HARRIS COUNTY REQUEST FOR PROPOSAL JOB #01/0093 Date Due: Tuesday, April 17, 2001 Cover Sheet DUE NO LATER THAN 1:00 P.M. Proposals received later than the date and time above will not be considered. PROPOSAL FOR: OPERATION of DENTAL FACILITIES for Harris County Hospital District’s Community Health Program OFFERORS NOTE!! Carefully read all instructions, requirements and Please return proposal in the envelope provided or in a specifications. Fill out all forms properly and comparable size envelope. Be sure that return envelope completely. Submit your proposal with all appropriate shows the Job Number, Description and is marked supplements and/or samples. "SEALED PROPOSAL." RETURN PROPOSAL TO: HARRIS COUNTY PURCHASING AGENT 1001 PRESTON AVENUE, SUITE 670 HOUSTON, TEXAS 77002 For additional information, contact Dan Thweatt at 713.755.5982 or Don Wilson at 713.755.5898. You must sign below in INK; failure to sign WILL disqualify the offer. All prices must be typewritten or written in ink. Total Amount of Proposal: $____________________________ Company Name: _________________________________________________________ Company Address: _________________________________________________________ _________________________________________________________ Taxpayer Identification Number (T.I.N.): _____________________________________ Telephone No. ________________ FAX No. ________________ E-Mail: ______________________ Print Name: ____________________________________________________________________ Signature: ______________________________________________________________________ [Your signature attests to your offer to provide the goods and/or services in this proposal according to the published provisions of this Job. When an award letter is issued, it becomes a part of this contract. Contract is not valid until Purchase Order is issued.] Page 1 of 33 TABLE OF CONTENTS Items checked below represent components which comprise this bid/proposal package. If the item IS NOT checked, it is NOT APPLICABLE to this bid/proposal. Offerors are asked to review the package to be sure that all applicable parts are included. If any portion of the package is missing, notify the Purchasing Department immediately. It is the Offeror's responsibility to be thoroughly familiar with all Requirements and Specifications. Be sure you understand the following before you return your bid packet. __X__ 1. Cover Sheet Your company name, address, the total amount of the bid/proposal, and your signature (IN INK) should appear on this page. __X__ 2. Table of Contents This page is the Table of Contents. __X__ 3. General Requirements You should be familiar with all of the General Requirements. __X__ 4. Special Requirements/Instructions This section provides information you must know in order to make an offer properly. __X__ 5. Specifications This section contains the detailed description of the product/service sought by the County. __X__ 6. Pricing/Delivery Information This form is used to solicit exact pricing of goods/services and delivery costs. __X__ 7. Attachments __X__ a. Residence Certification Be sure to complete this form and return with packet. _____ b. Bid Guaranty & Performance Bond Information & Requirements This form applies only to certain bids/proposals. Please read carefully and fill out completely. _____ c. Bid Check Return Authorization Form This form applies only to certain forms. Please read carefully and fill out completely. _____ d. Vehicle Delivery Instructions Included only when purchasing vehicles. __X__ e. Minimum Insurance Requirements Included when applicable (does not supersede "Hold Harmless" section of General Requirements). __X__ f. Workers' Compensation Insurance Coverage Rule 110.110 This requirement is applicable for a building or construction contract. _____ g. Financial Statement When this information is required, you must use this form. _____ h. Reference Sheet __X__ i. Other From time to time other attachments may be included. Revised 09/00 GENERAL REQUIREMENTS Page 2 of 33 FOR PROPOSALS READ THIS ENTIRE DOCUMENT CAREFULLY. FOLLOW ALL INSTRUCTIONS. YOU ARE RESPONSIBLE FOR FULFILLING ALL REQUIREMENTS AND SPECIFICATIONS. BE SURE YOU UNDERSTAND THEM. General Requirements apply to all advertised requests for proposals; however, these may be superseded, whole or in part, by the SPECIAL REQUIREMENTS/INSTRUCTIONS OTHER DATA CONTAINED HEREIN. Review the Table of Contents. Be sure your proposal package is complete. GOVERNING LAW This request for proposals is governed by the competitive bidding requirements of the County Purchasing Act, Texas Local Government Code, §262.021 et seq., as amended. Offerors shall comply with all applicable federal, state and local laws and regulations. Offeror is further advised that these requirements shall be fully governed by the laws of the State of Texas and that Harris County may request and rely on advice, decisions and opinions of the Attorney General of Texas and the County Attorney concerning any portion of these requirements. PROPOSAL COMPLETION Fill out and return to Purchasing, ONE (1) complete proposal form, using the envelope provided. An authorized company representative should sign the Cover Sheet. Completion of these forms is intended to verify that the offeror has submitted the proposal, is familiar with its contents and has submitted the material in accordance with all requirements. PROPOSAL RETURNS Offerors must return all completed proposals to the office of the Harris County Purchasing Agent reception desk at 1001 Preston Avenue, Suite 670, Houston, Texas before 1:00 P.M. on the date specified. Late proposals will not be accepted. GOVERNING FORMS In the event of any conflict between the terms and provisions of these requirements and the specifications, the specifications shall govern. In the event of any conflict of interpretation of any part of this overall document, Harris County's interpretation shall govern. ADDENDA When specifications are revised, the Harris County Purchasing Agent will issue an addendum addressing the nature of the change. Offerors must sign it and include it in the returned proposal package. HOLD HARMLESS AGREEMENT Contractor, the successful offeror, shall indemnify and hold Harris County harmless from all claims for personal injury, death and/or property damage resulting directly or indirectly from contractor's performance. Contractor shall procure and maintain, with respect to the subject matter of this proposal, appropriate insurance coverage including, as a minimum, public liability and property damage with adequate limits to cover contractor's liability as may arise directly or indirectly from work performed under terms of this proposal. Certification of such coverage must be provided to the County upon request. WAIVER OF SUBROGATION Offeror and offeror's insurance carrier waive any and all rights whatsoever with regard to subrogation against Harris County as an indirect party to any suit arising out of personal or property damages resulting from offeror's performance under this agreement. SEVERABILITY If any section, subsection, paragraph, sentence, clause, phrase or word of these requirements or the specifications shall be held invalid, such holding shall not affect the remaining portions of these requirements and the specifications and it is hereby declared that such remaining portions would have been included in these requirements and the specifications as though the invalid portion had been omitted. BONDS If this proposal requires submission of proposal guarantee and performance bond, there will be a separate page explaining those requirements. Offers submitted without the required