County of Mercer
McDade Administration Building, 640 South Broad Street, P.O. Box 8068, Trenton, NJ
08650-0068
REQUEST FOR PROPOSALS FOR OCCUPATIONAL HEALTH
SERVICES
For The
COUNTY OF MERCER
To Be Received On
February 2, 2017
Prepared By:
Department of Purchasing
CC 2017-01
COUNTY OF MERCER
NOTICE OF REQUEST FOR PROPOSAL
(CC2017-01)
Exempt Services
The County of Mercer is soliciting proposals through a fair and open process in
accordance with N.J.S.A. 19:44A-20.4 et seq. for:
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR THE COUNTY OF MERCER
Mercer County requires submission by January 31, 2017 at 11:00 A.M. to the Mercer
County Department of Purchasing, Specifications and instructions to bidders may be
obtained on the County website at www.mercercounty.org.
Proposals shall be delivered in sealed envelopes and addressed to the Mercer County
Department of Purchasing, Room 320, 640 South Broad Street, P.O. Box 8068, Trenton, NJ
08650-0068.
With the exception of the United States Postal Service, express mail shall be delivered to
the Mercer County Purchasing Department, 640 S. Broad Street, Room 321, Trenton, New
Jersey 08611.
NOTE:
The United States Postal Service does not deliver priority or overnight mail directly to the
County of Mercer’s physical address. If a bidder chooses to use the United States Postal
Service, it is the bidder’s responsibility to ensure that the bid package is delivered by
the bid opening date and time. Any bid document received after the deadline
established by the Department of Purchasing will not be accepted, regardless of the
method of delivery.
It is the responsibility of prospective respondent’s to check this website for any
Addenda issued prior to the proposal opening. Failure to do so could result in the
rejection of your submission.
RELEASE:
ALL QUESTIONS BY:
ADDENDA ISSUED:
PROPOSALS OPENED:
January 13, 2017
January 20, 2017
January 26, 2017
February 2, 2017 AT 11:00 A.M.
Respondents shall comply with the requirements of P.L. 1975 C127. (N.J.S.A. 17:27et
seq.)
COUNTY OF MERCER, NEW JERSEY
Department of Purchasing
CC2017-01
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
2
INTRODUCTION
The County of Mercer requests proposals through the Competitive Contracting process
(Authorizing Resolution 2013-125) for Occupational Health Services, testing and
evaluations and Emergency Room visits for 24 hour per day emergency treatment for
the County of Mercer employees. Respondents must have a minimum of three (3)
years’ experience and preferably, shall employ an occupational health, board certified
physician. Respondents shall be located within the County of Mercer for the
convenience of all County employees.
TERM
The contract shall be awarded for a period of two (2) years with an option to extend
one (1) year. The award shall be based upon the established criteria referenced in the
specifications.
ADMINISTRATIVE CONDITIONS AND REQUIREMENTS
The following items express the administrative conditions and requirements of the RFP.
They will apply to the RFP process, the subsequent contract and the project’s
production. Any proposed change, modification, or exception to these conditions and
requirements may be the basis for the County of Mercer to determine the proposal as
non-responsive to the RFP and will be a factor in the determination of an award of
contract. The contents of the proposal of the successful respondent, as accepted by
the County of Mercer will become part of any contract awarded as a result of this RFP.
SCHEDULE
A schedule has been established for respondent proposals, proposal review, contractor
selection, project initiation and completion. The following dates have been established:
RELEASE:
ALL QUESTIONS BY:
ADDENDA ISSUED:
PROPOSALS OPENED:
January 13, 2017
January 20, 2017 to [email protected] by 3:00 P.M.
January 26, 2017
February 2, 2017 AT 11:00 A.M.
The County disclaims any responsibility for proposals received late by regular or express
Mail. If the proposal is sent by express mail service, the designation must appear on the
outside of the express mail envelope. Proposals received after the designated time and
date will be returned unopened (no exceptions).
Submit One (1) Original and Four (4) copies. Clearly mark the submittal package with
the title of this RFP and the name of the responding firm, addressed to the County of
Mercer, McDade Administration Building, 640 South Broad Street, Trenton, NJ 08611. The
original proposal shall be marked to distinguish it from the copies. Responses delivered
before the submission date and time specified may be withdrawn upon written
application of the respondent who shall be required to produce evidence showing that
the individual is or represents the principal(s) involved in the proposal. After the
submission date and time specified above, responses must remain firm for a period of
sixty (60) days.
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
3
COUNTY REPRESENTATIVE FOR THIS SOLICITATION
Mercer County Department of Purchasing
PO Box 8068
640 S. Broad Street
Trenton, New Jersey 08611
Voice: (609) 989-6710
Fax (609) 989-6733
The County disclaims any responsibility for proposals received late by regular or
overnight mail. If the proposal is sent by express mail service, the designation must
appear on the outside of the express mail envelope. Proposals received after the
designated time and date will be returned unopened (there are no exceptions).
NOTE:
The United States Postal Service does not deliver priority or overnight mail directly to the
County of Mercer’s physical address. If a bidder chooses to use the United States Postal
Service, it is the bidder’s responsibility to ensure that the bid package is delivered by
the bid opening date and time. Any bid document received after the deadline
established by the Department will not be accepted, regardless of the method of
delivery.
INTERPRETATIONS AND ADDENDA
Respondents are expected to examine the RFP with care and observe all its
requirements. All questions about the meaning or intent of this RFP, all interpretations
and clarifications considered necessary by the owner’s representative in response to
such comments and questions will be issued by Addenda mailed or posted on the
County website at www.mercercounty.org . Only comments and questions responded
to by formal written Addenda will be binding. Oral interpretations, statements or
clarifications are without legal effect. All questions must be received 10 business days in
advance of the opening of proposals.
STATUTORY AND OTHER REQUIREMENTS
COMPLIANCE WITH LAWS
Any contract entered into between the contractor and the owner must be in
accordance with and subject to compliance by both parties with the New Jersey Local
Public Contracts Law. The contractor must agree to comply with the non-discrimination
provisions and all other laws and regulations applicable to the performance of services
there under. The respondent shall sign and acknowledge such forms and certificates as
may be required by this section.
MANDATORY AFFIRMATIVE ACTION COMPLIANCE
No firm may be issued a contract unless it complies with the Affirmative Action
requirements of P. L. 1975, C. 127 as identified in the documents attached hereto. The
form shall be properly executed.
AMERICANS WITH DISABILITIES ACT OF 1990
Discrimination on the basis of disability in contracting for the delivery of services is
prohibited. Respondents are required to read American with Disabilities language that
is part of the documents attached hereto and agree that the provisions of Title II of the
Act are made part of the contract. The contractor is obligated to comply with the Act
and hold the owner harmless.
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
4
STATEMENT OF CORPORATION OWNERSHIP 52:25-24.2. BIDDERS TO SUPPLY STATEMENT OF
OWNERSHIP OF 10% INTEREST IN CORPORATION OR PARTNERSHIP
No corporation or partnership shall be awarded any contract nor shall any agreement
be entered into for the performance of any work or the furnishing of any materials or
supplies, the cost of which is to be paid with or out of any public funds, by the State, or
any county, municipality or school district, or any subsidiary or agency of the State, or of
any county, municipality or school district, or by any authority, board, or commission
which exercises governmental functions, unless prior to the receipt of the bid or
accompanying the bid, of said corporation or said partnership, there is submitted a
statement setting forth the names and addresses of all stockholders in the corporation
or partnership who own 10% or more of its stock, of any class or of all individual partners
in the partnership who own a 10% or greater interest therein, as the case may be. If one
or more such stockholder or partner is itself a corporation or partnership, the
stockholders holding 10% or more of that corporation's stock, or the individual partners
owning 10% or greater interest in that partnership, as the case may be, shall also be
listed. The disclosure shall be continued until names and addresses of every noncorporate stockholder, and individual partner, exceeding the 10% ownership criteria
established in this act, has been listed.
NON-COLLUSION AFFIDAVIT
The Non-Collusion Affidavit, which is part of this RFP, shall be properly executed and
submitted with the RFP response.
PROOF OF BUSINESS REGISTRATION P.L. 2009, c.315
Reforms Business Registration Certificate Filing; permits filing prior to award of contracts if
not filed with bid. Effective with bids received and contracts awarded after January 18,
2010, this law removes the requirement of the Local Public Contracts Law (N.J.S.A.
40A:11-23.2) that required a bid to be rejected if the bidder failed to include a BRC with
the bid, even though it may have been the otherwise lowest responsible bid. The law
now allows the BRC to be filed anytime prior to award of the contract and the bidder
had to have obtained the BRC prior to receipt of bids. This permits the BRC to be
required with a bid, or submitted subsequently. If a BRC is required in a bid, but not
submitted with the bid, it would an immaterial defect; curable by being filed prior to
award of the contract. A BRC is obtained from the New Jersey Division of Revenue.
Information on obtaining a BRC is available on the internet at www.nj.gov/njbgs or by
phone at (609) 292-1730.
PAY TO PLAY
Starting in January, 2007, business entities are advised of their responsibility to file an
annual disclosure statement of political contributions with the New Jersey Election Law
Enforcement Commission (ELEC) pursuant to N.J.S.A. 19:44A-20.27 if they receive
contracts in excess of $50,000 from public entities in a calendar year. Business entities
are responsible for determining if filing is necessary. Additional information on this
requirement is available from ELEC at 888-313-3532 or at www.elec.state.nj.us.
RECORDS FOR THE NEW JERSEY STATE COMPTROLLER
Pursuant to N.J.S.A. 52:15C-14(d), relevant records of private vendors or other persons
entering into contracts with the County are subject to audit or review by the New
Jersey Office of the State Comptroller. Therefore, the Contractor shall maintain all
documentation related to products, transactions or services under this contract for a
period of five years from the date of final payment. Such records shall be made
available to the New Jersey Office of the State Comptroller upon request.
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
5
PROMPT PAYMENT
In compliance with N.J.S.A. 2A:30A-1 et seq., the County of Mercer shall impose the
following payment process:
The County of Mercer shall pay the submitted bill not more than 30 calendar days after
the receipt of the bill by the County if the vendor has performed in accordance with
the contract and the work has been approved and certified by the County. The billing
shall be deemed “approved” and “certified” 20 calendar days after the owner
receives it, unless the County provides, before the end of the 20-day period, a written
statement of the amount withheld and the reason for withholding payment.
HOMELAND SECURITY GRANT PROCUREMENT: EMERGENCY RESPONDER EQUIPMENT
PURCHASE PROGRAM, LOCAL FINANCE NOTICE 2009-20
Mercer County, consistent with LFN 2009-20 authorizes all counties and municipalities in
the State of New Jersey to utilize contracts awarded by the County of Mercer for the
Procurement of federal homeland security goods and services. The procurement must
be funded through the New Jersey Office of Homeland Security and Preparedness;
therefore, any county may buy under any other county's existing contract, under the
same terms and conditions, and with the approval of the County of Mercer and
vendor. The County of Mercer Freeholder Board must approve the use of the contract
by other counties through either a generic resolution permitting other counties to use all
contracts or on a case-by-case basis. The resolution shall reference Local Finance
Notice 2005-14, the county’s name and bid number.
P.L. 2012 BID OR PROPOSAL PROHIBITED
C.52:32-57 “P.L. 2012, c.25 prohibits State and local public contracts with persons or
entities engaging in certain investment activities in energy or finance sectors of Iran.”
INSURANCE AND INDEMNIFICATION
If it becomes necessary for the contractor, either as principal or by agent or employee,
to enter upon the premises or property of the owner in order to construct, erect,
inspect, make delivery or remove property hereunder, the contractor hereby
covenants and agrees to take use, provide and make all proper, necessary and
sufficient precautions, safeguards, and protection against the occurrence of
happenings of any accident, injuries, damages, or hurt to person or property during the
course of the work herein covered and his/her sole responsibility. The contractor further
covenants and agrees to indemnify and save harmless the owner from the payment of
all sums of money or any other consideration(s) by reason of any, or all, such accidents,
injuries, damages, or hurt that may happen or occur upon or about such work and all
fines, penalties and loss incurred for or by reason of the violation of any owner
regulation, ordinance or the laws of the State, or the United States while said work is in
progress.
The contractor shall maintain sufficient insurance to protect against all claims under
Workers Compensation, General Liability and Automobile and shall be subject to
approval for adequacy of protection and certificates of such insurance shall be
provided.
MULTIPLE PROPOSALS NOT ACCEPTED
More than one proposal from an individual, a firm or partnership, a corporation or
association under the same or different names shall not be considered.
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
6
FAILURE TO ENTER CONTRACT
Should the respondent, to whom the contract is awarded, fail to enter into a contract
within ten (10) days, Sundays and holidays excepted, the owner may then, at its option,
accept the proposal of another respondent.
COMMENCEMENT OF WORK
The contractor agrees to commence work after the date of award by the owner and
upon notice from the using department.
TERMINATION OF CONTRACT
If, through any cause, the contractor shall fail to fulfill in a timely and proper manner
obligations under the Contract or if the contractor violates any requirements of the
Contract, the owner shall thereupon have the right to terminate the Contract by giving
written notice to the contractor of such termination at least thirty (30) days prior to the
proposed effective date of the termination. Such termination shall relieve the owner of
any obligation for the balances to the contractor of any sum or sums set forth in the
Contract.
