderly paYent, A Case Report. PM&R. September 2016. Volume 7 Issue 9. Supplement pages S144-S155.

Ona, S., Norbury, J., Faulk C. Diagnosis of an Ulnar Nerve Foreign Body by Ultrasound. Case Report. PM&R. 2016 Sep 24;8(9S):S210. Epub 2016 Sep 24.

Ona S, Norbury JW, Faulk CE. Diagnosis of a Rare Case of Spontaneous Plantar Fascia Rupture-A Case Report.

Am J. Phys. Med Rehabil. 96S: a45, 2017.

Myers A, Morrison E, Ona S, Norbury J. Beyond Saturday Night: A Case Series of Radial Neuropathy in the Arm Diagnosed by Ultrasound and in ConjuncYon with Electrodiagnosis. PM&R, Sept 2017 Vol 9, Issue 9 Supplement 1 page S229.

The City of Anaheim ♦ Medical Evaluation Services

October 10, 2022 © 2022 Concentra Operating Corporation. All rights reserved. Attachment Attachment C
Sample Reports

Form MCSA-5875 OMB No.: 2126-0006 Expiration Date: 12/31/2024

Page 1 ends

U.S. Department of Transportation
Federal Motor Carrier
Safety Administration
Rev 12/15/2021
Public Burden Statement
A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0006. Public reporting for this collection of information is estimated to be approximately 25 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to:

Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.

Medical Examination Report Form
(for Commercial Driver Medical Certification)
Middle Initial:Last Name:

Street Address:

Driver’s License Number:

E-Mail (optional): CLP/CDL Applicant/Holder*:

Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years? Have you ever had surgery? If “yes, ” please list and explain below.

Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)? If “yes, ” please describe below.

First Name:

City: State/Province:

Issuing State/Province:

Zip Code:

Phone:

Driver ID Verified By**:

SECTION 1. Driver Information (to be filled out by the driver) Date of Birth: Age:

Yes
Yes
Ye s
Ye s
No
No
No
No
Not Sure
Not Sure
Not Sure
**This document contains sensitive information and is for official use only. Improper handling of this information could negatively affect individuals. Handle and secure this information appropriately to prevent inadvertent disclosure by keeping the documents under the control of authorized persons. Properly dispose of this document when no longer required to be maintained by regulatory requirements.** MEDICAL RECORD #
(or sticker)

PERSONAL INFORMATION

DRIVER HEALTH HISTORY
*CLP/CDL Applicant/Holder: See instructions for definitions. **Driver ID Verified By: Record what type of photo ID was used to verify the identity of the driver, e.g., CDL, driver’s license, passport. (Attach additional sheets if necessary)
Form MCSA-5875 OMB No.: 2126-0006 Expiration Date: 12/31/2024

Page 2 ends

Last Name: First Name: DOB: Exam Date:

DRIVER HEALTH HISTORY (continued)
CMV DRIVER’S SIGNATURE

DRIVER HEALTH HISTORY REVIEW
Do you have or have you ever had: Ye s Ye sNo No
Not
Sure
Not
Sure

1. Head/brain injuries or illnesses (e.g., concussion) 16. Dizziness, headaches, numbness, tingling, or memory loss

17. Unexplained weight loss

18. Stroke, mini-stroke (TIA), paralysis, or weakness

19. Missing or limited use of arm, hand, finger, leg, foot, toe

20. Neck or back problems

21. Bone, muscle, joint, or nerve problems

22. Blood clots or bleeding problems

23. Cancer

24. Chronic (long-term) infection or other chronic diseases

25. Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring

26. Have you ever had a sleep test (e.g., sleep apnea)?

27. Have you ever spent a night in the hospital?

28. Have you ever had a broken bone?

29. Have you ever used or do you now use tobacco?

30. Do you currently drink alcohol?

31. Have you used an illegal substance within the past two years?

32. Have you ever failed a drug test or been dependent on an illegal substance?

2. Seizures/epilepsy

3. Eye problems (except glasses or contacts)

4. Ear and/or hearing problems

5. Heart disease, heart attack, bypass, or other heart problems

6. Pacemaker, stents, implantable devices, or other heart procedures

7. High blood pressure

8. High cholesterol

9. Chronic (long-term) cough, shortness of breath, or
other breathing problems

10. Lung disease (e.g., asthma)

11. Kidney problems, kidney stones, or pain/problems
with urination

12. Stomach, liver, or digestive problems

13. Diabetes or blood sugar problems
Insulin used

14. Anxiety, depression, nervousness, other mental health problems

15. Fainting or passing out
Other health condition(s) not described above:

Did you answer “yes” to any of questions 1-32? If so, please comment further on those health conditions below:

Ye s
Ye s
No
No
Not Sure
Not Sure
I certify that the above information is accurate and complete. I understand that inaccurate, false or missing information may invalidate the examination and my Medical Examiner’s Certificate, that submission of fraudulent or intentionally false information is a violation of 49 CFR 390.35, and that submission of fraudulent or intentionally false information may subject me to civil or criminal penalties under 49 CFR 390.37 and 49 CFR 386 Appendices A and B.

Review and discuss pertinent driver answers and any available medical records. Comment on the driver’s responses to the “health history” questions that may affect the driver’s safe operation of a commercial motor vehicle (CMV).

Driver’s Signature: Date:

SECTION 2. Examination Report (to be filled out by the medical examiner) (Attach additional sheets if necessary)
(Attach additional sheets if necessary)
Form MCSA-5875 OMB No.: 2126-0006 Expiration Date: 12/31/2024

Page 3 ends

Last Name: First Name: DOB: Exam Date:

TESTING

PHYSICAL EXAMINATION
Pulse Rate: Height: Weight:feet poundsinchesPulse rhythm regular: Yes No Blood Pressure Systolic Diastolic
Sitting
Second reading
(optional)
Urinalysis Sp. Gr. Protein Blood Sugar
Urinalysis is required.

Numerical readings
must be recorded.

Other testing if indicated
Vision
Acuity
Body System

1. General 8. Abdomen

2. Skin 9. Genito-urinary system including hernias

3. Eyes 10. Back/spine

4. Ears 11. Extremities/joints

5. Mouth/throat 12. Neurological system including reflexes

6. Cardiovascular 13. Gait

7. Lungs/chest
Discuss any abnormal answers in detail in the space below and indicate whether it would affect the driver’s ability to operate a CMV.

Enter applicable item number before each comment.

14. Vascular system
Body SystemNormal NormalAbnormal Abnormal
Right Eye:

Left Eye:

Both Eyes:
20/
20/
20/
20/
20/
20/
Right Eye:

Left Eye:
degrees
degrees
Uncorrected Corrected Horizontal Field of Vision Check if hearing aid used for test:

Right Ear:

Average (right): Average (left):
500 Hz 500 Hz1000 Hz 1000 Hz2000 Hz 2000 Hz
Left Ear:

Whisper Test Results
Audiometric Test Results
Right Ear Left Ear
Record distance (in feet) from driver at which a forced whispered voice can first be heard
Hearing
OR
Protein, blood, or sugar in the urine may be an indication for further testing to rule out any underlying medical problem.

Standard: Must first perceive whispered voice at not less than 5 feet OR average hearing loss of less than or equal to 40 dB, in better ear (with or without hearing aid).

Standard is at least 20/40 acuity (Snellen) in each eye with or without correction.

At least 70° field of vision in horizontal meridian measured in each eye. The use of corrective lenses should be noted on the Medical Examiner’s Certificate.

