Exhibit A
Scope of Services
PACIFIC HARBOR MEDICAL GROUP INC. will perform the following services for the City:
Medical Exams: PACIFIC HARBOR MEDICAL GROUP INC. will provide the medical exam and tesƟng services set forth below in compliance with the applicable laws, regulaƟons, and City direcƟves:
a) Pre-employment Physical Exams (Exhibit A-1)
b) Drug and Alcohol Screening (Exhibit A-2)
c) DMV Commercial Driver TesƟng (Exhibit A-3)
d) Sworn Fire Department Personnel Physicals (Exhibit
A-4)
e) HazMat TesƟng (Exhibit A-5)
f) Fit for Duty/Return to Duty Exams (Exhibit A-6)
g) Executive/Professional Physical Exams (Exhibit A-7)
h) VaccinaƟons & Tuberculosis (TB) TesƟng (Exhibit A-8) i) Respirator TesƟng (Exhibit A-9)
Exhibit A-1:Preemployment Physical Exam Testing Requirements The City has established seven pre-employment physical testing categories (see chart below) to address the varying physical demands of the job classifications subject to testing. City Human Resources will coordinate with the medical provider to identify the correct exam and any accompanying testing (e.g., drug/alcohol test, medical clearance for fit test, etc.) and provide candidate with pre-employment physical packet to bring to exam.
Test Components Test 1 Test 2 Test 3 Test 4 Test 5 Test 6 Test 7 Desk/Field Manual Labor DMV DL 51 (d) Sworn Fire Sworn Police POST Dispatchers HazMat Tech City Medical History Questionnaire X X
DL 51 Medical History Questionnaire X
POST Medical History Questionnaire -- Sworn Police Officers X POST Medical History Questionnaire -- Public Safety Dispatchers X Fire Medical History Questionnaire (use OSHA Respirator Questionnaire) X HazMat Medical History Questionnaire (use OSHA Respirator Questionnaire) X Occupational History & Exposure Review X
Fitness to Work Wearing PPE Determination X
Basic Physical (a) X X (b) X X
Expanded Basic Physical (c) X X X
Vision & Color Screen X X X X X X X
Hearing Screen X X X X X X X
Resting EKG (12 Leads) X X X
Treadmill Stress Test X X X (e)
Chemistry Panel (electrolytes, renal function, liver function & glucose) X X X CBC (white blood count, red blood count & platelets) X X X Urinalysis X X X X
Spirometry X X X
Chest X-Ray -- PA & Lateral X X X
Other Lab Tests (at discretion of physician based on occupational exposure history) X a) Basic Physical Components: c) Basic Physical Components, plus:
* Height & weight * a more comprehensive head, eyes, ears, nose and throat exam * Blood pressure * a more comprehensive abdomen exam
* Pulse rate * a more comprehensive musculoskeletal check * Lung & chest check * a neck exam
* Head, eyes, ears, nose & throat check * an inguinal hernia check * Abdomen check
* Nervous system check (i.e., reflexes, gate) c) Physician must be listed on the National Registry of Certified Medical Providers * Musculoskeletal check
* Flexibility & range of motion d) At discretion of physician b) Basic Physical Components plus inguinal hernia check Exhibit A-2: Drug & Alcohol TesƟng Requirements
The City uses both regulated (DOT) and unregulated (Non DOT) drug and alcohol tests to administer its Drug and Alcohol TesƟng Program. Protocols Westchester will be expected to adhere to are idenƟfied below.
US Department of TransportaƟon (DOT) Drug & Alcohol TesƟng I. Drug TesƟng
* TesƟng will be carried out in accordance with DOT regulaƟons and 49 CFR, Part 40, Part 655 and Part 382 * Specimen Type: urine
The drug panel includes:
* marijuana
* cocaine
* amphetamines/methamphetamines
* PCP
* opiates (derived from poppy: e.g., heroin, morphine, codeine) * Contractor will use the Federal Drug TesƟng Custody and Control Form to process specimen * MRO will review test results and report outcome to City in compliance with DOT regulaƟons II. Alcohol TesƟng
* TesƟng will be carried out in accordance with DOT regulaƟons and 49 CFR, Part 40, Part 655, and Part 382 * Specimen Type: breath
* Approved evidenƟal breath tesƟng devices will be used to screen and confirm specimens * Collector will use the DOT Alcohol TesƟng Form to record test results * Collector will report test results to City in compliance with DOT regulaƟons Non DOT Drug & Alcohol TesƟng
I. Drug TesƟng
* TesƟng will be carried out in accordance with DOT regulaƟons and 49 CFR, Part 40 with two excepƟons❶ * Specimen Type: urine
This panel includes:
* cocaine
* amphetamines/methamphetamines
* PCP
* opiates (derived from poppy: e.g., heroin, morphine, codeine) * barbiturates
* benzodiazepines
* methaqualones
* methadone
* Contractor will use a 5 Part Drug TesƟng Custody and Control Form to process specimen * NegaƟve test results will be reported to City in compliance with City policies * MRO will review posiƟve test results and report outcome to City in compliance with DOT regulaƟons ❶ a) drug panel composiƟon includes 8 specimens (as opposed to 5), and b) an MRO is used to review posiƟve test results only (as opposed to posiƟve and negaƟve test results).