CHALLENGE OF SPECIFICATIONS
Any respondent who wishes to challenge a specification shall file such challenge in
writing with the Purchasing Agent no less than three (3) business days prior to the
opening of the RFP's. Challenges filed after that time shall be considered void and
having no impact on the owner or the award of contract.
TRANSITIONAL PERIOD
In the event services are terminated by contract expiration or by voluntary termination
by either the Contractor or The County of Mercer, the Contractor shall continue all
terms and conditions of said contract for a period not to exceed thirty (30) days at the
County’s request.
PAYMENT
Invoices shall specify, in detail, the period for which payment is claimed, the services
performed during the prescribed period, the amount claimed and correlation between
the services claimed and the Proposal Cost Form.
The owner may withhold all or partial payments on account of subsequently discovered
evidence including but not limited to the following:
Deliverables not complying with the project specification;
Claims filed or responsible evidence indicating probability of filing claims;
A reasonable doubt that the Contract can be completed for the balance then
unpaid.
When the above grounds are removed, payment shall be made for amounts withheld
because of them.
LOCATIONS AND QUANTITIES
The County of Mercer reserves the right to add locations and increase or decrease the
quantities at the proposed costs as defined in the awarded contractor’s proposal as
may be deemed reasonably necessary or desirable to complete the work detailed by
the contract. Such increase or decrease shall in no way violate this contract, nor give
cause for liability for damages.
STATISTICAL DATA REPORT
If requested, the contractor shall provide in writing to the County, a statistical data
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
7
Report identifying all goods and or services provided.
COST LIABILITY AND ADDITIONAL COSTS
The County of Mercer assumes no responsibility and liability for costs incurred by the
Respondents prior to the issuance of an agreement. The liability shall be limited to the
terms and conditions of the contract.
Respondents will assume responsibility for all costs not stated in the proposals. All hourly
rates either stated in the proposal or used as a basis for pricing are required to be allinclusive. Additional charges, unless incurred for additional work performed by request
of the County of Mercer, for indirect costs, fees, postage, licensing, commissions, taxes,
travel, subsistence, report preparation, meetings, administrative tasks, administrative
and clerical support, overhead, etc. are not to be billed and will not be paid.
OWNERSHIP OF MATERIAL
The County of Mercer shall retain all of its rights and interest in and to any and all
documents and property both hard copy and digital furnished by the County of Mercer
to the contractor, for the purpose of assisting the contractor in the performance of this
contract. All such items shall be returned immediately to the County of Mercer at the
expiration or termination of the work or completion of any related services, pursuant
thereto, whichever comes first. None of such documents and/or property shall, without
the written consent of the County of Mercer, be disclosed to others or used by the
contractor or permitted by the contractor to be used by their parties at any time in the
performance of the resulting contract.
Ownership of all data, materials and documentation originated and prepared for the
County of Mercer pursuant to this contract shall belong exclusively to the County of
Mercer. All data, reports, computerized information, programs and materials related to
this project shall be delivered to and become the property of the County of Mercer
upon completion of the project. The contractor shall not have the right to use, sell or
disclose the total of the interim or final work products, or make available to third parties,
without the prior written consent of the County of Mercer.
COMMENCEMENT OF WORK
The contractor agrees to commence work on the project within Thirty (30) calendar
days from the date of award by the County of Mercer.
GENERAL CONSIDERATIONS
Competitive Contracting is a formal procurement process governed by the New Jersey
State Local Public Contracts Law and Rules. The process utilizes an RFP containing
thoroughly developed specifications and scope of services, criteria for evaluating
proposals and statutorily required language and forms. Responses are ranked by a
team, on the RFP criteria, using a detailed methodology leading to a recommendation
to the governing body to award a contract based on price and other factors.
PROVIDING INFORMATION
Information will be made available at the County Office during regular business hours.
The County shall provide access, within reason, and at no cost to the Contractor, to all
information on file with the County and needed by the Contractor to complete the
Project.
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
8
METHOD OF ACCOMPLISHMENT
The RFP responses shall contain a narrative description of the proposed approach to
the project. Restating of the RFP will be considered an unacceptable response.
This section shall include a listing of the resources identified for use in the project.
PROJECT LEVEL OF EFFORT
The proposal shall include a project level of effort estimate based on, and
corresponding to, the Scope of Service provided in this RFP and the Respondents
Method of Accomplishment section. The estimate shall contain a task-oriented
schedule, which identifies milestones and their proposed initiation and completion
dates.
NOTICE OF AWARD
The Successful Respondent will be notified of the award of contract upon a favorable
decision by the Department of Purchasing
PROPOSALS TO REMAIN SUBJECT TO ACCEPTANCE
RFP responses shall remain open for a period of sixty (60) calendar days from the stated
submittal date. The County will either award the Contract within the applicable time
period or reject all proposals.
The County may extend the decision to award or reject all proposals beyond the sixty
(60) calendar days when the proposals of any Respondents who consent thereto may,
at the request of the County, be held for consideration for such longer period as may
be agreed.
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
9
SCOPE OF WORK:
OCCUPATIONAL HEALTH SERVICES
The County of Mercer requests proposals from Occupational Health Clinics for the
provision of occupational medicine for Mercer County employees. Respondents shall
provide quality medical services for County employees and shall provide workplace
evaluations and testing.
Respondents shall provide data related to the County’s evaluations and tests and shall
facilitate the prevention and treatment of occupational illnesses and injuries through
treatment and reporting.
The Occupational Health provider shall require employees to provide consent to tests
and procedures, provide results of tests and procedures, provide copy of medical
records, transmit electronic records, provide information to employees and the results of
all tests and procedures; inform employees about their rights to workplace health and
safety, and assist in improving the County’s workplace health and safety. Records and
Workers Compensation claims shall be maintained and released in accordance with
the law. The awarded contractor shall provide written reports and legal testimony of
findings, if requested.
BASIS OF AWARD
The intent of this RFP is to award a contract(s) to that (those) responsible provider(s) whose
proposal is most advantageous to the County of Mercer, price and other factors considered.
The number of evaluations and tests may increase or decrease; and respondents shall provide
firm pricing for years one, two and optional year three; however, pricing in year three shall not
exceed the index rate as issued by the Department of Community Affairs, Division of Local
Government Services. The awarded contractor shall invoice the county only for those actual
tests, evaluations, programs and consulting services performed. This is not a capitated rate
contract.
SCOPE OF SERVICES
The County of Mercer requests Occupational Health Services as defined. The awarded
provider shall provide scheduled services 5 days per week, 52 weeks per year
(excluding County Holidays) between the hours of 7:00 AM and 5:30 PM. Emergency
Room treatment shall be provided at all times if required. The contract shall be
awarded for a period of two years with an option to extend one year. The cost
proposal shall be based upon the cost per evaluation or test and interpretation and
reporting and the County will pay the hourly rates as stated in the proposal pages for
consulting and testimony as required. The County shall pay only for those services
performed as requested.
The qualified health provider must demonstrate proven ability to execute all
requirements as outlined in the specifications below. Respondents shall submit
evidence of medical malpractice or professional liability insurance. The health provider
shall submit credentials to demonstrate the required qualifications for each applicable
Part as specified below. The health provider shall submit references for credentials of
physicians who will be administering examinations and consultations. The qualified
health provider shall submit prior or present experience in the provision of health care
services similar to those requested. All services shall be performed at a facility or facilities
located within Mercer County, New Jersey for the convenience of employees. Provider
shall be available for appointments at least Monday through Friday, 7:00 AM to 5:30 PM,
throughout the year. Provider shall be a licensed to practice medicine in the State of
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
10
New Jersey, with credentials in internal medicine or occupational medicine.
Approximate quantities required per year are referenced on the proposal pages and
the provider shall invoice the County for those services provided including evaluations,
tests, and consulting.
SERVICES REQUESTED
Respondents shall provide services as reflected in the specifications and shall perform
additional services that are not referenced. Those services that are not reflected in the
specifications shall be billed at the usual and customary rate.
Respondents shall comply with all local, state and federal medical statutes, rules and
regulations including but not limited to the Americans with Disabilities Act (ADA), Family
and Medical Leave Act (FMLA), LAD, Pregnancy Discrimination Act, Public Employees
Occupational Safety and Health Act PEOSHA, etc.
Respondents shall provide a multidisciplinary, patient-centered, prevention oriented,
public health approach to Occupational Health. Respondents shall be prepared to
inform patients of their right to request and receive copies of all medical test results and
other information in the medical record and shall be available to visit County worksites.
Respondents must have on site a staff physician with either board-certification, or
demonstrated expertise in occupational medicine. Expertise may be demonstrated
through publication in the peer-reviewed literature or a regional or national reputation.
Respondents shall employ professionals with expertise in occupational health.
BASIS FOR COST PROPOSAL
The County has provided an estimated number of tests and evaluations based upon
history as the basis for this proposal. Respondents shall provide an hourly rate for
Physician onsite services for a period of two years with the option to extend one year.
Only those actual services provided shall be billed to the County by the awarded
provider at the rate or cost per test or evaluation as provided on the proposal form. A
description of required services follows.
Respondents shall provide pricing on the County supplied proposal page.
LICENSURE
The Facility shall be licensed as required by the Department of Health and Senior
Services, Division of Health Care Systems Analysis, Certificate of Need and Acute Care.
Contact (609) 292 6552 for licensure information. Physicians shall be licensed through
the New Jersey Department of Law and Public Safety, Division of Consumer Affairs.
IS ACUTE CARE LICENSE REQUIRED?
LICENSURE OF A CLINICAL LABORATORY (UNDER THE PROVISIONS OF N.J.S.A. 45:9-42.26
ET SEQ.)
Bidders must be licensed through the New Jersey Department of Health and Senior
Services in accordance with 45:9-42.26 et seq. “New Jersey Clinical Laboratory
Improvement Act” and laboratories located outside the state of New Jersey are
required to obtain a clinical laboratory license if the out-of-state lab has a collection
station in the state of New Jersey or is directly involved in the collection or transport of
specimens from New Jersey to the out-of-state lab. Bidders shall provide a copy of their
license with their bid response.
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
11
CLIA CLINICAL LABORATORY IMPROVEMENT AMENDMENTS CERTIFICATE
All Bidders must possess a CLIA Certificate and shall provide a copy of the certificate
with their bid response.
ELECTRONIC MEDICAL RECORDS
Respondents shall have Electronic Data Interchange capability.
PSYCHOLOGICAL EVALUATIONS
The County reserves the right to award a separate contract for psychological
evaluations. Professionals providing evaluations shall be duly licensed.
RECORDKEEPING, DOCUMENTATION AND ELECTRONIC RECORDS
The awarded health provider shall maintain medical records for each employee and
provide a report of their findings. The awarded provider shall provide the county access
to the complete employee medical file as permitted by laws. The health provider shall
maintain the releases for medical information signed by the employee. The health
provider shall provide a notice of Privacy Practice to the employee or applicant
relating to their physical or mental health, in compliance with HIPAA, about
safeguarding that information. The health provider shall provide the County with
documentation of all tests performed for the employee’s medical file. Monthly reports
shall be submitted to the County designee defining each service provided and cost per
service. Respondents shall have Electronic Data Interchange capability. Upon request,
the County shall have unlimited access to all employee files.
LOCATION OF SERVICING OFFICE
The proposal must list the location and address of the present, active office, which will
service and manage this project and provide the location of the off-site facility.
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
12
NOTICE OF AWARD
The Successful Respondent will be notified of the award of contract by the Department
of Purchasing.
PROPOSALS TO REMAIN SUBJECT TO ACCEPTANCE
RFP responses shall remain open for a period of sixty (60) calendar days from the stated
submittal date. The County will either award the Contract within the applicable time
period or reject all proposals.
The County may extend the decision to award or reject all proposals beyond the sixty
(60) calendar days when the proposals of any Respondents who consent thereto may,
at the request of the County, be held for consideration for such longer period as may
be agreed.
EVALUATION, REVIEW AND SELECTION PROCESS
All proposals received by the deadline will be reviewed first for substantial compliance
with this RFP and for fulfillment of the mandatory requirements. Proposals that are late,
non-compliant, or fail to meet the minimum mandatory requirements will not be
evaluated.
Proposals that are timely, compliant, and meet the mandatory requirements will be
reviewed by the Evaluation Committee and other personnel to sit in on the
presentations and review the proposals. However, only members of the Evaluation
Committee will grade the proposals and presentations.
The written proposals will be evaluated and graded in accordance with the Evaluation
Criteria. The vendors whose proposals are determined to be reasonably susceptible of
being selected will be invited to make an oral presentation. The purpose of the oral
presentation is to allow the evaluation committee to learn more about the information
contained in the written proposal.
EVALUATION PROCESS
An Evaluation Team will review all proposals to determine if they satisfy the proposal
requirements, determine if a proposal should be rejected and evaluate the proposals
based upon the Evaluation Criteria. The highest-ranking Respondent will then be
recommended by the Evaluation Team to The Mercer County Board of Chosen
Freeholders for award of contract.