Ye s No
Applicant can recognize and distinguish among traffic control signals and devices showing red, green, and amber colors The presence of a certain condition may not necessarily disqualify a driver, particularly if the condition is controlled adequately, is not likely to worsen, or is readily amenable to treatment. Even if a condition does not disqualify a driver, the Medical Examiner may consider deferring the driver temporarily. Also, the driver should be advised to take the necessary steps to correct the condition as soon as possible, particularly if neglecting the condition could result in a more serious illness that might affect driving.

Check the body systems for abnormalities.

Monocular vision
Referred to ophthalmologist or optometrist?
Received documentation from ophthalmologist or optometrist? Right Ear Left Ear Neither
(Attach additional sheets if necessary)
Form MCSA-5875 OMB No.: 2126-0006 Expiration Date: 12/31/2024

Page 4 ends

Last Name:

Medical Examiner’s Signature:

Medical Examiner’s Name (please print or type):

Medical Examiner’s Address:

Medical Examiner’s Telephone Number:

Medical Examiner’s State License, Certificate, or Registration Number:

City:

Date Certificate Signed:

Medical Examiner’s Certificate Expiration Date:National Registry Number:

State:

Issuing State:

Zip Code:

First Name: DOB: Exam Date:

MEDICAL EXAMINER DETERMINATION (Federal)
Please complete only one of the following (Federal or State) Medical Examiner Determination sections:

Use this section for examinations performed in accordance with the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49):

Does not meet standards (specify reason):

Determination pending (specify reason):

Incomplete examination (specify reason):

Meets standards, but periodic monitoring required (specify reason):

Wearing corrective lenses
MD
Accompanied by a Skill Performance Evaluation (SPE) Certificate Driving within an exempt intracity zone (see 49 CFR 391.62) (Federal) Qualified by operation of 49 CFR 391.64 (Federal)
Wearing hearing aid
DO
Accompanied by a waiver/exemption (specify type):

Physician Assistant Chiropractor Advanced Practice Nurse Return to medical exam office for follow-up on (must be 45 days or less):

Other Practitioner (specify):

Medical Examination Report amended (specify reason):
3 months 6 months 1 year other (specify):Driver qualified for:

Meets standards in 49 CFR 391.41; qualifies for 2-year certificate (if amended) Medical Examiner’s Signature: Date:

If the driver meets the standards outlined in 49 CFR 391.41, then complete a Medical Examiner’ s Certificate as stated in 49 CFR 391.43(h), as appropriate.

I have performed this evaluation for certification. I have personally reviewed all available records and recorded information pertaining to this evaluation, and attest that, to the best of my knowledge, I believe it to be true and correct.

Form MCSA-5875 OMB No.: 2126-0006 Expiration Date: 12/31/2024

Page 5 ends

Last Name: First Name: DOB: Exam Date:

MEDICAL EXAMINER DETERMINATION (State)
Use this section for examinations performed in accordance with the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49) with any applicable State variances (which will only be valid for intrastate operations):

Does not meet standards in 49 CFR 391.41 with any applicable State variances (specify reason):

Meets standards in 49 CFR 391.41 with any applicable State variances Meets standards, but periodic monitoring required (specify reason):
3 months 6 months 1 year other (specify):Driver qualified for:

Wearing corrective lenses Wearing hearing aid Accompanied by a waiver/exemption (specify type):

Accompanied by a Skill Performance Evaluation (SPE) Certificate Grandfathered from State requirements (State) If the driver meets the standards outlined in 49 CFR 391.41, with applicable State variances, then complete a Medical Examiner’ s Certificate, as appropriate.

Medical Examiner’s Signature:

Medical Examiner’s Name (please print or type):

Medical Examiner’s Address:

Medical Examiner’s Telephone Number:

Medical Examiner’s State License, Certificate, or Registration Number:

City:

Date Certificate Signed:

Medical Examiner’s Certificate Expiration Date:National Registry Number:

State:

Issuing State:

Zip Code:

MD DO Physician Assistant Chiropractor Advanced Practice Nurse Other Practitioner (specify):

Instructions MCSA-5875

Page 6 ends

Instructions for Completing the Medical Examination Report Form (MCSA-5875) I. Step-By-Step Instructions
Driver:

Section 1: Driver Information
• Personal Information: Please complete this section using your name as written on your driver’s license, your current address and phone number, your date of birth, age, driver’s license number and issuing state. ◦ CLP/CDL A
pplicant/Holder: Check “yes” if you are a commercial learner’s permit (CLP) or commercial driver’s license (CDL) holder, or are applying for a CLP or CDL. CDL means a license issued by a State or the District of Columbia which authorizes the individual to operate a class of a commercial motor vehicle (CMV). A CMV that requires a CDL is one that: (1) has a gross combination weight rating or gross combination weight of 26,001 pounds or more inclusive of a towed unit with a gross vehicle weight rating (GVWR) or gross vehicle weight (GVW) of more than 10,000 pounds; or (2) has a GVWR or GVW of 26,001 pounds or more; or (3) is designed to transport 16 or more passengers, including the driver; or (4) is used to transport either hazardous materials requiring hazardous materials placards on the vehicle or any quantity of a select agent or toxin. ◦ D
river ID Verified By: The Medical Examiner/staff completes this item and notes the type of photo ID used to verify the driver’s identity such as, commercial driver’s license, driver’s license, or passport, etc. ◦ Has y
our USDOT/FMCSA medical certificate ever been denied or issued for less than two years? Please check the correct box “yes” or “no” and if you aren’t sure check the “not sure” box. • Driver Health History:
◦ Ha
ve you ever had surgery: Please check “yes” if you have ever had surgery and provide a written explanation of the details (type of surgery, date of surgery, etc.) ◦ A
re you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements): Please check “yes” if you are taking any diet supplements, herbal remedies, or prescription or over the counter medications. In the box below the question, indicate the name of the medication and the dosage.
◦ #
1-32: Please complete this section by checking the “yes” box to indicate that you have, or have ever had, the health condition listed or the “No” box if you have not. Check the “not sure” box if you are unsure.
◦ O
ther Health Conditions not described above: If you have, or have had, any other health condi- tions not listed in the section above, check “Yes” and in the box provided and list those condition(s). ◦ A
ny yes answers to questions #1-32 above: If you have answered “yes” to any of the questions in the Driver Health History section above, please explain your answers further in the box below the question. For example, if you answered “yes” to question #5 regarding heart disease, heart attack, bypass, or other heart problem, indicate which type of heart condition. If you checked “yes” to question #23 regarding cancer, indicate the type of cancer. Please add any information that will be helpful to the Medical Examiner.
• CMV Driver Signature and Date: Please read the certification statement, sign and date it, indicating that the information you provided in Section 1 is accurate and complete.

