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HomeMy WebLinkAbout2015-583-E HR - Job Ready Services workplace fitness for duty and functional capacity testing DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 r } LETTER AGREEMENT THIS AGREEMENT made and entered into this the day of , 2015 ("Effective Date") by and between Job Ready Services, LLC, ("Provider"), a North Carolina corporation located at 2300 Westinghouse Boulevard, Suite 107, Raleigh, North Carolina, 27604, WorkSTEPS®, Inc., a Texas corporation located at University Business Park, 3019 Alvin Devanes Suite 150, Austin, Texas, 78741 ("Worl6TEPS"), and Orange County, a , a local political subdivision of the State of North Carolina, located at 200 South Cameron Street, Post Office.Box, Hillsborough, North Carolina ("COUNTY"), collectively("THE PARTIES"). t. t WHEREAS: COUNTY is desirous of implementing a functional employment testing program as a part of its work injury and disability management program, to, among other reasons, effectuate a reduction of on- the-J ob injuries by trying to determine if an a pp licant or employee can safely p erform the essential functions of the job. WHEREAS: WorkSTEPS has developed functional employment testing protocols and procedures that COUNTY desires to utilize for its functional employment testing program, and WHEREAS: WorkSTEPS desires to assist COUNTY in implementing the WorkSTEPS functional F employment-testing program, THEREFORE THE PARTIES HERETO DO HEREBY AGREE AS FOLLOWS: is I Scope of Services: The services and/or materials (hereinafter referred to collectively as "Services")to be furnished under this Agreement are as follows: Workplace Fitness for Duty and Functional Capacity i Testing for Certain Work Groups. The scope of the project shall include testing of job positions as identified by Orange County and as provided in the"Workplace Fitness for Duty and Functional Capacity Testing at Risk Work Groups Proposal" (`the Proposal") submitted by Provider and WorkSTEPS, dated August 24,2015 (Exhibit 1), Job Analysis Bid Proposal(Exhibit 2) and Attachments A and B, all of which are attached and incorporated by reference into this Agreement, except as to those parts that conflict with this Agreement. If there is any conflict between the Exhibits and the all other documents and this Agreement,this Agreement shall take precedence over any other document. WorkSTEPS and Provider represents and agrees that they are qualified to perform and are fully capable of r performing and providing the services required or necessary under this Agreement in a fully competent, professional and timely manner to the satisfaction of the County. WorkSTEPS and Provider shall be r responsible for all its' errors or omissions, in the performance of the Agreement. WorkSTEPS and Provider shall correct any and all its' errors, omissions, discrepancies, ambiguities,mistakes or conflicts at no additional cost to the County. WorkSTEPS and Provider agree that they will not sub-contract any of the services to be provided in this Agreement, nor shall Provider assign any right or responsibility granted or required by this Agreement,without the prior written approval of the County. Job Analyses is the foundation of the COUNTY'S functional employment testing program. A job analyses is a measurement of the physical demands and requirements of the essential functions of a specific job. Accurate and current job analyses are the COUNTY'S responsibility. Job Specific Authorization Forms that document essential function requirements must be executed by COUNTY'S representative and provided to WorkSTEPS before testing can begin. COUNTY representatives should use professionals experienced in assisting with job analyses or other trained and certified ergonomic assessment specialists to assist in the preparation of job analyses and documentation of essential functions. The job analyses should be based on a close, careful examination of the specific job by an individual trained and competent in making the physical measurements of the essential functions of the specific job. The job analyses provides specific job content validity to COUNTY's functional employment testing program, which seeks to simulate the specific physical demands necessary to perform essential job functions. Accurate and up-to- Revised 10/2015 1 DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 y date job analyses help ensure that employment decisions are based on objective, sound, individual, and job specific information. Likewise, an accurate and up-to-date job analysis helps ensure that no individual or i group of individuals is discriminated against. County acknowledges and understands that this Agreement contemplates the functional employment testing of prospective employees and/or actual employees of County. That County, as employer of the individuals tested have a significant role, both before and after the test, including, but not limited to, selection of the s essential functions of the applicable job,the writing of job descriptions, if any, in communicating with the individuals to be tested in a consistent manner, in making appropriate employment decisions based on test results and in properly processing and advising those individuals tested. County represents and agrees that they are qualified to perform their'role in the Functional Employment Testing Program. SPECIFIC TERMS h 1. Term: The term of this agreement shall be from the effective date of this Agreement September 1, z: 2015 for a period of one year ending August 31,2016. 2. PUm . The County agrees to pay at the rates specified for satisfactorily performed in accord with this Agreement. The amount to be paid by the County shall not exceed fifteen thousand dollars, ($15,000.00). Payment shall be made within thirty (30) days of an invoice properly submitted to the County. Should Provider fail to perform the duties under the terms of this Agreement, County may,without fault or penalty,withhold any payment associated with the work to be performed until such time as said work is completed. Based on the functional employment test(s)and services that have been identified the price for the test(s)and services shall be: r a.Fee Schedule: ♦ Comprehensive Post Offer Functional Employment Test $200.00. 4' ♦ Fit For Duty,Fit For Duty RTW $175.00 i ♦ Upper Quadrant/Carpal Tunnel/Post-Offer Evaluation $240.00 t ♦ Job Specific Test Development per hour $125,00 ♦ Validation per hour $125.00 ♦ Sincerity of Effort Test $300.00 0 No Show Fee(24 hour cancellation required) $175.00 s Return on Investment Study(annual) No Charge f b. Other Services. Fees shall be as provided for services other than described in 2.a. above in the ; Proposal(Exhibit 1). ii 3. Non—waiver: Failure by one Party at any time to require the performance by another Party of any of the provisions hereof shall in no way waive or affect the Complaining Party's right hereunder to enforce the same, nor shall any waiver by the Complaining Party of any breach be held to be a 4 waiver of any succeeding breach or a waiver of this Non-Waiver Clause. f 4. Independent Contractor: The Provider and WorkSTEPS shall operate as independent Contractors, and the County shall not be responsible for any of their acts or omissions. The Provider nor WorkSTEPS shall not be treated as an employee with respect to the Services performed hereunder for federal or state tax, unemployment or workers' compensation purposes. The Provider and WorkSTEPS understand that neither federal, state, or payroll tax of any kind shall be withheld or paid by the County on behalf of the Provider or WorkSTEPS,or their employees. 5. Provider and WorkSTEPS Employees: COUNTY acknowledges that WorkSTEPS has invested considerable time and financial resource in the training, education, and certification of the professional staff necessary to deliver the services set forth on Exhibit A to this Agreement. During the term of this Agreement, and for a period of one year after its termination, COUNTY agrees that it shall not actively or knowingly solicit for employment any of WorkSTEPS Revised 10/2015 2 DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 employees or WorkSTEPS licensed Providers associated with the delivery of these services to COUNTY. u 6. Insurance: The Provider and WorkSTEPS shall obtain,at its sole expense, all insurance needed to adequately insure itself during the performance of these services as required by the County's Risk Management Policy. 7. Indemni : The Provider and WorkSTEPS agrees to defend,indemnify, and hold harmless Orange County from all losses, liabilities, claims, demands, suits, costs, damages or expenses (including reasonable attorney's fees)arising from bodily injury, including death,to any person or persons or damage to or destruction of any property caused in whole or in part by any negligent or intentional act or omission on the part of the Provider or WorkSTEPS. 8. Compliance with Laws: The Parties agree that they will comply with all federal and state laws in the compliance of this Agreement. County acknowledges that the County is responsible for Y making employment decisions concerning any post-employment candidates' or current employees' suitability for employment or continued employment and for making decisions concerning reasonable accommodations. 9. Termination: This Agreement may be terminated by either Party upon written notice to the other Parties. Receipt shall be deemed effective upon actual delivery to the noticed Party. Upon termination, COUNTY shall be responsible to pay for any employment tests that have actually been performed prior to the termination. 10. Confidentiality: The Provider and WorkSTEPS shall keep all information or materials received from the COUNTY strictly confidential, and shall not divulge any such information or materials without the express written consent of COUNTY. Notwithstanding any prohibition contained within this Section, The PARTIES may release data or information as contemplated herein should a state or federal court of law require it. WorkSTEPS may also release data or information received from the testing of COUNTY's employees for any legitimate business purpose,provided that (i) any personal information is kept confidential, and (ii) that all state and federal laws regarding such data or information are strictly followed. 11. Trademark Copyright and Proprietary Information: COUNTY acknowledges that is has been advised that WorkSTEPS believes the WorkSTEPS name, and its marks and proprietary software, protocols and testing process are federally trademarked and copyrighted. COUNTY agrees that WorkSTEPS proprietary software, protocols, processes, procedures, including modifications thereto, are, and shall be considered "proprietary" and "confidential information." WorkSTEPS confidential and proprietary information will be provided to COUNTY for the sole purpose of having the WorkSTEPS Provider provide functional employment testing services to the COUNTY. COUNTY acknowledges, agrees and confirms that COUNTY's disclosure or misappropriation of WorkSTEPS proprietary information could cause irreparable injury to WorkSTEPS, and COUNTY hereby expressly agrees that it will not use the confidential and proprietary information provided to COUNTY, except for the express purposes described in this Agreement except as provided below. All data and information generated by the WorkSTEPS Functional Employment Testing Program for COUNTY shall be the property of WorkSTEPS and COUNTY. WorkSTEPS shall use best efforts to keep such data or information in a legally compliant manner pursuant to all state or federal laws affecting such data or information. COUNTY may keep copies of data or information for use in its normal course of business, but COUNTY hereby agrees that should it have possession of any WorkSTEPS materials, forms, procedures, protocols, or information, that such shall be deemed proprietary and confidential and kept strictly confidential. COUNTY shall use best efforts to see that such is not utilized for any purpose that would reasonably be deemed in competition with WorkSTEPS. Revised 10/2015 3 DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 is Without limiting the generality of this Section, THE PARTIES agree that after the termination or expiration of this Agreement, such PARTIES will not use the proprietary, confidential information of the other PARTY to provide the same or similar services to any person(unless and until such information ceases to be proprietary and confidential through no fault of the PARTY seeking to use the same),however,nothing in this Section shall prohibit Provider or its affiliates, after termination of this Agreement, from providing a service to County similar to the services provided by in this Agreement as long as neither Provider nor its affiliates uses the proprietary, confidential information of WorkSTEPS in so doing. ii 12. North Carolina Public Records Act. Provider and WorkSTEPS aclarowledge that this Agreement, the Confidential Information and any documents, memorandum, data, reports, analyses, compilations,records,pricing and evaluation of all or any portion of the transactions contemplated by this Agreement may be deemed public records and subject to disclosure, in whole or in part, pursuant to the North Carolina Public Records Law. County will provide WorkSTEPS with prompt notice of any intended disclosures or requests for disclosure pursuant to the North Carolina Public Records Law and an appropriate lopportunity to seek protection of the Confidential Information consistent with all applicable laws and regulations. Should a public records request be made for information WorkSTEPS claims is proprietary in nature, County will, within a reasonable time, notify WorkSTEPS of such public records request. WorkSTEPS shall, within five (5) business days of said notification provide notice that it does or does not object to the County disclosing the requested information pursuant to the subject public records request. If WorkSTEPS objects to the disclosure of the requested information, WorkSTEPS agrees that it shall be solely responsible for the defense of and the cost of defending any claim or complaint against the County for its refusal to disclose Confidential Information. WorkSTEPS agrees that if any such complaint or claim is filed it will indemnify County and will reimburse County for any and all damages awarded against County its refusal to disclose the requested information. WorkSTEPS agrees that it releases County from all loss, liability, claims or expense, including attorney's fees, arising out of or related to the release or disclosure or failure by the County to release or disclose Confidential Information. WorkSTEPS further agrees that it waives the right to file any court action for any such release, disclosure, or failure to release or disclose Confidential Information. 