1 Rev. October 2023
FIRST MODIFICATION OF AGREEMENT NO. 11727 (CCS)
This First Modification of Agreement Number 11727 (CCS) (“First Modification”), entered into as of 7/7/2025 (“Execution Date”), by and between the City of Santa Monica, a municipal corporation (“City”), and PACIFIC HARBOR MEDICAL GROUP INC. Corporation (PACIFIC HARBOR MEDICAL GROUP INC.) is made with reference to the following:
RECITALS
A. On or about August 15, 2024, the City and Pacific Harbor Medical Group Inc. entered into Agreement Number 11727 (CCS) for medical exam and testing services set forth below in compliance with the applicable laws, regulations, and City directives:
1. Pre-employment Physical Exams (Exhibit A-1)
2. Drug and Alcohol Screening (Exhibit A-2)
3. DMV Commercial Driver Testing (Exhibit A-3)
4. Sworn Fire Department Personnel Physicals (Exhibit A-4)
5. HazMat Testing (Exhibit A-5)
6. Fit for Duty/Return to Duty Exams (Exhibit A-6)
7. Executive/Professional Physical Exams (Exhibit A-7)
8. Vaccinations & Tuberculosis (TB) Testing (Exhibit A-8)
9. Respirator Testing (Exhibit A-9)
B. The City and PACIFIC HARBOR MEDICAL GROUP INC. desire to modify the Original Agreement to extend the agreement term for six months through December 31, 2025, and increase funding resulting in new total contract amount not to exceed $231,850.
TERMS AND CONDITIONS
Now, therefore, the undersigned parties do hereby mutually agree to modify the Original Agreement as follows:
1. Section 1 of the Original Agreement entitled “Term” shall be deleted in its entirety and replaced with the following paragraph:
Term. This Agreement begins on the Execution Date and terminates on December 31, 2025, unless terminated earlier as set forth in the Original Agreement or extended by the parties in writing.
2. Section 4 of the Original Agreement entitled “Compensation” shall be modified by adding the following paragraph:
Compensation. The City will compensate PACIFIC HARBOR MEDICAL GROUP INC. for the Additional Services in an amount not to exceed Docusign Envelope ID: 7A6C2F39-4FE0-412B-A760-C0BF10F9328C 2 Rev. October 2023
$136,850, as set forth in Exhibit B. The total agreement price for services pursuant to the Original Agreement and this First Modification shall not exceed $231,850.
3. Exhibits A and Exhibit B are attached hereto and incorporated herein by this reference.
4. Execution in Counterparts. This First Modification may be executed in counterparts with the same effect as if both parties hereto had executed the same document. All counterparts shall be construed together and shall constitute a single modification. Any signature to this First Modification transmitted electronically through DocuSign or PDF shall be deemed an original signature and be binding upon the parties hereto (it being agreed that such electronic signature shall have the same force and effect as an original signature).
5. Except as expressly modified by this First Modification, all other terms and conditions of the Original Agreement shall be and remain in full force and effect.
IN WITNESS WHEREOF, the parties have executed this First Modification as of the date and year first written above.
ATTEST:
CITY OF SANTA MONICA,
a municipal corporation
Elaine Polachek
Interim City Manager
City of Santa Monica
APPROVED AS TO FORM:
DOUGLAS SLOAN
City Attorney
CITY ATTORNEY
By:
Docusign Envelope ID: 7A6C2F39-4FE0-412B-A760-C0BF10F9328C City Clerk
City of Santa Monica
Nikima Newsome
3 Rev. October 2023
By:
Peter Mikhail
Medical Director, DO
Pacific Harbor Medical Group
Docusign Envelope ID: 7A6C2F39-4FE0-412B-A760-C0BF10F9328C 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)
Docusign Envelope ID: 7A6C2F39-4FE0-412B-A760-C0BF10F9328C 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 Docusign Envelope ID: 7A6C2F39-4FE0-412B-A760-C0BF10F9328C 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 Docusign Envelope ID: 7A6C2F39-4FE0-412B-A760-C0BF10F9328C 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 Docusign Envelope ID: 7A6C2F39-4FE0-412B-A760-C0BF10F9328C 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
Docusign Envelope ID: 7A6C2F39-4FE0-412B-A760-C0BF10F9328C 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 Docusign Envelope ID: 7A6C2F39-4FE0-412B-A760-C0BF10F9328C 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.