CRITERIA EVALUATION
The following criteria shall be considered in the evaluation of each proposal. The
arrangement of the criteria is not meant to imply order of importance in the selection
process. The criteria weighting will be presented at the scheduled opening of
proposals. All criteria will be used to select the Successful Respondent. The qualification
statement shall be limited to ten pages.
MANAGEMENT AND TECHNICAL EXPERTISE
The county will evaluate based upon the respondent’s experience and ability to meet
the scope of work outlined in the RFP. The Respondent shall provide a qualification
statement, including qualification of physicians assigned to the contract. Respondents
shall provide name and credentials of the Physician(s) assigned to this contract. The
Occupational Health Physician and Staff shall be identified. Medical expertise of the
respondent including years providing occupational health services shall be defined by
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
13
past successes providing government agencies and private companies with
Occupational Health Services. Respondents shall have Electronic Data Interchange
capability.
AVAILABILITY
Respondents (in the qualification statement) shall define their ability to provide
scheduled services and emergency services as required. Respondents shall state the
ability to provide services at the provider’s Occupational Center and Emergency Room
as defined.
COST
Lowest cost proposal divided by next low cost, multiplied by points; Example: cost
assigned 30 points, lowest cost proposal $100,000 next low $120,000 (Divide the low cost
by the next low) multiplied by 30 = (100,000/120,000) * 30 = 25 Low cost respondents
earns 30 points, next low earns 25 points, etc.
Proposals shall be evaluated based upon the costs as defined in the proposal for
Occupational Health Services. Respondents shall accept payment as re priced by the
County’s Third Party Administrator and there shall be no balance billing to the County.
Respondents shall confirm that they will accept payment through the county’s current
or subsequent claims administrator. Proposal meets budget.
RESPONDENTS WILL BE EVALUATED AGAINST THE FOLLOWING CRITERIA AND SHALL
RESPOND WITH THE FOLLOWING INFORMATION IN THE QUALIFICATION STATEMENT:
1.
Knowledge and experience (INCLUDE NUMBER OF YEARS EXPERIENCE AND
ACCREDITATION)
2.
Sufficient staffing and resources (REFERENCE PHSYCIAN ONSITE, AND
STAFFING AFFILIATED WITH THE SERVICES AND LOCATION)
3.
Ability to provide services as required from 7:00 AM through 5:30 PM
4.
Will provide Electronic Data Interchange
5.
Respondent accepts re-pricing for Workers Compensation claims and shall
not balance bill the County
6.
Respondent will accept reasonable and customary payment for those
services that are not identified
7.
Cost
Respondents will comply with all requirements stated in the RFP and shall identify key
staff assigned to the contract. Respondents shall submit resumes for those key staff.
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
14
WORKERS COMPENSATION TREATMENT (INITIAL AND SUBSEQUENT) AND EMERGENCY
ROOM TREATMENT
Respondents shall provide initial and subsequent treatment for employee injuries
sustained on the job. The initial and final examination shall be conducted by a
physician.
Respondents shall provide electronic data interchange. Workers
Compensation Claims are repriced in accordance with usual and customary fee
schedules utilizing the Wasserman Fee Schedule for in-state pricing and the Injenix Fee
schedule for out-of-state pricing. Respondents shall accept payment as repriced by the
County’s Third Party Administrator, and there shall be no balance billing to the County.
In the event that the awarded provider has entered into a contract with the County’s
Third Party Administrator, repricing at the lesser rate shall apply.
All charges associated with emergency room visits are billed directly to the County’s
Worker’s Compensation insurance carrier and shall be paid in accordance with the
usual and customary fee schedule. This shall include all services associated with
treatment.
REIMBURSEMENTS
Respondents shall accept the reimbursement structure provided through the County’s
third party administrator and shall not balance bill the County. Excepted are defined
services with defined pricing as defined in the specifications and proposal pages.
FOR WORKERS COMPENSATION CLAIMS, COUNTY EMPLOYEES MUST BE SEEN THE SAME
BUSINESS DAY BUT IN NO CIRCUMSTANCE GREATER THAN 24 HOURS AFTER BEING
ADVISED OF THE INJURY.
RESPONSE TIME
Respondents shall provide services within the time frame agreed upon by Raissa
Walker, Director of Employee Relations.
INVOICING
THE AWARDED CONTRACTOR SHALL PROVIDE DETAILED INVOICING ON A MONTHLY
BASIS. INVOICING SHALL REFLECT THE SERVICE PROVIDED WITH UNIT COST. ALL SERVICES
SHALL BE INVOICED WITHIN 30 DAYS FROM DATE OF SERVICE.
CONSULTING
Respondents shall provide consulting services as needed. The county has established
an estimated number of consulting hours; however consulting shall be billed based
upon the actual number of hours provided. The Mercer County Risk Manager requires
approximately 60 hours annually; including monthly claims review meetings; however
the provider shall provide consulting services with any and all agencies through onsite,
offsite, telephony, electronic communication and court testimony. The provider shall
meet with the County Administrator, as requested. The provider shall bill incrementally
i.e. A fifteen minute consultation shall be billed at fifteen minutes. The county has
established a maximum consultation rate of $175.00 per hour for years one and two
and $180.00 per hour for year three.
SUBSTANCE ABUSE TESTING
The County of Mercer’s Department of Personnel dictates supervision, selection and
collection process. A representative from this office will coordinate the process for DOT
and NON-DOT urine and BAT testing and will notify provider of County employees who
are in need of testing.
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
15
LOCATION OF SERVICING OFFICE AND CONTRACT ADMINISTRATOR
Reference the location and address of the office serving as the contract manager for
this project and provide the location of the facility.
PRIMARY CONTACT:__________________________________________________________
TITLE: ________________________________________________________________________
ADDRESS:____________________________________________________________________
ADDRESS:____________________________________________________________________
TELEPHONE:__________________________________________________________________
EMAIL ADDRESS:______________________________________________________________
TELEFACSMILE:________________________________________________________________
SERVICE LOCATION: __________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
EMERGENCY CONTACT:_______________________________________________________
TITLE: ________________________________________________________________________
ADDRESS:____________________________________________________________________
ADDRESS:____________________________________________________________________
TELEPHONE:__________________________________________________________________
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
16
RESPONDENTS WILL BE EVALUATED AGAINST THE FOLLOWING CRITERIA AND SHALL
RESPOND TO THE FOLLOWING IN THEIR QUALIFICATION STATEMENT IN TEN PAGES OR LESS
KNOWLEDGE AND EXPERIENCE
(INCLUDE NUMBER OF YEARS EXPERIENCE AND ACCREDITATION)
STAFFING AND RESOURCES
(REFERENCE AND STAFFING ASSIGNED TO THIS CONTRACT, SERVICES TO BE PROVIDED
AND LOCATION)
ABILITY TO PROVIDE SERVICES AS REQUIRED MONDAY – FRIDAY FROM 7:00 AM THROUGH
5:30 PM
ABILITY TO PROVIDE ELECTRONIC DATA INTERCHANGE WITH THE COUNTY AND THIRD
PARTY ADMINISTRATOR
RESPONDENT ACCEPTS RE-PRICING FOR WORKERS COMPENSATION CLAIMS AND SHALL
NOT BALANCE BILL THE COUNTY
ADHERENCE TO ALL REQUIREMENTS AS STATED IN THE RFP
ABILITY TO COMPLY WITH HIPPA REGULATIONS
RESPONDENT WILL ACCEPT REASONABLE AND CUSTOMARY PAYMENT FOR THOSE
SERVICES THAT ARE NOT IDENTIFIED
COST
Cost
Lowest cost proposal divided by next low cost, multiplied by points
Example: cost assigned 30 points, lowest cost proposal $100,000 next low $120,000
(Divide the low cost by the next low) multiplied by 30 = (100,000/120,000) * 30 = 25
Low cost respondents earns 30 points, next low earns 25 points, etc.
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
17
DESCRIPTION OF PHYSICALS, TESTS AND EVALUATIONS
ALL INITIAL AND FINAL EVALUATIONS MUST BE PERFORMED BY A PHYSICIAN, preferably a
BOARD CERTIFIED, OCCUPATIONAL HEALTH PHYSICIAN. The following tests and
evaluations are typical of those ordered by the County; however, the tests and
evaluations performed over the past three years are referenced on the proposal
pages.
During any physical, test, and evaluation, all vitals shall be taken and must be stable. If
vitals are not stable, appropriate medical action must be taken immediately, i.e.
emergency room, appropriate medical care. These vitals are to include temperature,
pulse, respiration, blood pressure, and oxygen saturation.
PART 1.
PRE-EMPLOYMENT PHYSICALS AND DRUG SCREENING FOR NEW EMPLOYEES
Physically examine perspective hires to determine suitability for employment – matching
job descriptions to physical abilities. Examination will include:
a.
Patient history
b.
Vital signs
c.
Visual acuity test
d.
Color blindness test
e.
Physical examination
f.
Medications History
Provider shall perform a physical examination including: Height; Weight; History of
operations, diseases, nervous disorders, disability awards, etc.; Teeth; Mouth; Nose;
Throat; Hearing; Vision; Color Test; Chest; Lungs; Heart; Blood Pressure; Pulse; Extremities;
Reflexes; Feet-Toes; Hernia; Hemorrhoids; Urine: Specific Gravity, Reaction, Sugar; and
determination that employee is or is not physically capable of sustaining the labors and
exposures in the performance of his duties.
Provider shall complete and return the original “Report of Examining Physician” form
within five (5) business days.
RFP Requirements:
Respondent shall state the total cost of the complete physical. The examining Physician
shall complete and submit to the County a report of the physical. At end of
examination, complete paperwork and make preliminary determination regarding
applicant’s ability to perform job.
Pre-Employment Drug Screen (2 subparts)
Subpart A: 5-panel urine screen
Specification Requirements: Provider shall be thoroughly familiar with Procedures for
Workplace Drug and Alcohol Testing Programs (49 CFR 40). Appointments shall be
available within three (3) calendar days of request. Samples shall be collected in a
manner consistent with Federal drug screening requirements (i.e. 49 CFR 40). Testing
shall be performed by a SAMHSA (Substance Abuse and Mental Health Services
Administration) certified laboratory.
Test shall consist of:
Subpart A: 5-panel urine drug screen, including:
Amphetamines, Cocaine, Marijuana (THC), Opiates, Phencyclidine (PCP)
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
18
Test results shall be reviewed by a certified medical review officer. Provider shall report
results within three (3) business days.
DRUG AND ALCOHOL SCREENING, COLLECTION, TESTING AND REPORTING
 Drug testing shall be a 10 panel drug screening including THC (Marijuana),
MOR (Opiate/Morphine), PCP (Phencyclidine), AMP (Amphetamines),
COC (Cocaine), BZO (Benzodiazepine), BAR (Barbiturate), MTD
(Methadone), MDMA (Ecstasy), synthetic opiates with confirmation via a
“chain of custody” collection. Initial screening shall be instant test; send
for confirmation if non-negative.
 The county may consider requiring a twelve panel drug screening and
respondents shall provide the cost per test for a twelve panel drug
screening
 Pre-employment drug screening and Commercial Driver’s License, and
alcohol screening collection, testing interpretation and reporting.
 Specimens to be collected in accordance with all applicable rules and
regulations governing collection of “chain of custody” specimens.
 CDL’s will be a five panel DOT drug screen and breath alcohol screen
with positive confirmation. (GCMS).
PART 2.
RANDOM DRUG TESTING (MAY BE AFTER HOURS) (PROVIDE COST PER PANEL, BAT
AND ALCOHOL)
 Random selection, collection, review and interpretation of a ten panel
drug screen to be provided to the employees of the County of Mercer
 Collection to be done at the respective County site at a date and time
specified by the County.
 Random drug testing may be collected at any time during a 24 hour
period.
 Non-Negatives will be reviewed by a Medical Review Officer who will
determine if the positive drug result is consistent with legal drug use.
PART 3.
OSHA RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE
Employee will complete Appendix A to Section 1910.134: OSHA Respirator Medical
Evaluation Questionnaire. Upon completion of the questionnaire, County Physician will
review questionnaire and approved or disprove employee for respirator fit-testing. Per
the Standard, “the employer shall provide a medical evaluation to determine the
employees ability to use a respirator before the employee is fit tested or required to use
the respirator in the workplace”. County Physician will document that the employee is
medically fit to use a respirator and place said document in employee’s medical file.
Respirator Fit Evaluation for 3M™ N95 AND N100: For employees identified as essential
personnel, Physician shall determine if employee is medically fit to use a respirator. At
the time of the pre-employment physical, employee will complete Appendix C to
Section 1910.134: OSHA Respirator Medical Evaluation Questionnaire. Upon completion
of the questionnaire, County Physician will review questionnaire and approved or
disprove employee for respirator fit-testing. Per the Standard, “the employer shall
provide a medical evaluation to determine the employees ability to use a respirator
before the employee is fit tested or required to use the respirator in the
workplace”. County Physician will document that the employee is medically fit to use a
respirator and place said document in employee’s medical file. The actual fit test is
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
19
performed by a county technician. Sample attached – refer to appendix A.
PART 4.
LEAVE OF ABSENCE APPROVAL/DENIAL (PROVIDE A FLAT RATE)
a.