13. Entire Agreement and Signatures: The parties have read this Agreement and agree to be bound by all of its terms, and further agree that it constitutes the complete and exclusive statement of the Agreement between the parties unless and until modified in writing and signed by the parties. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article I IA and Article 40 of North Carolina General Statute Chapter 66. 14. Governing aw: The Parties agree that this Agreement shall be governed b the laws of the State � �' �' g y of North Carolina. Should any party initiate litigation to settle any dispute involving the terms of this Agreement such litigation shall be initiated in the General Court of Justice of North Carolina seated in Orange County,North Carolina. 15. Non Appropriation: Provider and WorkSTEPS acknowledge that County is a governmental entity, and the validity of this Agreement is based upon the availability of public funding under the authority of its statutory mandate. In the event that public funds are unavailable and not appropriated for the performance of County's obligations under this Agreement, then this Agreement shall automatically expire without penalty to County immediately upon written notice to Provider of the unavailability and non-appropriation of public funds. Revised 10/2015 4 DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 IN WITNESS WHEREOF, Orange County, WorkSTEPS and the Provider have signed this Agreement, effective as of the day first written above. a AGREED TO THIS DAY OF 2015. is � DocuSi d RAYKKiVsb—� a o°r nc. O ange�o ty,NC OVUkAf q �3�g79184gg_ 0637004B755E477 By: By:Bonnie Hammersley,County Manager President Title Peter Gallaher Printed Signature r ��'. 8Pi d eady Services,LLC 028E-0D�85B6S42 ... By: President Title Debra Lord Printed Signature r 3 Revised 10/2015 5 DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 Exhibit 1,Proposal u r Ii Revised 10{2015 DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 G I' rr? i I' fir i Exhibit"2" Contract for Services r For Job Analysis Bid Proposal Orange County ("COUNTY") understands that a job analysis must be completed in order to meet requirements for the Americans with Disabilities Act(ADA)so that Job Ready Services,LLC("Provider") may perform post-offer and post employment testing pursuant to WorkSTEPS employment testing protocols. While the ADA does not require that a formal job analysis be conducted to determine the essential functions of a specific job position, the ADA does require an employer to prove that any exclusionary criteria obtained from a medical examination used to withdraw an offer of employment or terminate employment are "job related and justified by business necessity." (EEOC ADA Technical Assistance Manual II at 19 and VI at 2).Thus,the Provider must conduct a job analysis of the positions for which employment tests are performed to ensure that the employment test is measuring the candidate's or employee's ability to perform essential job functions. It is imperative that the COUNTY provides accurate information to the Provider regarding the essential job functions for specific job positions. The EEOC G provides a discussion relating to the identification of essential job functions in its Technical Assistance Manual. (EEOC ADA Technical Assistance Manual 11 at 13-22). The COUNTY acknowledges that the COUNTY is responsible for familiarizing itself with this section of the ADA Technical Assistance Manual and providing the Provider accurate information concerning essential job functions. f' I A separate job analysis must be performed for each position for which the COUNTY desires to utilize employment testing. The job analysis may include filming, weighing, and measuring tasks for the selected major job positions for the COUNTY. i The COUNTY understands that the evaluation usually takes between one (1) and four (4) hours to complete and is billed at $250.00 per hour. Mileage for services outside of a 20 mile radius fi-om Job i Ready is billed at $0.57 per mile and travel time at $100.00/hour. The COUNTY hereby authorizes Provider to provide said job analysis for each job position for which the COUNTY will be requesting employment testing at the above referenced rate. Lb60V.C_U Signed by: lit tf. C1AaMlMtVS�I� 11/3/2015 k YdI@epresentatrve/Title Date Vtbreu th4 10/23/2015 f Provider Representative/Title Date i is I ii G Revised 10/2015 7 DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 "Attachment A" Description of Services a Post Offer Testing to Include: Medical History—The job candidate is asked to complete a comprehensive medical history administered by an occupational healthcare professional that has been trained and certified in the WorkSTEPS Program. This history includes information gathering on previous injuries. and/or surgeries, previous physical therapy/chiropractor visits, etc. The employee also signs a statement that falsification of the information he/she has provided could result in the withdrawal of the conditional job offer. Musculoskeletal Examination — A WorkSTEPS certified clinician completes this portion of the exam. The exam looks at all major joints and muscle groups. Thirty(30)baseline measurements are documented. The muscle groups are checked for strength as well as any atrophy. The shoulders, elbows, wrists, back, ankles, knees and hips are checked for signs of crepitus as well as ligament stability. In addition, the lumbar and the cervical spine is also checked. Flexion, extension, side bending and twisting are all measured. Visual inspection of the spine for signs of surgery is performed. Deep tendon reflexes of the biceps, triceps, patellar tendon and Achilles tendon are performed to further check for spinal cord problems. Shoulder range of motion is checked and measured as well for movement in the internal and external rational planes. The rotator cuff is also thoroughly checked. Static Grip -This portion of the tests measures grip strength and gathers baseline strength readings on the employee. Dynamic Lifting - This portion of the test gathers baseline, full motion, and strength readings. The employee is asked to lift a NIOSH box from 4 different positions. These 4 positions are lifting the box from floor to knuckle height, 12 inches off the floor to knuckle height, knuckle height to shoulder and shoulder to overhead. With each of these lifts,the employee is asked to lift the box. After the lift,they are asked if they can safely handle more weight. The employee is asked at the beginning to try and lift their maximum safe lift. The employee is shown and instructed on the proper lifting techniques for each of these lifting positions. I Job Specific Tasks - This portion tests assesses the job candidate's ability to perform the essential functions of the job he/she is applying for. The essential functions for a job description are created through job analysis that is performed by a qualified vendor of the employer's choosing (this can be the WorkSTEPS Provider who will be providing testing service but is not required).The employer is obligated to participate in the job analysis process by approving and verifying that the essential functions have been properly identified and are accurate. Upper Quadrant/Carpal Tunnel Test - A series of baseline upper extremity tests utilized to identify carpal tunnel syndrome ("CTS"). This test consists of a brief musculoskeletal examination focusing primarily on the upper extremities, grip,pinch, and forearm strength and endurance tests, an optional nerve ---- - --conduction-test,-and-essential functions tests if applicable.--T-he-results-are-compared to-recognized-norms- - —and an employment recommendation is given to the employer. The Upper Quadrant/Carpal Tunnel Test is NOT used to diagnose CTS. It is performed only as a baseline test to identify abnormalities that have resulted in strength, motion, or sensory loss that correlates to pain or other symptoms consistent with common upper extremity problems and cumulative traumas like CTS. When symptoms or loss of function are identified during the testing process,a"Refer for"Additional Medical Clearance" Revised 10/2015 8 DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 Fit For Duty Testing As Part Of A Return To Work("RTW")Program To Include: WorkSTEPS will be conducting Fit-for-Duty(Post-Injury RTW)Tests on existing employees to include the following: i • Any reported injury,illness,or condition that gives the employer reasonable belief that the employee's ability to perform essential job functions will be impaired or create a direct threat to health and safety. • This category may also include testing at the request of the employer because, although there has been no formal injury or medical condition reported,the employer has observed current performance problems or has received reliable reports of performance problems indicating that the i' employee may not be able to perform essential job functions, or may pose a direct threat to the fr health and safety of the employee or others. • Even if the employee has fully"recovered"from injury or illness and no longer considers him or herself"injured",for documentation purposes the test should be identified as a"post-injury"fit for duty,or an injured worker,because that was the trigger for the test. I' • When testing an employee post-injury or illness the provider will: • Use the WorkSTEPS Fit for Duty Physical Capacity Consent Form • Use the WorkSTEPS Post Injury Fit for Duty Medical History Interview • Not perform"routine"medical measures,including heart rate and blood pressure,that are not related to the injury or condition for which the employee is being seen, or that are not contributing to a job related functional deficit. • Not perform the standard"baseline"tests such as step test, Sorenson's or grip if they are not related to the injured area. • Perform only the dynamic lift postures that are considered qualifying criteria. • Perform any and all standard job specific tasks for the position,and expand to include any additional essential function tasks that could be impacted by their injury or condition. DocuSigned by: b6VuLkA'f, 11/3/2015 nFZ�ooe®755�7�... Representative/Title Date DoL ��cu��Signed by: Puy Ga 10/22/2015 48 Rlaa =a4 WorkSTEPS Representative/Title Date Revised 10/2015 9 DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 i l Job Ready Services, LLC 2300 Westinghouse Boulevard,Suite 107 Raleigh, NC 27604 ux� 919 256.1400 Phone: 919 256-1403 Fax www.iiobreadyseruices.net t is ii Prory p WORKPLACE FITNESS FOR DUTY AND FUNCTIONAL CAPACITY TESTINGFOR AT RISK WORK GROUPS PROPOSAL August 24, 2015 PREPARED FOR: Orange County r BRENDA BARTHOLOMEW Human Resources Director k_ PREPARED BY: Debra C. Lord, PT, CEAS II President description Job Ready Services, LLC is a an independent provider of The WorkSTEPS® Program which was developed by physical therapists in a clinical setting over two decades ago in response to industry's need for reliable, medically/legally defensible employment testing program which could effectively reduce work place injury incidence and work place injury costs. Debra Lord, PT has been a licensed provider of the WorkSTEPS®Program since 1998 and has been awarded the ACE Award by WorkSTEPS corporate for six of the last seven years recognizing excellence in functional testing and product delivery. The testing program,which is based upon objective scientific data collected on new hires and existing workers,conforms fully to EEOC guidelines for application of the Americans with Disabilities Act(ADA)and ADA Amendment Act(ADAAA). Visit www.worksteps.com or contact WorkSTEPS at 512 617-4100 or www,iobreadyservices.net for further information. Job Ready Services, LLC 1 919 256-1400 www.jobreadyservices.net DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 f executive summary The Objective... The WorkSTEPS®Program is a system of ADA compliant employment tests that are both scientific and objective. These tests establish baseline information on employees and help insure '. that they are appropriately matched to the physical demands of their jobs. Information collected during these tests is invaluable to employers in both the hiring and post injury management of workplace injury. ♦ Need#1: Develop a Job Analysis in a standardized format for describing each unique job function within each designated department's job description. ♦ Need#2: Implement functional capacity testing to objectively measure current and future employees'ability to perform the required tasks outlined by the analysis. ♦ Need#3: Standardize data collection and reporting pre and post injury ♦ Need#4: Prevent injuries in the workplace by appropriately matching employees'abilities to their job responsibilities, ♦ Need#5: Detect"at risk"employees who have significant pre-existing impairments, ♦ Need#6 : Intervene following the inception of an injury to effectively rehab workers and minimize lost work days, ♦ Need#7: Eliminate fraud through the use of scientific consistency 'checks"post injury, The Opportunity... Reduce costs associated with work-related injury by implementing a functional employment testing program. ♦ Goal#1 :Significantly reduce workplace injury incidence, ♦ Goal#2: Reduce workplace injury costs, ♦ Goal#3 : Reduce lost time, ♦ Goal#4: Create accountability for employees&treating providers. Job Ready Services, LLC 2 919 256-1400 www.jo bread yservices.net i DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 mission statement Mission Statement Statistics prove that the best way to treat any injury or illness is to prevent it from ever occurring. However,there are many debates about what interventions are the most effective and which ones achieve the highest measures of success. It is well recognized by experts in the field of occupational and industrial medicine,that the single highest degree of injury reductions are accomplished through functional testing. Functional testing is a bio-ergonomic intervention that measures human strength and performance, and appropriately matches them to the physical demands of the job. The WorkSTEPS® Functional