II. Alcohol TesƟng
* TesƟng will be carried out in accordance with DOT regulaƟons and 49 CFR, Part 40 with one excepƟon ❷ * Specimen Type: breath
* Approved evidenƟal breath tesƟng devices will be used to screen and confirm specimens * Alcohol TesƟng Forms will be used to record test results * Contractor will report test results to City in compliance with DOT regulaƟons ❷ Non DOT Alcohol TesƟng Forms will be used to report results Exhibit A-3: DMV Commercial Driver Testing Requirements All commercial drivers in the City are required to undergo a DL51 medical evaluation every two years. The exam components for the test are listed in the chart below.
Test ComponentsDL 51 Medical History QuestionnaireBasic PhysicalInguinal Hernia CheckVision & Color Screen Hearing Screen Urinalysis Exhibit A-4: Sworn Fire Personnel Physical Exam Requirements The City requires its sworn firefighters, with the exception of the Fire Chief, to undergo a standard physical (Firefighter 1) or comprehensive physical (Firefighter 2) every two years (see charts below). The exam type is dictated by age (a); both exams contain optional components the employee can opt to select or decline. The City will advise medical provider of desired exam and optional components when scheduling exam, and provide employee with appropriate materials to bring to exam. (a) -- Exam Schedule:
* All sworn firefighter personnel (with exception of Fire Chief) between the ages of 20 and 39 are required to undergo a FF1 Physical every two years * All sworn firefighter personnel (with exception of Fire Chief) between the ages of 40 and 49 are required to undergo a physical every two years -- alternating between the FF1 and FF2 Physicals (i.e., over a four year period, each employee will undergo one FF1 Physical and one FF2 Physical) * All sworn firefighter personnel (with exception of Fire Chief) age 50 or older are required to undergo a FF2 Physical every two years Firefighter 1 (FF1) Physical Test Components Firefighter 2 (FF2) Physical Test Components Mandatory Components: Mandatory Components:
Expanded Basic Physical (c) Expanded Basic Physical (c) Vision & Color Screen Vision & Color Screen
Hearing Screen Hearing Screen
Chemistry Panel (electrolytes, renal function, liver function & glucose) Resting EKG (12 Leads) CBC (white blood count, red blood count & platelets) Treadmill Stress Test Urinalysis Chemistry Panel (electrolytes, renal function, liver function & glucose) Spirometry CBC (white blood count, red blood count & platelets) TB Test Urinalysis
Optional Components (b): Spirometry
Vaccinations (c) TB Test
Glaucoma Screen Optional Components (b):
(b) Employees can choose to request or reject "optional" tests/vaccinations Vaccinations (c) (c) Tdap, MMR, Varicella, & Hep A and B or Twinrix Glaucoma Screen Lipid Panel (cholesterol)
Thyroid Panel
Chest X-Ray -- PA & Lateral
Colon Cancer Screen
Genital Cancer Screen offered
* Male: genitals, rectum & prostrate
* Female: pelvic exam and pap smear
(b) Employees can choose to request or reject "optional" tests/vaccinations (c) Tdap, MMR, Varicella, & Hep A and B or Twinrix
Exhibit A-5: HazMat Testing Requirements
All HazMat Team members are required to undergo testing before placement in the assignment, annually while in the assignment, and at the termination of assignment. The exam components for the baseline test and annual/final test are located in Charts 1 & 2 below.
Annual Firefighter Physicals will be combined with HazMat exams in the years that both exams are required (see Charts 3 & 4 below).
The City will advise medical provider of desired exam and optional components when scheduling exam, and provide employee with appropriate materials to bring to exam.