proposal bond or Cashier's Check are not acceptable. TAXES Page 3 of 33 Harris County is exempt from all federal excise, state and local taxes unless otherwise stated in this document. Harris County claims exemption from all sales and/or use taxes under Texas Tax Code §151.309, as amended. Texas Limited Sales Tax Exemption Certificates will be furnished upon written request to the Harris County Purchasing Agent. FISCAL FUNDING A multi-year lease or lease/purchase arrangement (if requested by the specifications), or any contract continuing as a result of an extension option, must include fiscal funding out. If, for any reason, funds are not appropriated to continue the lease or contract, said lease or contract shall become null and void on the last day of the current appropriation of funds. After expiration of the lease, leased equipment shall be removed by the contractor from the using department without penalty of any kind or form to Harris County. All charges and physical activity related to delivery, installation, removal and redelivery shall be the responsibility of the offeror. PRICING Prices for all goods and/or services shall be negotiated to a firm amount for the duration of this contract or as agreed to in terms of time frame. All prices must be written in ink or typewritten. Where unit pricing and extended pricing differ, unit pricing prevails. SILENCE OF SPECIFICATIONS The apparent silence of specifications as to any detail, or the apparent omission from it of a detailed description concerning any point, shall be regarded as meaning that only the best commercial practice is to prevail and that only material and workmanship of the finest quality are to be used. All interpretations of specifications shall be made on the basis of this statement. The items furnished under this contract shall be new, unused of the latest product in production to commercial trade and shall be of the highest quality as to materials used and workmanship. Manufacturer furnishing these items shall be experienced in design and construction of such items and shall be an established supplier of the item proposed. SUPPLEMENTAL MATERIALS Offerors are responsible for including all pertinent product data in the returned proposal package. Literature, brochures, data sheets, specification information, completed forms requested as part of the proposal package and any other facts which may affect the evaluation and subsequent contract award should be included. Materials such as legal documents and contractual agreements, which the offeror wishes to include as a condition of the proposal, must also be in the returned proposal package. Failure to include all necessary and proper supplemental materials may be cause to reject the entire proposal. MATERIAL SAFETY DATA SHEETS Under the "Hazardous Communication Act", commonly known as the "Texas Right To Know Act", an offeror must provide to the County with each delivery, material safety data sheets which are applicable to hazardous substances defined in the Act. Failure of the offeror to furnish this documentation will be cause to reject any bid applying thereto. EVALUATION Evaluation shall be used as a determinant as to which proposed items or services are the most efficient and/or most economical for the County. It shall be based on all factors which have a bearing on price and performance of the items in the user environment. All proposals are subject to negotiations by the Purchasing Agent and other appropriate departments, with recommendation to Commissioners Court. Compliance with all requirements, delivery and needs of the using department are considerations in evaluating proposals. Pricing is NOT the only criteria for making a recommendation. A preliminary evaluation by Harris County will be held and appropriate proposals will be subjected to the negotiating process. Upon completion of the negotiations, Harris County will make an award. All proposals that have been submitted shall be available and open for public inspection after the contract is awarded except for trade secrets or confidential information contained in the proposals and identified as such. INSPECTIONS Harris County reserves the right to inspect any item(s) or service location for compliance with specifications and requirements and needs of the using department. If an offeror cannot furnish a sample of a proposed item, where applicable, for review, or fails to satisfactorily show an ability to perform, the County can reject the offer as inadequate. TESTING Page 4 of 33 Harris County reserves the right to test equipment, supplies, material and goods proposed for quality, compliance with specifications and ability to meet the needs of the user. Demonstration units must be available for review. Should the goods or services fail to meet requirements and/or be unavailable for evaluation, the offer is subject to rejection. DISQUALIFICATION OF OFFEROR Upon signing this proposal document, an offeror offering to sell supplies, materials, services, or equipment to Harris County certifies that the offeror has not violated the antitrust laws of this state codified in §15.01, et seq., Business & Commerce Code, or the federal antitrust laws, and has not communicated directly or indirectly the offer made to any competitor or any other person engaged in such line of business. Any or all proposals may be rejected if the County believes that collusion exists among the offerors. Proposals in which the prices are obviously unbalanced may be rejected. If multiple proposals are submitted by an offeror and after the proposals are opened, one of the proposals is withdrawn, the result will be that all of the proposals submitted by that offeror will be withdrawn; however, nothing herein prohibits a vendor from submitting multiple offers for different products or services. AWARD Harris County reserves the right to award this contract on the basis of LOWEST AND BEST OFFER in accordance with the laws of the State of Texas, to waive any formality or irregularity, to make awards to more than one offeror, to reject any or all proposals. In the event the lowest dollar offeror meeting specifications is not awarded a contract, the offeror may appear before the Commissioners Court and present evidence concerning his responsibility after officially notifying the Office of the Purchasing Agent of his intent to appear. ASSIGNMENT The successful offeror may not assign, sell or otherwise transfer this contract without written permission of Harris County Commissioners Court. TERM CONTRACTS If the contract is intended to cover a specific time period, the term will be given in the specifications under SCOPE. MAINTENANCE Maintenance required for equipment proposed should be available in Harris County by a manufacturer-authorized maintenance facility. Costs for this service shall be shown on the Pricing/Delivery Information. If Harris County opts to include maintenance, it shall be so stated in the purchase order and said cost will be included. Service will commence only upon expiration of applicable warranties and should be priced accordingly. CONTRACT OBLIGATION Harris County Commissioners Court must award the contract and the County Judge or other person authorized by the Harris County Commissioners Court must sign the contract before it becomes binding on Harris County or the offeror. Department heads are NOT authorized to sign agreements for Harris County. Binding agreements shall remain in effect until all products and/or services covered by this purchase have been satisfactorily delivered and accepted. TITLE TRANSFER Title and Risk of Loss of goods shall not pass to Harris County until Harris