Test Model("Model")has proven to reduce work-related MSD's by an average of 50%in its first year of implementation when used as a first line of defense in the prevention of MSD's. Functional testing combined with other injury management programming such as conditioning,ergonomics,etc,,can help achieve reductions which are even more significant. The Model has gained wide acceptance in the business community due to the rising costs associated with workers'compensation and increased federal regulations being imposed on employers by the Occupational Health and Safety Administration and the Equal Employment Opportunity Commission. The Model helps employers stay compliant with federal hiring practices and the Americans'with Disabilities Act. The Model utilizes appropriately designed and administered tests, historical pre-and post-injury data, and evaluations relevant to physical performance to help mitigate the incidence and costs of injury and provide better data to its employers to assist in resolution of claims. The Model is currently utilized in 48 states and has proven invaluable to both large and small employers in their ongoing efforts to reduce workplace injury incidence and their related costs. This Model is appropriate for use in all industries as it addresses common musculoskeletal problems that encompass heavy labor to high tech, repetitive motion injuries. Many employers using the Model have been recognized both nationally and regionally for exemplary accomplishments in safety and prevention programming. The employer/occupational medicine partnership created through this Model has resulted in hundreds of safer,more productive workplaces. Litigation WorkSTEPS®has never been found negligent or contributory in any settlement regarding ADA or EEOC non-compliance. WorkSTEPS® has a history of litigation successes. Once pre-injury status is achieved,medical costs are justifiably stopped and maximum improvement is assigned. WorkSTEPS® has established a significant precedent by subtracting pre-existing impairments in a final workers'compensation award. Job Ready Services, LLC 3 919 256-1400 www.jobreadyservices.net DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 r a , expected" results Job Ready Services as a provider of WorkSTEPS®has been successful in saving many area employers thousands of dollars in workers'compensation insurance claims and lost time accidents. This has been a accomplished by providing a unique test that determines whether a job candidate can perform the essential functions of theirjob. This testing program is a proven method of reducing costs associated with workplace injuries. Many employers currently utilizing the testing program are reporting an average reduction of 50% i= of their previous year's work injury costs, and many companies have achieved savings of as high as 80%. Statement of Problem/Need The University of Massachusetts recently reported that 10%of existing employees are not physically capable of performing their job tasks. This same 10%also accounts for 75%of the costs associated with workplace injuries. Information collected during WorkSTEPS®testing identifies individuals who are at high risk for injury and prevents an employer from placing or retaining them in job positions that they are not physically capable of performing. ♦ One back injury costs over$100,000(medical, replacement income, indemnity,etc.) ♦ One carpal tunnel costs over$100,000(medical, replacement income, indemnity,etc.) ♦ One fraudulent claim costs over$70,000 Project Scope and Objectives t The Scope of the project may include testing of job positions as identified by Orange County The following objectives shall be achieved: ♦ Reduce work related injury costs by 50%over a one year period o Identify individuals who do not meet job specific strengths or aerobic requirements ♦ Appropriately match current and new employees to the physical demands of their jobs ♦ Provide the company with capable/not-capable recommendations ♦ Substantiate legitimate injuries and disqualify fraudulent claims Reduce employee turnover o Expedite injured employees return to work o Standardize data collection and reporting pre and post injury Job Ready Services, LLC 4 919 256-1400 www.jobreadyservices.net DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 services provided The WorkSTEPS® Employment Testing Program consists of 5 parts; Information Gathering, Detection, Intervention,Assessment,and Fraud Elimination. ♦ Information Gathering—The WorkSTEPS®Program starts with a thorough job analysis,which shall be completed by trained Job Ready Services, LLC personnel certified in ergonomics. The job analysis information forms the basis for preparation of the essential function component of the WorkSTEPS® Employment Test per EEOC and ADA guidelines. ♦ Detection—Job Ready Services, LLC will then begin testing potential employees to ensure they are capable of performing the physical components of the identified position. This test involves a functional evaluation involving lifting and job specific testing. Following completion of the test, results are entered into the WorkSTEPS®database for outcome generation. This provides a profile of each individual employee according to the DOT physical demand of each specific job. The capable/not-capable recommendation is received almost immediately via a computerized network. The report generated establishes the baseline functional capabilities of the candidate for possible comparison to future, post-injury data. The employer receives an ADA compliant report. ♦ Intervention—If the candidate is hired and incurs an injury or illness,a Fit-For-Duty examination may be required under certain circumstances before return to work to ensure this employee's safety in performing the essential functions of the job and also for the purpose of documenting the change in that individual's baseline due to a change in their physical status and identifying functional deficits and establishing rehab goals. ♦ Assessment—If an employee remains on"transitional duty"for more than 2 weeks(for example) or is taken off of work for a work-related or a non work-related injury/illness, the employee may be required to participate in a Fit-For-Duty testing process during the rehab process or at MMI. This test allows the injured/ill person to perform the essential functions of their normal job in a controlled environment. If the person is deemed to be able to perform their job safely based upon the essential functions,Job Ready Services, LLC will recommend that they resume their normal job. If the person is deemed unable to perform their job safely or with reasonable accommodations, Job Ready Services, LLC will notify you in writing of tasks the employee is capable of performing safely, Orange County can then place the employee in the appropriate transitional position. The employee may be involved in a rehab or conditioning program and then retested per Company Policy. Policies can be developed to manage those individuals who have reached MMI and cannot return to full duty after due process. ♦ Fraud Elimination—If an applicant is hired and through the course of his/her employment suffers any type of injury,the post-offer information is used to compare the employee's current status with his/her initial baseline status. This alleviates speculation regarding pre-existing conditions and comparisons to other persons of his/her age and weight. Furthermore,since the consistency of post-injury data and diagnostic information is easily monitored,the ability to detect faking an injury and reduce workers'compensation liability/expense is greatly enhanced. Job Ready Services, LLC 5 919 256-1400 www.jobreadyservices.net DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 is t 77-7,77— cost summary Development Costs Price -Physical Demands Analysis(to establish essential job functions) $250/Hour (minimum of 2 hrs) -Customized Job Descriptions and Essential Functions Test Development $150/Job Type -Validation of Job Specific Testing $125.00/Test Testing Costs Price -Post Offer/Pre Placement Comprehensive Exam $200 -Carpal Tunnel/Comprehensive Exam $240 -Fit-For-Duty Testing $175 -No Show Fee $175 E; Additional Services Available Price Ergonomic Analysis or Causal Relations Job Analysis $200/hour Annual Review/Update of Job Descriptions/Job Specific Tests Review $125/hour Ergonomic Training **Per Agreement Functional Capacity Evaluation $900.00 Sincerity of Effort Testing $300.00 Work Conditioning $80/hr Medical-Legal Interventions $150/hour Price Miscellaneous Costs I I` Travel $100/hour I Mileage $0.57/mile There are no additional start-up costs,annual administrative costs,or hidden fees associated with program. —Training class pricing is dependent on number of attendees per class,number of classes needed,scheduling needs,class time and materials provided.** * des job titles/positions that are similar in nature, le: handling A Job Type analysis sis inclu J p Yp Y t/tools exposure to same work environment and job functions overlap of same equtpmen p J k h G The above pricing is valid for 30 days from the date of Proposal Submission Job Ready Services, LLC 6 919 256-1400 www.jobreadyservices.net DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 is project summary Cost Estimate for Implementing Post Offer/Fit for Duty Program for 1 Job Type Job Analysis 3 hrs per job type x $200/hr $600 t Test Development 1 hr per job type x$150/hr $150 t Validation 2 hrs per job type x$150/hr $300 Miscellaneous Travel time and Mileage $110 Estimated Cost Full Program Implementation $1160 f j is j F expected results Return on Investment Estimated costs are based on review of Job Analysis, development of job specific testing criteria, content I validation of testing protocol and physical abilities testing for 5 Job Types. F Job Analysis —1 Independent Job Type Includes time on site,Job Specific Test Design, and Content Validation $1160 i j Post Offer Pre Placement Testing 10 New Hires $2000 $3160 Research indicates 10% of your employees are unable to safely perform the essential functions of their job and have a significant risk for injury. It is also known that 80% of your time and monies are spent in managing claims for this 10%. The Worker's Comp Research Institute recently reported the average direct cost of a worker's comp claim in NC is$42,000. DOL's Safety Pays Program provides a conservative estimate of the indirect cost of the claim as $46,000 for a total claim cost of$88,000. If the WorkSTEPS® model is successful in finding 1 out of the 10 employees tested who could not safely perform the essential job functions and has a significant risk for injury, it would pay for all of the costs of testing at this level with a savings of 90% of direct and indirect claim costs. A Conservative R01 would be$30 for each $1 spent h C Serious consideration should be given to a method that demonstrates savings with testing and not hiring your next claim. F Job Ready References Available per Request WorkSTEPS References Available per Request Job Ready Services, LLC 7 919 256-1400 www.jobreadyservices.net DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 r G a 'A,I"y" recommendations Find out what other companies already know here in North Carolina and nationwide about successful work injury management with the WorkSTEPS®Program: The following recommendations provided by Job Ready Services, LLC will result in a successful work injury management experience with the WorkSTEPS® Program: Do Job Analysis o Validate essential functions and physical demands necessary for safe job performance it e Do implement post offer pre placement testing to gather baseline for pre-existing factors • Don't pay pre-existing apportionment • Do educate your medical providers to provide accountability for treatment/rehab goals ♦ Do implement post employment physical agility testing • Do single out struggling employees for individualized assessment IR • Do test all employees periodically to maintain job readiness i ♦ Do implement Return to Work policies after leave • Do create accountability post injury with Fit-For-Duty testing • Do post injury ry Functional Capacity Evaluations to RTW with residual function [ Do best practice programming e Do stop injuries and save significant dollars j Please contact Debra Lord at Job Ready Services to discuss finalization of this agreement: 919-256-1400 or email:debra.lord(d)iobreadyservices.net Looking Forward to a Successful Partnership I As a representative of Orange County, my signature below indicates acceptance of the proposal as offered by Job Ready Services, LLC. E DocuSigned by: lajOV Lk,tf. (1 Mmtysb_I? 11/3/2015 06a79g¢ Date signature Bonnie Hammersley county Manager Print Name Title is Job Ready Services, LLC 8 919 256-1400 www.jobreadyservices,net DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 f ORANGE COUNTY RETURN TO: STATE OF NORTH CAROLINA Debra C. Lord DEPARTMENT OF Job Ready Services, LLC DIVISION OF 2300 Westinghouse Blvd, Suite 107, Raleigh, NC 27604 DESIGNATION OF CONFIDENTIAL AND PROPRIETARY INFORMATION The attached material submitted in response to Contract Proposal for Functional Employment Testing Services includes proprietary and confidential information which qualifies as a trade secret as provided in North Carolina General Statutes 132 — 1.2(i), or is otherwise material that can be kept confidential under the North Carolina Open Records Law. As such, we ask that certain pages, as indicated below, of this bid/proposal response be treated as confidential material and not be released without our written approval. Prices always become public information when bids/proposals are opened, and therefore cannot be kept confidential. Other information cannot be kept confidential unless it is a trade secret. Trade secret is defined in s 66— 152 (3)N.C. General Statutes, as follows: is "Trade secret" means business or technical information, including but not limited to a formula, pattern,program, device, compilation of information,method,technique, or process that: a. Derives independent actual or potential commercial value from not being generally known or readily ascertainable through independent development or reverse engineering by persons who can obtain economic value from its disclosure or use; and I E# b. Is the subject of efforts that are reasonable under the circumstances to maintain its r secrecy. i= i ; i We request that the following documents not be released. Document Page# Topic WorkSTEPS Test Guidance 1-33 WorkSTEPS Testing