Instructions MCSA-5875

Page 7 ends

Medical Examiner:

Section 2: Examination Report
• Driver Health History Review: Review answers provided by the driver in the driver health history section and discuss any “yes” and “not sure” responses. In addition, be sure to compare the medication list to the health history responses ensuring that the medication list matches the medical conditions noted. Explore with the driver any answers that seem unclear. Record any information that the driver omitted. As the Medical Examiner conducting the driver’s physical examination you are required to complete the entire medical examination even if you detect a medical condition that you consider disqualifying, such as deafness. Medical Examiners are expected to determine the driver’s physical qualification for operating a commercial vehicle safely. Thus, if you find a disqualifying condition for which a driver may receive a Federal Motor Carrier Safety Administration medical exemption, please record that on the driver’s Medical Examiner’s Certificate, Form MCSA-5876, as well as on the Medical Examination Report Form, MCSA-5875. • Testing:
◦ P
ulse rate and rhythm, height, and weight: record these as indicated on the form. ◦ Blo
od Pressure: record the blood pressure (systolic and diastolic) of the driver being examined. A second reading is optional and should be recorded if found to be necessary. ◦ U
rinalysis: record the numerical readings for the specific gravity, protein, blood and sugar. ◦ V
ision: The current vision standard is provided on the form. When other than the Snellen chart is used, give test results in Snellen-comparable values. When recording distance vision, use 20 feet as normal. Record the vision acuity results and indicate if the driver can recognize and distinguish among traffic control signals and devices showing red, green, and amber colors; has monocular vision; has been referred to an ophthalmologist or optometrist; and if documentation has been received from an ophthalmologist or optometrist.
◦ H
earing: The current hearing standard is provided on the form. Hearing can be tested using either a whisper test or audiometric test. Record the test results in the corresponding section for the test used. • Physical Examination: Check the body systems for abnormalities and indicate normal or abnormal for each body system listed. Discuss any abnormal answers in detail in the space provided and indicate whether it would affect the driver’s ability to safely operate a commercial motor vehicle.

In this next section, you will be completing either the Federal or State determination, not both. • Medical Examiner Determination (Federal): Use this section for examinations performed in accordance with the FMCSRs (49 CFR 391.41-391.49). Complete the medical examiner determination section completely. When determining a driver’s physical qualification, please note that English language proficiency (49 CFR part 391.11: General qualifications of drivers) is not factored into that determination. ◦ Do
es not meet standards: Select this option when a driver is determined to be not qualified and provide an explanation of why the driver does not meet the standards in 49 CFR 391.41. ◦ M
eets standards in 49 CFR 391.41; qualifies for 2-year certification: Select this option when a driver is determined to be qualified and will be issued a 2-year Medical Examiner’s Certificate.

Instructions MCSA-5875

Page 8 ends

◦ M eets standards, but periodic monitoring is required: Select this option when a driver is determined to be qualified but needs periodic monitoring and provide an explanation of why periodic monitoring is required. Select the corresponding time frame that the driver is qualified for, and if selecting “other” specify the time frame.
— Determination that driver meets standards: Select all categories that apply to the driver’s certification (e.g., wearing corrective lenses, accompanied by a waiver/exemption, driving within an exempt intracity zone, etc.).
◦ D
etermination pending: Select this option when more information is needed to make a qualification decision and specify a date, on or before the 45 day expiration date, for the driver to return to the medical exam office for follow-up. This will allow for a delay of the qualification decision for as many as 45 days. If the disposition of the pending examination is not updated via the National Registry on or before the 45 day expiration date, FMCSA will notify the examining medical examiner and the driver in writing that the examination is no longer valid and that the driver is required to be re-examined. — MER amended: A Medical Examination Report Form (MER), MCSA-5875, may only be amended while in determination pending status for situations where new information (e.g., test results, etc.) has been received or there has been a change in the driver’s medical status since the initial examination, but prior to a final qualification determination. Select this option when a Medical Examination Report Form, MCSA-5875, is being amended; provide the reason for the amendment, sign and date. In addition, initial and date any changes made on the Medical Examination Report Form, MCSA-5875. A Medical Examination Report Form, MCSA-5875, cannot be amended after an examination has been in determination pending status for more than 45 days or after a final qualification determination has been made. The driver is required to obtain a new physical examination and a new Medical Examination Report Form, MCSA-5875, should be completed. ◦ I
ncomplete examination: Select this when the physical examination is not completed for any reason (e.g., driver decides they do not want to continue with the examination and leaves) other than situations outlined under determination pending.
◦ M
edical Examiner information, signature and date: Provide your name, address, phone number, occupation, license, certificate, or registration number and issuing state, national registry number, signature and date.
◦ M
edical Examiner’s Certificate Expiration Date: Enter the date the driver’s Medical Examiner’s Certificate (MEC) expires.
• Medical Examiner Determination (State): Use this section for examinations performed in accordance with the FMCSRs (49 CFR 391.41-391.49) with any applicable State variances (which will only be valid for intrastate operations). Complete the medical examiner determination section completely. ◦ Do
es not meet standards in 49 CFR 391.41 with any applicable State variances: Select this option when a driver is determined to be not qualified and provide an explanation of why the driver does not meet the standards in 49 CFR 391.41 with any applicable State variances. ◦ M
eets standards in 49 CFR 391.41 with any applicable State variances: Select this option when a driver is determined to be qualified and will be issued a 2-year Medical Examiner’s Certificate.

Instructions MCSA-5875

Page 9 ends

II. If updating an existing exam, you must resubmit the new exam results, via the Medical Examination Results Form, MCSA-5850, to the National Registry, and the most recent dated exam will take precedence.

III. To obtain additional information regarding this form go to the Medical Program’s page on the Federal M
otor Carrier Safety Administration’s website at http://www.fmcsa.dot.gov/regulations/medical. ◦ M
eets standards, but periodic monitoring is required: Select this option when a driver is deter- mined to be qualified but needs periodic monitoring and provide an explanation of why periodic monitoring is required. Select the corresponding time frame that the driver is qualified for, and if selecting “other” specify the time frame.
— Determination that driver meets standards: Select all categories that apply to the driver’s certification (e.g., wearing corrective lenses, accompanied by a waiver/exemption, etc.). ◦ M
edical Examiner information, signature and date: Provide your name, address, phone number, occupation, license, certificate, or registration number and issuing state, national registry number, signature and date.
◦ M
edical Examiner’s Certificate Expiration Date: Enter the date the driver’s Medical Examiner’s Certificate (MEC) expires.
©Concentra® 2021. All rights reserved.

V10

Page 4 of 4 ends

CVDCLEARRTW - RSLT
C
oronavirus (COVID-19) Clearance/Return to Work
Or Coronavirus Clinical Lab Only Form
Work Status
Patient Name: Date of Service:
______ P
OC Coronavirus (COVID-19) Test Result:
 Negative
 Positive
 N/A
POC Accession number/Specimen ID _________________________________ Based on the employee’s responses to the Coronavirus (COVID-19) Clearance/Return to Work concerning symptoms of Coronavirus illness (COVID-19) and recent exposures to an individual with suspected or confirmed coronavirus illness (COVID-19), I recommend the following:

Medical recommendation*
Cl eared to work
N ot cleared to work until ________________ date
D etermination pending**, additional evaluation and/or testing recommended as indicated below:
 Coronavirus (COVID-19) Clearance/RTW Evaluation (in person or telemedicine)  SARS CoV-2 RNA COVID19 39448
 SARS CoV-2 Ab IgG Spike 34499
 POC Coronavirus (COVID-19) Test ____ RNA ____ Antigen P atient presented for clinical labs only, as requested by employer. Work status not applicable. ______ Travel health consult recommended
______ COVID-19 Travel Certificate issued
R
emarks: (No protected health information in this area)
Clinician’s Printed Name Clinician’s Signature Date
Clinician NPI if POC test ordered: _______________________________ *The above work status is issued with the understanding that all employers will adhere to the recommendations of the CDC and OSHA for coronavirus workplace practices and controls applicable to the employee’s risk of exposure at work. ______________________________________________________________________________________________________ **If status above listed as determination pending, please document status after review of additional records/testing:
______ Cleared to work
______ Not cleared to work until _______________ date
______ COVID-19 Travel Certificate issued
Remarks: (No protected health information in this area) _______
____________________________ ___________________________________ ______________________ Clinician Signature Clinician’s Printed Name Date