County actually receives and takes possession of the goods at the point or points of delivery. Receiving times may vary with the using department. Generally, deliveries may be made between 8:30 a.m. and 4:00 p.m., Monday through Friday. Offerors are advised to consult the using department for instructions. The place of delivery shall be shown under the "Special Requirements/Instructions" section of this proposal and/or on the Purchase Order as a "Deliver To:" address. WARRANTIES Offerors shall furnish all data pertinent to warranties or guarantees which may apply to items in the proposal. Offerors may not limit or exclude any implied warranties. Offeror warrants that product sold to the County shall conform to the standards established by the U.S. Department of Labor under the Occupational Safety and Health Act of 1970. In the event product does not conform to OSHA Standards, where applicable, Harris County may return the product for correction or replacement at the offeror's expense. If offeror fails to make the appropriate correction within a reasonable time, Harris County may correct at the offeror's expense. Page 5 of 33 PURCHASE ORDER AND DELIVERY The successful offeror shall not deliver products or provide services without a Harris County Purchase Order, signed by an authorized agent of the Harris County Purchasing Agent. The fastest, most reasonable delivery time shall be indicated by the offeror in the proper place on the proposal document. Any special information concerning delivery should also be included, on a separate sheet, if necessary. All items shall be shipped F.O.B. INSIDE DELIVERY unless otherwise stated in the specifications. This shall be understood to include bringing merchandise to the appropriate room or place designated by the using department. Every tender or delivery of goods must fully comply with all provisions of these requirements and the specifications including time, delivery and quality. Nonconformance shall constitute a breach which must be rectified prior to expiration of the time for performance. Failure to rectify within the performance period will be considered cause to reject future deliveries and cancellation of the contract by Harris County without prejudice to other remedies provided by law. Where delivery times are critical, Harris County reserves the right to award accordingly. CONTRACT RENEWALS Renewals may be made ONLY by written agreement between Harris County and the offeror. Any price escalations are limited to those stated by the offeror in the original proposal. INVOICES AND PAYMENTS Offerors shall submit an original invoice on each purchase order or purchase release after each delivery, indicating the purchase order number. Invoices must be itemized. Any invoice which cannot be verified by the contract price and/or is otherwise incorrect, will be returned to the offeror for correction. Under term contracts, when multiple deliveries and/or services are required, the offeror may invoice following each delivery and the County will pay on invoice. Contracts providing for a monthly charge will be billed and paid on a monthly basis only. Prior to any and all payments made for good and/or services provided under this contract, the offeror should provide his Taxpayer Identification Number or social security number as applicable. This information must be on file with the Harris County Auditor’s office. Failure to provide this information may result in a delay in payment and/or back-up withholding as required by the Internal Revenue Service. TERMINATION Harris County reserves the right to terminate the contract for default if Seller breaches any of the terms therein, including warranties of offeror or if the offeror becomes insolvent or commits acts of bankruptcy. Such right of termination is in addition to and not in lieu of any other remedies which Harris County may have in law or equity. Default may be construed as, but not limited to, failure to deliver the proper goods and/or services within the proper amount of time, and/or to properly perform any and all services required to Harris County's satisfaction and/or to meet all other obligations and requirements. Harris County may terminate the contract without cause upon thirty (30) days written notice. RECYCLED MATERIALS Harris County encourages the use of products made of recycled materials and shall give preference in purchasing to products made of recycled materials if the products meet applicable specifications as to quantity and quality. Harris County will be the sole judge in determining product preference application. SCANNED OR RE-TYPED RESPONSE If in its response, offeror either electronically scans, re-types, or in some way reproduces the County's published proposal package, then in the event of any conflict between the terms and provisions of the County's published proposal package, or any portion thereof, and the terms and provisions of the response made by offeror, the County's proposal package as published shall control. Furthermore, if an alteration of any kind to the County's published proposal package is only discovered after the contract is executed and is or is not being performed, the contract is subject to immediate cancellation. FLOPPY DISK If offeror obtained the specifications on a floppy disk in order to prepare a response, the proposal must be submitted in hard copy according to the instructions contained in this Request-for-Proposals package. If, in its response, offeror makes any changes whatsoever to the County's published specifications, the County's specifications as published shall control. Furthermore, if an alteration of any kind to the County's published specifications is only discovered after the contract is executed and is or is not being performed, the contract is subject to immediate cancellation. YEAR 2000 COMPLIANCE All products and/or services furnished as part of this contract must be year 2000 compliant. This applies to all computers including hardware and software as well as all other commodities with date sensitive embedded chips. Revised 01/00 Page 6 of 33 SPECIAL REQUIREMENTS/INSTRUCTIONS The following requirements and instructions supersede General Requirements where applicable. the term “Harris County” is understood to include the Harris County Hospital District (District or HCHD). PROPOSAL FOR: OPERATION of DENTAL FACILITIES for Harris County Hospital District’s Community Health Program 1.0 SPECIAL REQUIREMENTS - Vendor Instructions Proposals shall be formatted as follows: All proposals must be typed on standard 8 1/2 x 11 paper, indexed and placed in a binder or folder. One original, clearly marked “original”, and five (5) copies, clearly marked “copy”, must be submitted. The complete proposal should be sealed in an envelope or box for delivery to the Office of the Harris County Purchasing Agent per instructions in the general requirements (see returning the proposal and proposal completion). All documents included in the proposal and the outside of the package must be labeled with the vendor's name and the job number that corresponds to this RFP. Each proposal shall be organized as follows: Section 1: Bid Cover Sheet (completed) and Residency Certificate (completed) Section 2: Pricing Section 3: Any standard agreement(s) and/or contract(s) associated with your response Section 4: Proposer’s listing of references Section 5: Proposer’s Information (License Information, Certifications, etc.) Section 6: Statement of Objectives and Scope as described in subsection 3.3 of this proposal Section 7: “Work Plan and Methodology” as described in subsection 3.4 of this proposal Section 8: “Organization and