For any employee who will be out of work for an extended period of
time due to illness or injury, an extended leave certification must be
completed by the employee’s primary care physician.
b.
Upon receipt of the completed certification, Physician evaluates the note
based on the information given and recommends approval or denial of
the request for leave of absence and or FMLA determination.
c.
Physical examinations may be required for suitability of leave of absence.
d.
The recommendation to allow or deny the leave of absence is
communicated in writing to Personnel and to the immediate supervisor.
PART 5.
RETURN TO WORK EVALUATIONS (MUST BE PERFORMED BY A BOARD CERTIFIED,
OCCUPATIONAL HEALTH PHYSICIAN
a.
A physical exam is required for any County employee who has been off
the job for five consecutive days due to illness.
b.
Examination is performed to determine whether the employee is
physically and/or mentally ready to return to duty based on
documentation received from primary care physician regarding the
nature of the illness.
c.
Return to work physicals shall be scheduled prior to the employee’s return
date. Physician shall be available Monday through Friday to provide this
service.
e.
Documentation regarding the decision to allow or deny patient to return
to work is sent to Office of Employee Relations as well as the employee’s
supervisor.
f.
Physician shall provide Fitness for Duty evaluations with or without referrals
for Functional Capacity Evaluations and Final Determination shall be
made by the Physician.
PART 6.
CAST/PROSTHESIS EVALUATIONS (PROVIDE COST PER EVALUATION)
Any employee who is not off the job for five days but wants to work while using
crutches, cane, cast, slings, etc.; must be examined by the County Physician.
The employee is physically examined to determine suitability to work, based
on the job activities and the type of aide the person is using. The County
Physician shall make a recommendation to the County Office of Employee
Relations.
SPECIAL PROGRAMS AS DEFINED IN THE PROPOSAL
At specific times during the course of the year the County Physician provides
screening programs and preventative programs for the employees who wish
to participate. Respondents shall provide a cost per screening and
evaluation.
PART 7 AND 8. (PROVIDE COST PER TEST)
Twice yearly the pesticide workers are screened using psuedocholinesterase test for
cholinesterase exposure. Park employees are periodically evaluated for baseline levels
of Lyme disease for future diagnosis using Lyme Antibody Titer for screening. Serological
testing shall be used to support a clinically suspected case. Provide the cost per test on
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
20
the proposal pages.
PART 9. (PROVIDE BUNDLED COST)
COTA/Officer training academy eligibility evaluations and testing including Physical
examinations, lab testing, urinalysis, EKG or Stress Test. Provide bundled pricing as follows
for Correction Officers and Youth Detention Center Employees: EKG, CARE Titer (Cardiac
Risk Profile containing a lipid profile including cholesterol, HDL, LDL, and triglycerides
ratio), UA, Glucose. Provide bundled pricing as follows for Sheriff’s Officers: Exercise
Stress Test, CARE Titer (Cardiac Risk Profile containing a lipid profile including
cholesterol, HDL, LDL, and triglycerides ratio), UA, Glucose.
PART 10.
(PROVIDE COST PER VACCINE WITH INOCULATION AND COST PER INOCULATION IF
COUNTY SUPPLIES VACCINE) ALL OTHERS BILLED AT U&C
Shall provide influenza vaccine and inoculation as required. Shall administer vaccines
as requested. Administration of the H1N1 influenza vaccine or vaccines as supplied by
the County, to county employees including law enforcement and emergency/essential
personnel. Provide the cost per inoculation including vaccine and cost per inoculation
only (County Supplied vaccine).
PART 11. (CONSULTING SERVICES)
MEDICAL DIRECTOR FOR THE MERCER COUNTY DIVISION OF PUBLIC HEALTH AND
BIOTERRORISM PREPAREDNESS/LINCS (THE COUNTY WILL PAY AS CONSULTING HOURS ARE
REQUESTED FOR THIS SERVICE) (IF AND WHEN REQUIRED).
In the event that the County requires services, the Physician will act as the Medical
Director for the Mercer County Division of Public Health and Bioterrorism
Preparedness/LINCS (Local Information Network Communication System). Physician will
be available to provide guidance and offer advice to County LINCS Health Officer,
Bioterrorism Public Health Nurse and County Epidemiologist in preparation for and
during public health emergencies. Physician will review and approve medical protocols
and provide standing orders to the LINCS Bioterrorism Public Health Nurse. Upon request
of the Mercer County Bioterrorism Public Health Nurse, Physician will write prescriptions
to permit the purchase and stockpile of preventative and emergency medications in
preparation for a public health event.
Physician will evaluate emergency
preparedness plans developed by the Mercer County Division of Public Health and
Bioterrorism Preparedness/LINCS. The County is not bound to services and will pay only
as needed at the consulting rates.
Part 12.
Hepatitis-B Vaccination (2 subparts, Vaccination and post Vaccination Verification)
Part A: Hepatitis-B Vaccine injections (Each employee x 3 injections per employee)
Part B: Post-vaccination testing
Specification Requirements:
Hepatitis-B vaccination and post-vaccination testing shall be performed in accordance
with Centers for Disease Control and Prevention guidelines for adults who have
occupational exposure to bloodborne pathogens (refer to “A Comprehensive
Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the
United States: Recommendations of the Advisory Committee on Immunization Practices
(ACIP) Part II: Immunization of Adults”, December 8, 2006), and OSHA Bloodborne
Pathogens Standard, 29 CFR 1910.1030.
Appointments:
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
21
Provider shall be available for initial vaccination appointments within five (5) business
days of request. Provider shall schedule appointments for vaccination and postvaccination testing protocol. Provider shall contact employee two (2) business days
before appointments to confirm. Provider shall contact any employee who fails to keep
an appointment within two (2) business days to reschedule. Provider shall report second
missed appointments within two (2) business days.
Refusal/declination: Provider shall obtain a signed declination form when an employee
declines vaccination. Provider shall forward signed declination forms within five (5)
business days.
Provider shall determine appropriate evaluation and follow-up in the event of an
adverse reaction to the vaccination.
Provider shall provide a quarterly (or more frequent) invoice including the names of
employees treated, the dates of treatment, and the treatment (i.e. vaccination or postvaccination testing) performed.
Provider shall provide an individual record of vaccination dates and post-vaccination
testing for each employee within five (5) business days of completion of postvaccination testing.
Provider shall report any post-vaccination test result that requires re-vaccination to the
Somerset County Safety Coordinator within two (2) business days.
RFP Requirements:
Respondent shall state cost per injection (Part A) and total cost of post-vaccination
testing (Part B) on Proposal Page.
Part 13.
Tuberculosis Screening – General (2 subparts)
Specification Requirements:
General: Provider shall be available for appointments at least Monday through Friday,
7:00 am to 5:30 pm, throughout the year. Provider shall be thoroughly familiar with
current US CDC guidelines for tuberculosis surveillance of employees. Provider shall
report the results of the test on a form provided by Somerset County. Provider shall be
available for initial appointment within five (5) business days of request. Provider shall
schedule all follow-up appointments. Provider shall contact employee two (2) business
days before appointments to confirm. Provider shall contact any employee who fails to
keep an appointment within two (2) business days to reschedule. Provider shall report
second missed appointments within two (2) business days. Provider shall report the
results of the test within five (5) business days.
Part A TB Skin Test Provider shall perform TB skin testing in accordance with current CDC
guidelines for health care facility employees. Initial testing shall consist of a two-step TB
skin test as per CDC guidelines for health care facility employees.
Part B: Blood Assay for M. Tuberculosis Provider shall perform a Blood Assay for M.
Tuberculosis in accordance with current CDC guidelines for health care facility
employees.
RFP Requirements:
Respondent shall state total cost of each test (TB Skin Test and/or Blood Assay) for each
employee including performing the test, reading the result, and reporting the result.
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
22
PART 14.
Medical Report Review
Provider shall review medical reports provided by employees for the purpose of
interpreting and developing conclusions and recommendations in the context of
employee’s job description, as supplied by Mercer County. Provider may be required to
contact employee’s physician. Provider shall report the results of the examination within
five (5) business days. Reports shall include objective conclusions, within a reasonable
degree of medical certainty, as to whether or not the employee is able to perform the
essential functions of the job without accommodations; What, if any, accommodations
may enable the employee to perform the essential functions of the job; or Whether or
not the employee is able to perform the essential function of the job with or without
reasonable accommodations.
RFP Requirements:
Respondent shall indicate the cost, per employee, per review.
Part 15.
Fitness for Duty Examinations
Provider shall examine employee for the purpose of objectively determining whether
the employee is physically able to perform the essential functions of his or her position
(as described in a written Job Description), with or without accommodations. Provider
may be required to contact employee’s physician. Provider shall report the results of
the examination within five (5) business days. Reports shall include objective findings,
within a reasonable degree of medical certainty, as to whether or not the employee is
able to perform the essential functions of the job without accommodations; what, if
any, accommodations may enable the employee to perform the essential functions of
the job; or whether or not the employee is able to perform the essential function of the
job with, or without, reasonable accommodations.
RFP Requirements:
Respondent shall indicate the cost per examination.
Part 16.
Audiometric Testing
Specification Requirements: All services shall be provided at times, dates, and locations
specified by Mercer County.
Provider shall perform test at a rate of at least 20 employees per hour. Provider shall be
qualified as required by the OSHA Occupational Noise Exposure standard, 29 CFR
1910.95(g)(3). Provider shall be thoroughly familiar with: OSHA Occupational Noise
Exposure standard (29 CFR 1910.95), with particular attention to Audiometric Testing
Program requirements (29 CFR 1910.95(g)), OSHA standards for recording occupational
hearing loss (29 CFR 1904.10), and NJ Workers’ Compensation Law (NJSA 34:15), as it
relates to occupational hearing loss.
Provider shall perform audiometric testing in accordance with OSHA standards (29 CFR
1910.95) and NJ Workers’ Compensation requirements for occupational hearing loss
(NJSA 34:15). Provider shall evaluate each audiogram as required by 29 CFR
1910.95(g)(7). Provider shall determine whether the audiogram may indicate a
compensable hearing loss as defined by the NJ Workers’ Compensation Law (NJSA
34:15).
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
23
Provider shall report the results of the test, individually for each employee, within five (5)
working days. Reports shall include: A copy of the audiogram, whether or not there
may have been an OSHA recordable hearing loss (29 CFR 1904.10), whether or not
there may have been a compensable hearing loss (NJSA 34:15).
RFP Requirements:
Respondent shall state cost per employee of test, evaluation, and report.
Part 17.
Haz Mat Medical Surveillance, Prosecutor’s Office Forensic Team
Provider shall be a physician licensed to practice medicine in the State of New Jersey,
with credentials in internal medicine, occupational medicine, clinical toxicology, and
shall have special training in the area of toxicology. Providers shall be thoroughly
familiar with:
OSHA standards for medical evaluation of Hazardous Materials response workers (29
CFR 1910.120(f)), NIOSH Occupational Safety and Health Guidance Manual for
Hazardous Waste Site Activities, OSHA Asbestos Standard medical surveillance
regulations (29 CFR 1910.1001), OSHA Access to Employee Exposure and Medical
Records regulations (29 CFR 1910.1020)
Provider shall perform a medical surveillance examination including:
All vital signs i.e. height, weight, vision, color vision and blood pressure. In-depth Patient
History which reviews past occupational exposures, personal/family health, hazardous
exposure physical examination will include evaluation of skin, respiratory, cardiac, ENT,
neurological and musculoskeletal and genital-urinary tract and lymphatic systems,
critical assessment for chemical, physical agent and carcinogenic exposures with close
examination of all skin areas looking for possible cancer signs and consultation with the
physician to discuss all results and all risk factors, pulmonary Function Testing with
interpretation, Chest X-ray (PA and LAT) with interpretation by a qualified Radiologist,
Executive 1 Panel = CBC with Differential and Platelets, SMA and thyroid profile,
Urinalysis (dipstick), EKG with interpretation
In addition to the above tests, provider shall perform: Audiometric testing and
tuberculosis screening as defined in specifications. Results of all studies and conclusions
must be conveyed to the examinee in a timely fashion with recommendations for follow
up or additional testing.
RFP requirements:
Respondent shall state total cost of examination, including audiometric testing and
tuberculosis screening.
Part 18.
Haz Mat Medical Surveillance and Respirator Evaluation, Sheriff’s Office and
Prosecutor’s Office SWAT Team (2 subparts)
Provider shall be a physician licensed to practice medicine in the State of New Jersey,
with credentials in internal medicine, occupational medicine, clinical toxicology, and
shall have special training in the area of toxicology. Providers shall be thoroughly
familiar with:
OSHA standards for medical evaluation of Hazardous Materials response workers (29
CFR 1910.120(f)), NIOSH Occupational Safety and Health Guidance Manual for
Hazardous Waste Site Activities, OSHA Respiratory Protection Standard (29 CFR
1910.134), OSHA Asbestos Standard medical surveillance regulations (29 CFR 1910.1001),
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
24
OSHA Access to Employee Exposure and Medical Records regulations (29 CFR
1910.1020)
Provider shall be familiar with respirator and personal protection use associated with
SWAT Team activities.