Documents Introductory Employer Packet 34-64 Sample Policy and New Employer Documents In the event the designation of confidentiality of this information is challenged, the undersigned Company will be notified and upon reasonable notice hereby agrees to provide legal counsel or other necessary assistance to defend the designation of confidentiality and agrees to hold the County harmless for any costs or damages arising out of the County's agreeing to withhold the materials. DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 j f l I k Company Name W -STEPS Inc. Authorized Representative P t Signature Acknowledged B- Orange County Government ! Authorized Representative I Pn�rsI ey 11 Signature Date MI�5E477___ l r F This document can be made available in alternate formats to individuals with disabilities upon µ request. I' E r i i i G is e• i= ii k DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 Section VII f f Introductory Employer Packet CONFIDENTIAL Page Contents 157 Letter Agreement (SAMPLE Contract for Services) 161 Company Information Sheet 162 Introductory Employer Pack - Outline 163 Essentials for Implementing a Functional Employment Testing Program 164 Resources for Legal Information on Functional Employment Testing 165 Job Analysis Process 166 Sample Policies to Implement Before Post-Offer Testing 167 Sample Policy—Post Offer/Pre-Placement Testing 169 Scheduling Divider 170 Recommendations for Testing 171 Communicating Test Results to the Employer 174 Fit for Duty/Return to Work Information 175 Physical Fitness and Agility Testing for Existing, Uninjured Workers is 176 Post Injury Fit for Duty Testing 177 Sample Policy Regarding Post Employment Tests 178 ADAAA/Reasonable Accommodation Resources for Employers 180 Request for Medical Information; Reasonable Accommodation Documents 185 Department of Labor FMLA Resources 187 What to Do if... Divider 188 Notice to Employer Should an Candidate be Injured During Testing 189 Required Medical Examination (RME) E kkk ti F' f` I f# d DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 LETTER AGREEMENT TI L WorkSTEPSOEmployment Testing Price List/Company Information/Special Instructions s DATE: COMPANY NAME: TYPE OF BUSINESS: i ADDRESS: CONTACT PERSON BILLING: PHONE: FAX#: CONTACT PERSON TEST RESULTS: PHONE: FAX#: PRICES: JOB ANALYSIS $ POST-OFFER EMPLOYMENT TEST(BASIC) $ POST-OFFER EMPLOYMENT TEST(COMPREHENSIVE) $ CARPAL TUNNEL TEST $ POST EMPLOYMENT FIT FOR DUTY TEST $ FUNCTIONAL CAPACI'T'Y EVALUATION OTHER(SPECIFY ) $ SPECIAL INSTRUCTIONS: Company Representative/Title Date Provider Represeritaiive%Title Date DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 r Y Introductory Y Employer Packet CONFIDENTIAL Post-Offer/Post Employment Testing Program A. Essentials for Implementing a Functional Employment Testing Program 3 } B. Resources for Legal Information on Employment Testing C. Job Analysis D. Sample Policies to Implement Post-Offer Testing r a. Sample Policy Regarding Post Offer Testing E. Scheduling Candidates for Testing a. Recommendations for Testing R Fit for Duty/Return to Work Information a. Sample Policy Regarding Post Employment/Fit for Duty Employment Tests for Existing Employees �f G. What to Do IF... a. Notice to Employer Should An Candidate Be Injured During Testing b. Required Medical Examination (RME) r Any functional employment testing program should be considered a "partnership" between a test provider and employer. Just as there are numerous considerations that must be met for the test process to "pass muster" as a safe and legally compliant testing process, the employer must be diligent to develop "policies and procedures" that effectively manage the "test data" and "test recommendations" being provided to them by the test provider. The state in which the employer operates, how the employer is insured, whether the employer is working with a unionized workforce, whether or not the employer is using temporary workers, etc., are all considerations 4 that must be addressed in the design and administration of an employer's functional employment testing program. Policy and procedure design is the responsibility of the employer. The sample policies contained in this implementation package and all related or accompanying materials are provided for informational /sample purposes only. They are not intended as legal advice. WorkSTEPS recommends that recipients of this content should consult legal counsel of their own choice to discuss how these matters relate to their individual circumstances. is i DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 Essentials for Implementing a Functional Employment Vesting CURMENTIAL Before implementing a functional employment testing program., employers should at a minimum ensure the following steps have.been taken. ® Legal counsel.has been consulted prior to implementing the functional employment testing program. Consult with employment counsel to ensure the necessary policies and procedures are implemented prior to testing and that such policies are integrated with any existing policies. NOTE : The sample r policies provided in these materials are only samples and should be approved.by legal counsel as set forth in the disclaimers provided on the individual policies: ® Training has been completed for all employees who will be involved in the functional employment testing program. Individuals trained should include employees with responsibility for implementing the functional employment testing program (i.e. safety, human resources, operations, etc.), employees responsible for deciding which employees will be subject to the selected functional employment tests to be includ e in the employer's program, em p to ees responsible,for making employment e nt decisions based on the results of the functional employment tests, employees responsible for maintaining confidential information obtained during functional employment testing, and any additional employees perixtitted under the ADA to have access to the medical information generated during functional employment testing. Such individuals should be trained on various aspects of the Americans with Disabilities Act and its interplay with state worker's compensation laws and federal and state family and medical leave laws. ® A job analysis has been completed by your licensed WorkSTEPS representative. Before an employment test can be performed; your licensed WorkSTEPS -representative must perform a job analysis for the job position being tested. Additional information on the importance of a job analysis and the importance of accurately identifying essential functions is provided in these materials. DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 Resources for Legal Information on Employment T"WINNTIA1 Individuals involved in an employer's functional employment testing program should be familiar with the following list of resources. These resources are obtainable directly from the Equal Employment Opportunity Commission's website located at http://wwW.eeoc,gov. h • The Technical Assistance Manual on the Employment Provisions of(Title I) of the Americans with Disabilities Act. Employers may obtain a free copy from the EEOC's Publications Page (http://www.eeoc.gov/publications.html) or by calling 500-669-3362. • The Americans with Disabilities Act of 1990 (ADA) specifically Section 12112(d). http://www.eeoc.gov/policy/ada.htnil . s • The implementing regulations of the ADA, including the Appendix to the regulations, specifically 29 C.F.R. Parts 1630.11 —1630.14, http://www.access.gpo.gov/nara/cfr/waisidx_02/29cfrI 630_02.htm1 . • Enforcement Guidance: Pre-employment Disability Related Questions and Medical Examinations, http://www.eeoc.gov/policy/does/preemp.html. • Enforcement Guidance: Workers' Compensation and the ADA. http://www.eeoc.gov/policy/docs/Workco-n-ip.ht". • EEOC Enforcement Guidance on Disability-Related Inquiries and Medical Examinations of Employees Under the Americans with Disabilities Act. http://www.eeoc.gov/policy/docs/guidance-inquiries.html. • Questions and Answers: EEOC Enforcement Guidance on Disability-Related Inquiries and Medical Examinations of Employees Under the Americans with Disabilities Act. littp://www.eeoc.gov/policy/does/qanda-inquiries.html. • EEOC Enforcement Guidance on Reasonable Accommodation and Undue Hardship Under the Americans with Disabilities Act. http://www.eeoc.gov/policy/docs/accommodation.html. • The Family and Medical Leave Act, the American with Disabilities Act, and Title VII of the Civil Rights Act of 1964. http://www.eeoc.gov/policy/docs/fmlaada.htrnl. • Fact Sheet on Obtaining and Using Employee Medical Information as Part of an Emergency Evacuation Procedures. http://www.eeoc.gov/facts/evacuation.htmi, • Job Candidates and the Americans with Disabilities Act. http://www.eeoc.gov/facts/jobeandidate.html. DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 i. Job Analysis CONFIDENTIAL A job analysis should be performed prior to testing to determine the essential functions of each position to be tested, and to help accurately establish qualifying criteria. Why must a lob anahVsis be performed prior-to testing`? When using medical information obtained from a functional employment test to make an. employment decision, the ADA requires that an employer base any such employment decision on the individual's ability to perform the essential job functions with or without a reasonable accommodation. An eiployer cannot snake such a determination unless-the essential job functions have been identified. What Employers Should Know About The Tob Analysis Process Since the.e accurate identification of essential .functions is critical to ensure that employment decisions are ADA compliant, employers must provide accurate information to the licensed WokSTEPS® representative conducting the job analysis and employers must review the information presented in the job analysis prepared by the licensed`WorkSTOW.representative to ensure its accuracy. The EEOC has provided guidance in its Technical Assistance Manual and implementing regulations to assist employers in identifying essential job functions. Essential Functions are "the fundamental job duties of the employment position." 29 C.F.R. § 163.0.2(n). The EEOC provides that an essential function determination is a "factual determination that must be made on a case by case basis"considering all relevant evidence, 29 ORR,Appendix § 1630.2(n). The regulations provide guidance on why a job function may be considered essential. Noting the list is not all inclusive, the EEOC provides the following examples of reasons a job function might be considered .essential; "(i) The function may be essential because the reason the position exists is to perform that function; (ii) The function may be essential because of the limited number of employees available among whom the performance of that job function can be distributed; and/or (iii) The function may be highly specialized so that the incumbent in the position is hired for his or her expertise or ability { to perform the particular function." 29 C.F.R. § 1630.2(n)(2). Further guidance is provided on what will be considered as evidence that a job function.is essential, Evidence of whether a particular function is essential includes,but is not limited to: (i) The employer's judgment as to which functions are essential-; (ii)Written job descriptions prepared before advertising or interviewing candidates for the job; (iii) The amount of time spent on the.job performing the function; (iv) The consequences of not requiring the incumbent to perform the function; (y) The terms of a collective bargaining agreement; (vi) The work experience of past incumbents in the job, and/or (vii)The.current work experience of incumbents in similar jobs. 29 C.F.R, § 1630.2(n)(2) In the EEOC's Technical Assistance Manual, the EEOC recognized that the "nature of the work operation" and "organizational structure" of the employer may also be relevant factors in an essential function determination. EEOC Technical Assistance Manual,_11 at 18 (1992), DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 CONFIDENTIA1 Sample Policies to Implement Before Post-Offer Testing NOTE: This policy is a sample policy provided by WorkSTEPS and must be tailored to fit your company's individual situation. It is imperative that legal counsel be consulted so your post-offer testing policy can be coordinated and 3 integrated into your existing policies. Disclaimer: This is a sample policy. State law, or changes in federal law, may cause gray are that could increase liability. Consulting an employment law attorney is recommended prior to policy implementation. t DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 k Sample -- Policy Regarding Post Offer, Pre-Placement Tests MARTIAL Post offer[Pre-placement examinations are successful tools utilized to create.a safer working environment for employees. With the advent of'sports technology applied to the industrial worker, comprehensive stress tests monitor heart and musculoskeletal function to detect disease processes, wear and tear syndromes,and many other problems that lead to injuries and disability. [Company Name] is willing to pay for such servicesto help its employees remain safe.in the workplace and to reduce costs associated with injuries Training provided during'the examinations increases body awareness during work activities to prevent cumulative trauma and to successfully reduce injuries. Furthermore, employee turnover.and operating expenses are.reduced by maintaining properly qualified personnel in each position. As a result, [company Name] is implementing the WorkSTEPS° evaluation prop am for all prospective employees in designated job categories as set forth below.. [Employer must apply these to all entering employees in the designated job categories.] This program has been in effect since 1986,has one of the largest normative databases in the United States,and has"proven its success by creating safety in the work place. Recognizing that every job and every empio.yee are different,the tests are utilized to determine whether or not the employee can safely perform job duties. i When necessary to enable an otherwise qualified candidate with a `-`disability" to participate in testing; the Company will provide reasonable accommodations provided such accommodations do not cause an undue hardship. Candidates who believe they need an accommodation to partl6pate in the testing program,must request such accommodations. To minimize or avoid delays in testing, the Company asks candidates to advise the Company of the need for any accommodation as soon as possible after you have received a conditional offer of employment. Policy: Effective (Date), all persons.applying for employment in the following positions will be required to successfully complete a functional employment test. The following is the process that will be followed. 