Staffing” as described in subsection 3.5 of this proposal Section 9: “Budget” as described in subsection 3.6 of this proposal Section 10: “Candidate Profile and Capabilities” as described in subsection 3.7 of this proposal Section 11: “Critical Operational Documents” as described in subsection 3.8 of this porposal The proposal response may be incorporated into any contract, which results from this RFP. Vendors are cautioned not to make claims or statements to which they are not prepared to commit contractually. Failure by the vendor to meet such claims will result in a requirement that the vendor provide resources necessary to meet submitted claims. The vendor is expected to examine all documents, forms, specifications and instructions. Failure to do so will be at vendor’s risk. Page 7 of 33 Harris County will not be liable for any costs incurred by the vendor in preparing a response to this RFP. Vendors submit proposals at their own risk and expense. Harris County makes no guarantee that any product or service will be purchased as a result of this request for proposal, and reserves the right to reject any and all proposals. All proposals and their accompanying documents will become the property of Harris County. All proposals are open to negotiation. All documents will be held by the County and are NOT subject to public review until an award is made. Under the Request for Proposal process, sealed offers will be received and opened in the Office of the Purchasing Agent. At and after opening, proposals will NOT be part of the public record and subject to disclosure, but will be kept confidential until time of award. When such award is completed, proposals will be available for public inspection, including those portions marked confidential and/or proprietary. 2.0 EVALUATION PROCESS All proposals will be examined by an evaluation committee consisting of representatives from various departments and clinics within Harris County Hospital District as well as members from Harris County Purchasing. Members may be added as needed. Proposals which do not conform to the instructions given or which do not address all the questions and/or services specified may be eliminated from consideration. Harris County, however, reserves the right to accept such a proposal if it is determined to be in the County’s best interest to do so. Harris County may initiate discussions with vendors. Proposals will be accepted during this period but only from vendors who responded to the original request. Discussions may not be initiated by vendors. Harris County expects to conduct discussions with vendor personnel authorized to contractually obligate the vendor with an offer. Proposals, vendor interviews and/or evaluations will develop into negotiating sessions with the successful vendor as selected by the evaluation committee. If Harris County is unable to agree to contract terms, Harris County reserves the right to terminate contact negotiations with that vendor and initiate negotiations with another vendor. All correspondence relating to this RFP, from advertisement to award, shall be sent to the Office of the Harris County Purchasing Agent. All presentations and/or meetings between Harris County and the vendor relating to this RFP shall be coordinated by the Office of the Harris County Purchasing Agent. All correspondence, written and/or verbal, shall be through the Office of the Harris County Purchasing Agent. Before, during or after award, Harris County will not be obligated to the vendor for products and/or services until the completion of a signed purchase order from Harris County Hospital District. Progress toward this end is solely at the discretion of Harris County and may be terminated at any time prior to the issuance of a purchase order. Submission of a proposal implies the vendor’s acceptance of the evaluation criteria and vendor recognition that subjective judgements must be made by the evaluating committee. 3.0 EVALUATION CRITERIA Page 8 of 33 Award of the proposal shall be made to the responsible vendor whose proposal is determined to be the best evaluated offer resulting from negotiations, taking into consideration compliance with instructions, specifications and quality of the services proposed which best meet the needs of the using department. Harris County may use references to make judgements directly affecting the award of this proposal. Page 9 of 33 SPECIFICATIONS PROPOSAL FOR: OPERATION of DENTAL FACILITIES for Harris County Hospital District’s Community Health Program SCOPE: Harris County Hospital District invites qualified vendors to submit proposals for the OPERATION OF DENTAL FACILITIES FOR HCHD. The awarded vendor(s) will have the responsibility of the staffing of dentists and ancillary personnel (dental assistants, hygienists, etc.) as well as other obligations as outlined within the RFP to carry on the day to day operations of the dental clinics, those currently operational as well as those proposed in the future, under the umbrella of the District. Questions should be directed to the Office of the Harris County Purchasing Agent, Dan Thweatt @ 713.755.5982 (E-mail: firstname.lastname@example.org) or Don Wilson @ 713.755.5898 (E-mail: email@example.com). A bid bond or cashier’s check in the amount of 5% of the total proposal amount will be required with your submittal. There will be a PRE-PROPOSAL CONFERENCE on Tuesday, April 10, 2001 at 9:30 a.m. at the Harris County Hospital District’s Administration Building, 2525 Holly Hall, Board Room, Houston, Texas 77025. Vendors are STRONGLY URGED TO ATTEND. At the same conference, site visits will be scheduled for vendors if necessary. Persons with disabilities requiring special accommodations should contact Dan Thweatt at 713.755.5982 or Don Wilson at 713.755.5898 at least two (2) days prior to the Pre-Proposal Conference or the site visits. 1.0 HARRIS COUNTY HOSPITAL DISTRICT PROFILE The Harris County Hospital District is a tax-supported public authority providing hospital care and health services to the general public as well as to qualified medically indigent persons who are legal residents of Harris County. The Hospital District was established as a result of a referendum in 1965 and became operative in January 1966. The governing body, the Board of Managers, is composed of nine members appointed by Harris County’s Commissioners Court. The District consists of three hospitals and eleven outlying Community Health Centers. Ben Taub General Hospital located at 1504 Taub Loop and Lyndon B. Johnson located at 5656 Kelley are general hospital facilities. Quentin Mease Community Hospital located at 3601 N. MacGregor Way has the primary responsibility for the care of the District’s Physical Medicine, Rehabilitation. The Community Health Program Health Centers are strategically located throughout Harris County. COMMUNITY HEALTH PROGRAM HEALTH CENTERS Page 10 of 33 *Acres Home Health Center Baytown Health Center 818 Ringold 1602 Garth Road Houston, TX Baytown, TX Mon – Fri 8:00am – 5:00pm Mon – Fri 7:30am – 4:00pm Casa de Amigos Health Center **Dental Center 1615 North Main 1612 Fannin Houston, TX Houston, TX Mon – Fri 7:00am –4:30pm Mon – Fri 8:00am – 5:00pm E.A. Squatty Lyons Health Center *Gulfgate Health Center 1712 First Street 7550 Office City Drive Humble, TX Houston, TX Mon – Fri 8:00am –4:30pm Mon – Fri 8:00am – 5:00pm Martin Luther King Health Center *People’s Health Center 3601 North MacGregor Way 6630 DeMoss Houston, TX Houston, TX Mon – Fri 8:00am –5:00pm Tues – Fri 7:45am – 5:00pm Saturday 6:45am – 3:30pm *Settegast Health Center *Aldine Health Center 9105 North Wayside 4755 Aldine Mail Route Houston, TX Houston, TX Mon – Fri 7:30am – 5:15pm Tues – Fri 8:00am – 5:00pm Saturday 6:45am – 3:30pm *Strawberry Health Center 927 East Shaw Pasadena, TX Mon – Fri 7:30am - 4:30pm *Dental Satellite Sites ** Specialty Service – Oral Surgery, Denture, Emergency Care In addition to these health centers, the District operates the Thomas Street HIV/AIDS Clinic located at 2015 Thomas Street. 