Docusign Envelope ID: 7A6C2F39-4FE0-412B-A760-C0BF10F9328C 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
Docusign Envelope ID: 7A6C2F39-4FE0-412B-A760-C0BF10F9328C 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.
Docusign Envelope ID: 7A6C2F39-4FE0-412B-A760-C0BF10F9328C 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.).
Docusign Envelope ID: 7A6C2F39-4FE0-412B-A760-C0BF10F9328C Pacific Harbor Medical Group
Exhibit B - Budget
Service Agreement Execution Date - June 30, 2025
Pre-Employment Exam
Test 1 - Desk / Field $ 200
Test 2 - Manual Labor $ 380
Test 3 - DMV DL 51 $ 215
Test 4 - Sworn Fire $ 510
Test 5 - Sworn Police $ 510
Test 6 - POST Dispatchers $ 225
Test 7 - HazMat Tech w/Treadmill Stress Test $ 595
Test 7 - HazMat Tech w/o Treadmill Stress Test $ 465
Drug & Alcohol Testing
DOT Drug Test (including lab and MRO costs) $ 45
DOT and non-DOT Alcohol Screen and Confirmation Test $ 60 Non DOT Drug Test - Negative Result (including lab costs) $ 60 Non DOT Drug Test - Positive Result (including lab and MRO costs) $ 100 Vaccinations
Tdap $ 170
MMR (per vaccines) $ 250
Varicella (per vaccine) $ 455
Hepatitis A (per vaccine) $ 755
Hepatitis B (per vaccine) $ 1,120
Twinrix (per vaccine) $ 310
Rabies (per vaccine) $ 960
Flu (per vaccine) $ 125
TB Testing
Blood Test (IGRA) $ 150
Respirator Fit Testing
Review Questionnaire $ 50
Spirometry Test $ 75
Chest X-Ray - PA & Lateral $ 75
DMV Commercial Testing
Test 3 - DL 51 Exam $ 215
Drug & Alcohol Test w/Negative Drug Test (including lab costs) $ 100 Drug & Alcohol Test w/Positive Drug Test (including lab costs and MRO costs) 140 $ HazMat Testing
Baseline or Annual HazMat Exam w/Treadmill Stress Test $ 745 Baseline or Annual HazMat Exam w/o Treadmill Stress Test $ 615 Combo Annual Exam Hazmat & FF1 Physical - Mandatory Components w/Treadmill Stress Test 745 $ Combo Hazmat & FF1 Physical - Mandatory Components w/o Treadmill Stress Test 615 $ Combo Hazmat & FF2 Physical - Mandatory Components $ 745 Combo Hazmat & FF Physical - Optional Components
Vaccinations (see above)
Glaucoma Screen $ 50
Lipid Panel $ 40
Thyroid Panel $ 25
Colon Cancer Screen $ 50
Genital Cancer Screen
Male $ 50
Female (not available) n/a
Sworn Fire Personnel Physical Exam
FF1 Physical - Mandatory Components $ 525
FF2 Physical - Mandatory Components $ 655
FF Physical - Optional Components
Vaccinations (see above)
Glaucoma Screen $ 50
Lipid Panel $ 40
Thyroid Panel $ 25
Chest X-Ray - PA & Lateral $ 75
Colon Cancer Screen $ 50
Genital Cancer Screen
Male $ 50
Female (not available) n/a
Miscellaneous Tests / Costs
Hearing Screen $ 25
Resting EKG (12 Leads) $ 50
Inguinal Hernia Test $ 50
Treadmill Stress Test $ 180
Appointment No Show (less than 24 hour notice) $ 25
Executive / Professional Physical $ 830
Docusign Envelope ID: 7A6C2F39-4FE0-412B-A760-C0BF10F9328C