1. Candidates should report to personnel office to comp application forms. lete the necessary 2. A Human Resources manager and/or any other authorized staff member will interview candidates. I 3. A Human Resources manager and/or any other authorized staff member will offer employment to those candidates deemed to be the most ualified and suitable for the ositions sou ht. The offer of employ meat will be contingent q. P g. . b upon [the successful completion of a post-offer drug screen (if applicable) and] the functional employment test. [Note:. Companies who utilize drug tests should consult employment counsel to review any applicable legal requirements under federal or state law. In general,if a drug screen is required,the Company should inform candidates of the procedures followed regarding the drug screen.] 4. Upon receiving conditional offers of employment, candidates will be given written job descriptions and additional written information regarding the post bfferlpfc=placoineht functional ern Pto ment test. After carefully reviewing this information and/of consulting with their personal physicians, candidates must complete a release authorizing the Company, Work-STEPS, and the licensed WbrkSTEPS testing facility to conduct the post-offer functional employment tests. Requests for accommodations should be noted on the release. Depending on the nature of the accommodation sought,further discussions and/or medical documentation may be needed to identify an appropriate k accommodation. Testing will be.delayed until the interactive process aimed at identifying appropriate and necessary reasonable accommodations is completed. 5. Once the Company receives a fully completed release and any requests for reasonable accommodation are resolved, the Company will schedule candidates for the post-offer/pre-placement functional employment test. 6. Upon reporting to the licensed WORKSTEPS testing facility, candidates will be examined by a licensed occupational or physical therapist and their staff 7. Candidates, who successfully complete the post-offer/pre-placement functional employment test, will be informed of a"start"date by the.Company Human Resource Manager or other authorized representative. The Company will notify candidates who are determined to be"not capable"of performing the essential functions of the job. Since the.Company seeks to make employment decisions based on the best available objective medical evidence; candidates who receive a"not capable"result or who are unable to complete the test should provide the Company with any additional information they believe the Company should consider in evaluating the conditional offer.of employment. DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 8. Absent receipt of additional information that persuades the Company that an candidate can safely L perform the essential functions of the position sought, the Company will not place candidates WwRail o successfully complete the post-offer/pre-placement functional employment test. If the candidate provides the Company with information documenting a disability, the Company will analyze the medical and functional data i relating to the candidate's functional abilities, limitations and work restrictions as such relate to the candidate's capability to perform essential job functions, with or without a reasonable accommodation. If the Company determines that the candidate is not qualified to perform the essential job functions with or without a reasonable accommodation or the candidate would pose a direct threat to the health and safety of the candidate or others, which threat cannot be reduced to an acceptable level with a reasonable accommodation, the Company will withdraw the conditional offer of employment. Additional Points: The cost of post-offer/pre-placement employment test procedures are paid by the company. Medical information collected in connection with such tests will be maintained in confidential files in accordance with requirements of the Americans with Disabilities Act(ADA)and the information collected will not be used for any purpose inconsistent with the ADA, The Company is an equal opportunity employer and does not discriminate against individuals on the basis of race,color,age, ( religion,gender,national origin,disability,or any other basis protected by federal,state or local law. { Nothing in this policy is intended to be, and should not be construed as, a contract for any particular term or condition of employment. Unless otherwise set forth in a written agreement signed by the candidate/employee and the Company, individuals are employed"at will." This means that the Company and the candidate/employee can terminate the employment relationship at any time, with or without cause or notice. If you believe you are employed on something other than an "at will" basis, you should advise the Company of such belief in writing. Failure to do so will be deemed by the Company as a i further indication that you and the Company agree that the employment relationship is"at will." Acknowledgment. I have read the above policy and understand that if offered employment it will be conditioned on the successful completion of a post-offer/pre-placement functional employment examination. I hereby agree to comply with the above procedure and request that my application for employment be processed pursuant to this policy. c i Signature of Employee/Date Company Representative/Date Disclaimer: This is a sample. State law, or changes in federal law,may cause gray areas that could increase liability. Consulting an employment lacy attorney is recontmeuded prior to policy implementation. 1 is i r I ii I j C i i DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 F i CONFIDENTIAL I G Schedulin, Candidates for 'Testiri E 1) Call your WorkSTPPS° provider and schedule test r r 2) Give all candidates the following two pages: a) Recommendations for testing b) Map to the facility r i DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 4 ® CONFIDENTIAL Authorization for WorkSTEPS Testing and Information for Candidate (to be completed by Employer) C U r E Employee/Candidate's Name Appointment Date/Time Company Name Employee/Candidate's Position • Pre-Offer Agility Testing • Post-Offer Basic Test • Post-Offer Comprehensive Test • Post-Employment/Fit For Duty Test • Upper Quadrant Testing (circle one: UQBasic UQ/Standard UQ/Comprehensive) k h Recommendations For Testing 1. A Photo I.D. is required for all candidates. 2. Wear loose fitting and comfortable clothing. (Preferably shorts) 3. Wear tennis shoes or low top shoes if possible. 4. If you smoke, try to refrain approximately 30 minutes to 1 hour prior to testing. f I' 5. Try to refrain from drinking caffeinated beverages 30 minutes to 1 hour prior to testing. t 6. Try to eat something light approximately 30 minutes to 1 hour prior to testing. 7. Do not drink ANY alcoholic beverages the day of testing. 8. If you have been ill,please notify our staff and we will reschedule you if necessary. t 9. Please notify the employer if you anticipate any accommodation to perform the physical requirements of this test. **A physician's release may be required if you are (or have recently been) under a physician's care for any condition, or if you have had a recent injury or surgery." 10. The test takes approximately two hours. Plan your schedule accordingly. Recomendacion Para La Evaluation I 1. Se requiere que tomames un foto de todos aplicantes. 2. Usar ropa comoda y flexible. 3. Usar zapatos de tacon bajo o tenis Para ejercicios. 4. Si fuma trate de no fumar 30 minutos a una (1) hora antes de la evaluaeion. 5. No tomar bebidas con cafeina 30 minutos a una (1) horas antes de la evaluaeion. 6. Tratarde comer LIVIANO 30 minutos a una(1) hora antes de la evaluaeion. 7. No tomar bebidas alcholicas el dia de la evaluaeion. 8. Si ha estado enfermo, (o esta enfermo) favor notificar la oficina para posponer la cita. 9. Por favor de notificar el patron si es necesarro de acomodacion para hater condiciones de este examen. 10. Aga planes para el examen que dure dos horas. h I DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 E CONFIOENTIAL Communicating the Test Results to the Employer Upon completion of the WorkSTEPS°Employment Testing process,the test administrator("Provider') should contact the authorized"Company"representative and convey the results of the test in the agreed upon mariner.WorkSTEPS recommends that results be conveyed via the "WorkSTEPS®Evaluation Summary: Qualification Report". Test results are NOT typically given directly to the test candidate by the Provider. Since the"Company"is the entity that extended the offer of employment (or is the employer,in post-employment testing scenarios), it is ultimately the responsibility of the "Company"to review the results, make the final placement or return to work decision, and notify the candidate (or I employee) of that decision. The EEOC's Technical Assistance Manual for the ADA Section 6.4,P. VI-9, addresses the role of the physician(or any health care providers administering medical tests for an employer),in the employment process as follows: "A doctor who conducts medical examinations for an employer should not be responsible for rriakina employment decisions or deciding whether or not it is possible to make a reasonable accommodation for a person with a disability. That responsibility lies with the employer." Following are the various results generated by the.WorkSTEPS°Employment Testing software and based upon information about the essential functions obtained through objective job analysis and input from the employer, and a brief explanation of each: L "Capable.": Candidate (or employee) is capable of performing essential functions of the job without safety concerns In this situation,the individual performed all the job-related functions and no medical or physical safety- related concerns were raised during the test. The "Provider" should advise the Company of the results. In all likelihood, the employer will place the,candidate in this situation. XL "Not Capable of Perforinink the essential fu �ictions of the position sought but does not have arty present or past medical condition/impatrment that we believe would pose a significant risk to himMerself or others should he/she be placed in the position sought" In this situation, the individual was not able to perform all essential job functions or meet the dynamic lifting qualifying criteria; but the test did not identify any significant medical risk issues or a contributing medical condition/impairment. The reason for the. candidate's inability to meet the criteria is likely a strength issue, whereby they lack the essential strength to safely perform the physical demands of the job. The specific criteria that was not met should .be listed on the WorkSTEPS" Evaluation Summary under the heading "Not Capable for the following reasons:" Here, Work-STEPS° recommends that the provider advise the employer to consider holding the decision in abeyance for a time period they feel would be reasonable. During this period,the.employer should give the individual an opportunity to submit evidence to dispute the test findings and/or to request any reasonable accommodations that might enable him/her to safely 'and successfully perform the position sought. The provider should offer to remain available to assist the employer if further testing or evaluation is needed. If the individual provides information during the stated period, the employer should consider the information in its overall.assessment as to whether the candidate is qualified for the position sought. If the individual does not provide any additional information during the allotted time period, presumably the employer would confirm that the offer has been rescinded based oil the information obtained through the WorkSTEPS°test. DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 CONFUNT, 1. III"Not Capable — Impairment to Essential Function(s): Not Capable of performing the s essential functions of the positions sought, but the candidate does have a present or past medical condition or impairment that we believe is contributing to their functional deficit. Such a result may trigger- a reasonable accommodation consideration/obligation by the employer under the ADAAA or similar federal, state or local laws. When the individual has a known medical condition/impairment that is contributing to their loss of function, resulting in an inability to perform the physical demands of the job, the employer may be obligated (under ADA Amendment Act) to engage in an interactive process to determine if the candidate's condition is raised to a level of disability, and if so, explore reasonable accommodations. WorkSTEPS®recommends that the provider advise the employer to hold their placement decision in abeyance for a time period they feel would be reasonable. During this period, the employer should give the individual an opportunity to submit evidence to dispute the test findings and/or to request any reasonable accommodations that might enable him/her to safely and successfully perform the position F sought (essentially,this is now handled in the same manner as the medical risk protocol). However, the employer may not be able to retain the position due to work demands. The provider should offer to remain available to assist the employer if further testing or evaluation is F needed. If the candidate provides information during the abeyance period and the position or a similar position becomes available, the employer should consider the information in its overall assessment as to whether the candidate is qualified for the position sought. If the candidate does not provide any additional information during the abeyance period,presumably the employer would confirm that the offer has been rescinded based on the information obtained through the WorkSTEPS" test. IV. Not Capable—Medical Risk.Not Capable of performing the essential functions of the job because candidate does have a present or past medical condition/impairment that we believe f should pose a significant risk to him/lierself or others should he/she be placed in the position sought."