1. PROGRAM DESCRIPTION 1.1 OBJECTIVES Page 11 of 33 The District envisions the program to provide access to cost-effective, quality dental care and to maximize the accessibility of facilities to the greatest extent possible for the indigent of Harris County. Through an agreement, the City of Houston Health Department and the Harris County Hospital District maximizes resources by delivering dental care to targeted age groups. The plan to serve the eligible population of Houston/Harris County, Texas is: a. Children and young adults under the age of 16 years are to be referred to the City Health Department for dental services. The District will concentrate on patients 16 and older. b. Each new patient will be evaluated and prioritized. The dental services delivery system employed by the District will provide the patient with appropriate level(s) of care. c. Each dental provider is expected to provide care for a minimum of sixteen (16) patients per business day. d. Operation policies and procedures will be determined through a collaborative effort between the Harris County Hospital District and the contractor. In its effort to insure quality care is rendered to the community, the Harris County Hospital District will secure an independent auditor to perform an annual utilization review. APPROPRIATE LEVELS OF CARE i. Urgent Care Urgent Care – that level of care which is required to alleviate acute dental pain and/or dental infections which may result in pain. (Examples: Abscessed tooth, acute periodontal infection, etc.). Patients will be seen by appointment. Every effort will be made to ensure same day availability of urgent appointment slots. ii. Episodic Care Episodic Care – that level of care which might be required to prevent an existing dental problem from becoming acute or urgent.(Example: Broken tooth or filling). These patients would receive dental services on an “as needed” basis. iii. Preventive Care: Preventive Care – the level of care that may be required to restore and maintain the patient’s oral health status to an acceptable condition. 1.2 EXISTING FACILITIES’ DESCRIPTIONS 2.2.1 Clinical facility includes: Central Location (Specialty Service, etc.) @ 1612 Fannin, Houston, TX Page 12 of 33 a. (6) Chair Operatory (to accommodate sit-down 4-handed dentistry) b. (2) X-ray Rooms (1 panorex) c. Dispensary Area and Sterilization Area d. Waiting rooms (with area for registration, appointment and billing functions). e. Records Room f. Storage Area g. Patient Education Room h. Office Space i. Dental Instruments Satellite Sites: Peoples Health Center, Settegast Health Center, Aldine Health Center, Strawberry Health Center, Acres Home Health Center, Gulfgate Health Center a. (4) Chair Operatory (to accommodate sit-down, 4-handed dentistry) b. X-Ray (1 Panorex) c. Dispensary Area and Sterilization Area d. Waiting Room e. Dental Instruments f. Storage Area g. Office Space h. Medical Records – space allocated in Health Information Management Department Total number of chairs for Dental Services (Central Location and Satellite Sites) is 30, with 15.25 Dentist FTE’s and Support Staff. 1.3 SERVICE DESCRIPTION 1.3.1 Clinical Program to include: a. Screening and Examination Page 13 of 33 b. Patient Education for Preventing Dental and Oral Disease c. Prophylaxis d. Fluoride Treatment e. X-ray f. Class I, II, III, IV, and V restorations g. Endodontia h. Exodontia i. Periodontia j. Pedodontia k. Fixed Multiple Restorations – Crowns Only (Non-Precious Metals and Acrylic Only) l. Complete Dentures and Partial Dentures (Chrome or Acrylic Only) m. Consultation n. Orthodontics, impactions, and bone surgery services are not provided. 1.3.2 Patients entering and receiving care in this program will be screened for eligibility by the Harris Count Hospital District in one of its facilities. 1.3.3 Patients will be seen by appointment; however, every effort shall be made to see drop- in patients with urgent care needs. 1.3.4 A mechanism to address broken appointments should be provided. 1.3.5 For calendar year 2001, the Dental Clinics will observe: New Year’s Day MLK Day President’s Day Good Friday Memorial Day Independence Day Labor Day Thanksgiving Day Day After Thanksgiving Christmas Eve Christmas Day The awarded vendor will observe designated Community Health Program holidays. 1.4 RESPONSIBILITIES OF THE HARRIS COUNTY HOSPITAL DISTRICT: 1.4.1 To Provide For: a. A management team responsible for monitoring quality of service, budget, patient relations and compliance. Page 14 of 33 b. Physical Facility c. Security Service d. Janitorial Service e. All Utilities and Telephone f. Building Equipment Maintenance g. Medical Records Maintenance h. Linen Service – No Uniforms i. Clerical Staff j. Replacement of capital equipment. k. Replacement of instruments that have reached their life expectancy l. Supplies: i. tubing (peel), sterile ii. gloves iii. cover, shoe iv. cap, kaycel fabric surgeon v. cleaners, scope metrozyme vi. barrier, multi-use vii. cap, bouffant viii. integrator sterilization ix. label, sterilization x. sharps container xi. gowns, surgical – disposable XL xii. tape, autoclave steam xiii. face mask, disposable xiv. indicator, attest steam xv. surgeon cap, blue Page 15 of 33 2.5 RESPONSIBILITIES OF CONTRACTOR 2.5.1 To staff the necessary dentists, and ancillary personnel (dental assistants, dental hygienists, etc.) to carry out the program. 2.5.2 The contractor shall comply with the requirements of the Texas Department of Health regarding immunization requirements for staff which will involve direct patient contact with blood or body fluids in dental or medical facilities (Title 25, Chapter 97 of the Texas Administrative Code, as amended). Additionally, staff assigned to District facilities shall meet the following testing and immunization requirements: a. Tuberlin (PPD) Skin Test - The contractor shall require PPD testing yearly on their staff who have not previously tested positive. For any staff member whose test becomes positive, the Contractor must present documentation of treatment status. For staff with previous known positive skin tests, the Contractor will present a yearly screening of clinical symptoms for active tuberculosis. b. Hepatitis B - The contractor shall maintain information as to whether their staff have received a Hepatitis B vaccination or has been offered the vaccination and declined. c. Chicken Pox (Varicella) - The Contractor shall ensure that their staff know their immune status to Varicella by providing acceptable documentation of varicella vaccination, serologic testing for the presence of varicella antibodies, or a positive medical history for Varicella. Non-immune individuals are strongly encouraged to be vaccinated prior to working in HCHD. d. Rubella\Rubeola – Immunizations are strongly recommended for non-immune individuals who work in HCHD. Non-immune Healthcare workers who refuse vaccination will not be cleared to work in certain areas. The contractor agrees to provide documentation to the Employee Health Clinic that each staff member has met the above requirements prior to assignment to a District facility (EXHIBIT “B”). Both parties agree that release of a staff member’s health information shall be subject to proper written authorization from staff. The contractor understands and agrees that those failing to meet the above requirements for testing or immunization shall not be eligible for assignment to District facilities. The contractor will insure that staff is knowledgeable of the Harris County Hospital District’s staff educational requirements: General Safety (Life Safety, Electrical, Fire, Back, Infection Control) Blood borne Pathogens (HIV/HBV) Standard Precautions Hazard Communications Tuberculosis Advanced Directives Substance Abuse Performance Improvement Emergency Preparedness (i.e., disaster plan, bomb threat) Page 16 of 33 Abuse Age-Specific Criteria CPR (where applicable) Corporate Compliance Other educational classes required by the education department of the Harris County Hospital District. 