TVF&R, COT Police - Occupational Health and Wellness Services e
a
TV111
INTERGOVERNMENTAL AGREEMENT
Ttialatin Valle Tualatin Valley Fire&Rescue
� � Rescue Occupational Health&Wellness Services
Amendment 2
This is Amendment 2 to the Intergovernmental Agreement ("IGA")between Tualatin Valley Fire&
Rescue("TVF&R")and Tigard, City of(Police)("Agency');each acting by and through their elected
officials.
RECITALS:
The parties desire to amend the IGA for the provision of occupational health and wellness serviecs to
extend the period of the IGA and to establish the services and fee schedule for the July 1, 2015 through
June 30, 2016 term.
TVF&R hereby changes the program name to the Occupational Health & Wellness ("OHW"). TVF&R
operates OHW program and offers certain services from its new Clinic location at TVF&R North
Operating Center, 20665 SW Blanton,Aloha, OR 97078.
Post-Exposure Management. OHW will no longer provide post exposure information phone service
after June 30, 2015.Upon request,OHW may provide referrals for alternative service providers as
applicable for post-exposure counseling,exposure referral and follow-up.
Beginning July 1, 2015 the TVF&R Representative for OHW is Nicole Tzantarmas or designee 503-
259-1689.
TERMS OF AGREEMENT:
A. Pursuant to paragraph 1.a.i. of the original IGA the term of the IGA shall automatically extend from July 1,
2015 through June 30,2016,
B. Under paragraph 2- Scope of Services,delete all subparagraphs and replace with the following:
2.a. Pre-physical testing. TVF&R can provide scheduled pre-physical testing on an as requested basis at the
OHW Clinic.
2.b. Bloodborne and Airborne Pathogens Training and Services. OHW will provide bloodborne and
airborne pathogen training via digital multi-media. Face to face training can be provided upon mutual
agreement at the OHW Clinic,
2.c.Vaccination and Testing Services Delivery. OHW will provide the Agency vaccination and testing
services only at the Clinic. OHW will provide the Agency with the records and documentation necessary for
OSHA compliance. Each participant will have a vaccination record established with OHW.
2.d. Record kee in OHW will maintain records for services provided in accordance with applicable
standards,statutes,and guidelines(HIPAA,OSHA,OAR,ORS,and CDC guidelines).
2.e.Records Transfer. In the event the Agency chooses to no longer use TVF&R OHW services,'FVF&R
will transfer participant medical records as per Oregon records retention laws and HIPAA,and will deliver to
the Agency.
I
cr
D
INTERGOVERNMENTAL AGREEMENT
a $tln ValleTualatin Valley Fire&Rescue
J Occupational Health&Wellness Services
Fire & Rescue Amendment 2
21. Service Level. Services are provided on a per use basis,see Exhibit A for details.
C. Delete paragraph 3 —Consideration and replace it with the following:
3.Consideration. Rates for OHW services are based on a fee-for-service and are charged on a per use basis
(see Exhibit A for details).
BE IT FURTHER AGREED by the parties hereto,that but for those changes set forth herein, all other
terms,conditions and provisions of the original IGA, and as previously amended, shall remain in full
force and effect.
SIGNATURES:
In witness whereof, all the aforementioned is hereby agreed upon by the Parties and executed by the
duly authorized signatures below:
Agency: TVF&R:
Tigard,City of(Police) Tualatin Valley Fire&Rescue
13125 SW Hall Blvd 11945 SW 70th Ave.
Tigard,OR 97223 Tigard,OR 97223
By Authorized Head of Agency: By Authorized Head of Agency:
�L�JSienatnre Si attire
Debra Grabler-Guzman,Chief Financi Officer
Name&Titic(tyry or rim) Name
Date � Date
2
Tigard,City of(Police)
Amendment 2
Exhibit A
The following services and fees are provided by the TVF&R Occupational Health and Wellness(OHW)
ro!ram under a Fee for Service structure:
Service Description FY15-16 Fee Rate/Per
Bloodborne/Airborne Pathogen Training TBD/web ex Hour
Bloodborne Pathogen/Communicable Disease DVD $ 75.00 DVD
Nursing $ 75.00 Hour
CMA $ 40.00 Hour
UA-Annual Physical $ 5.00 Person/Test
UA w/micro $ 20.00 Person/Test
PSA-Annual Physical $ 35.00 Person/Test
Resting EKG-Annual Physical $ 35.00 Person/Test
CBC-Annual Physical $ 25.00 Person/Test
Comp Metabolic-Annual Physical $ 30.00 Person/Test
C-Reactive Protein High Sensitivity-Phys $ 30.00 Person/Test
Glycohemoglobin A1C-Annual Physical $ 30.00 Person/Test
Lipid Panel(blood draw)-Annual Physical $ 38.00 Person/Test
Audiometric Test $ 30.00 Person/Test
Spirometry Test $ 30.00 Person/Test
Vision Test $ 10,00 Person/Test
TB Skin Test $ 20.00 Person/Test
TB QunatiFERON Gold Test $ 75.00 Person/Test
Hepatitis A-Adult Vaccine V05.3 $ 50.00 Person/Test
Hepatitis B-Adult Vaccine V05.3 $ 50.00 Person/Test
Influenza VO4.8 Market Person/Test
Adacel-Diph/Tei/Pert V06.1 $ 60.00 Person/Test
MMR-Measels,Mump, Rub V06.4 $ 65.00 Person/Test
Varicella (Chicken Pox)Antibody $ 35.00 Person/Test
Hepatitis B Antibody $ 40.00 Person/Test
Hepatitis C Antibody $ 45.00 Person/Test
82935--HCV RNA PCR $ 130.00 Person/Test
HIV Antibody $ 45.00 Person/Test
Direct Bilirubin (Miscellaneous) $ 30-00 Person/Test
Free PSA(Miscellaneous) $ 45.00 Person/Test
Draw fee $ 10.00 Person/Test
Records management fee $ 15.00 Hour
Mileage(current IRS rate) IRS Rate Mlle
Pricing Reservation: The pricing above is at or near QHW costs,any increase/decrease to the costs may be
passed on to the Agency, including casts that increase due to market conditions(e.g., vaccinations).
Increases/decreases will be communicated in writing to the Agency and must be accepted prior to becoming
effective.
I
Tigard,City of(Police)
Amendment 2
Exhibit A
Services no longer provided or charged by TVF&R:
Respiratory Questionnaire Review
Exposure Line Access
Audiometric Test Setup Fee
Audiometric Setup Fee
Lipid Panel(finger stick)
Spirometry Test Setup Fee
HIV Antibody Rapid
Lead Quantitative
Zinc Protophyrin
EMPLOYEE COUNT:
Please see the current count of employees who may receive these services---indicate any changes in the
counts in the right column:
Estimated Number of: Current Est Employee Count: Change Est Employee Count to:
Police and/or Fire Employees: 76
All other Employees: 0
AGENCY CONTACTS:
Please see the current list of name(s)and contact information—indicate any changes in the right column:
Agency Contacts: Current Name: Change to:
Representative Name: Loreen Mills,Asst to the City
Manager
Representative Email: loreen@tigard-or.gov
Records Custodian: Jennifer Curran
Records Custodian Email: jenniferc@tigard-or.gov
Records Custodian Phone: (503)718-2417
2