- Here, the test indicates that the individual has the present ability to perform the position sought but cannot do so safely. There is a specific reporting protocol that the WorkSTEPS°Provider must follow. The Provider should document the clinical findings AND the job demands that place the candidate at risk in the"Basis for Conclusion",and should also provide the employer with the "Physician Consent to Work with a Medical Condition". The question the employer must consider is whether the safety concern rises to a"direct threat". Currently, the U.S. Equal Employment Opportunity Commission defines "direct threat" as a significant risk of substantial harm that cannot be eliminated or reduced through reasonable accommodation. The determination of whether a direct threat exists should be based on objective medical evidence and/or the most current medical knowledge and should consider a number of factors, including: • duration of risk • nature/severity of potential harm • likelihood potential harm will occur • inuninence of potential harm r The WorkSTEPS°test is designed to assist employers in making an individualized assessment consistent with these principles. DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 CONFIDENTIAL (Medical Risk, continued) The provider should explore the following situations and determine whether a direct threat exists: o When testing discloses a history of or the preseaco.of serious injury(ies)that would-be impacted by the performance of essential job functions. e When testing discloses a history of or presence of medical conditions that increase the likelihood of injury or illnesses through the performance of essential job functions. ' Here again,WorkSTEPS°recommends that the provider advise the employer to consider holding the decision in abeyance for a reasonable period of time. During this time,the employer should give the individual an opportunity to submit evidence (a second medical opinion,provided at the expense of the candidate)to dispute the test findings and/or to request any.reasonable accommodations that might enable him/her to safely and successfully perform the position sought. However,the employer may not be able to retain the position due to.work demands. The provider should offer to remain available to assist the employer if further testing or evaluation is needed. If the candidate provides information during the abeyance period and the position or a sirrilar position becomes available, the employer should consider the information in its overall assessment as to whether the candidate is qualified for the position sought. If the candidate does not provide any additional information during the abeyance period;presumably the employer would confirm that the offer has been rescinded based on the information obtained through the WorkSTEPSO test. IV. "Refer for-Additional Medical Clearance" (U pper.Quadrant Formats) WorkSTEPS©Upper Quadrant/Carpal Tunnel Evaluation software is designed to identify existing signs and symptoms of the hands and upper extremities that may indicate significant neurological and/or neuromusculat problems that present a significant risk of injury if the client is placed into a position that involves repetitive use of the upper�extremities. The result for an Upper Quadrant/Carpal Tunnel Basic 'Pest(no physical demand requirements identified) will no longer include the language"Not Capable".If the results indicate"Refer.for Additional Medical Clearance",then the provider should recommend that the employer consider holding the decision in abeyance for'a period of time(days). During this time, the employer should give the individual ari opportunity to seek additional medical clearance from the physician of their choice.The employer may specify that the physician be a specialist with direct knowledge of the affected area. The candidate should submit the additional information/medical clearance to the employer for review,and the employer should make their final placement decision based upon the best, objective medical evidence, considering whether or not the individual will be able to safely and successfully perform the position sought. N DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 Fit for Duty/Return to Work Information CONFIDENTIAL Following is additional information regarding Post-Employment Fit for Duty Testing and Return to Work E In the EEOC's Enforcement Guidance: Disability Related Inquiries and Medical Examinations of F Employees Under the Americans with Disabilities Act(2000),pages 7-16, the EEOC sets forth situations when a medical examination of an employee may be "job related and consistent with business necessity" as follows: f • when the employer observes reliable, objective evidence of current performance C problems indicting that the employee may not be able to perform essential job functions or may pose a direct threat to the health and safety of the employee or others because of a medical condition; • when an employer has a "reasonable belief that an employee's ability to perform essential job functions will be impaired by a medical condition or that s/he will pose a direct threat due to a medical condition" (must be based on objective evidence); B • when an employee seeks to return to work after being on leave for a medical reason if the employer"has a reasonable belief that an employee's present ability to perform essential job functions will be impaired by a medical condition or that s/he will pose a direct threat due to a medical condition" (employer's covered by h the federal Family and Medical Leave Act and any state medical leave laws should be aware of possible conflicting obligations); i • when an employee requests a reasonable accommodation; • when the employer requires periodic testing and monitoring of employees in positions affecting public safety; • when an employer requests medical examinations required by federal law or j regulation; and • when an employee voluntarily participates in a wellness program(examples include cancer detection, screening for high blood pressure, etc.) in NOTE TO EMPLOYERS: Post-Employment/Fit for Duty testing is rarely used to say an employee is �f not capable" of performing a job, and should never by used by the employer to terminate an employee without extreme caution and the appropriate due process necessary to prove that, given every opportunity, the employee could not be expected to adequately and safely perform the job or be given a reasonable accommodation to do so. This information is intended strictly for educational purposes for WorkSTEPS providers.This should not be considered legal advice,and the employer should consult counsel of their own choosing to determine how this information applies to individual circumstances. I DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 Physical Fitness and.Agility Testing for Existing, Uninjured W E TI L In accordance with EEOC Enforcement Guidelines, employers may not require "medical exams or inquiries" for existing employees unless such exams are "job related and consistent with business necessity", or in certain instances if the employment position directly impacts public health and safety. However, "physical fitness and physical agility tests" are not considered medical exams and it is permissible for an employer to require annual physical fitness and agility tests that focus on job related physical performance parameters.Baseline musculoskeletal evaluations are not performed in such tests. e Post employment physical fitness and agility tests of existing, uninjured employees.are a dministered to determine.an employee's ability to continue to successfully perforin the essential functions of their jobs. Physical fitness and agility tests should be customized to look at essential motion, strength, and job specific capabilities required to perform the essential functions of the job. Again, routine medical measurements and tests may not be performed in this test protocol, However, if a job related functional deficit is identified, testing may be expanded to include medical measures of the affected area for the sole purpose of determin=ing whether or not the employee can safely perform the essential functions of their specific job and/or to devise a positive intervention strategy to insure their continued safety in doing so. ° does not give a "Not Capable"-result for post- employment WorkSTEPS software version of the g p p The newest v. employment physical fitness and agility tests. The provider should always know to enter their comments regarding wellness intervention strategies, work conditioning,, recommended modifications, accommodations and/or expected follow up in the Employer Notes section of the WorkSTEPS° test booklet, and to. contact the employer to discuss the fact that any deficits identified should not mean "termination." Testing Existing Workers upon Transfer: The EEOC defines a very narrow scope of medical information that may be collected when assessing an existing, uninjured employee regarding the performance of their CURRENT job. However, it expressly ALLOWS medical inquiries and medical tests to be performed to existing employees who are moving to a different job classification in the same company. The "EEOC Enforcement Guidance: Disability-Related Inquiries and Medical Exanunations of Employees under the..ADA" states that an employer should treat an employee who applies for a new position as a job applicant. Once an offer of employment is made to that individual, the employer may "ask the individual disability-related questions or require a medical examination as long as it does so for all entering employees in the same job .category". The full, post-offer comprehensive test may be administered at this post offer stage. Examples given by the EEOC in which the employee may not,be tested as a '!'post offer candidate" when transferring positions are as follows: 1. The individual is noncompetitively entitled to the other position, because of seniority or satisfactory performance in the current position, 2. The individual is changing positions temporarily, but will be returning to their regular job. Although it is not specifically addressed in the Guidance, WorkSTEPS recommends that the employer refrain from hiring someone into the transferring employee's previous position until it has been determined that the employee can successfully meet the demands of the newly offered position. If the current employee did not meet the demands of the new position, the offer could be withdrawn, and the employee could be returned to their formex position without penalty or termination. This infonnation is intended strictly for educational purposes for WbrkSTEPS providers.This should not be considered legal advice,and the employer should consult counsel of their own choosing to determine how this iiifornaation applies to individual circumstances. DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 Post Injury Fit for Duty Testing CONFIDENTIAL Post employment testing of existing employees who have been injured is administered to determine an employee's ability to continue to safely perform the essential functions of their job. Tests must be job related and consistent with business necessity. This means Post Injury Fit for Duty tests may be customized to look at essential motion, strength, and job specific capabilities but should only focus on job-related medical conditions -- those conditions that may reasonably be viewed as affecting an employee's continued ability to safely perform the essential functions of the job. To ensure the scope of the functional testing is job related, the provider should perform only the portions of the musculoskeletal evaluation that correlate to the area of injury/symptoms. Similarly, dynamic lifting should only be performed in postures necessary to evaluate the injury/symptoms that might implicate safe performance of essential job functions and progressed only to the point of the individual's best safe effort or to the criteria established for the position—not beyond. Post employment testing for injured employees is rarely used to say an employee is "not capable" of performing a job, and should never be used by the WorkSTEPS° provider and/or the employer to terminate an employee from the work force. Employers also should enter into a dialogue with the employee to determine whether the employee could demonstrate the ability to safely perform the essential functions of the job and/or to determine that the employee, given a reasonable accommodation, could safely return to work and perform the job. The newest version of the WorkSTEPS© software does not give a "Capable/Not Capable" result for post-employment tests. The provider should identify any deficits and perform any additional essential function tasks necessary to identify the employee's capabilities. The provider also should always know to enter their comments regarding modifications, accommodations and/or expected follow-up in the Employer Notes section of the WorkSTEPS a test booklet and to contact the employer to discuss that any deficits identified do not necessarily mean "immediate termination". This information is intended strictly for educational purposes foa-WorkSTEPS providers. This should not be considered legal advice,and the employer should consult counsel of their own choosing to determine how this information applies to individual circumstances. DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 Sample—Policy Regarding CONFIDENTIA Post Employment Tests L NOTE: Thus policy is a sample policy provided by WorkSTEPS and must be tailored to fit your company's individual situation. It is imperative that leg P al counsel be consulted so your post- employment testing policy can be coordinated and integrated into your existing policies. Post Employment examinations are successful tools utilized to create a more safe and secure working environment-for employees. With the advent of sports technology applied to the industrial worker;Comprehensive stress tests monitor heart and rnusculoskeletal function to detect disease processes, wear and tear syndromes, and many other problems that lead to injuries and disability. Computerized testing and stres's evaluations by licensed professionals in a medical setting typically cost over one thousand dollars,but (Company)is willing to pay for such services to help their employees remain safe in the workplace and to reduce costs associated with injuries. Training provided during the examinations increases body awareness during work activities to prevent cumulative trauma and to successfully reduce injuries. Furthermore,employee turnover and operating expenses are reduced by maintaining properly qualified personnel in each position. Poli;c Post employment tests may be conducted;. 