Patient: DOB: Service Date:

Concentra Medical Centers
123 Street Address Town, State 12345
Phone: (123) 456-7890 Fax: (123) 456-7890

Audiometric Examination Results

OTOSCOPIC EVALUATION
Left Right
Ear canal clear Yes___ No___ Yes___ No___
Ear drum visible Yes___ No___ Yes___ No___
Inflammation/obstruction Yes___ No___ Yes___ No___ Scarring of ear drum Yes___ No___ Yes___ No___
Drainage from ear Yes___ No___ Yes___ No___

Comments:
_________________________________________________________________________________________________ _________________________________________________________________________________________________

Tape Audiometric Result HERE
Is this study the employee's baseline (initial test for new employer) audiogram?
Yes ___ No ___ Unknown ___

___ Audiogram is acceptable
___ Evidence of high frequency hearing loss:

On the ____ left and/or ____ right
___ Evidence of hearing loss in the speech range:

On the ____ left and/or ____ right
___ Ear protection necessary at 85 db. Employee
informed.
___ Employee advised to follow-up with his/her
physician.
___ Employee’s hearing could not be evaluated by
audiogram due to use of (a) hearing aid(s).

Clinician Print:________________________________

Clinician Signature:____________________________

Technician Signature: __________________________

CAOHC certification if applicable: _________________

Date ________________________________________

Audiometer make & serial no: __________________________________ Calibration date: __________________

AUDIOHSRY-2

C o n c e n t r a M e d ic a l C e n t e r s
02/ 01/ 2004Claim Number: Service Date:

Activity Status Report
P hone: ( 601) 972- 4434 F ax: ( 601) 720- 7999
1735 S outh R edwood R oad, S uite 115 S LC , U T 84104 Case Date:
02/ 01/ 2004
924.21 Ankle Contusion - Right
719.47 Ankle/Foot Pain - Right
928.20 Crush Injury, Foot - Right
Visit Date:

Provider/Facility:

Sat urday February 2, 2004 8: 15 am
Sam Smith, MD
This Visit:

Treating Physician:

Diagnosis:

Patient Status:

Modified Activity - Returning for follow-up visit
Next Visit(s):

Employer Location:

Address:

Auth. by:

ABC Company
456 Fr ont St r eet
Jackson, TN 39206
Jim J ones
Contact:

Role:
301Ext.:( 601) 555-9876Phone:

Fax:
( 601) 555-6789
Gr eg Smith
Warehouse Manager
Address:

Pat i ent :

Doe, John
SSN:
123-45-6789
Jackson, TN 39206
Hom e:
( 601) 555-1234
Wor k:
( 601) 555- 4321
Ext . :

Anti ci pated Date of MMI :
02/ 15/ 2004
Restricted Activity (In effect until next physician visit):

Ret urn t o work on 02/ 02/ 2004 wit h t he f ollowing rest rict ions Off work rest of shift with limited activity as follows:

No prolonged standing and/or walking longer than 30 Minutes No pushing and/or pulling over 5 lbs. of force
Keep wound clean and dry
Must wear Splint
Remarks:
123 Easy Street
T i me I n : T i me O u t :
04: 30 pm
Reco rd ab l e:

Visit Type:
03: 55 pm
New
Sam Smith, M D
Yes
Ac tivity Sta tus R e por t
1 9 9 6 - 2 0 0 4 C o n c e n t r a M a n a g e d C a r e , I n c . A l l R i g h t s R e s e r v e d . R e vis ion D a te : 0 1 /1 4 /2 0 04 04AA/EEO Employer /0 /1 /2 /3 /4 /5 /2 /6 □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ /8 /9 /10 /6 □ □ □ □ □ /11 /4 /12 /13 /3 /14 /4□ /8 /1 /2 /4 /6 □ □
/15 /16 /5 /14 /4 /5 /2 /12 /1 □ /17 /4 /18 /3 /14 /1 /19 □ /15 /4 /5 /2 /4 /12 /20 □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □□ □ □ □ □ □ □ □ □ □ □ /22 /23 /24 □ /25 /26 /27 /28 /28 /26 □ /29 /30 /30 /27 /28 /31 /31 □ /32 /33 /34 /35 /36 □ /25 /26 /37 /26 /28 □ /22 /23 /24 /38 /39 □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □□ □ □ □ □ /40 /41 /33 /35 /28 /42 □ /43 /22 /23 /24 /44 □ /38 /39 /45 /46 /47 /48 /49 /50 □ □ □ /51 /37 /52 /42 □ /43 /22 /23 /24 /44 □ /38 /39 /45 /46 /47 /48 /49 /50 □ □
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/17 /4 /18 /3 /14 /1 /19 □ /4 /13 /1 /19 /77 /1 /2 /3 /16 /5 □ /55 /16 /12 □ /12 /4 /20 /54 /3 /12 /1 /2 /16 /12 □ /77 /20 /4 □ /78 /1 /20 □ /14 /16 /79 /54 /19 /4 /2 /4 /18□ /3 /5 □ /1 /14 /14 /16 /12 /18 /1 /5 /14 /4 □ /78 /3 /2 /80 □ /81 /82 □ /15 /83 /56 □ /84 /82 /84 /85 /86 /84 /87 /88 /86 □ /43 /89 /37 □ /28 /90 /37 /91 /92 /37 /93 /94 /95 /35 □ /96 /97 /30 /94 /93 /37 □ □ /98 □ /33 /99 /94 /35 /94 /95 /35 □ /99 /37 /27 /37 □ /28 /91 □ /92 /31 /33 □ /30 /28 □ /27 /28 /31/99 /94 /27 /37 /30 /33 /27 /28 /31 □ /31 /28 □ /93 /33 /96 /99 /91 /28 /26 /95 □ /30 /28 □ /37 /93 /92 /28 /27 /30 /33 □ /93 /33 /35 □ /23 /49 □ /100 /51 /101 □ /22 /49 /22 /50 /102 /22 /24/38 /44 □ □
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/100 /91 /94 /35 /94 /93 /94 /37 /35 /145 /31 □ /35 /37 /96 /28 □ /99 /27 /94 /35 /26 /28 /30 □/43 /128 /94 /27 /31 /26 /36 □ /91 /37 /31 /26 /44 □□ □ /133 /37 /26 /28 □ □ □ □
/100 /91 /94 /35 /94 /93 /94 /37 /35 /145 /31 □ /25 /94 /125 /35 /37 /26 /92 /27 /28 □ □□ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □/56 /146 /11 /0 /15 /147 /146 /148 /56 /146 /149 /148 /17 /150 /81□ VSSCRNGR -1
Concentra Medical Center Service Date:
123 Street Address Town, State 12345
Phone: (123) 456-7890 Fax: (123) 456-7890
VSSCRNGR -1 ©Concentra® 2021. All rights reserved.