2.5.3 To insure that all dentists qualify as members of the Medical and Dental Staff of the Harris County Hospital District by meeting the qualifications below: 2.5.3.a Qualifications for Membership Only those practitioners licensed to practice in the State of Texas and registered in Harris County, who can document their background, experience, training and demonstrate competence, their adherence to the ethics of their profession, their good reputation and their ability to work with other, shall be qualified for membership on the Medical and Dental Staff of the Harris County Hospital District. 2.5.4 To develop and maintain a method of quality control in accordance with the standards of the Harris County Hospital District. 2.5.5 To insure that all medical care is documented accurately and timely. 2.5.6 To maintain an inventory control system. 2.5.7 To Provide For: a. Replacement of Dental Instruments that result from misuse or abuse b. Repair of Dental Units c. Repair of Handpieces d. Laboratory Fees e. Supplies which are not included in the District’s supply list (see section 1.4.1) 2.5.8 To establish a working plan for providing after hour alternatives for all dental patients that are actively in the process of receiving dental care. 2.5.9 To submit for reimbursement an itemized monthly statement of operating expenses by Salaries, Supplies, and Services. Reimbursement will be limited to the total amount of the contract. 2.5.10 To procure and submit a bid bond or cashier’s check in the amount of 5% of the total proposal. A performance bond in an amount agreed upon prior to award may also be required. Page 17 of 33 2.5.11 To obtain and/or maintain during the term of the contract, minimum insurance coverage as follows: 2.5.12 Professional Liability Per Person Per Occurrence $500,000 $1,000.000 2.5.12 Texas Worker’s Compensation The contractor will provide the District with a certificate of insurance for the above coverage prior to execution of the contract. 2.6 DEFINITIONS The contractor will provide compassionate, timely, and cost effective care to a minimum of 16 patients per provider per business day. Patient care encounters will be defined as: 2.6.1 Dental Visit – A face-to-face contact between the patient and the dentist in which a service is rendered. This visit generates a patient charge. 2.6.2 Dental Follow-up Visit – A face-to-face contact between the patient and the dentist in which the primary purpose of the visit is a post-operative check or a suture removal. This visit does not generate a patient charge. 2.6.3 Procedure – A unit of dental service rendered (fillings, extractions, etc.) (see EXHIBIT “A”) 2.6.3.a examinations 2.6.3.b radiographic survey 2.6.3.c laboratory tests 2.6.3.d prevention 2.6.3.e peridontics 2.6.3.f restorative dentistry 2.6.3.g oral surgery 2.6.3.h endodontics 2.6.3.i complete dentures 2.6.3.j removal partial dentures 2.6.3.k repair, refine, adjustments 2.6.3.l crowns 2.7 PROFILE OF HCHD DENTAL ACTIVITY: FEBRUARY 99 – FEBRUARY 00 (See EXHIBIT A) 2.8 TERM Page 18 of 33 The initial term of the contract shall be for one (1) year from date of execution of the agreement with options to renew for four (4) additional years, one year at a time, upon mutual agreement by each party. Any annual increase/decrease shall be agreed upon mutually by both parties, however, the selected vendor will guarantee that any annual increase shall not exceed the Regional Medical Consumer Price Index. 3.0 PROPOSALS 3.1 Proposals must be returned in the format indicated in the “Special Requirements/Instructions” Section of this document. 3.2 Each part of the proposal must consider relevant information provided by section 2.0 of this document, directly addressing any significant difference between what is described in 2.0 and what is proposed and expressing all appropriate qualifications or significant concerns the candidate may have. 3.3 Statement of Objectives and Scope (returned in Section 6 of your response) Provide a statement of objectives and scope that demonstrates understanding of the intent and requirements of the program. 3.4 Work Plan and Methodology (returned in Section 7 of your response) Describing the technical plan and methods proposed for accomplishing program in existing facilities and/or contract facilities. 3.5 Organization and Staffing (returned in Section 8 of your response) Describe the organization and staffing proposed for the program. This description must explain the types and roles of the candidate’s personnel. 3.6 Budget (returned in Section 9 of your response) This part of the proposal must include: 3.6.1 The cost for the program as a whole. 3.6.2 The cost for staffing, services, supplies, etc. detailed by each group. 3.6.3 The example of the methods used in pricing each segment. 3.7 Candidate Profile and Capabilities (returned in Section 10 of your response) This part must include: 3.7.1 A short history and current profile of the candidate. Include organizational structure, names and addresses of key management personnel, parent company and division(if applicable). 3.7.2 A description of all recently completed projects that are of similar nature to this project, stating the name of institution and location. Page 19 of 33 3.7.3 Names and resumes of “key” on-site personnel for the project. 3.8 Critical Operational Documents (returned in Section 11 of your response) 3.8.1 Provide a copy of your organization’s OSHA manual. 3.8.2 Provide a copy of Performance Improvement Plan developed by your organization, including policies, evaluation documents and procedures that will be used by your organization to document quality assurance. Give the original date of implementation and date of last revision, if applicable. 3.8.3 Describe the Information Management System that your organization, will use, including report format, sample copies, types of data analyzed, etc. 3.8.4 Provide PROOF of JCAHO certification for your organization, including last certification date, type of certification given and expiration date. Please explain any deficiencies given and how they were resolved. 3.8.5 Describe how nosocomial infections will be tracked, trended and resolved by your organization. When was protocol trial tested for accuracy? What is the nosocomial rate in your existing facilities. 3.8.6 Describe how your organization will obtain medical data on medically compromised patients requiring dental services. 