1) as part of employee's participation in a voluntary wellness-program; 2) to determine an employee's fitness for duty;or 3)in response to an employee's request for reasonable accommodation. Voluntary Testing. Effective. (Date),all persons employed by (Company)in the positions listed below will be e)igible to participate in voluntary testing once every Csix%twelv0I months. Employees are not required to participate in such testing and employees who elect not to participate will not be penalized for failing to participate. Fitness:forDuty Testing: Fit for duty testis may also be required on an as needed basis should employee demonstrate difficulty performing any Fi y g Y q essential function of their positions or there is some other reasonable basis for believing that an individual's ability to perform essential job functions is limited or impaired by a medical condition. Fit for duty testing may also be conducted when an employee returns from a medical leave of absence and the company has a reasonable basis to believe that the employee's medical condition will prevent the employee frorn performing essential job functions or will pose a "direct threat to the health and safety of the employee or others. NOTE: Employers"should consult legal counsel before testing employees returning from an FMLA covered medical leave of absence or a leave covered under a state medical leave law to ensure compliance with all applicable federal and state laws. Testing Xn Response to Requests for Reasonable Accommodation: Post employment testing might also be required when an employee requests a reasonable accommodation for a medical condition that is not known'or obvious. The cost of all post employment test procedures are paid by the Company. Medical information collected in connection with such tests will be maintained in confidential files in accordance with requirements of the Americans with Disabilities Act (ADA)and the information collected will not be used for any purpose inconsistent with the ADA. When necessary to enable an otherwise qualified candidate with a "disability" to participate in testing, the Company will provide reasonable accommodations provided such accommodations do not cause an undo hardship. Candidates who believe they need an accommodation to participate in the testing program,must request such accommodations.To minimize or avoid delays in testing, the Company asks candidates to advise the Company of the need for any accommodation as soon as possible.Thank you for you attention to these matters. Management Disclaimer: This is a sample. .State law, or changes in federal law, may cause gray areas that could increase liability. Consulting an employment law attorney is recommended prior to policy implementation, DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 ADAAA/Reasonable Accommodation Resources for Employers CONFIDENTIAL The following questions &answers are taken from the EEOC Enforcement Guidance: Reasonable Accommodation and Undue Hardship under the ADA: f (http://eeoc goy/policy/docs/accomrnodation.html#requestin�) i 1. Do requests for reasonable accommodation need to be in writing? No. Requests for reasonable accommodation do not need to be in writing. Individuals may request accommodations in conversation or may use any other mode of communication.u2-lAn employer may choose to write a memorandum or letter confirming the individual's request. Alternatively, an employer may ask the individual to fill out a form or submit the request in written form, but the employer cannot Ignore the initial request. An employer also may request reasonable documentation that the individual has an ADA disability and needs a reasonable accommodation. (See Question 4). 2. When should an individual with a disability request a reasonable accommodation? An individual with a disability may request a reasonable accommodation at any time during the application process or during the period of employment. The ADA does not preclude an employee with a disability from requesting a reasonable accommodation because s/he did not ask for one when applying for a job or after receiving a job offer. Rather, an individual with a disability should request a reasonable accommodation when s/he knows that there is a workplace barrier that is preventing him/her, due to a disability, from effectively competing for a position, performing a job, or gaining equal access to a benefit of employment. 23 As a practical matter, it may be in an employee's interest to request a reasonable accommodation before performance suffers or conduct problems occur. 3. What must an employer do after receiving a request for reasonable accommodation? The employer and the individual with a disability should engage in an informal process to clarify what the individual needs and identify the appropriate reasonable accommodation. The employer may ask the individual relevant questions that will enable it to make an informed decision about the request. This includes asking what type of reasonable accommodation is needed. zs The exact nature of the dialogue will vary. In many instances, both the disability and the type of accommodation required will be obvious, and thus there may be little or no need to engage in any discussion. In other situations, the employer may need to ask questions concerning the nature of the disability and the individual's functional limitations In order to identify an effective accommodation. While the individual with a disability does not have to be able to specify the precise accommodation, s/he does need to describe the problems posed by the workplace barrier. Additionally, suggestions from the individual with a disability may assist the employer in determining the type of reasonable accommodation to provide. Where the individual or the employer are not familiar with possible accommodations, there are extensive public and private resources to help the employer identify reasonable accommodations once the specific limitations and workplace barriers have been ascertained. 2e 4. May an employer ask an individual for documentation when the individual requests reasonable accommodation? Yes. When the disability and/or the need for accommodation is not obvious, the employer may ask the individual for reasonable documentation about his/her disability and functional limitations. L2zl The employer is entitled to know that the individual has a covered disability for which s/he needs a reasonable accommodation. DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 6 Reasonable documentation means that the employer may require only the docu s needed to establish that a person has an ADA disability, and that the disability n1faMITIAL reasonable accommodation. Thus, an employer, In response to a request for reasonable accommodation, cannot ask for documentation that is unrelated to determi,n.ing the existence of a disability and the necessity for an accommodation. This means that in most situations an employer cannot request a person's complete.medical records because they are likely to contain information unrelated to the disability at issue and the need for accommodation. If an individual .has more than one disability, an employer can I request information pertaining only to the disability that requires a reasonable accommodation. i An employer may require that the documentation about the disability and the functional limitations come from an appropriate health care or rehabilitation professional. The appropriate z professional in any particular situation will depend on the disability and the type of functional E limitation it imposes. Appropriate professionals include, but are not limited to., doctors (including psychiatrists), psychologists, nurses, physical therapists, occupational therapists, speech therapists, Vocational rehabilitation specialists, and licensed mental health professionals. In requesting documentation, employers should specify what types of information they are seeking regarding the disability, its functional limitations, and the need for reasonable l accommodation. The individual can be asked to sign a limited release allowing the employer to P submit a list of specific questions to the health care or vocational professional." As an alternative to requesting documentation, an employer may simply discuss with the person the nature of his/her disability and functional limitations. It would be useful for the employer to make clear'to the individual why it is requesting information, i.e., to verify the existence of an ADA disability and the need for a reasonable accommodation. i F. i r i h i' L. DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 CONFIDENTIAL EMPLOYERS' REQUEST FOR MEDICAL INFORMATION TO SUPPORT EMPLOYEE'S REQUEST FOR REASONABLE ACCOMMODATION' Dear Physician: Our employee, ,has informed us that(s)he has a physical or mental impairment, condition, or disease and that (s)he needs the company to reasonably accommodate him/her so that(s)he can perforrn the essential functions of his/her job. We are including a copy of[NAME OF EMPLOYEE]'s written request for reasonable accommodation. [NAME OF EMPLOYEE] also has authorized the company to obtain medical information from your office in support of his/her request for reasonable accommodation. We also are including a copy of[NAME OF EMPLOYEE'S] authorization for release of medical information. t [NAME OF EMPLOYEE] holds the position of[POSITION]. The essential functions of the position are [OPTION: (1)LIST ESSENTIAL FUNCTIONS; OR"listed in the attached job description."]. I [NAME OF COMPANY] appreciates your office's cooperation and assistance in our evaluation of[NAME OF EMPLOYEE'S] request for reasonable accommodation. Please return this document to us by mail at [ADDRESS], confidential fax at [CONFIDENTIAL FAX NUMBER], or electronic correspondence in PDF form at [EMAIL ADDRESS]. If your office has any questions about this form, we may be reached at [NAME, POSITION,AND PHONE I NUMBER]. 1. Does the employee have a health condition/disability that results in a physical or mental impairment that limits one or more"major life activities"? Major life activities include by are not limited to breathing, walking, hearing, seeing, working, and reproduction. Yes No E 2. If the answer to Question 1 is "yes",please describe the employee's current health condition/disability. E �r 3. Please provide date condition/disability commenced. What is estimated duration of condition/disability? I f k i` i 'NOTE TO EMPLOYER:This form must be kept in a separate file that is not part of the personnel file. DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 ii CONFIDENTIAL 4. Please describe the functional limitations and the"major life activity" or activities affected. 4 a 5. Please indicate your professional opinion as follows: The employee should be able to perform the essential job functions WITHOUT any accommodations. The employee is not able to perform the essential job functions and a reasonable accommodation is not advised/feasible. The employee should be able to perform the essential job functions WITH reasonable accommodations. Based on your professional opinion, Please provide the specific accommodations recommended for consideration by the Company f G r 6. If appropriate, please indicate any actions necessary for the protection of the health and safety of the employee and other employees and any special instructions for first- u aid providers and supervisors.. Health Care Provider(Print) Address Area of Medical Specialty Phone Number Signature 107353A DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 NFL TILL r REASONABLE ACCOMMODATION AND INTERACTIVE PROCESS DOCUMENTATION FORM' E G 1. Name of individual requesting reasonable accommodation: I=. f 2. Dates of communications with individual regarding types of reasonable accommodation. Please list types of communication (email, letter,meeting) and other individuals present,if any. 3. Type(s) of reasonable accommodation requested: 4. If individual and company were able to agree on a reasonable accommodation, please identify the reasonable accommodations agreed to: f 5. If request for reasonable accommodation denied, please identify the reason (may check more than one box).2 • Accommodation ineffective . • Accommodation would cause undue hardship • Medical documentation inadequate • Accommodation would require removal of an essential function • Accommodation would require lowering of performance or production standard ❑ Other(please identify): f I G 6. Detailed reason(s) for the denial of reasonable accommodation (must be specific, e.g. why accommodation is ineffective or causes undue hardship): r 'NOTE TO EMPLOYER: The purpose of this form is to provider documentation that the employer engaged in the interactive process. ''The decision to deny reasonable accommodation is fraught with peril. We strongly recommend that an employer �.. consult with legal counsel before determining that it cannot reasonably accommodate an employee's disability. We also strongly recommend that legal counsel review this form(and particularly questions 5 and 6)before it is finalized if an employer decides to deny reasonable accommodation. i. is DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 t i t CONFIDENTIAL 4 I 7. If the individual proposed one type of reasonable accommodation that is being denied,but rejected an offer of a different type of reasonable accommodation, explain both.the reasons for denial of the requested accommodation and why you believe the chosen accommodation would be effective. g. If accommodation is being denied, please identify the resources. consulted/reviewed in.making the determination to deny reasonable accommodation(e.g.medical records,Job Accommodation Network (www Jan.wvu,edu). i 9. If accommodation is being denied,please identify all individuals who participated in-the decision to deny accommodation. i Name and Position Signature Date 107354M DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 CONFIDENTIAL i k AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION PURSUANT TO REQUEST i FOR REASONABLE ACCOMMODATION r f Name of License Physician or Practitioner Licensed Physician Phone(OPTIONAL) Name of