Rev. 12/10/2021
Vision Screening Results
Patient Name: Date of Birth: Employee ID/Alternate ID:

Employer Name:

Place a checkmark to indicate the employer approved vision test(s) performed.  Snellen Distance  Sloan Distance Right Left Both Corrected: ____/____ ____/____ ____/____
Uncorrected: ____/____ ____/____ ____/____
 Jaeger Near  J1  J2  J3  J4 Both at ___________ inches. If requested by employer: Right at _______inches Left at _______inches Visual Acuity Complete (Titmus) Right Left Both  Distance Corrected: ____/____ ____/____ ____/____
Uncorrected: ____/____ ____/____ ____/____
 Near Corrected: ____/____ ____/____ ____/____
Uncorrected: ____/____ ____/____ ____/____
 Peripheral Temporal Nasal Total
Right: _______˚_ + _______˚_ = _______˚_
Left: _______˚_ + _______˚_ = _______˚_
 Depth Seconds of Arc: _______˚_ Shepard-Fry: _______%_  Color Number Correct: ________ Total Number Plates: ________ Any number correct less than total number of plates tested requires a valid color screen for confirmation.

Color (No colored/tinted lenses)
 Ishihara (14 plates) Number Correct:______ Total Number Plates: _______ Complete patient response if employer directed:

Plate 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Response
Color with Extent of Defect (No colored/tinted lenses)
 Hardy Rand Rittler (HRR) 4th Number Correct: _________ Total Number Plates: ______  Farnsworth D15 Number Correct: _________
Color vision impairment extent:
(Clinician must determine)  Mild  Medium  Strong Clinician Initials _______  Amsler Grid (Clinician must review) Clinician Initials _______  Tonometry (Clinician must perform) __________________ mm Hg Clinician Initials _______ Completed by: Date:

VSSCRNGR -2
Concentra Medical Center
123 Street Address Town, State 12345
Phone: (123) 456-7890 Fax: (123) 456-7890

Patient: DOB: Employee ID/Alternate ID:___________ Service Date:

Rev. 12/10/2021
Vision Screening Results

 Clinician determination NOT requested by employer (testing only).

Remarks: No protected health information

___________________________________________________________________________________________________________

Clinician’s Determination for Vision Testing Service:

Requirements
 Vision requirements were provided by the employer and have been reviewed by the examining clinician.  Vision requirements were NOT provided (determination based on Department of Transportation vision standard).

Determination
 Meets vision requirements
 with correction  without correction
 Does not meet vision requirements
 Determination pending, additional information required (visual acuity correction,etc.)

 Recommend futher evaluation

Remarks: No protected health information

_____________________________________________________ Date:

Clinician’s Printed Name:

_____________________________________________________  DO  MD  NP  PA Clinician’s Signature:

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Patient: DOB: Service Date:

Concentra Medical Centers
123 Street Address Town, State 12345
Phone: (123) 456-7890 Fax: (123) 456-7890

Return to Work Evaluation Results

Job Description

_______ Job description was provided by the
employer and has been reviewed by
the examining provider.

_______ Job description not available.

Determination is based solely upon
description of duties provided by
the patient/applicant.

Return to Work Examination Results

_______ May work without limitations/restrictions.

_______ May work only with the following limitations/restrictions

________________________________________________

_______ Unable to meet physical requirements of the job.

_______ Determination pending: additional information
required. Requested information and/or additional
evaluation must be completed within 45 days. **

Remarks: Do not include protected health information (PHI) _________________________________________________________________________________________ _________________________________________________________________________________________

____________________________________________
Clinician’s Printed Name

____________________________________________
Clinician’s Signature

**If status above listed as Determination Pending, please document status after review of additional records/testing:

_______ May work without limitations/restrictions

_______ May work only with the following limitations/restrictions: ___________________________________

_______ Unable to meet physical requirements of the job.

___________________________________________ __________________________________ Clinician’s Printed Name Date Final Determination Made

____________________________________________
Clinician’s Signature

RTW-2
Concentra Medical Centers
5910 N MacArthur Blvd Ste 133 IRVING, TX 75039
Phone: (972) 554-8494 Fax: (972) 438-4647

PULMONARY FUNCTION TEST RECORD

PLMNFUNC
DALLAS, TX. 75201
Archana's MA Employer
Attach Print Out Here Or To The Back Of This Form
Employee SSN:

List Medications Used: _____________________________
Hours Since Last Smoked _______
Hours Since Medication Used _______
Former SmokerNon Smoker Smoker
Sex: Male Female
Hispanic White AsianBlackRace Other:

Age
Date of last calibration
(P)
Test Date:

Location: ____ In Clinic _____ In Plant _____ Other Spirometer/Pulmonometer (circle one)
Test Number:

Time of Test:
(S)
Address:

Employer Name: (Check when print out is attached)
Check indicates the one that applies
Height in Inches
Ambient Temp - C
Observed Values (BTPS)
Complete this section when print out is not available
FEV1 FVC FEV1/FVC%
Comments:

FEV1%
FEV1 ( > 8%) FVC ( > 8%) FEV1/FVC% (> 6 %)
Change (%)
Predicted Normals *
FVC%
Technicians Name (Signature)
BTPS- Body Temperature Ambient Pressure Saturated with Water Vapor Calculation.

The predicted FEV and FVC in Black individuals must be multiplied by 0.85.

In stocking feet
*
123 Main Street
Technicians Name (Print)
52 XXX-XX-1111
Patient's Last Name, First Name and Middle Initial:

Lindor, Francis
Employee ID/Alternative ID:
55555555
r_pulmonary_func Page 1 of 1 02/04/2022Print Date:

Revision Date:08/06/2021
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15810 Midway Road ADDISON, TX 75001
Concentra Medical Centers
Fax: (972) 458-7776 (972) 458-8111 Phone:

HPE–7
Concentra Medical Center
123 Street Address Town, State 12345
Phone: (123) 456-7890 Fax: (123) 456-7890

Patient Name: _______________________________________ Date of Birth: _____________ Service Date: _____________

HUMAN PERFORMANCE EVALUATION

HPE Questionnaire. Rev. 9/27/21
Job Title:

Evaluation Results

1. Check one:
 Able to perform the essential job functions
 Unable to perform the essential job functions

2. If unable to perform all the essential job functions, check the tasks below that the candidate was unable to perform:

 Lift  Climb  Carry
 Confined access  Push-pull  Limited headroom
 UE push-pull  Repetitive posture  Repetitive coupling  Static posture  Grip strength  Balance
 Pinch strength  Step test
 Other / Otras:

3. Results to be provided to employer by third party:
 Yes
 No

Evaluator Name:

Evaluator Signature:

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/119 /3 /34 /92 □ /1 /36 □ /98 /1 /32 /33 /36 □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □□ □ □ □ □ □ □ □ □ □ □ □ □ □□ □ /175 /6 /2 □ /32 /34 □ /96 /97 /1 /91 /3 □ /105 /6 /34 /97 /95 □ /32 /7 □ /33 /89 /90 /6 /110 /92 □ /110 /33 /3 /92 /106 □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □□ □ □ □ □ □ □ □ □ □□□□□□□□□□□□□□□ □ □ /111 /6 /90 /94 /1 /97 □ /119 /90 /3 /1 /36 /89 /32 /34 /2 □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □□ □ □ □ □ □ □ □ □ □ □□ □ /118 /110 /93 /152 /3 /91 /36 □ /90 /1 /36 /3 /92 □ /91 /6 /94 /7 /6 /90 /36 □ /6 /7 □ /90 /3 /33 /96 /32 /90 /1 /36 /6 /90 □ /7 /90 /6 /94 □ □ /5 □ /105 /97 /3 /1 /33 /36 □ /91 /6 /94 /7 /6 /90 /36 /1 /93 /97 /3 /106 □ /36 /6 □ /5 /38 □ /105 /94 /6 /33 /36 □ /91 /6 /94 /7 /6 /90 /36 /1 /93 /97 /3 /106 □ □ □ □ □ □ □ □ □ □ □ □
□/118 /110 /93 /152 /3 /91 /36 □ /94 /1 /92 /3 □ /34 /6 □ /1 /36 /36 /3 /94 /96 /36 /105 /33 /106 □ /36 /6 □ /1 /92 /152 /110 /33 /36 □ /90 /3 /33 /96 /32 /90 /1 /36 /6 /90 □ /92 /110 /90 /32 /34 /2 □ /1 /33 /33 /3 /33 /33 /94 /3 /34 /36 /102 □ /151 /63 /70
□
/83 /73
□
/162 /70 /70 /63 /70 /70 /80 /63 /87 /61 □ /65 /163 /86 /63 /72 /174 □ /58 /59 /59 □ /61 /86 /58 /61 □ /58 /81 /81 /59 /82 /69 □ /88 /3 /33 /36 □ /92 /32 /33 /91 /6 /34 /36 /32 /34 /110 /3 /92 □ /92 /110 /3 □ /36 /6 /37 □ □ □ □ □ □ □ /172 /1 /32 /90 □ /2 /90 /6 /98 /36 /89 /155 □ /93 /3 /1 /90 /92 /156 □ /94 /110 /33 /36 /1 /91 /89 /3 /156 □ /33 /32 /92 /3 /93 /110 /90 /34 /33 □ /98 /89 /32 /91/89 □ /91 /90 /6 /33 /33 □ /90 /3 /33 /96 /32 /90 /1 /36 /6 /90 □ /33 /3 /1 /97 /32 /34 /2 □ /33 /110 /90 /7 /1 /91 /3
□ □ □ □ □ □ □ □ /176 /143 /139 /146 /131 /148 /128 /133 /127 □ /160 /140 /132 /125 /133 /158 /143 /142 /141 □ /177 □ /71 /63 /84 /63 /74 □ /61 /73 □ /72 /59 /60 /87 /60 /72 /60 /58 /87 □ □ □ □ □ □ □ □ /178 /124 /126 /139 /124 /140 /133 □ /124 /140 □ /146 /133 □ /124 /139 □ /140 /132 /123 /145 /143 /140 /125 /133 /124 /140 □ /157 /125 /123 □ /148 /142 /125 /131 /131 /132 /145 /133 /125 /160 /128/132 □ /133 /124 □ /132 /126 /145 /128 /124 /127 /132 /132 /71 /63 /72 /73 /80 /80 /63 /87 /75 /58 /61 /60 /73 /87 /65 /70 /69 /78 □ □□ □ □
/163 /59 /60 /87 /60 /72 /60 /58 /87 □ /163 /73 /80 /80 /63 /87 /61 /70 /78 □ □ □ □
□ □ □ □ □ □ □ □ /109 /94 /96 /97 /6 /95 /3 /3 □ /90 /3 /91 /6 /94 /94 /3 /34 /92 /3 /92 □ /7 /6 /90 □ /30 /3 /33 /96 /32 /90 /1 /36 /6 /90 □ /171 /3 /92 /32 /91 /1 /97□ /109 /31 /1 /97 /110 /1 /36 /32 /6 /34 □ □ □ □ □ □ □ □ /0 /1 /33 /33 /3 /92 □ /101 /32 /36 □ /88 /3 /33 /36 □ □ □ □ □ □ □ □ /101 /1 /32 /97 /3 /92 □ /101 /32 /36 □ /88 /3 /33 /36 □ □ □ □ □ □ □ □ □ □ □ □
/68 /63 /72 /86 /87 /60 /72 /60 /58 /87 □ /76 /60 /169 /87 /58 /61 /57 /74 /63 The City of Anaheim ♦ Medical Evaluation Services

Secretary of State
Certificate of Status

I, SHIRLEY N. WEBER, Ph.D., Secretary of State of the State of California, hereby certify:

Entity Name: OCCUPATIONAL HEALTH CENTERS OF CALIFORNIA, A MEDICAL

CORPORATION
File Number: C2055819
Registration Date: 09/15/1997
Entity Type: DOMESTIC STOCK CORPORATION
Jurisdiction: CALIFORNIA
Status: ACTIVE (GOOD STANDING)

As of January 5, 2022 (Certification Date), the entity is authorized to exercise all of its powers, rights and privileges in California.

This certificate relates to the status of the entity on the Secretary of State's records as of the Certification Date and does not reflect documents that are pending review or other events that may affect status.

No information is available from this office regarding the financial condition, status of licenses, if any, business activities or practices of the entity.

IN WITNESS WHEREOF, I execute this certificate
and affix the Great Seal of the State of California
this day of January 6, 2022.

SHIRLEY N. WEBER, Ph.D.

Secretary of State

Certificate Verification Number: RGX686Y

To verify the issuance of this Certificate, use the Certificate Verification Number above with the Secretary of State Certification Verification Search available at bebizfile.sos.ca.gov/certification/index.

The City of Anaheim ♦ Medical Evaluation Services

Our Legal and Risk Departments reviewed the terms, conditions, and insurance requirements and made minor modifications to the language. We include these suggested revisions on the following pages. If Concentra is the successful bidder, we desire to engage in open dialogue with the City, review the proposed modifications, and ultimately create an agreement that not only outlines the schedule of services, but also protects the business interests of both the City and Concentra.

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.

INSURER(S) AFFORDING COVERAGE
INSURER F :

INSURER E :

INSURER D :

INSURER C :

INSURER B :

INSURER A :

NAIC #
NAME:

CONTACT
(A/C, No):

FAX
E-MAIL
ADDRESS:

PRODUCER
(A/C, No, Ext):

PHONE

INSURED
REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.

If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS

CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

OTHER:
(Per accident)
(Ea accident)
$
$
N / A
SUBR
WVD
ADDL
INSD

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS

CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. $ $
$
$PROPERTY DAMAGE
BODILY INJURY (Per accident)
BODILY INJURY (Per person)

COMBINED SINGLE LIMIT

AUTOS ONLY

AUTOSAUTOS ONLY

NON-OWNED

SCHEDULEDOWNED

ANY AUTO

AUTOMOBILE LIABILITY
Y / N

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
DESCRIPTION OF OPERATIONS below
If yes, describe under

ANY PROPRIETOR/PARTNER/EXECUTIVE
$
$
$
E.L. DISEASE - POLICY LIMIT
E.L. DISEASE - EA EMPLOYEE
E.L. EACH ACCIDENT
ER
OTH-

STATUTE
PER

LIMITS(MM/DD/YYYY)

POLICY EXP
(MM/DD/YYYY)

POLICY EFF

POLICY NUMBERTYPE OF INSURANCELTR
INSR
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

EXCESS LIAB
UMBRELLA LIAB $EACH OCCURRENCE
$AGGREGATE
$
OCCUR

CLAIMS-MADE
DED RETENTION $
$PRODUCTS - COMP/OP AGG
$GENERAL AGGREGATE
$PERSONAL & ADV INJURY
$MED EXP (Any one person)
$EACH OCCURRENCE

DAMAGE TO RENTED
$PREMISES (Ea occurrence)

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR
GEN'L AGGREGATE LIMIT APPLIES PER:

POLICY PRO-

JECT LOC

CERTIFICATE OF LIABILITY INSURANCE

DATE (MM/DD/YYYY)

CANCELLATION

CERTIFICATE HOLDER
The ACORD name and logo are registered marks of ACORD
HIRED

AUTOS ONLY
10/7/2022
The Graham Company
The Graham Building
1 Penn Square West
Philadelphia PA 19102-
Concentra Unit
215-567-6300
215-405-2694
[email protected]
Columbia Casualty Company
31127
CONCGRO-01
Liberty Mutual Fire Ins. Co.
23035
Occupational Health Centers of California,
A Medical Corporation, c/o Select Medical Corporat
4716 Old Gettysburg Road
Mechanicsburg PA 17055
Liberty Insurance Corporation
42404
Liberty Mutual Insurance Group
23043
American Guarantee & Liability Ins. Co.
26247
Allied World Assurance Company, AG
1649422535
A
X
1,000,000
X
500,000
X
Professional Lia
X
$1M Claim/$3M Ag
1,000,000
3,000,000
X
Y
Y
HAZ 4032244581-6
1/1/2022
1/1/2023
3,000,000
B
2,000,000
X
Y
Y
AS2-631-510199-322
4/1/2022
4/1/2023
A
X
X
9,000,000
Y
HMC 4032235752
1/1/2022
Y
1/1/2023
10,000,000
X
3,000,000
C
D
X
Y
WA7-63D-510199-352
WC5-631-510199-362
4/1/2022
4/1/2022
4/1/2023
4/1/2023
1,000,000
1,000,000
1,000,000
E
F
Property
Excess Liability
ZMD0119116-06
C023701-007
1/1/2022
1/1/2022
1/1/2023
1/1/2023

SEE BELOW
$10M Each Occurrence

$10M Aggregate
UMBRELLA LIABILITY COVERAGE includes Excess General Liability on an Occurrence Basis and Excess Professional Liability on a Claims Made Basis.

Both Coverages are excess of a $3,000,000 Self-Insured Retention each Occurrence/Claim subject to a $18,000,000 Aggregate.

PROFESSIONAL LIABILITY COVERAGE includes Case Management Services including the rendering of case management or utilization review performed by insured for others.

INDIANA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244595-8; Effective 1/1/2022-1/1/2023 - $500,000 Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon See Attached...

CITY OF ANAHEIM
Attn: HUMAN RESOURCES DEPT
201 SOUTH ANAHEIM BLVD, 5TH FLOOR ANAHEIM

WEST TOW
ANAHEIM CA 92805

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE:

ADDITIONAL REMARKS
ADDITIONAL REMARKS SCHEDULE Page of
AGENCY CUSTOMER ID:

LOC #:

AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED
EFFECTIVE DATE:

CONCGRO-01
1 1
The Graham Company
Occupational Health Centers of California,
A Medical Corporation, c/o Select Medical Corporat
4716 Old Gettysburg Road
Mechanicsburg PA 17055
25 CERTIFICATE OF LIABILITY INSURANCE
KANSAS PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244600-8; Effective 1/1/2022-1/1/2023 - $500,000 Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon LOUISIANA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244614-8; Effective 1/1/2022-1/1/2023 - $100,000 Each Medical Incident/$300,000 Aggregate Per Insured or Surgeon NEBRASKA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244628-8; Effective 1/1/2022-1/1/2023 - $500,000 Each Medical Incident/$1,000,000 Aggregate Per Insured or Surgeon PENNSYLVANIA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244631-8; 1/1/2022-1/1/2023 - $500,000 Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon WISCONSIN PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244659-8; 1/1/2022-1/1/2023 - $1,000,000 Each Medical Incident/$3,000,000 Aggregate Per Insured or Surgeon PROPERTY COVERAGE: Risk of Physical Loss or Damage to Covered Property subject to policy terms and conditions.

WORKERS COMPENSATION - Occupational Health Centers of California, A Medical Corporation - Liberty Mutual Insurance Corp. - Policy #WA5-63D-510199-312; Effective: 4/1/2022-4/1/2023
WORKERS COMPENSATION - Occupational Health Centers of Southwest, P.A. - Liberty Insurance Corp. - Policy #WA7-63D-510199-402; Effective:
4/1/2022-4/1/2023
WORKERS COMPENSATION - Occupational Health Centers of Southwest, P.A. - Liberty Mutual Insurance Corp. - Policy #WC5-631-510199-252 (WI); Effective: 4/1/2022-4/1/2023
ADDITIONAL WORKERS COMPENSATION POLICIES:

OHC of Arkansas – Liberty Insurance Corp. - Policy #WC7-631-510199-282; Effective: 4/1/2022-4/1/2023 OHC of Southwest (AZ/UT) – Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-242; Effective: 4/1/2022-4/1/2023 OHC of Delaware – Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-332; Effective: 4/1/2022-4/1/2023 OHC of Georgia/Hawaii – Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-382; Effective: 4/1/2022-4/1/2023 OHC of Illinois – Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-412; Effective: 4/1/2022-4/1/2023 OHC of Louisiana – Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-292; Effective: 4/1/2022-4/1/2023 OHC of Michigan – Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-272; Effective: 4/1/2022-4/1/2023 OHC of Nebraska – Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-372; Effective: 4/1/2022-4/1/2023 OHC of New Jersey – Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-262; Effective: 4/1/2022-4/1/2023 OHC of North Carolina – Liberty Insurance Corp. - Policy #WC7-631-510199-342; Effective: 4/1/2022-4/1/2023 OHC of Southwest (KS) – Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-422; Effective: 4/1/2022-4/1/2023 Therapy Centers of Southwest I, PA (OR) - Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-392; Effective: 4/1/2022-4/1/2023 Therapy Centers of South Carolina, PA - Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-302; Effective: 4/1/2022-4/1/2023 OHC of Minnesota - Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-452; Effective: 4/1/2022-4/1/2023 OHC of Alaska - Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-442; Effective: 4/1/2022-4/1/2023 CYBER LIABILITY - AIG Specialty Insurance Company - Policy #01-581-98-19; Effective: 9/25/2022-9/25/2023 - Limit: $10,000,000 EXCESS CYBER LIABILITY - Endurance American Specialty Insurance Company - Policy #NVX30025438400; Effective: 9/25/2022-9/25/2023 - Limit:
$10,000,000 Excess of $10,000,000
CRIME COVERAGE - National Union Fire Insurance Company of Pittsburgh, PA - Policy #02-406-10-33; Effective: 12/31/2021-12/31/2022 - Limit: $10,000,000 Coverage is provided for all medical professionals currently or previously employed or contracted by the above Named Insured, but only for professional services performed for or on behalf of the above Named Insured.

RE: OHC OF CA/CMC IS BIDDING ON AN RFP WHICH IS BIDDING TO PROVIDE MEDICAL SERVICES TO THE EMPLOYEES OF THE NAMED CLIENT.

CITY OF ANAHEIM; ITS OFFICERS, EMPLOYEES, AGENTS, VOLUNTEERS AND REPRESENTATIVES are all included as additional insureds on the above General Liability, Auto Liability and Umbrella Liability Policies and coverage shall apply on a Primary and Non-Contributory basis if required by written contract.

Prior to loss, and if required by written contract, Waiver of Subrogation is provided on General Liability, Auto Liability, Umbrella Liability and Workers Compensation Policies for work performed under contract if permissible by state law.

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -

CALIFORNIA
Person or Organization
Schedule
Job Description
Where required by contract or
written agreement prior to loss and
allowed by law.

We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule.

The additional premium for this endorsement shall be 2% of the California workers' compensation premium otherwise due on such remuneration.

Additional premium is a percent of the California Manual Workers Compensation premium. Subject to a minimum premium charge of $ 250
Effective Date Premium $
Issued by Liberty Insurance Corporation 21814
For attachment to Policy No. WA7-63D-510199-312
Issued to Concentra Group Holding Parent, LLC
WC 04 03 06
Ed: 04/1984
Page of 1 1
POLICY NUMBER: COMMERCIAL AUTO
CA 20 48 10 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

DESIGNATED INSURED FOR
This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM

SCHEDULE
Name Of Person(s) Or Organization(s):

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

COVERED AUTOS LIABILITY COVERAGE

BUSINESS AUTO COVERAGE FORM

MOTOR CARRIER COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.

This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form.

Each person or organization shown in the Schedule is
an "insured" for Covered Autos Liability Coverage, but
only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision
contained in Paragraph A.1. of Section II - Covered
Autos Liability Coverage in the Business Auto and
Motor Carrier Coverage Forms and Paragraph D.2. of
Section I - Covered Autos Coverages of the Auto
Dealers Coverage Form.

Any person or organization whom you have agreed in writing to add as an additional insured, but only to coverage and minimum limits of insurance required by the written agreement, and in no event to exceed either the scope of coverage or the limits of insurance provided in this policy.

AS2-631-510199-32 2
282
POLICY NUMBER: AS2-631-510199-038 COMMERCIAL AUTO
CA 04 44 10 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US (WAIVER OF SUBROGATION)
This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

MOTOR CARRIER COVERAGE FORM
With respectto coverage provided by this endorsement, the provisionsof the Coverage Form apply unless modified by the endorsement.

SCHEDULE
Name(s) Of Person(s) Or Organization(s):

Any person or organization for whom you perform work under a written contract if the contract requires you to obtain this agreement from us, but only if the contract is executed prior to the injury or damage occurring.

Premium: $ INCL
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

The Transfer Of Rights Of Recovery Against
Others To Us condition does not apply to the
person(s) or organization(s) shown in the Schedule,
but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with
that person or organization.

CA 04 44 10 13 © Insurance Services Office, Inc., 2011 Page 1 of I 249
Policy Number: AS2-631-510199-322
P o l i c y
General Liability
A u t o
Umbrella
Deductible
$1,000,000
$1,000 for Each Auto ‐ Comprehensive Collision
$3,000,000 General/Professional Liability Self Insured Retention $5,000,000 Abuse or Molestation Self Insured Retention
WC ‐ Concentra
WC ‐ OHC CA
WC ‐ OHC SWPA
Policy #
HAZ 4032244581‐6
AS2‐631‐510199‐322
HMC 4032235752
WA7‐63D‐510199‐352
WA5‐36D‐510199‐312
WA7‐63D‐510199‐402
$500,000 Deductible
$250,000 Deductible
$100,000 Deductible
Property ZMD0119116‐06
Excess Liability C023701‐007
$50,000 Property Damage Per Occurrence Deductible EXCEPT:
$150,000 Water or Liquid Damage
QUAKE:
$100,000 Property Damage and Time Element Combined ‐ Per Occurrence EXCEPT:
5% Property Damage and 5% Time Element Combined At each premises, but not less than $250,000 Property Damage and Time Element combined at any and all premises within defined Earthquake Zone 1.
2% Property Damage and 2% Time Element Combined At each premises, but not less than$250,000 Property Damage and Time Element Combined at any and all premises within defined Earthquake Zone 2.

FLOOD:
$ 100,000 Property Damage and Time Element Combined at any and all premises (Per Occurrence) EXCEPT:
$ 1,000,000 Property Damage and $1,000,000 Time Element at each Location within a Special Flood Hazard Area
$ 250,000 Property Damage and Time Element Combined at each Location within a Moderate Flood Hazard Area
$150,000 Self Insured Retention
/g38/g50 /g48/g48/g40/g53/g38/g44/g36/g47/g3/g42/g40/g49/g40/g53/g36/g47/g3/g47/g44/g36/g37/g44/g47/g44/g55/g60/g3 /g3 /g38/g42/g3/g21/g19/g3/g21/g25/g3/g19/g23/g3/g20/g22/g3 /g3
/g55/g43/g44/g54/g3/g40/g49/g39/g50/g53/g54/g40/g48/g40/g49/g55/g3/g38/g43/g36/g49/g42/g40/g54/g3/g55/g43/g40/g3/g51/g50/g47/g44/g38/g60/g17/g3/g3/g51/g47/g40/g36/g54/g40/g3/g53/g40/g36/g39/g3/g44/g55/g3/g38/g36/g53/g40/g41/g56/g47/g47/g60/g17/g3 /g3
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/g55/g75/g76/g86/g3/g72/g81/g71/g82/g85/g86/g72/g80/g72/g81/g87/g3/g80/g82/g71/g76/g73/g76/g72/g86/g3/g76/g81/g86/g88/g85/g68/g81/g70/g72/g3/g83/g85/g82/g89/g76/g71/g72/g71/g3/g88/g81/g71/g72/g85/g3/g87/g75/g72/g3/g73/g82/g79/g79/g82/g90/g76/g81/g74/g29/g3 /g3
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/g3
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/g51/g50/g47/g44/g38/g60/g3/g49/g56/g48/g37/g40/g53/g29 HAZ 4032244581-6 POLICY NUMBER: HAZ 4032244581-6 COMMERCIAL GENERAL LIABILITY CG 20 01 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

PRIMARY AND NONCONTRIBUTORY –

OTHER INSURANCE CONDITION
T
his endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
T
he following is added to the Other Insurance
Condition and supersedes any provision to the
contrary:

Primary And Noncontributory Insurance
This insurance is primary to and will not seek
contribution from any other insurance available
to an add itional insured under your policy
provided that:
(1) The additional insured is a Named Insured
under such other insurance; and
(2) You have agreed in writing in a contract or
agreement that this insurance would be
primary and would not seek contribution
from any other insurance available to the
additional insured.

WAIVER OF RIGHTS OF RECOVERY

APPLICABLE TO GENERAL LIABILITY COVERAGE FORM
The changes set forth below are applicable only to the Commercial General Liability Coverage Form G- 145566-A, G-145567-A).

The Healthcare Liability Policy Common Conditions (G-144102-A) are amended as set forth below:

Condition XII., Transfer of Rights of Recovery is amended by the addition of the following:
/g120 Solely within the scope of this endorsement as indicated above, we waive any right of recovery w e m
ay have against any person or organization that you have agreed with, in writing, prior to the da te of
loss, to waive your right to recover against because of payments we make under the Commerci al G
eneral Liability Coverage Form for injury or damage arising out of your ongoing operations. This endorsement applies only to:

All other terms and conditions of the Policy remain unchanged.

This endorsement, which forms a part of and is for attachment to the Policy issued by the designated Insurers, takes effect on the effective date of said Policy at the hour stated in said Policy, unless another effective date is shown below, and expires concurrently with said Policy.

GSL6554XX (4-11)

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Anaheim City CouncilFebruary 7, 2023

Anaheim City Council
February 7, 2023