Chart 1 Chart 2
HazMat Exam -- Baseline Test Components HazMat Exam -- Annual / Final Test Components Medical History Questionnaire Review (use OSHA respirator questionnaire) Medical History Questionnaire Review (use OSHA respirator questionnaire) Occupational History & Exposure Review Exposure Review
Fitness to Work Wearing PPE Determination Fitness to Work Wearing PPE Determination Expanded Basic Physical Expanded Basic Physical
Vision & Color Screen Vision & Color Screen
Hearing Screen Hearing Screen
Resting EKG (12 Leads) Resting EKG (12 Leads)
Treadmill Stress Test (at discretion of physician) Treadmill Stress Test (at discretion of physician) Spirometry Spirometry
Chest X-Ray -- PA & Lateral Chest X-Ray -- PA & Lateral Chemistry Panel (electrolytes, renal function, liver function & glucose) Chemistry Panel (electrolytes, renal function, liver function & glucose) CBC (white blood count, red blood count & platelets) CBC (white blood count, red blood count & platelets) Urinalysis Urinalysis
TB Test TB Test
Other Lab Tests (at discretion of physician based on occupational exposure history) Other Lab Tests (at discretion of physician based test results and recent exposures) Chart 3 Chart 4
Combo HazMat Exam & FF1 Test Components Combo HazMat Exam & FF2 Test Components Mandatory Components: Mandatory Components:
Medical History Questionnaire Review (use OSHA respir questionnaire) Medical History Questionnaire Review (use OSHA respir questionnaire) Occupational History and/or Exposure Review Occupational History and/or Exposure Review Fitness to Work Wearing PPE Determination Fitness to Work Wearing PPE Determination Expanded Basic Physical Expanded Basic Physical
Vision & Color Screen Vision & Color Screen
Hearing Screen Hearing Screen
Resting EKG (12 Leads) Resting EKG (12 Leads)
Treadmill Stress Test (at discretion of physician) Treadmill Stress Test Spirometry Spirometry
Chest X-Ray -- PA & Lateral Chest X-Ray -- PA & Lateral Chemistry Panel (electrolytes, renal function, liver function & glucose) Chemistry Panel (electrolytes, renal function, liver function & glucose) CBC (white blood count, red blood count & platelets) CBC (white blood count, red blood count & platelets) Urinalysis Urinalysis
TB Test TB Test
Other Lab Tests (at discretion of physician based test results and recent exposures) Other Lab Tests (at discretion of physician based test results and recent exposures) Optional Components(a): Optional Components(a):
Vaccinations(b) Vaccinations(b)
Glaucoma Screen Glaucoma Screen
Lipid Panel (cholesterol)
(a) Employees can choose to request or reject "optional" tests/vaccinations Thyroid Panel (b) Per state law, the City must offer Tdap, MMR, Varicella, & Hep A and B or Twinrix Colon Cancer Screen Genital Cancer Screen offered
* Male: genitals, rectum & prostrate
* Female: pelvic exam and pap smear
(b) Per state law, the City must offer Tdap, MMR, Varicella, & Hep A and B or Twinrix Exhibit A-6: Fit-for-Duty / Return-to-Duty Exams Testing Requirements * Components of Fit-for-Duty and Return-to-Duty exams will be determined by Human Resources staff on a case-by-case basis. * Medical provider will review job description, job analysis, and any other documentation provided by City prior to conducting exam. * Medical provider findings will be provided to Human Resources.
Exhibit A-7: Executive / Professional Physical Testing Requirements * Certain classifications are entitled to annual physicals; exam components are listed below. * City Departments will provide employee with necessary forms and exam instructions. * Medical provider findings will be provided to employee only.
Test Components
Basic Physical
Laboratory
Urinalysis
CBC
Chemistry Panel (Comprehensive Metabolic Panel)
Cardiovascular Risk Profile
C-Reactive Protein
Thyroid-stimulating hormone function test (TSH)
Renal Lytes
Hepatic Function Panel
Lipid Panel
Homocysteine Panel
Stool Guaiac (Age 40 and above)
Vision Screening
Hearing Screen
Tonometry
Spirometry
Treadmill Stress Test/Resting EKG
Body Composition
Strength/Flexibility
Exhibit A-8: Vaccinations & TB Testing Requirements
Vaccinations
Pursuant to Cal OSHA and City policy, certain job classifications are offered one or more of the following vaccinations:
● Tdap (Tetanus / Diphtheria / Pertussis): 1 dose of vaccine ● MMR (Measles / Mumps / Rubella):
* Sworn Fire personnel and Pier and Harbor Patrol Officers receive 2 doses of vaccine (due to health care duties)
● Varicella: 2 doses of vaccine
● Hepatitis A & B or Twinrix:
* Hepatitis A only: 2 doses of vaccine
* Hepatitis B only: 3 doses of vaccine
* Twinrix: 3 doses of vaccine
● Rabies (pre-exposure): 2 doses of vaccine
The City will advise the medical provider of the vaccinations needed when scheduling appointment; employees will bring appropriate vaccination paperwork to appointment.
TB Testing
The medical provider will administer an FDA approved TB Blood Test (IGRA) to detect TB.
Exhibit A-9: Respirator Testing Requirements
New Hire Respirator Testing
Medical provider will review Cal OSHA Respirator Medical Evaluation with candidate; medical provider will either provide clearance for fit testing or request additional testing (e.g., spirometry, chest x-ray, etc.).
Annual Respirator Testing for Existing Employees
Existing employees subject to respirator fit testing will complete the Respirator Medical Evaluation and send to medical provider for review; medical provider will either provide clearance for fit testing or request additional testing (e.g., spirometry, chest x-ray, etc.).