Medical Surveillance Exam: Provider shall perform a comprehensive medical
examination including: Complete medical, occupational and environmental exposure
history including review of systems, level of protection (A, B, C), and medication history.
Assessment must include history of heat stroke, claustrophobia, panic disorder or
difficulties while wearing personal protective equipment, Complete physical
examination, Vision (far, near, color, depth and peripheral), Evaluation for hernia,
Urinalysis, 12-lead Electrocardiogram, Spirometry (ATS/NIOSH compliant); Blood tests
including at a minimum: Complete blood and platelet count with differential,
Sodium, potassium, chloride, creatinine, calcium, blood urea nitrogen, total protein,
albumin, total cholesterol, ALT, AST, GGTP, alkaline phosphatase, lactate
dehydrogenase, Thyroid stimulating hormone, Blood lead / ZPP level; and,
Breast, genital, and digital rectal (with or without occult blood testing) examinations are
not required but may be included at the physician's discretion or examinee's request.
In addition to the above tests, provider shall perform: Audiometric testing and
tuberculosis screening as defined above.
Provider shall conduct a respirator medical evaluation in accordance with the
requirements of the OSHA Respiratory Protection Standard, 29 CFR 1910.134(e),
including:
Employees will use Filtering facepiece, Air-Purifying Respirator, and/or Self-Contained
Breathing Apparatus used to protect against air-borne pathogens, riot-control agents,
and known or unknown hazardous substances less than once per week for more than
four hours at a time; obtaining and reviewing OSHA Respirator Medical Evaluation
Questionnaire (29 CFR 1910.134), or equivalent. Determine any limitations on the
respirator use relating to the employee’s medical condition, or relating to the
workplace conditions, including whether or not the employee is able to use the
respirator. Provider shall give the employee an opportunity to discuss the questionnaire
and examination results with the provider. Provide shall provide the employee with a
copy of the provider’s written recommendation. Provider shall provide a written
recommendation as required under 29 CFR 1910.134(e)(6)(i), including: Any limitations
on respirator use related to the medical condition of the employee, or relating to the
workplace conditions in which the respirator will be used, including whether or not the
employee is medically able to use the respirator; The need, if any, for follow-up medical
evaluations; and A statement that the provider has provided the employee with a copy
of the written recommendation.
Chest X-Ray:
A Chest x-ray shall be performed at baseline or when appropriate based on exposure,
symptoms, personal history, or spirometry results. Chest x-ray must be interpreted by a
board certified radiologist. Results of all studies and conclusions must be conveyed to
the examinee in a timely fashion with recommendations for follow up or additional
testing.
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
25
RFP requirements:
Part A. Respondent shall state total cost of examination, including audiometric testing
and tuberculosis screening. Part B. Respondent shall state cost per Chest X-Ray.
Part 19.
Medical Examination and B. Chest X-Ray
Part A: Medical Exam:
Specification Requirements:
Provider shall be available for appointment within 14 days of request. Providers shall by
thoroughly familiar with the NJ DHSS Standards for Licensure of Ambulatory Care
Facilities – Employee Health (NJAC 8:43A-3.7); Provider shall perform a medical
examination including:
Part A: Medical Exam: Rubella Serology, Rubeola Serology, Chicken pox (if no history of
disease), Fitness for Duty Examination
Part B: a Chest X-Ray shall be performed if the candidate has a history of positive TB skin
test, Chest x-ray must be interpreted by a board certified radiologist; Provider shall
report the results of the examination within five (5) business days to the County of
Mercer; Provider shall give one copy of the report to the employee; Provider shall
maintain a list of all employees who are seronegative and unvaccinated for rubella, to
be used in the event that an employee is exposed to rubella and a determination is
needed as to whether or not the employee may continue to work; Provider shall
maintain a list of all employees who are seronegative or unvaccinated for rubeola.
RFP requirements:
Part A. Respondent shall state total cost of examination including Fitness for Duty
Part B. Respondent shall state cost per Chest X-Ray.
Part 20.
Medical Surveillance, Temephos (Mosquito Control)
Specification requirements: Provider shall be a physician licensed to practice medicine
in the State of New Jersey, with credentials in internal medicine, occupational
medicine, clinical toxicology, and shall have special training in the area of toxicology;
Provider shall perform annual medical monitoring for employees who are or will be
exposed to products containing temephos (CAS 3383-96-8) including: Pre-assignment
medical evaluation; On-going medical evaluation; Post-assignment medical evaluation
and Physical exam focusing on the nervous system.
Laboratory tests including:
Red blood cell count, Cholinesterase levels, Plasma cholinesterase, Measurement of
delayed neurotoxicity and other effects of temephos; Provider shall report results of
surveillance within five (5) business days. Report shall include a statement indicating
whether or not the employee is medically able to work safely with temephos during the
next mosquito control season, Provider shall inform employee of results and of any
recommended follow-up.
RFP Requirement: State total cost, per employee, of examination, interpretation, and
report.
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
26
Part 21.
Medical Examination, DOT (Transportation)
Approximate quantity required per year:
Specification requirements:
Provider shall be a physician licensed to practice medicine in the State of New Jersey,
with credentials in internal medicine and special training in occupational medicine.
Provider shall be thoroughly familiar with US DOT regulations for Physical Qualifications
and Examinations applicable to drivers of Commercial Motor Vehicles (40 CFR 391,
subpart E), and current FMCSA Medical Review Board guidelines; Provider shall perform
a thorough, objective medical examination for the purpose of determining, within a
reasonable degree of medical certainty, that the employee’s is physically qualified to
drive a commercial motor vehicle.
The examination shall be performed as required by current DOT regulations (40 CFR
391.43), and current FMCSA Medical Review Board guidelines including: Health History,
Vision, Hearing, Blood pressure/pulse rate; Urine testing including: Specific gravity,
Protein, Blood, Sugar; Height, weight; Body systems including General appearance,
Eyes, Ears, Mouth and throat, Heart, Lungs and chest, not including breast examination,
Abdomen and viscera, Vascular system, Genito-urinary system, Extremities – limb
impaired. Driver may be subject to Skill Performance Evaluation Certificate if otherwise
qualified; Spine, other musculoskeletal, Neurological, Other parameters as
recommended by current FMCSA Medical Review Board guidelines.
Provider shall report results using forms as specified in US DOT regulations within five (5)
business days. Whenever a certificate is denied, and whenever an employee is certified
for a period less than one (1) year, provider shall provide a report stating the basis
(FMCSA regulation or Medical Review Board guideline) and reason (examination
findings).
RFP requirements:
preparation.
State total cost, per employee, of examination and report
Part 22.
Police Academy Physical Examinations (Sheriff’s Office, Correction Center)
Specification requirements:
Provider shall be available for appointments at least Monday through Friday, 7:00 am to
5:00 pm, throughout the year; Provider shall be a physician licensed to practice
medicine in the State of New Jersey, with credentials in internal medicine or
occupational medicine. Provider shall perform a thorough medical evaluation to
provide reasonable assurance that there is no medical reason why the employee
should not participate in the Police Academy Training Program, which includes:
Physical conditioning (60-70 minutes, 3-5 times per week), Flexibility, Cardiovascular
endurance (aerobics), Strength, Power, Speed, Neuromuscular coordination (agility,
balance), Defensive tactics
(unarmed defense) training, Open hand, elbow,
forearm, knee, foot, and hand defensive moves, Maneuvers include: take-down
tactics, holds, punching, straight kicks, and headblocks, Balance and leverage
(extensive use of trunk and abdominal muscles), Baton training, Physical restraint
training;
Exposure
to
chemical
agents,
Chloroacetophenone
(CN),
Orthochlorbenzalmalonitrile (CS), Oleoresin capsicum (OC), Hexachlorethane (HC).
Firearms training, Standing, prone, kneeling, and barricaded positions used, Hand gun,
Shot gun (approximately 11 pounds), Rifle (approximately 12-13 pounds), Manual
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
27
dexterity required, Swimming, Pool entries, Various strokes, Swimming laps above and
below (3’-14’ below the water surface), Rescue techniques, Obtaining submerged
items, Treading water, Exposure to smoke and heat during fire suppression training.
Physical examination must include, as a minimum:
Physical examination of the spine and limbs for bone and joint abnormalities and of the
neck, chest, abdomen, eyes, ears, nose and throat, Auscultation of heart and lung
sounds for identification of possible cardiac murmurs, dysrhythmias, or chronic lung
disease, Measurement of resting heart rate, blood pressure, and respiration, Height and
weight, Chemical analysis of blood for levels of serum cholesterol, triglycerides, glucose,
and uric acid, Urinalysis, Electrocardiogram, Bruce Protocol (treadmill) Stress Test.
Provider shall report the results on forms provided by the Police Academy.
The provider shall provide a report to the County designee that explicitly indicates that
the employee is:
Medically fit to participate in the Defensive Tactics, Chemical Agent Exposure, Baton
Training, Physical Restraint Training, Firearms Training, and in the Police Academy’s
Physical Conditioning Training Program without limitations; Medically fit to undergo
training with limitations that will enable a temporary injury or illness of short duration to
clear and thus enable the individual to participate fully in Defensive Tactics, Chemical
Agent Exposure, Baton Training, Physical Restraint Training, Firearms Training, and in the
Police Academy’s Physical Conditioning Training Program; or Not medically fit to
undergo training. The nature and severity of any risks or disease should be viewed in
light of the content of the training program and the trainee’s physical condition.
To ensure confidentiality, the completed Medical Certification Form and Health History
Statement shall be returned to the County Designee of the referring division in an
envelope marked “Confidential”.
RFP requirements:
Shall state the total cost, per employee, of the complete evaluation including report
preparation.
Part 23.
Psychological Screening
Specification requirements: Provider shall be available for appointments at least
Monday through Friday, 7:00 am to 5:30 pm, throughout the year; Provider shall have
qualifications and experience for the psychological evaluation of law enforcement
candidates and in service personnel for fitness for duty.
Provider shall perform a minimum four (4) hour psychological evaluation including:
The Shipley Institute of Living Scale, The Public Safety Writing Sample, The Speed
Completion Form-Sentence Completion Test, The Edwards Personal Preference
Schedule, The How to Supervise Test, The Social Opinion Inventory (Locus of Control),
The Police Opinion Survey, The Candidate and Officer’s Personnel Survey (“Cops Test”),
The Police Situations Test (Oral Administration), In-depth personal interview.
Provider shall supply a full, detailed, reporting of the results within five (5) business days.
Report shall include a final recommendation of suitability for employment and fitness for
duty as a law enforcement officer. Report shall be provided within five (5) business
days.
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
28
RFP requirements:
Shall indicate the total cost, per subject, of the examination, including evaluation of
results and report preparation.
Part 24.
Psychological Screening (Sheriff’s Officers, Correction Officers, Park Rangers)
Specification Requirements: Provider shall be available for appointments at least
Monday through Friday, 7:00 am to 5:00 pm, throughout the year. Provider shall have
qualifications and experience for the psychological evaluation of law enforcement and
corrections candidates and in service personnel for fitness for duty. Provider shall
perform a minimum four (4) hour psychological evaluation including: Hilson Background
Investigation Inventory, Hilson Life Adjustment Profile, Inwald Personality Inventory, Hilson
Management Inventory, In-depth personal interview.
Provider shall supply a full, detailed reporting of the results within five (5) business days.
Report shall include a final recommendation of suitability for employment and fitness for
duty as a law enforcement officer. Reports shall be provided within five (5) business
days.
RFP requirements:
Shall indicate the total cost, per subject, of the examination, including evaluation of
results and report preparation.
Part 25.
Psychological Fitness for Duty Examinations (Psychiatrist)
Specification Requirements: Provider shall be available for appointments at least
Monday through Friday, 7:00 am to 5:00 pm, throughout the year; Provider shall be a
physician licensed to practice psychiatric medicine in the State of New Jersey, with
credentials in psychiatry including certification by the ABPN.
Provider shall examine employee for the purpose of objectively determining, within a
reasonable degree of medical certainty, that the employee is sufficiently free of
psychiatric disability to be able to perform the essential functions of his or her position
(as described in a written Job Description), with or without accommodations. Provider
may be required to contact employee’s physician. Provider shall report the results of
the examination within five (5) business days. Reports shall include objective findings,
within a reasonable degree of medical certainty, as to: Whether or not the employee
presents immediate indicators, based upon history and examination, of imminent threat
to safety of self or others. Whether or not the employee is able to perform the essential
functions of the job without accommodations; What, if any, accommodations may
enable the employee to perform the essential functions of the job; or Whether or not
the employee is able to perform the essential function of the job with, or without,
reasonable accommodations.
RFP requirements:
State total cost, per employee, of examination.
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
29
PROPOSAL CHECKLIST
The following checklist is provided as assistance to the development of the RFP
Response. It in no way supersedes or replaces the requirements of the RFP. Please
initial on the lines below for each document/section attesting to the fact that you have
read and/or included the documents with your RFP.
Acknowledgement of Receipt of Addenda
(MUST BE INCLUDED IF ISSUED)
________
Non-Collusion Affidavit
________
Affirmative Action Statement
________
Affirmative Action Mandatory Language
(INCLUDE)
________
Read: Sexual Harassment Guidelines
________
Read: Americans with Disabilities Act Language
________
Stockholder Disclosure
(MUST BE COMPLETED AND SUBMITTED WITH PROPOSAL)
________
NJ Business Registration Required if Awarded
(MUST BE SUBMITTED PRIOR TO CONTRACT AWARD)
________
Insurance and Indemnification Requirements
________
Signed Proposal
________
Continuity of Operation during Emergencies
________
Contract Award
________
Iran Certification
________
Qualification Statement (LIMITED TO TEN PAGES)
________
Draft Report
________
Medical Licensure
________
Occupational Health Board Certification
(PROVIDE IF BOARD CERTIFIED)
________
Three References on enclosed form
________
CLIA CLINICAL LABORATORY IMPROVEMENT AMENDMENTS CERTIFICATE
All Bidders must possess a CLIA Certificate and
shall provide a copy of the certificate with their proposal
________
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
30
PROVIDE THREE CLIENT REFERENCES IN SIMILAR SCOPE AND COST
CLIENT NAME
CONTACT
ADDRESS
CITY, STATE, ZIP
__________________________
TELEPHONE NUMBER
______
SCOPE OF WORK AND CONTRACT VALUE
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
CLIENT NAME
CONTACT
ADDRESS
CITY, STATE, ZIP
__________________________
TELEPHONE NUMBER
______
SCOPE OF WORK AND CONTRACT VALUE
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
CLIENT NAME
CONTACT
ADDRESS
CITY, STATE, ZIP
__________________________
TELEPHONE NUMBER
______
SCOPE OF WORK AND CONTRACT VALUE
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
31
APPENDIX A
Appendix C to Sec. 1910.134: OSHA Respirator Medical Evaluation Questionnaire
(Mandatory)
To the employer: Answers to questions in Section 1, and to question 9 in Section 2 of
Part A, do not require a medical examination.
To the employee:
Can you read (circle one): Yes/No
Your employer must allow you to answer this questionnaire during normal working
hours, or at a time and place that is convenient to you. To maintain your
confidentiality, your employer or supervisor must not look at or review your answers,
and your employer must tell you how to deliver or send this questionnaire to the health
care professional who will review it.
Part A. Section 1. (Mandatory) The following information must be provided by every
employee who has been selected to use any type of respirator (please print).
1. Today's date:_______________________________________________________
2. Your name:__________________________________________________________
3. Your age (to nearest year):_________________________________________
4. Sex (circle one): Male/Female
5. Your height: __________ ft. __________ in.
6. Your weight: ____________ lbs.
7. Your job title:_____________________________________________________
8. A phone number where you can be reached by the health care professional who
reviews this questionnaire (include the Area Code): ____________________
9. The best time to phone you at this number: ________________
10. Has your employer told you how to contact the health care professional who will
review this questionnaire (circle one): Yes/No
11. Check the type of respirator you will use (you can check more than one category):
a. ______ N, R, or P disposable respirator (filter-mask, non- cartridge type only).
b. ______ Other type (for example, half- or full-facepiece type, powered-air purifying,
supplied-air, self-contained breathing apparatus).
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
32
12. Have you worn a respirator (circle one): Yes/No
If "yes," what type(s):______________________________________________
_____________________________________________________________________
Part A. Section 2. (Mandatory) Questions 1 through 9 below must be answered by
every employee who has been selected to use any type of respirator (please circle
"yes" or "no").
1. Do you currently smoke tobacco, or have you smoked tobacco in the last month:
Yes/No
2. Have you ever had any of the following conditions?
a.
b.
c.
d.
e.
Seizures (fits): Yes/No
Diabetes (sugar disease): Yes/No
Allergic reactions that interfere with your breathing: Yes/No
Claustrophobia (fear of closed-in places): Yes/No
Trouble smelling odors: Yes/No
3. Have you ever had any of the following pulmonary or lung problems?
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
Asbestosis: Yes/No
Asthma: Yes/No
Chronic bronchitis: Yes/No
Emphysema: Yes/No
Pneumonia: Yes/No
Tuberculosis: Yes/No
Silicosis: Yes/No
Pneumothorax (collapsed lung): Yes/No
Lung cancer: Yes/No
Broken ribs: Yes/No
Any chest injuries or surgeries: Yes/No
Any other lung problem that you've been told about: Yes/No
4. Do you currently have any of the following symptoms of pulmonary or lung illness?
a. Shortness of breath: Yes/No
b. Shortness of breath when walking fast on level ground or walking up a slight hill
or incline: Yes/No
c. Shortness of breath when walking with other people at an ordinary pace on
level ground: Yes/No
d. Have to stop for breath when walking at your own pace on level ground:
Yes/No
e. Shortness of breath when washing or dressing yourself: Yes/No
f. Shortness of breath that interferes with your job: Yes/No
g. Coughing that produces phlegm (thick sputum): Yes/No
h. Coughing that wakes you early in the morning: Yes/No
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
33
i. Coughing that occurs mostly when you are lying down: Yes/No
j. Coughing up blood in the last month: Yes/No
k. Wheezing: Yes/No
l. Wheezing that interferes with your job: Yes/No
m. Chest pain when you breathe deeply: Yes/No
n. Any other symptoms that you think may be related to lung problems: Yes/No
5. Have you ever had any of the following cardiovascular or heart problems?
a.
b.
c.
d.
e.
f.
g.
h.
Heart attack: Yes/No
Stroke: Yes/No
Angina: Yes/No
Heart failure: Yes/No
Swelling in your legs or feet (not caused by walking): Yes/No
Heart arrhythmia (heart beating irregularly): Yes/No
High blood pressure: Yes/No
Any other heart problem that you've been told about: Yes/No
6. Have you ever had any of the following cardiovascular or heart symptoms?
a.
b.
c.
d.
Frequent pain or tightness in your chest: Yes/No
Pain or tightness in your chest during physical activity: Yes/No
Pain or tightness in your chest that interferes with your job: Yes/No
In the past two years, have you noticed your heart skipping or missing a beat:
Yes/No
e. Heartburn or indigestion that is not related to eating: Yes/ No
f. Any other symptoms that you think may be related to heart or circulation
problems: Yes/No
7. Do you currently take medication for any of the following problems?
a.
b.
c.
d.
Breathing or lung problems: Yes/No
Heart trouble: Yes/No
Blood pressure: Yes/No
Seizures (fits): Yes/No
8. If you've used a respirator, have you ever had any of the following problems? (If
you've never used a respirator, check the following space and go to question 9:)
a.
b.
c.
d.
e.
Eye irritation: Yes/No
Skin allergies or rashes: Yes/No
Anxiety: Yes/No
General weakness or fatigue: Yes/No
Any other problem that interferes with your use of a respirator: Yes/No
9. Would you like to talk to the health care professional who will review this
questionnaire about your answers to this questionnaire: Yes/No
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
34
Questions 10 to 15 below must be answered by every employee who has been
selected to use either a full-facepiece respirator or a self-contained breathing
apparatus (SCBA). For employees who have been selected to use other types of
respirators, answering these questions is voluntary.
10. Have you ever lost vision in either eye (temporarily or permanently): Yes/No
11. Do you currently have any of the following vision problems?
a.
b.
c.
d.
Wear contact lenses: Yes/No
Wear glasses: Yes/No
Color blind: Yes/No
Any other eye or vision problem: Yes/No
12. Have you ever had an injury to your ears, including a broken ear drum: Yes/No
13. Do you currently have any of the following hearing problems?
a. Difficulty hearing: Yes/No
b. Wear a hearing aid: Yes/No
c. Any other hearing or ear problem: Yes/No
14. Have you ever had a back injury: Yes/No
15. Do you currently have any of the following musculoskeletal problems?
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
Weakness in any of your arms, hands, legs, or feet: Yes/No
Back pain: Yes/No
Difficulty fully moving your arms and legs: Yes/No
Pain or stiffness when you lean forward or backward at the waist: Yes/No
Difficulty fully moving your head up or down: Yes/No
Difficulty fully moving your head side to side: Yes/No
Difficulty bending at your knees: Yes/No
Difficulty squatting to the ground: Yes/No
Climbing a flight of stairs or a ladder carrying more than 25 lbs: Yes/No
Any other muscle or skeletal problem that interferes with using a respirator:
Yes/No
Part B Any of the following questions, and other questions not listed, may be added to
the questionnaire at the discretion of the health care professional who will review the
questionnaire.
1. In your present job, are you working at high altitudes (over 5,000 feet) or in a place
that has lower than normal amounts of oxygen: Yes/No
If "yes," do you have feelings of dizziness, shortness of breath, pounding in your chest, or
other symptoms when you're working under these conditions: Yes/No
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
35
2. At work or at home, have you ever been exposed to hazardous solvents, hazardous
airborne chemicals (e.g., gases, fumes, or dust), or have you come into skin contact
with hazardous chemicals: Yes/No
If "yes," name the chemicals if you know them:_________________________
_______________________________________________________________________
_______________________________________________________________________
3. Have you ever worked with any of the materials, or under any of the conditions,
listed below:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
Asbestos: Yes/No
Silica (e.g., in sandblasting): Yes/No
Tungsten/cobalt (e.g., grinding or welding this material): Yes/No
Beryllium: Yes/No
Aluminum: Yes/No
Coal (for example, mining): Yes/No
Iron: Yes/No
Tin: Yes/No
Dusty environments: Yes/No
Any other hazardous exposures: Yes/No
If "yes," describe these exposures:____________________________________
_______________________________________________________________________
_______________________________________________________________________
4. List any second jobs or side businesses you have:___________________
_______________________________________________________________________
5. List your previous occupations:_____________________________________
_______________________________________________________________________
6. List your current and previous hobbies:________________________________
_______________________________________________________________________
7. Have you been in the military services? Yes/No
If "yes," were you exposed to biological or chemical agents (either in training or
combat): Yes/No
8. Have you ever worked on a HAZMAT team? Yes/No
9. Other than medications for breathing and lung problems, heart trouble, blood
pressure, and seizures mentioned earlier in this questionnaire, are you taking any other
medications for any reason (including over-the-counter medications): Yes/No
If "yes," name the medications if you know them:_______________________
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
36
10. Will you be using any of the following items with your respirator(s)?
a. HEPA Filters: Yes/No
b. Canisters (for example, gas masks): Yes/No
c. Cartridges: Yes/No
11. How often are you expected to use the respirator(s) (circle "yes" or "no" for all
answers that apply to you)?:
a.
b.
c.
d.
e.
f.
Escape only (no rescue): Yes/No
Emergency rescue only: Yes/No
Less than 5 hours per week: Yes/No
Less than 2 hours per day: Yes/No
2 to 4 hours per day: Yes/No
Over 4 hours per day: Yes/No
12. During the period you are using the respirator(s), is your work effort:
a. Light (less than 200 kcal per hour): Yes/No
If "yes," how long does this period last during the average
shift:____________hrs.____________mins.
Examples of a light work effort are sitting while writing, typing, drafting, or performing
light assembly work; or standing while operating a drill press (1-3 lbs.) or controlling
machines.
b. Moderate (200 to 350 kcal per hour): Yes/No
If "yes," how long does this period last during the average
shift:____________hrs.____________mins.
Examples of moderate work effort are sitting while nailing or filing; driving a truck or bus
in urban traffic; standing while drilling, nailing, performing assembly work, or transferring
a moderate load (about 35 lbs.) at trunk level; walking on a level surface about 2 mph
or down a 5-degree grade about 3 mph; or pushing a wheelbarrow with a heavy load
(about 100 lbs.) on a level surface.
c. Heavy (above 350 kcal per hour): Yes/No
If "yes," how long does this period last during the average
shift:____________hrs.____________mins.
Examples of heavy work are lifting a heavy load (about 50 lbs.) from the floor to your
waist or shoulder; working on a loading dock; shoveling; standing while bricklaying or
chipping castings; walking up an 8-degree grade about 2 mph; climbing stairs with a
heavy load (about 50 lbs.).
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
37
13. Will you be wearing protective clothing and/or equipment (other than the
respirator) when you're using your respirator: Yes/No
If "yes," describe this protective clothing and/or equipment:__________
_______________________________________________________________________
14. Will you be working under hot conditions (temperature exceeding 77 deg. F):
Yes/No
15. Will you be working under humid conditions: Yes/No
16. Describe the work you'll be doing while you're using your respirator(s):
_______________________________________________________________________
_______________________________________________________________________
17. Describe any special or hazardous conditions you might encounter when you're
using your respirator(s) (for example, confined spaces, life-threatening gases):
_______________________________________________________________________
_______________________________________________________________________
18. Provide the following information, if you know it, for each toxic substance that you'll
be exposed to when you're using your respirator(s):
Name of the first toxic substance:___________________________________________
Estimated maximum exposure level per shift:__________________________________
Duration of exposure per shift:______________________________________________
Name of the second toxic substance:__________________________________________
Estimated maximum exposure level per shift:__________________________________
Duration of exposure per shift:______________________________________________
Name of the third toxic substance:___________________________________________
Estimated maximum exposure level per shift:__________________________________
Duration of exposure per shift:______________________________________________
The name of any other toxic substances that you'll be exposed to
while using your respirator:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
19. Describe any special responsibilities you'll have while using your respirator(s) that
may affect the safety and well-being of others (for example, rescue, security):
_____________________________________________________________________________
[63 FR 1152, Jan. 8, 1998; 63 FR 20098, April 23, 1998]
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
38
COUNTY OF MERCER
ACKNOWLEDGMENT OF RECEIPT OF ADDENDA
The undersigned hereby acknowledges receipt of the following Addenda:
Addendum Number
Dated
Acknowledge Receipt
(initial)
_______________
_______________
____________
_______________
_______________
____________
_______________
_______________
____________
_______________
_______________
____________
No Addenda were received
Acknowledged for: __________________________________________
(Name of Bidder)
By: _________________________________________
(Signature of Authorized Representative)
Name: ______________________________________
(Print or Type)
Title: ________________________________________
Date: ________________________________________
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
39
Revised Contract Language for BRC Compliance
Goods and Services Contracts (including purchase orders)
* Construction Contracts (including public works related purchase orders)
N.J.S.A. 52:32-44 imposes the following requirements on contractors and all
subcontractors that knowingly provide goods or perform services for a contractor
fulfilling this contract:
1) the contractor shall provide written notice to its subcontractors and suppliers to
submit proof of business registration to the contractor;
2) subcontractors through all tiers of a project must provide written notice to their
subcontractors and suppliers to submit proof of business registration and
subcontractors shall collect such proofs of business registration and maintain them
on file;
3) prior to receipt of final payment from a contracting agency, a contractor must
submit to the contacting agency an accurate list of all subcontractors and
suppliers* or attest that none was used; and,
4) during the term of this contract, the contractor and its affiliates shall collect and
remit, and shall notify all subcontractors and their affiliates that they must collect
and remit to the Director, New Jersey Division of Taxation, the use tax due pursuant
to the Sales and Use Tax Act, (N.J.S.A. 54:32B-1 et seq.) on all sales of tangible
personal property delivered into this State.
A contractor, subcontractor or supplier who fails to provide proof of business registration
or
provides false business registration information shall be liable to a penalty of $25 for
each day
of violation, not to exceed $50,000 for each business registration not properly provided
or
maintained under a contract with a contracting agency. Information on the law and its
requirements is available by calling (609) 292-9292.
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
40
SAMPLE OF THE NEW JERSEY BUSINESS REGISTRATION CERTIFICATE ACCEPTABLE BY THE
COUNTY OF MERCER
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
41
EEO/AFFIRMATIVE ACTION COMPLIANCE NOTICE
N.J.S.A. 10:5-31 and N.J.A.C. 17:27
GOODS, PROFESSIONAL SERVICE AND GENERAL SERVICE CONTRACTS
All successful bidders are required to submit evidence of appropriate affirmative action
compliance to the County and Division of Public Contracts Equal Employment
Opportunity Compliance. During a review, Division representatives will review the
County files to determine whether the affirmative action evidence has been submitted
by the vendor/contractor. Specifically, each vendor/contractor shall submit to the
County, prior to execution of the contract, one of the following documents:
Goods and General Service Vendors
1. Letter of Federal Approval indicating that the vendor is under an existing Federally
approved or sanctioned affirmative action program. A copy of the approval letter is to
be provided by the vendor to the County and the Division. This approval letter is valid
for one year from the date of issuance.
Do you have a federally-approved or sanctioned EEO/AA program?
Yes
No
If yes, please submit a photostatic copy of such approval.
2. A Certificate of Employee Information Report (hereafter “Certificate”), issued in
accordance with N.J.A.C. 17:27-1.1 et seq. The vendor must provide a copy of the
Certificate to the County as evidence of its compliance with the regulations. The
Certificate represents the review and approval of the vendor’s Employee Information
Report, Form AA-302 by the Division. The period of validity of the Certificate is indicated
on its face. Certificates must be renewed prior to their expiration date in order to
remain valid.
Do you have a State Certificate of Employee Information Report Approval? Yes
No
If yes, please submit a photostatic copy of such approval.
3. The successful vendor shall complete an Initial Employee Report, Form AA-302 and
submit it to the Division with $150.00 Fee and forward a copy of the Form to the County.
Upon submission and review by the Division, this report shall constitute evidence of
compliance with the regulations. Prior to execution of the contract, the EEO/AA
evidence must be submitted.
The successful vendor may obtain the Affirmative Action Employee Information Report
(AA302) on the Division website www.state.nj.us/treasury/contract_compliance.
The successful vendor(s) must submit the AA302 Report to the Division of Public
Contracts Equal Employment Opportunity Compliance, with a copy to Public Agency.
The undersigned vendor certifies that he/she is aware of the commitment to comply
with the requirements of N.J.S.A. 10:5-31 and N.J.A.C. 17:27 and agrees to furnish the
required forms of evidence.
The undersigned vendor further understands that his/her bid shall be rejected as nonresponsive if said contractor fails to comply with the requirements of N.J.S.A. 10:5-31
and N.J.A.C. 17:27.
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
42
COMPANY: ____________________________ SIGNATURE: __________________________
PRINT NAME:__________________________TITLE: ________________________________
DATE: __________________
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
43
(REVISED 4/10)
EXHIBIT A
MANDATORY EQUAL EMPLOYMENT OPPORTUNITY LANGUAGE
N.J.S.A. 10:5-31 et seq. (P.L. 1975, C. 127)
N.J.A.C. 17:27
GOODS, PROFESSIONAL SERVICE AND GENERAL SERVICE CONTRACTS
During the performance of this contract, the contractor agrees as follows:
The contractor or subcontractor, where applicable, will not discriminate against any
employee or applicant for employment because of age, race, creed, color, national origin,
ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability,
nationality or sex. Except with respect to affectional or sexual orientation and gender identity or
expression, the contractor will ensure that equal employment opportunity is afforded to such
applicants in recruitment and employment, and that employees are treated during
employment, without regard to their age, race, creed, color, national origin, ancestry, marital
status, affectional or sexual orientation, gender identity or expression, disability, nationality or
sex. Such equal employment opportunity shall include, but not be limited to the following:
employment, upgrading, demotion, or transfer; recruitment or recruitment advertising; layoff or
termination; rates of pay or other forms of compensation; and selection for training, including
apprenticeship. The contractor agrees to post in conspicuous places, available to employees
and applicants for employment, notices to be provided by the Public Agency Compliance
Officer setting forth provisions of this nondiscrimination clause.
The contractor or subcontractor, where applicable will, in all solicitations or
advertisements for employees placed by or on behalf of the contractor, state that all qualified
applicants will receive consideration for employment without regard to age, race, creed, color,
national origin, ancestry, marital status, affectional or sexual orientation, gender identity or
expression, disability, nationality or sex.
The contractor or subcontractor will send to each labor union, with which it has a
collective bargaining agreement, a notice, to be provided by the agency contracting officer,
advising the labor union of the contractor's commitments under this chapter and shall post
copies of the notice in conspicuous places available to employees and applicants for
employment.
The contractor or subcontractor, where applicable, agrees to comply with any regulations
promulgated by the Treasurer pursuant to N.J.S.A. 10:5-31 et seq., as amended and
supplemented from time to time and the Americans with Disabilities Act.
The contractor or subcontractor agrees to make good faith efforts to meet targeted
county employment goals established in accordance with N.J.A.C. l7:27-5.2.
The contractor or subcontractor agrees to inform in writing its appropriate recruitment
agencies including, but not limited to, employment agencies, placement bureaus, colleges,
universities, and labor unions, that it does not discriminate on the basis of age, race, creed,
color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
44
or expression, disability, nationality or sex, and that it will discontinue the use of any recruitment
agency which engages in direct or indirect discriminatory practices.
The contractor or subcontractor agrees to revise any of its testing procedures, if
necessary, to assure that all personnel testing conforms with the principles of job-related testing,
as established by the statutes and court decisions of the State of New Jersey and as established
by applicable Federal law and applicable Federal court decisions.
In conforming with the targeted employment goals, the contractor or subcontractor
agrees to review all procedures relating to transfer, upgrading, downgrading and layoff to
ensure that all such actions are taken without regard to age, race, creed, color, national origin,
ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability,
nationality or sex, consistent with the statutes and court decisions of the State of New Jersey,
and applicable Federal law and applicable Federal court decisions.
The contractor shall submit to the public agency, after notification of award but prior to
execution of a goods and services contract, one of the following three documents:
Letter of Federal Affirmative Action Plan Approval
Certificate of Employee Information Report
Employee Information Report Form AA302, electronically provided by the Division and
distributed to the public agency through the Division’s website at:
www.state.nj.us/treasury/contract_compliance
The contractor and its subcontractors shall furnish such reports or other documents to the
Division of Public Contracts Equal Employment Opportunity Compliance as may be requested
by the office from time to time in order to carry out the purposes of these regulations, and
public agencies shall furnish such information as may be requested by the Division of Public
Contracts Equal Employment Opportunity Compliance for conducting a compliance
investigation pursuant to Subchapter 10 of the Administrative Code at N.J.A.C. 17:27.
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
45
STOCKHOLDER DISCLOSURE CERTIFICATION
No corporation or partnership shall be awarded any contract for the performance of any work
or the furnishing of any materials or supplies, unless, prior to the receipt of the bid or
accompanying the bid of said corporation or partnership, there is submitted a statement setting
forth the names and addresses of all stockholders in the corporation or partnership who own ten
(10) percent or more of its stock of any class, or of all individual partners in the partnership who
own a ten (10) percent or greater interest therein. Form of Statement shall be completed.
The Attorney General has concluded that the provisions of N.J.S.A. 52:25-24.2, in referring to
corporations and partnerships, are intended to apply to all forms of corporations and
partnerships, including, but not limited to, limited partnerships, limited liability corporations,
limited liability partnerships, and Subchapter S corporations.
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
46
STOCKHOLDER DISCLOSURE CERTIFICATION
This Statement Shall Be Included with Bid Submission
I certify that the list below contains the names and home addresses of all stockholders
holding 10% or more of the issued and outstanding stock of the undersigned.
OR
I certify that no one stockholder owns 10% or more of the issued and outstanding stock of
the undersigned.
Check the box that represents the type of business organization:
Limited Liability Partnership
-Profit Corporation
This form shall be completed and signed. Failure of the bidder to submit the required information
is cause for automatic rejection of the bid.
Stockholders:
Name: ______________________________
Name: ______________________________
Home Address: _______________________
Home Address: _______________________
____________________________________
____________________________________
Name: ______________________________
Name: ______________________________
Home Address: _______________________
Home Address: _______________________
____________________________________
____________________________________
Name: ______________________________
Name: ______________________________
Home Address: _______________________
Home Address: _______________________
____________________________________
____________________________________
NAME OF BUSINESS_________________________________________________
Signature________________________________ Date___________________________
Printed Name & Title______________________________________________________
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
47
P.L. 2012 BID OR PROPOSAL PROHIBITED
C.52:32-57 “P.L. 2012, c.25 prohibits State and local public contracts with persons or
entities engaging in certain investment activities in energy or finance sectors of Iran.”
I am the duly authorized agent making certification that there has been no
engagement in certain investment activities in energy or finance sectors of Iran as
prohibited by P.L. 2012, c.25. The Chapter 25 list is found at:
http://www.state.nj.us/treasury/purchase/pdf/Chapter25List.pdf
NAME OF BIDDER
_____________________________________________________________________________________
SIGNATURE OF AUTHORIZED REPRESENTATIVE
_____________________________________________________________________________________
TITLE
_____________________________________________________________________________________
DATE
_____________________________________________________________________________________
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
48
AMERICANS WITH DISABILITIES ACT OF 1990
Equal Opportunity for Individuals with Disability
The CONTRACTOR and the County of Mercer do hereby agree that the provisions of Title II of
the Americans With Disabilities Act of 1990 (the “Act”) (42 U.S.C. S12101 et seq.), which prohibits
discrimination on the basis of disability by public entities in all services, programs and activities
provided or made available by public entities, and the rules and regulations promulgated
pursuant hereunto, are made a part of this contract. In providing any aid, benefit, or service on
behalf of the County pursuant to this contract, the CONTRACTOR agrees that the performance
shall be in strict compliance with the Act. In the event that the CONTRACTOR, its agents,
servants, employees, or subcontractors violate or are alleged to have violated the Act during
the performance of this contract, the CONTRACTOR shall defend the County in any action or
administrative proceeding commenced pursuant to this Act. The CONTRACTOR shall indemnify,
protect, and save harmless the County, its agents, servants, and employees from and against
any and all suits, claims, losses demands, or damages, of whatever kind or nature arising out of
or claimed to arise out of the alleged violation. The CONTRACTOR shall, at its own expense,
appear, defend, and pay any and all charges for legal services and any and all costs and
other expenses arising from such action or administrative proceeding or incurred in connection
therewith. In any and all complaints brought pursuant to the County grievance procedure, the
CONTRACTOR agrees to abide by any decision of the County which is rendered pursuant to
said grievance procedure. If any action or administrative proceeding results in an award of
damages against the County or if the County incurs any expense to cure a violation of the ADA
which has been brought pursuant to its grievance procedure, the CONTRACTOR shall satisfy
and discharge the same at its own expense.
The County shall, as soon, practicable after a claim has been made against it, give written
notice thereof to the CONTRACTOR along with full and complete particulars of the claim. If any
action or administrative proceedings is brought against the County or any of its agents,
servants, and employees, the County shall expeditiously forward or have forwarded to the
CONTRACTOR every demand, complaint, notice, summons, pleading, or other process
received by the County or its representatives.
It is expressly agreed and understood that any approval by the County of the services provided
by the CONTRACTOR pursuant to this contract will not relieve the CONTRACTOR of the
obligation to comply with the Act and to defend, indemnify, protect, and save harmless the
County pursuant to this paragraph.
It is further agreed and understood that the County assumes no obligation to indemnify or save
harmless the CONTRACTOR, its agents, servants, employees and subcontractors for any claim
which may arise out of their performance of this Agreement. Furthermore, the CONTRACTOR
expressly understands and agrees that the provisions of this indemnification clause shall in no
way limit the CONTRACTOR’S obligations assumed in this agreement, nor shall they be
construed to relieve the CONTRACTOR from any liability, nor preclude the County from taking
any other actions available to it under any other provisions of the Agreement or otherwise at
law.
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
49
EXCERPTS FROM THE EEOC SEXUAL HARASSMENT GUIDELINES
PART 1604 -- GUIDELINES ON DISCRIMINATION BECAUSE OF SEX
1604.11 Sexual Harassment
(a) Harassment on the basis of sex is a violation of Sec. 703 of Title VII (of the Civil Rights
Act of 1964). Unwelcome sexual advances, requests for sexual favors, and other verbal or
physical conduct of a sexual nature constitute sexual harassment when (1) submission to such
conduct is made either explicitly or implicitly a term or condition of an individual’s employment,
(2) submission to or rejection of such conduct by an individual is used as the basis for
employment decisions affecting such individual, or (3) such conduct has the purpose or effect
of unreasonably interfering with an individual’s work performance or creating an intimidating,
hostile or offensive working environment.
(b) In determining whether alleged conduct constitutes sexual harassment, The
Commission (EEOC) will look at the record as a whole and at the totality of the circumstances,
such as the nature of the sexual advances and the context in which the alleged incidents
occurred. The determination of the legality of a particular action will be made from the facts,
on a case by case basis.
(c) Applying general Title VII principles, an employer, employment agency, joint
apprenticeship committee or labor organization (hereinafter collectively referred to as
“employer”) is responsible for its acts and those of its agents and supervisory employees with
respect to sexual harassment regardless of whether the specific acts complained of were
authorized or even forbidden by the employer and whether the employer knew or should have
known of their occurrence. The Commission will examine the circumstances of the particular
employment relationship and the job functions performed by the individual in determining
whether an individual in determining whether an individual acts in either a supervisory or
agency capacity.
(d) With respect to conduct between fellow employees, employer is responsible for acts
of sexual harassment in the workplace where the employer (or its agents or supervisory
employees) knows or should have known of the conduct, unless it can be show that it took
immediate and appropriate corrective action.
(e) An employer may also be responsible for the acts of non-employees, with respect to
sexual harassment of employees in the workplace, where the employer (or its agents or
supervisory employees) knows or should have known of the conduct and fails to take
immediate and appropriate corrective action. In reviewing these cases the Commission will
consider the extent of the employer’s control and any other legal responsibility, which the
employer may have with respect to the conduct of such non-employees.
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
50
INSURANCE CERTIFICATE
PLEASE TAKE NOTE OF THE FOLLOWING CHANGE
As you may be aware, there has been a recent change to the ACCORD insurance certificate
which precludes placing the number of days for cancellation notification in the lower left hand
box. You may fulfill the requirement for a 30-day notice of cancellation for a County of Mercer
contract in any one of the following ways:
1. indicate a 30-day notice of cancellation in the Description of Operations box at the
bottom of the certificate
2. indicate a 30-day notice of cancellation on a separate page
3. provide a copy of the cancellation clause from the policy (you do not need to provide a
copy of the entire policy, only the page(s) referencing the cancellation clause)
If you need further clarification on this or other insurance certificate issues, please contact the
Insurance and Property Management Office at 609-989-6655.
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
51
INSURANCE AND INDEMNIFICATION REQUIREMENTS
If it becomes necessary for the consultant, either as principal or by agent or employee, to enter
upon the premises or property of the County, the consultant hereby covenants and agrees to
take use, provide and make all proper, necessary and sufficient precautions, safeguards, and
protection against the occurrence of happenings of any accidents, injuries, damages, or hurt to
person or property during the course of the work herein covered and be his/her sole
responsibility.
The consultant further covenants and agrees to indemnify and save harmless the County from
the payment of all sums of money or any other consideration(s) by reason of any, or all, such
accidents, injuries, damages, or hurt that may happen or occur upon or about such work and
all fines, penalties and loss incurred for or by reason of the violation of any County regulation,
ordinance or the laws of the State, or the United States while said work is in progress.
The consultant shall maintain sufficient insurance to protect against all claims under Workers
Compensation as statutorily required, General Liability and Professional Liability in the amount of
$1,000,000.00 single occurrence and $2,000,000.00 general aggregate and Automobile
Insurance in the amount of $1,000,000.00 combined single limit. Vendors are responsible to
provide updated certificates as policies renew. Depending upon the scope of work and goods
or services provided, specific types of insurance may not be required. The Mercer County
Division of Insurance and Property Management will make this determination.
In all cases where a Certificate of Insurance is required, the County of Mercer is to be named as
an additional insured and named as the certificate holder as follows: “County of Mercer, 640
South Broad Street, PO Box 8068, Trenton, NJ 08650-0068”. The Certificate shall contain a 30day notice of cancellation.
WAIVER OF SUBROGATION CLAUSE
Consultant, as a material part of the consideration to be rendered to the County, hereby
waives all claims against the County for damages to the goods, wares and merchandise in,
upon or about said premises, and consultant will hold the County exempt and harmless from
any damage and injury to any such person or to the goods, wares or merchandise of any such
person, arising from the use of the premises by the consultant or from failure of the consultant to
keep the premises in good condition and repair as herein provided.
______________________________________________________________________
Dated and Signed
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
52
NON-COLLUSION AFFIDAVIT
STATE OF NEW JERSEY
COUNTY OF MERCER SS:
I, ____________________________ of the City of___________________,
in the County of_____________________, and the State of___________________,
of full age, being duly sworn according to law on my oath depose and say that:
I am________________________________________________________
of the firm of_______________________________________________________
The respondent making the proposal for the above named Contract, and that I executed the
said proposal with full authority so to do; that said bidder has not, directly or indirectly, entered
into any agreement, participate in any collusion, or otherwise taken any action in restraint of
free, competitive bidding in connection with the above named Contract; and that all
statements contained in said proposal and in this affidavit are true and correct, and made with
full knowledge that the County of Mercer relied upon the truth of the statements contained in
said Proposal and in the statements contained in this affidavit in awarding the Contract for the
said proposal.
I further warrant that no person or selling agency has been employed or retained to
solicit or secure such Contract upon an agreement or understanding for a commission,
percentage, brokerage, or contingent fee, except bonafide employees or bonafide
established commercial or selling agencies maintained by
________________________________
(Name of Vendor)
Subscribed and sworn to before me
This______ day of____________, 20____.
(Signature of Notary Public)
Notary Public of_________________________
My Commission expires ____________, 20___
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
53
PROPOSAL
The undersigned bidder declares that he/she has read the Notice to Bidders, Instructions to
Bidders, Affidavits and Specifications attached, that he/she has determined the conditions
affecting the bid agrees, if this proposal is accepted, to furnish and deliver the following:
OCCUPATIONAL HEALTH SERVICES FOR THE COUNTY OF MERCER CC2017-01
____________________________________________________________________________
(SIGNATURE BY AUTHORIZED REPRESENTATIVE)
The undersigned is a Corporation, Partnership or Individual under the laws of the State of
___________________ having its principal office at___________________________________
COMPANY
___________________________________________________________________
ADDRESS
___________________________________________________________________
ADDRESS
___________________________________________________________________
NAME
___________________________________________________________________
TELEPHONE
___________________________________________________________________
FAX
___________________________________________________________________
CELL
___________________________________________________________________
E-MAIL
___________________________________________________________________
DATE
___________________________________________________________________
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
54
CONTRACT AWARD
Upon opening bids, pricing shall remain firm for a period of sixty (60) calendar days. In
the event that the award is not made within sixty (60) calendar days, bidders may
hold their bid consideration beyond sixty days or until the contract is awarded.
Check here if willing to hold the pricing consideration beyond sixty days or until the contract is
awarded.
Check here if not willing to hold the pricing consideration beyond sixty days or until the
contract is awarded.
_________________________________________________________________________
AUTHORIZED SIGNATURE
COUNTY OF MERCER
Certification of Political Contributions
(Effective February 1, 2005)
PROFESSIONAL BUSINESS ENTITY:
NAME AND POSITION OF FILING OFFICER
___________________________________________________________
BUSINESS ADDRESS:___________________________________________
CITY STATE AND ZIP CODE:______________________________________
Refer to the attached link:
http://nj.gov/counties/mercer/news/publications/pdf/2004_14_ordinance.pdf
Mercer County Ordinance No. 2004-14 This Ordinance, effective February 1, 2005, provides
that all professional business entities seeking a professional services contract on a no-bid
basis with the County of Mercer or any of its boards, independent authorities or commissions
are required to provide a sworn statement or certification that the professional business entity
has not made and will not make a political contribution in violation of said Ordinance.
Certification I, the undersigned, certify that:
(1) I have reviewed Mercer County Ordinance No. 2004-14 and understand the terms
therein.
(2) The following individuals and/or entities have not solicited a political contribution
or made a political contribution in violation of the provisions set forth in Mercer
County Ordinance No. 2004-14 (No-Bid Professional Services Contracts) in excess
of the limits set forth in said Ordinance: (i) the professional business entity
identified above; (ii) all principals who own or control 10% or more of the equity of
the corporation, partnership or professional business entity including principals,
partners and officers in the aggregate; (iii) any subsidiaries directly controlled by
the professional business entity; and (iv) if the professional business entity is a
natural person, that person’s spouse and/or child, living at the same address.
(3) I am duly authorized and empowered to make this certification on behalf of the
professional business entity and those others referenced above.
(4) The foregoing statements made by me are true. I am aware that if any of the
foregoing statements made by me are willfully false, I am subject to punishment
including, but not limited to, the penalty terms set forth in Mercer County
Ordinance No. 2004-14.
NAME:_________________________________________________________________
TITLE:_________________________________________________________________
DATE:_________________________________________________________________
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
56
COUNTY OF MERCER
Disclosure of Political Contributions
Professional Business Entity:
Pursuant to Mercer County Ordinance No. 2004-14 all professional business entities with which
the County of Mercer or any of its boards, independent authorities or commissions intends to
award professional services contracts on a no-bid basis are required to disclose, among
other things, all political contributions made within the twelve month period immediately
preceding the date of the awarding of the contract or agreement to (1) a campaign
committee or fund of any candidate for or holder of a public office within Mercer County
government; (2) any municipal or county party committee; or (3) any political action
committee (PAC) that is organized for the purpose of promoting or supporting Mercer
County government candidates or officeholders. Indicate “none” if no such contributions
have been made.
A separate Disclosure must be submitted by each of the following, defined as a “Professional
Business Entity” under the Ordinance:
(i) a professional business entity submitting a Disclosure on its own behalf;
(ii) all principals who own or control 10 % or more of the equity of the corporation,
partnership or professional business entity;
(iii) any subsidiaries directly controlled by the professional business entity; or
(iv) if a professional business entity is a natural person, that person’s spouse and/or child,
living at the same address.
Pertaining to Disclosure of Political Contributions to any political action committee (PAC) that
is
organized
for
the
purpose
of
promoting/supporting
Mercer
County
candidates/officeholders. Indicate “none” if no such contributions have been made.
Name of Political
Action Committee
Date of
Contribution
Amount of
Contributio
n
Type of
Contribution
i.e., Cash,
Check,
Loan, In Kind
Purpose of Political
Action Committee
Pertaining to Disclosure of Political Contributions to: any candidate committee and/or election
fund of any candidate for or current holder of a public office within Mercer County
government; and any municipal or county political party committee. Indicate “none” if no
such contributions have been made.
Name of Committee
or Fund
Date of
Contribution
Amount of
Contribution
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
Type of
Contribution
i.e., Cash,
Check,
Loan, In Kind
57
I have reviewed Mercer County Ordinance No. 2004-14 and understand its terms. I certify
that, to the best of my knowledge and belief, the foregoing statements by me are true and
that I am duly authorized to make this certification. I am aware that if any of the statements
are willfully false, I am subject to punishment.
Company or Professional Business Entity:
By: _________________________________
Name:_______________________________
Title:_________________________________
Date:_________________________________
Relationship to Professional Business Entity: (See ii, iii and iv above)
If ii applies, list principals and % of ownership or control:
If iii applies, name and address of subsidiary:
If iv applies, name of spouse and/or child:
CC2017-01 OCCUPATIONAL HEALTH SERVICES FOR COUNTY OF MERCER
58