3.8.7 Recap the Policies and Procedures Manual developed by your organization which will be used to run the day to day operation of dental centers. Submit a copy of the manual. Page 20 of 33 REFERENCES (returned in Section 4 of your response) 1. Location or Clinic: ______________________________________ Address: ______________________________________ ______________________________________ Contact Name: _______________________________________ Contact Telephone: _______________________________________ 2. Location or Clinic: ______________________________________ Address: ______________________________________ ______________________________________ Contact Name: _______________________________________ Contact Telephone: _______________________________________ 3. Location or Clinic: ______________________________________ Address: ______________________________________ ______________________________________ Contact Name: _______________________________________ Contact Telephone: _______________________________________ 4. Location or Clinic: ______________________________________ Address: ______________________________________ ______________________________________ Contact Name: _______________________________________ Contact Telephone: _______________________________________ 5. Location or Clinic: ______________________________________ Address: ______________________________________ ______________________________________ Contact Name: _______________________________________ Contact Telephone: _______________________________________ Page 21 of 33 PRICING & DELIVERY (Return in Section 2 of your Response) COST: Year 1: $_______________________ Year 2: $ _______________________ Year 3: $ _______________________ Year 4: $ _______________________ Year 5: $ _______________________ Page 22 of 33 ATTACHMENTS Page 23 of 33 RESIDENCE CERTIFICATION (Return in Section I of your response) Pursuant to Texas Government Code §2252.001 et seq., as amended, Harris County requests Residence Certification. §2252.001 et seq. of the Government Code provides some restrictions on the awarding of governmental contracts; pertinent provisions of §2252.001 are stated below: (3) "Nonresident bidder" refers to a person who is not a resident. (4) "Resident bidder" refers to a person whose principal place of business is in this state, including a contractor whose ultimate parent company or majority owner has its principal place of business in this state. I certify that __________________________________ is a Resident Bidder of Texas as defined in [Company Name] Government Code §2252.001. I certify that ______________________________________ is a Nonresident Bidder as defined in [Company Name] Government Code §2252.001 and our principal place of business is _____________________________. [City and State] Page 24 of 33 Minimum Insurance Requirements • The contractor shall, at all times during the term of this contract, maintain insurance coverage with not less than the type and requirements shown below. Such insurance is to be provided at the sole cost of the contractor. These requirements do not establish limits of the contractor's liability. • All policies of insurance shall waive all rights of subrogation against the County, its officers, employees and agents. • Upon request, certified copies of original insurance policies shall be furnished to Harris County. • The County reserves the right to require additional insurance should it be deemed necessary. A. Workers' Compensation (with Waiver of subrogation to Harris County) Employer's Liability, including all states, U.S. Longshoremen, Harbor Workers and other endorsements, if applicable to the Project. Statutory, and Bodily Injury by Accident: $100,000 each employee. Bodily Injury by Disease: $500,000 policy limit $100,000 each employee. B. Commercial General Liability Occurrence Form including, but not limited to, Premises and Operations, Products Liability Broad Form Property Damage, Contractual Liability, Personal and Advertising Injury Liability and where the exposure exists, coverage for watercraft, blasting collapse, and explosions, blowout, cratering and underground damage. $300,000 each occurrence Limit Bodily Injury and Property Damage Combined $300,000 Products- Completed Operations Aggregate Limit $500,000 Per Job Aggregate $300,000 Personal and Advertising Injury Limit. Harris County shall be named as "additional insured" on commercial general liability policy. C. Automobile Liability Coverage: $300,000 Combined Liability Limits. Bodily Injury and Property Damage Combined. Harris County shall be named as "additional insured" on automobile policy. Revised 12/00 Page 25 of 33 TWCC RULE 110.110 WORKERS' COMPENSATION INSURANCE COVERAGE If this bid/proposal package is for a building or construction contract, all of the provisions of this rule as shown below apply. Since this is a mandatory requirement, cost increases should not be experienced because of the need to comply with the Texas Workers' Compensation Law. For additional information contact the Texas Workers' Compensation Commission, Southfield Building, 400 S. IH-35, Austin, Texas 78704-7491, (512) 440-3618. A. Definitions: Certificate of coverage ("Certificate") - A copy of a certificate of insurance, a certificate of authority to self-insure issued by the commission, or a coverage agreement, TWCC-81, TWCC-82, TWCC-83, or TWCC-84 showing statutory workers' compensation insurance coverage for the person's or entity's employees providing services on a project, for the duration of the project. Duration of the project - Includes the time from the beginning of the work on the project until the contractor's/person's work on the project has been completed and accepted by the governmental entity. Persons providing services on the project ("subcontractor" in §406.096) - Includes all persons or entities performing all or part of the services the contractor has undertaken to perform on the project, regardless of whether that person contracted directly with the contractor and regardless of whether that person has employees. This includes, without limitation, independent contractors, subcontractors, leasing companies, motor carriers, owner-operators, employees of any such entity, or employees of any entity which furnishes persons to provide services on the project. "Services" include, without limitation, providing, hauling or delivering equipment or materials, or providing labor, transportation, or other service related to a project. "Services" does not include activities unrelated to the project, such as food/beverage vendors, office supply deliveries, and delivery of portable toilets. B. The Contractor shall provide coverage, based on proper reporting of classification codes and payroll amounts and filing of any coverage agreements, which meets the statutory requirements of Texas Labor Code, Section 401.011(44) for all employees of the contractor providing services on the project, for the duration of the project. C. The Contractor must provide a certificate of coverage to the governmental entity prior to being awarded the contract. D. If the coverage period shown on the Contractor's current certificate of coverage ends during the duration of the project, the Contractor must, prior to the end of the coverage period, file a new certificate of coverage with the governmental entity showing that coverage has been extended. E. The Contractor shall obtain from each person providing services on a project, and provide to the governmental entity: Page 26 of 33 (1) A certificate of coverage, prior to that person beginning work on the project, so the governmental entity will have on file certificates of coverage showing coverage for all persons providing services on the project; and (2) No later than seven (7) days after receipt by the Contractor, a new certificate of coverage showing extension of coverage, if the coverage period shown on the current certificate of coverage ends during the duration of the project. F. The Contractor shall retain all required certificates of coverage for the duration of the project and for one (1) year thereafter. G. The Contractor shall notify the governmental entity in writing by certified mail or personal delivery, within ten (10) days after the contractor knew or should have known, of any change that materially affects the provision of coverage of any person providing services on the project. H. The Contractor shall post on each project site a notice, in the text, form and manner prescribed by the Texas Workers' Compensation Commission, informing all persons providing services on the project that they are required to be covered, and stating how a person may verify coverage and report lack of coverage. I. The Contractor shall contractually require each person with whom it contracts to provide services on a project to: (1) Provide coverage, based on reporting of classification codes and payroll amounts and filing of any coverage agreements, which meets the statutory requirements of Texas Labor Code, Section 401.011(44) for all its employees providing services on the project, for the duration of the project. (2) Provide to the Contractor, prior to that person beginning work on the project a certificate of coverage showing that coverage is being provided for all employees of the person providing services on the project, for the duration of the project. (3) Provide the Contractor, prior to the end of coverage period, a new certificate of coverage showing extension of coverage, if the coverage period shown on the current certificate of coverage ends during the duration of the project. (4) Obtain from each other person with whom it contracts, and provide to the Contractor: (a) A certificate of coverage, prior to the other person beginning work on the project, and (b) a new certificate of coverage showing extension of coverage, prior to the end of the coverage period, if the coverage period shown on the current certificate of coverage ends during the duration of the project; Page 27 of 33 (5) Retain all required certificates of coverage on file for the duration of the project and for one (1) year thereafter. (6) Notify the government entity in writing by certified mail or personal delivery, within ten (10) days after the person knew or should have known, of any change that materially affects the provision of coverage of any person providing services on the project; and (7) Contractually require each person with whom it contracts, to perform as required by paragraphs (1) - (7), with the certificates of coverage to be provided to the person for whom they are providing services. J. By signing this contract or providing or causing to be provided a certificate of coverage, the Contractor is representing to the governmental entity that all employees of the contractor who will provide services on the project will be covered by workers' compensation coverage for the duration of the project, that the coverage will be based on proper reporting of classification codes and payroll amounts, and that all coverage agreements will be filed with the appropriate insurance carrier or, in the case of a self-insured, with the commission's Division of Self-Insurance Regulation. Providing false or misleading information may subject the contractor to administrative penalties, criminal penalties, civil penalties, or other civil actions. K. The Contractor's failure to comply with any of these provisions is a breach of contract by the contractor which entitles the governmental entity to declare the contract void if the Contractor does not remedy the breach within ten (10) days after receipt of notice of breach from the governmental entity. Page 28 of 33 EXHIBIT “A” Page 29 of 33 EXHIBIT A EXAMINATIONS PERIODONTICS Complete Dental Exam 14,204 Sublgingival Scaling 5,761 Emergency Dental Exam 15,687 Curettrage-Per Quad. 24 Dental Visit Follow-up 47,485 Gingivec-Gingivopl/Quad 2 2nd Phy. Encounter 193 Retromolar Tissue Reduction 3 3rd Phy. Encounter 6 Periodontal Recall 1 Adjustment & Check Visit 28 5,791 Surgery Follow-up Visit 42 Blood Pressure 101 Referral to Ben Taub 371 RESTORATIVE DENTISTRY Referral to Outpatient Clinic 271 Amalgam-One Surface-Perm 5,103 78,388 Amalgam-Two Surfaces-Perm 2,720 Amalgam-Three Surfaces-Perm 660 RADIOGRAPHIC SURVEY Amalgam-Four Surfaces-Perm 113 Regional Periapical 2,824 Amalgam-Five Surfaces-Perm 6 Bite Winds(each) 6,998 Amalgam-One Surface-Decidu 3 Occlusal 45 Amalgam-Two Surfaces-Decidu 2 Panogram 12,735 Amalgam-Three Surfaces-Decidu 3 Special Views 68 Pin Retention 15 22,670 Palliative Base 350 Composite-One Surface 1,275 DOCUMENTATION Composite-Two Survaces 584 Diagnostic Casts 3 Composite-Three Surfaces 471 Composite-Four Surface 238 LABORATORY TEST Acid Etch 2,454 Biopsy 1 Stainless Steel Crown 33 Poly Carbonate Crown 9 PREVENTION Pulp Cap Direct 360 Prevention Program 1 7,343 Pulp Cap Indirect 6,483 Prevention Program 2 7,286 Pulpotomy 27 Prevention Program 3 72 Crown Band Loop 2 Toothbrush 962 Space Maintainer 1 Floss 796 Cementation of Restorative Matl 18 Prophylaxis 5,695 Copal (Varnish) 7,477 Fluoride Treatment 5,807 Temporary Filling 1,601 Mouth Protector 64 Post-N-Core 32 Pit & Fissure Sealant 2 Gelfoam 2,149 28,027 32,189 Page 30 of 33 COMPLETE DENTURE ORAL SURGERY Full Denture-Delv. Each 795 Prescription 22,075 Initial Impression 1,009 Tooth Removal Perm 9,913 Full Impression 708 Tooth Removal Prim 50 Wax Bite 1,527 Tooth Removal Impacted 7 Try-In 1,634 Tooth Removal Surgical 607 5,673 Residual Root Removal 1,890 Bone Trim Minor 408 REMOVABLE PARTIAL DENTURE Alveoplasty 354 Part. Den-Del. Ea. 753 Frenoplasty 9 Initial Impression 833 Frenoctomy 1 Full Impression 115 Reduction of Tuberosity 16 Try-In & Adjustment 1,634 Soft Tissue Surgery 31 Steel's Facing 22 Incision + Drainage 24 Trans. Part. Dent-Wire + Acryli 8 Preprosthetic Surgery 6 3,365 Post Operative Treatment 97 Other Oral Surgery 40 REPAIR, REFINE, ADJUSTMEN Suture/Removal 3,500 Partial Denture Repair Simple 32 Occlusal Adjustment 22 Partial Denture Repair Complex 98 39,050 Full Denture Repair Simple 20 Full Denture Repair Complex 62 ENDODONTICS Partial Denture Reline (Each) 8 Root Canal-1 Completion 10 Full Denture Reline (Each) 90 Pulpectomy 17 Full or Partial Denture Adjust. 502 Instrumentation 11 Occ/Adjustment/Reduction 22 Root Canal 2 - Completion 1 834 Pulpectomy 3 Instrumentation 3 CROWNS Root Canal 3 - Completion Prep. + Temporization 2 Pulpectomy 3 Impression Instrumentation Crown Build-up 1 Root Canal 4 - Completion 1 Re-Cement Bridge or Crown 26 Pulpectomy 1 Re-Cement Facing 1 Instrumentation 1 Re-Cement Stainless Steel Cro 6 Endodontic Surgery 1 36 Pulp Test 1 53 Page 31 of 33 EXHIBIT “B” Page 32 of 33 EXHIBIT “B” Institution Date Submitted VACCINATION LOG NAME RUBEOLA/ MMR TD PPD HB VARICELLA RUBELLA DATE (S) DATE VAC* MEASLES Dz. Hist Sero(+) Dz. Hist Sero(+) Vac Dz. Hist Sero(+) Date ---------- seY ٱ seY ٱ seY ٱ seY ٱ seY ٱ seY ٱ oN ٱ oN ٱ oN ٱ oN ٱ oN ٱ oN ٱ knU ٱ knU ٱ knU ٱ knU ٱ knU ٱ knU ٱ ---------- seY ٱ seY ٱ seY ٱ seY ٱ seY ٱ seY ٱ oN ٱ oN ٱ oN ٱ oN ٱ oN ٱ oN ٱ knU ٱ knU ٱ knU ٱ knU ٱ knU ٱ knU ٱ ---------- seY ٱ seY ٱ seY ٱ seY ٱ seY ٱ seY ٱ oN ٱ oN ٱ oN ٱ oN ٱ oN ٱ oN ٱ nU ٱk knU ٱ knU ٱ knU ٱ knU ٱ knU ٱ ---------- seY ٱ seY ٱ seY ٱ seY ٱ seY ٱ seY ٱ oN ٱ oN ٱ oN ٱ oN ٱ oN ٱ oN ٱ knU ٱ knU ٱ knU ٱ knU ٱ knU ٱ knU ٱ ---------- seY ٱ seY ٱ seY ٱ seY ٱ seY ٱ seY ٱ oN ٱ oN ٱ oN ٱ oN ٱ oN ٱ oN ٱ knU ٱ U ٱnk knU ٱ knU ٱ knU ٱ knU ٱ ---------- seY ٱ seY ٱ seY ٱ seY ٱ seY ٱ seY ٱ oN ٱ oN ٱ oN ٱ oN ٱ oN ٱ oN ٱ knU ٱ knU ٱ knU ٱ knU ٱ knU ٱ knU ٱ *HEP B EXAMPLES # of doses rec For waiver-----> 0-Waiver date of last dose 10/97 or waiver For vaccinated 4 __ or 3 doses in 80’s 10/97 boosted 1997 PREPARED BY INFECTION CONTROL – BEN TAUB Page 33 of 33
"Pulp Log Purchasing Contract"