Office,Clinic,Hospital,etc. Medical Number Street Address Requestor's Social Security Number City,State,Zip Requestor's Birth Date i TO: Any licensed physician,other licensed practitioner,hospital,clinic or other Medically-related facility,or United States Veterans Administration that there is in the possession of medical records pertaining to: NAME OF EMPLOYEE: (Please Print) I have requested that my employer, , grant me reasonable E accommodation due to my diagnosed physical or mental impairment of: i I authorize you to copy and transmit to the Reasonable Accommodation Coordinator of the Department of General Services all records concerning the above-referenced impairment and to answer any questions related to this condition. A copy of my request for reasonable accommodation is i attached to this release. The authorization shall be valid for a period of 180 days after the date of my signature or earlier if revoked by me in writing to the Reasonable Accommodation Coordinator. k I hereby acknowledge I have been informed of my right to receive a copy of this i authorization upon request. I further acknowledge I have been informed if the medical information covered herein is not release, my request for accommodation may be denied. r i Signature Date 107351.vl E is DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 CONFIDENTIAL Family Medical heave Act Resources (Dept, of Labor— dol.gov) http://www.dol.gov/w-hd/fmla/ : Compliance Assistance-FMLA hLtp://www,dol.gov/whd/fnilaifinalrale/factshect.p ; Fact Sheet on the Final Rule Common Forms: http://www.dol.gov/whd/f"oi-n-isfWH-381..pd : Notice of Eligibility and Rights &Responsibilities hLtp://www.dol.gov/whd/f"orms/WH-380-E.pd-f: Certification of Health Care Provider for Employee's Serious Health Condition hLtp://www.dol.gov/whd/forms/WHr380-F.pdf: Certification of Health Care Provider for Family Member's Serious Health Condition http://www.dol.gov/whd/forms/WH-382.pdf: Designation Notice DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6ElA4FD76 CONFIDENTIAL l t t ii �i A"Seri ous Health Condition"means an illness,injury Impairment,or physical or mental condition that involves one of the following: i 1. Hospital Care Inpatient care(i.e.,an overnight stay)In a hospital,hospice,orresidential medical carefacility,Including any period of Incapacity?or subsequent treatment in connection with or consequent to such Inpatient care. !_ i t 2. kbsencePlusTreatment (a) Aperiod Of Incapacity?ofmore than three consecutive calendar days(Including any subsequent treatment or period of IncapacIty2 relating to the same condition),that also involves: (1) Treatments two or more times by a health care provider,by a nurse or physician's assistant under direct supervision of a healthcare provider,or by a provider of healthcare services(e.g.,physical therapist) s under orders of,or on referral by,a health care provider;or (2) Treatment by a healthcare provideron at least one occasion which results in a regimen of continuing { treatment4 under the supervision of the health care provider, 3, Pregnancy Any period Of Incapacity due to pregnancy,or for prenatal care. t 4, ChronicConditivnsRegyirLgTreatments A chronic condition which: (1) Requires periodic visits for treatment by a healthcare provider,or by a nurse or physician's assistant under direct supervision of health care provider; (2) Continues overan extended period of time(Including recurring episodes of a single underlying condition); r and (3) May cause episodic rather than a continuing period of incapacity2(e.g.,asthma,diabetes,epilepsy,etc.). 5, )?grmanenliLong-term Conditions Reguir)gg&perylsl gn A period of Incapacity2 which is permanent or tong-term due to a condition for which treatment may not be effective,The employee orfamily membermust be underthe continuing supervision of,but need not be receiving active treatment by,a health care provider, Examples include Mzhelmees,a severe stroke,or the terminal stages of a disease. 6, Mulkiole Treatments(Nan-Chronic Conditions) Any period of absence to receive multiple treatments(including any period of recovery therefrom)by a health care provider or by a provider of health care services under orders of,or an referral by,a health care provider,either for restorative surgery after an accident or other Injury,or for a condition that would likely result in a period c f Incapacity? of more than three consecutive calendar days in the absence of medical Intervention or treatment,such as cancer (chemotherapy,radiation,etc,),severe arthritis(physical therapy),and kidney disease(dialysis). This optional form may be used by employees to satisfy a mandatory requirement to furnish a medical certification(when requested)from a health care provider,including second or third opinions and recertification(23 CPR 825.306). Note;Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. 3 Treatment includes amminaitons to dalarmina Ifaaadoue health condition exists and evaluallons of the condition.Treatment dons not include routine physical examinations,eye examinations,ordental examinations, A A regimen nfcontinuing treatmentindudes,forexample,a course afproscripton medication(a.g.,an antiblotic)or therapy requiring special equipment to resolve or alleviate the health condition.A regimen of treatment does not Include the taking of over-the-counter medications such as aspidn, antihistamines,or anivan;or bad-rest,ddnldng fluids,ammise,and tither similar aotvities that can be initialed vAthout a vislt to a health care pmvldar. Public Burden Statement We estimate that it will take an average of 20 minutes to complete this collection of information,Including the lime for reviewing instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection of Information,including suggestions for reducing this burden,send them to the Administrator,Wage and Hour Division,Department of Labor,Room S-3502,200 Constitution Avenue,NN,Washington,D.C.20210. DO NOT SEND THE COMPLETED FORM TO THiS OFFICE,IT GOES TO THE EMPLOYEE, Non 4aril ll.S ePO:�O6D4e1854r7S505 DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 CONFIDENTIAL What to do if... 1. A candidate is injured during testing 2. An employer wants to get an RME (Required Medical Examination) DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 CONFIDENTIAL Notice to Employer Should a Candidate Be Injured During Testing The ADA allows an employer to ask a post offer candidate to demonstrate their ability to perform the functions of their job with or without an accommodation. Just as there is some risk of injury performing a job, the worker may face some risk of injury, albeit minimal, during the employment test. WorkSTEPS® and its certified medical providers utilize recognized medical standards and established job simulation parameters to provide a controlled safe environment under direct supervision that BEST qualifies the individual to safely perform their job functions. It is ultimately the responsibility of the local, licensed medical practitioner to ensure their personnel understand and follow the WorkSTEPS® protocols, be aware of any particular precautions, and make every effort to insure maximum safety during testing on an individual basis. Over 1,000,000 tests have been performed since 1986 with very few soft tissue injury claims, and most of them were able to return and complete testing within a couple of days. WorkSTEPS° believes that anyone who could possibly suffer an injury during testing in a controlled medical environment would likely have been injured soon after starting work. To the contrary, historical data confirms that by implementing WorkSTEPS® post offer employment tests, literally thousands of injuries have been prevented by matching employees' capabilities specifically to the physical demands of their job. Neither WorkSTEPS®, nor the independent medical provider network that administers the test, would ever want anyone to be hurt. WorkSTEPS° specifically instructs the providers as well as the candidates on precautions to avoid injury, and helps candidates understand how to work within their own safe limitations. In the state of Texas, an employee is hired at the post-offer stage contingent upon passing the employment test and / or a drug test. Thus, if injured during an employment test, the injury f would likely not be compensable under the Texas Workers' Compensation System. In other states, the employee is considered employed at the post offer stage and the injury may be compensable. You need to be aware of your Sate law and its relevance to this issue. Should an injury claim be made, the employer should contact the local medical provider who performed the WorkSTEPS°test. That provider should then notify WorkSTEPS°corporate office. I DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 CONFIDENTIAL REQUIRED ME.DI AL EXAMINATION (RME) r When an employee is not being treated by the company physician, and the medical provider doesn't seem to have objective data on the candidate and is essentially rendering cookbook Rx, an RME may well be indicated. If the status of the candidate remains undetermined after a "reasonable" treatment time and the company is concerned about progress; the WorkSTEPS° vendor and employer should agree on a medical provider to evaluate the employee. The i insurance carrier should be contacted and a suggestion made to g et an RME. As a part of the RME, the practitioner should request objective data collection (the Work.$TEPS° Test) to be compared to the pre-injury data. The RME doctor should be familiar with and amenable to this process. Finally, the insurance carrier should do one of the following: 1. If the employee is agreeable, schedule and write a letter to the employee informing them of the appointm.ent: 2. If the employee is not agreeable, the insurance carrier will request an order for an independent medical examination from the Workers' Comp Commission and upon receiving the order from WCC, give a copy of the order to the employee and make an appointment with the doctor for the independent medical examination. This process may vary according to state-worker's compensation guideline& x DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 �..�.� JOBRE-1 OP ID:S1 ACOR/�►� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) �.,..� 03/11/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). I 0 IT PRODUCER NAME: DUPREE&WEBB INC Dupree&Webb,Inc. PHONE F PO Box 6522 WC.No Eat:919-828-3241 A/c N.!919-821-3911 Raleigh,NC 27628-6522 ADDRESS: Adrian B.Bond INSURER S AFFORDING COVERAGE NAIC p INSURER A-.Hartford Casualty Insurance Co _ 29424 INSURED JOB READY SERVICES,LLC INSURER B:Hartford Ins.Co.of Midwest 37478 2300 WESTINGHOUSE BLVD#107 INSURER C.Evanston Insurance Company RALEIGH,INC 27604 INSURER D f INSURER E; INSURER F; COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 1 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS h CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. QTR TYPE OF INSURANCE POLICY NUMBER MMID /YYYY MMID LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000:00 CLAIMS-MADE N OCCUR 22SBAIF7783 03101/2015 03/01/2016 PREMISES Ea occurrence $ 300,00 00 MED EXP(Any one parson) $ i0,00( PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,0 PRO LOC - PRODUCTS-COMP/OPAGG $ 2,000,00 f ❑JECT POLICY HOTHER: AUTOMOBILE LIABILITY EA(EA SINGLE LIMIT $ 1,000,00 A ANY AUTO 22SBAIF7783 03/0112015 0310112016 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS Ix NON-OWNEO PeracddentD GE $ h $ X UMBRELLA X OCCUR EACH OCCURRENCE $ 2,000,00 A EXCESS LIAB CLAIMS-MADE 22SBAIF7783 03101/2015 03/01/2016 AGGREGATE $ 2,000,00 DED X RETENTION WORKERS COMPENSATION X STA UTE ER AND EMPLOYERS'LIABILITY B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 22WBCE03770 03/01/2015 03/01/2016 EL EACH ACCIDENT $ 500,00 OFFICERIMEMBER EXCLUDEDI N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,00 "P describe under 508 00 DE RIPTIO OF PERATIO S below E.L.DISEASE-POLICY LIMIT $ r C PROFESSIONAL LIAR SM906908 03/01/2015 03/01/2016 PER CLAIM 1,000,00 AGGREGATE 3,000,0 I DESCRIPTION OF OPERATIONS/LOCATIONS[VEHICLES(ACORD 101,Additional Remarks Schedule,may be'attached If more space Is required) I k CERTIFICATE HOLDER CANCELLATION JOBREAD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. JOB READY SERVICES LLC 4 2300 WESTINGHOUSE BLVD#107 AUTHORIZED REPRE NT RALEIGH,NC 27604 Adrian B.Bon 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 JOBRE-1 OP ID:SI CERTIFICATE OF LIABILITY INSURANCE DATE 03/1 1 120 1 5 Y) 03/1112015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES F BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. if SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAµ T DUPREE&WEBB INC Dupree&Webb,Inc. PHONE Ext•91 g$28-3241 Arc No:919-821-3911 PO Box 6522 .MAIL Raleigh,NC 27626-6522 ADDRESS: Adrian B.Bond INSURE R($)AFFORDING COVERAGE NAIC# INSURER A:Hartford Casualty Insurance Co 29424 INSURED JOB READY SERVICES,LLC INSURER s;Hartford Ins.Co.of Midwest 37478 2300 WESTINGHOUSE BLVD#107 INSURER C: RALEIGH,NC 27604 INSURER D: INSURER E, INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THE INSURED NAMED ABOVE FOR THE POLICY PERIOD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. AM IN&q TYPE OF INSURANCE POLICY NUMBER MMIDDlYYYY MMIDDNM LIMITS tm A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE a OCCUR 22SBAIP7783 03/01/2015 03/01/2016 PREMISE$(Ea.l currence $ 300,00 MED EXP(Any one person) $ 10,00 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000+00 2,000,00 PRO- PRODUCTS-COMPlOP AGO $ POLICY❑JECT �LOC $ G OTHER: COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Eaaccldent $ 1,0,00'00 22SBAIF7783 03101/2015 03/0112016 BODILY INJURY(Parperson) $ A ANY AUTO BODILY INJURY(Par accident) $ ALL-9 AUTOSULED NON-OWNED (Pe08ERdTnDAMAGE $ HIRED AUTOS X AUTOS $ UMBRELLA LIAR EACH OCCURRENCE $ OCCUR ESS L1A8 AGGREGATE EXC $ CLAWS-MADE DED RETENTION $ WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS'LIABILITY Yt N 22WBCE03770 03/01/2015 03/01/2016 E,L.EACH ACCIDENT $ 600,00 B ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERlMEMBER EXCLUDED? LN NIA E.L.DISEASE-EA EMPLOYE $ 600,00 (Mandatory In NH) 600,00 1( 86 describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more apace is raqulred) E i V; i j'. l' CERTIFICATE HOLDER CANCELLATION k JOBREAD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, JOB READY SERVICES LLC 2300 WESTINGHOUSE BLVD#107 AUTHORIZED REP E TIVI- ""'o RALEIGH,INC 27604 Adrian B. o ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD