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HomeMy WebLinkAbout#16 - Service Agreements with Industrial Health ServicesSTAFF REPORT DATE: February 20, 2018 CONSENT ITEM #: 16 TO: Mayor and City Council FROM: Jake Foster, Assistant City Administrator AGENDA ITEM: Approve Service Agreements with Industrial Health Services Network (IHSN) BACKGROUND: Staff and the Human Resources Committee have determined that there is a need for vendor to help administer the City’s proposed drug-free workplace and drug testing policies for City employees. The vendor that has been identified is Industrial Health Services Network (IHSN) in Hudson, WI. IHSN would provide a comprehensive service to City staff to ensure compliance with any state or federal regulations, including those for DOT employees. ISSUE FOR DISCUSSION: Should Council approve the HR Committee’s recommendation to enter into service agreements with Industrial Health Services Network (IHSN) to help administer the City’s proposed drug-free workplace and drug testing policies? PROPOSAL DETAILS/ANALYSIS: IHSN provides a completely comprehensive drug testing offering for both DOT and non-DOT employees. Both of these groups would require individual service agreements as the needs for each pools differ. The services staff recommends for non-DOT employees as outlined by IHSN are pre-employment drug screening, alcohol and drug screening based on suspicion, and alcohol and drug screening if an accident occurs while an employee is on duty or City property is involved. IHSN also offers optional services and support materials that could be purchased if the need arises. Staff further recommends using IHSN for DOT drug testing which includes, pre-employment drug screening, alcohol and drug screening based on suspicion, alcohol and drug screening if an accident occurs while an employee is on duty or City property is involved, as well as random selection for testing, and all other DOT requirements. IHSN will provide result reporting and the arrangement of specimen collection at the Stillwater Medical Group collection facility for both programs. Additionally IHSN will help with the policy development for each of these programs to ensure compliance with state statute and federal regulations. FISCAL IMPACT: IHSN charges and annual service fee of $229.00 for the DOT service program. The annual service fee for non-DOT employees will be waived if a service agreement is in place with IHSN for DOT testing. There is an additional one time account set-up fee of $50. Each drug test has an administration/currier fee of $44.90 plus a collection fee from the clinic of $24 for a total of $68.90 each test. Alcohol/breath tests are also done at the Stillwater Medical Group Clinic and carry a charge of $44. Random drug testing needs to occur at a 25% rate annually for the City to be DOT compliant. Tests will be performed quarterly. Currently there are eight employees who are subject to DOT regulations. This means two employees will have to be tested randomly at an annual total cost of $137.80 for the drug tests. Additionally, DOT employees need to be randomly tested for alcohol consumption at a rate of 10% annually with a minimum of one employee needing to be tested each year. The analysis for random testing requirements is performed quarterly, but the system may not require employees to be tested each quarter if annual thresholds are being met. The 2018 cost to implement the City proposed drug testing and drug-free workplace policies would be approximately $470 plus any additional pre-employment, suspicion based, or accident based drug or alcohol screens at $68.90 or $44 respectively. The cost to continue the program in subsequent years would be approximately $420 annually, which is the total cost from 2018 less the one time account set-up fee of $50. RECOMMENDATION: If removed from the consent agenda: “Motion to approve the service agreements with Industrial Health Services Network” ATTACHMENTS: 1. Service agreement for the DOT (FMCSA) employee program 2. Service agreement for the non-DOT employee program I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . Premier Service Program - FMCSA IHSN’s Premier Service Program is a high service model designed for employers who want a comprehensive solution for their drug and alcohol testing program needs. This service package is ideal for employers who want the assistance and experience of knowledgeable staff to coordinate their testing services and assist with the administration of their program. Clients who enroll in our Premier Service program receive the following Superior Quality and Value Added Service Package: IHSN Services Guide Upon enrollment each IHSN client receives our valuable IHSN Services Guide. Our IHSN Services Guide provides: • An introduction to our service program, • Answers to your common service questions, • A listing of your designated service providers (Lab, MRO & collection sites), • Program Management Resources, • Sample Forms, • Sample Company Policy Information, and • Tabbed sections for you to store your service contracts and copies of our monthly newsletter, IHSNews. This handy ring-bound guidebook is divided into convenient tabbed sections for easy reference and convenient storage of your important program documents. Laboratory and MRO Services IHSN makes using or changing to our services a snap by making all the arrangements for establishing your laboratory testing and Medical Review Officer (MRO) accounts. IHSN will set-up your account with one of our contracted top quality SAMHSA certified labs and establish your MRO services account with our MRO Services Department. IHSN also takes care of ordering and arranging for the laboratory to ship the initial supply of drug testing materials directly to you or to each of your designated collection sites, making a change to IHSN services a breeze. Test Panel DOT clients who enroll in our Premier service program receive the DOT mandated 5-panel drug screen. This panel tests for THC/Marijuana, Cocaine, Amphetamines/Methamphetamines, Opiates and PCP. Rapid Result Reporting IHSN understands that drug test results cannot come too soon. Your company’s critical personnel and operations decisions depend on them. Our MRO Services Department is dedicated to providing the rapid, top quality service you need. Negative test results are generally reported the afternoon following specimen collection (provided the collection facility ships the sample the same day it is collected and faxes a copy of the MRO copy of the custody and control form to our offices the day of collection). Positive laboratory test results are handled immediately upon receipt from the laboratory ensuring minimal wait times for your MRO verified result. Deluxe Result Reporting Options IHSN recognizes that some companies may require test results to be reported to multiple locations or require varying levels of access to test results. Our sophisticated result reporting system has the ability to report test results to multiple locations and to accommodate varying access levels to result data. I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . Premier Service Program - FMCSA Specimen Collection Supplies IHSN provides all specimen collection supplies needed for drug testing including: ♦ Specimen collection and bottle containers ♦ Custody and Control Forms (CCF) pre-printed with your company’s account information; and, ♦ Courier overnight shipping envelope and airbill for sending specimens to your designated SAMHSA-certified lab IHSN will order and ship the initial supply of testing materials to you or directly to your collection site(s). Collection Site Location and Account Set-Up Our Premier service clients receive IHSN’s Collection Site Locator & Account Set-up Service. Locating and establishing urine specimen collection and alcohol testing sites is critical to the success of your Drug and Alcohol Testing Program. Using our vast collection site database and collection site locator resources, we will locate collection sites in your designated testing areas and help you determine which sites best meet your unique service needs. We will then coordinate the set-up of your account at each chosen collection site by providing the site with detailed instructions concerning the establishment of your account, including: ♦ Your company name, address, phone numbers and authorized contacts ♦ The names, addressees and phone numbers of your testing lab and MRO ♦ Specimen shipping instructions ♦ Instructions concerning how to order additional testing supplies, ♦ Instructions concerning the disbursement of testing paperwork, and ♦ Billing instructions For DOT regulated employers IHSN will also obtain a certification form from the facility verifying that the site agrees to provide services in compliance with all applicable DOT regulations and agrees to provide copies of all required documentation including training records when requested by the employer or DOT agency.* Additionally, we will also order and ship the initial supply of specimen collection materials to each collection site or if you prefer we will ship the supplies directly to you for distribution to your sites or employees. IHSN will also act as a liaison between the employer and the collection site on an ongoing basis. * IHSN does not obtain copies of the training documentation for each collector or alcohol test technician. IHSN obtains a certification form from the site stating that they agree to provide all services in compliance with DOT regulations including ensuring that all of their staff are trained according to DOT requirements. If a DOT auditor requests the training information for a specific collector or alcohol technician, the employer is responsible for obtaining this documentation from each site location. I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . Premier Service Program - FMCSA Premier Random Selection Services IHSN’s drug and alcohol random selection services are included at no extra charge for clients enrolled in our Premier service program. IHSN’s sophisticated computerized random selection service is designed to simplify the management and employee list maintenance duties of your random selection program. IHSN creates an individual random selection pool for each client enrolled in our Premier service program. To help you keep your employee list up to date, each quarter IHSN sends you a reminder to submit changes to your employee list. Our easy to complete update forms or electronic submission procedures make updating your employee list quick and painless! Our random computer system automatically calculates the number of random selections required for the quarter and then selects the appropriate number of employees for random drug and/or alcohol testing. We also automatically select a percentage of alternates in addition to the primary selections. These alternates are provided for your convenience to be used in cases when the original employees selected are not available for testing due to termination, medical leave, etc. Premier service clients also receive the following additional random selection service and reporting benefits. • For Premier service clients, our computer system tracks your drug tests as they enter our test results system and matches the selections made to the random tests you have completed. If a test enters our test results system labeled as a random test, but does not match a selection in our system, (i.e. the test was marked as a random, but is actually a different category of test; or the SS# on the paperwork does not match the SS# in our data base; etc.) we automatically contact you to determine the cause of the discrepancy and then submit any necessary data changes to the testing laboratory. This process ensures that all of your random testing is properly completed and labeled so that your IHSN random progress and laboratory statistical reports will reflect the correct data. • Premier service clients are sent a progress report just prior to the end of each selection period detailing the status of the random drug testing for the current period. This report includes a summary of the number of selections made, the number of drug tests completed to date and the number of drug tests remaining to be completed for the selection period. This value added report is a timely management tool providing either a confirmation that you have completed all the required drug testing for the period or a friendly reminder that you still have testing to complete before the period ends. • Premier Service Clients who fail to complete their random testing by the end of the selection period are issued a notice of non-compliance each month until the testing has been completed. These friendly reminders are designed to assist you in maintaining compliance with DOT regulations and/or company policy and serve as a gentle reminder that you still have outstanding tests that need to be completed. Our Premier random selection system makes managing your random selection program as easy as 1-2-3! Please Note: If a client does not complete all the required random selections for two successive selection periods, IHSN reserves the right to cancel random selection services on the account. I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . Premier Service Program - FMCSA Split Sample Testing Services DOT regulations require that all DOT drug screen collections be completed using the split sample collection method. In short this collection method requires that the urine specimen be divided into two separate specimen bottles at the time of collection. Both bottles are sealed and shipped to the laboratory. However, only the primary bottle is originally tested. If an employee’s test result is verified as positive or as a refusal to test by the Medical Review Officer (MRO), the employee has the right to request that the second or “split” specimen bottle be shipped to a second certified testing laboratory for reanalysis. IHSN’s MRO automatically informs the employee of this right during the donor interview process. If the employee requests this specimen be re-tested, DOT regulations require our MRO Services Department to process this request immediately. The fee for this test is billed to the employer. The employer may choose to collect re-imbursement from the employee if this is required by the employer’s company policy. DOT Regulatory and Program Compliance Assistance Premier service clients receive assistance with DOT regulatory and program compliance questions and concerns for no additional charge. IHSN’s friendly, dedicated staff is extensively trained to provide answers to your regulatory and program compliance questions. Wading through and reading DOT regulations can be confusing and time consuming. Our highly knowledgeable staff can quickly guide you through the rules to help you locate and understand the appropriate regulations and procedures. Access to IHSN’s 24 hour Emergency Testing Assistance Because accidents do not occur just on weekdays or during regular office hours, IHSN has staff on call 24 hours a day, 365 days a year to assist our Premier service Clients with post-accident or other emergency testing situations. To utilize this service simply call our toll free number day or night. Our on call representative will locate a test site and make all the arrangements with the collection site for the required testing. When you are dealing with an accident or other emergency testing situation the last thing you want to worry about is locating a competent site to perform drug and alcohol testing. We make arranging for emergency testing worry free!* *Note: Due to the urgent nature of this testing and the immediate need for the completion of the site set-up, IHSN will not obtain a signed collection site certification statement prior to completing an emergency site set-up. If the employer wishes to obtain this information, it is the employer’s responsibility to obtain this documentation from the test site after the completion of services. Access to IHSN’s Non-Emergency Over-The-Road Collection Site Set-up Services For situations where is it not convenient to use your permanent collection sites for pre- employment, random or other testing, IHSN offers our Premier service Clients our IHSN “Over- the-Road” Collection Site Set-Up Service. To use this service simply call our toll free number during regular office hours. We will locate a collection site in the requested area and make all the arrangements for the required testing. We then call you back with the facility information so you can direct your employee to the test site. This service is a great tool for completing random testing on-the-road or pre-employment testing on applicants who live far distances from your place of business, saving you travel and lodging expenses when qualifying applicants. * *Note for DOT employers only: To ensure that all testing is completed in compliance with DOT regulations, IHSN’s standard policy is to obtain a collection site certification form from each site prior to completing a site set-up for your company. However, this can delay the site set-up. If the employer does not want the set-up delayed for this process, the employer can request that IHSN not obtain the site certification. In these cases the employer will be required to sign a release form. Premier Specimen Status Tracking & Expedited Result Reporting IHSN understands that drug test results cannot come too soon, your critical personnel decisions depend on them. If you are particularly anxious about the status of a pending test result simply call our offices. Our MRO staff will contact the lab to 1) verify that the lab has received the specimen, 2) determine the testing status of the specimen and, 3) obtain an estimate of when the lab is expected to release the result to the MRO for review. I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . Premier Service Program - FMCSA In addition to contacting the lab to verify the status of your test results, for Premier service clients, our MRO staff will also contact your collection site to verify that the employee did complete the test, we will verify when the sample was shipped, and track the specimen with the courier service responsible for transporting the specimen to the testing laboratory. If you are particularly anxious about a specific result our MRO staff can also enter a “flag” in our computer system that will automatically notify the staff member the minute that specific result is received into our computer system. The result can then be flagged for “priority or emergency” processing to further expedite the MRO review and reporting process. Expedited Correction of Custody and Control Form errors Some MRO’s simply cancel specimens that are submitted to the lab with minor Custody and Control Form Errors (i.e. missing date, missing collector signature, collector failed to mark test type, etc.) rather than taking the time to correct them. Other MRO’s leave it up to the laboratory to obtain the necessary documentation required to correct paperwork errors. These practices cost the employer not only time and lost revenue, but also the cost and hassle of arranging for a second collection if the sample must be re-collected. IHSN, however, takes an active role in the correction process. When a correctable Custody and Control form error occurs, the laboratory notifies our MRO of any errors for your account. Our MRO administrative staff then expedites the correction process by coordinating with the collector to correct the error. Our MRO staff contacts the collector to inform the collector of the error, review the proper procedures to ensure that the error does not happen again, and obtain the necessary corrective paperwork. This involvement in the correction process to expedite the correction of custody and control form errors is not common practice for most MRO organizations. Our MRO Services Department is committed to going the extra mile, ensuring that you receive your test results as rapidly as possible. This commitment to excellence speeds up the processing time for Custody and Control form errors saving you time and money. Regular Customer Service Account Reviews All Premier service clients receive regular account reviews. Our friendly, dedicated staff will contact you to review your account history and point out any changes in testing activity that may indicate a service or compliance concern. This personalized service helps you identify and correct compliance issues before they become a problem. Subscription to IHSNews Our monthly newsletter, IHSNews keeps you up to date on changes in DOT regulations. IHSNews also provides regulation reviews, DOT interpretive guidance, procedure reviews, and articles on other drug and alcohol testing topics. One subscription to IHSNews is provided to each IHSN client as part of their service program. Drug and/or Alcohol Free Workplace Policies Each DOT regulated employer is required to have a written drug and alcohol testing policy. Industrial Health Services Network, Inc. provides each employer regulated by the Federal Motor Carrier Safety Administration (FMCSA) Regulations with a sample drug free workplace policy at no extra charge. This sample is designed to be used as a model for developing your drug and alcohol testing policy. IHSN recommends that you have a competent attorney review any new policy before adopting it as your company policy. I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . Premier Service Program - FMCSA IHSN’s on-line Regulation and Compliance Resource Center Premier Service Clients have access to our on-line DOT Regulation and Compliance Resource Center. This Resource Center located on IHSN’s web site (www.ihsn.com) provides access to: ♦ The 49 CFR Part 40 Drug and Alcohol Testing Regulations ♦ The Part 382 Federal Motor Carriers Safety Administration Drug & Alcohol Testing Regulations ♦ DOT Interpretive Guidance ♦ Common Regulation Questions and Answers ♦ Guidance for Making Post-Accident Testing Decisions ♦ Program Management Tools ♦ Past issues of IHSNews, and ♦ Links to Variety of useful DOT, Government and Industry Drug and Alcohol Testing Web Sites. Optional Services Employee Information and Supervisor Training Programs Employee Information and Supervisor Training Programs are key to maintaining an effective drug and alcohol testing program. DOT regulations require that you distribute materials to your drivers explaining what is expected of them under the DOT drug and alcohol testing rules. Our driver guide is packed with easy to read information and includes a certificate of receipt for your driver testing files. Supervisors play a crucial role in an effective drug and alcohol-testing program. More than anyone else, they are in a position to recognize changes in an employee’s job performance. FMCSA regulations require that each person in a supervisory role over drivers complete 60 minutes of training on drug abuse and 60 minutes of training on alcohol misuse. Our supervisor training guide is designed to comply with this training requirement. This training manual is packed with valuable information and includes sample forms and a certificate of completion. Program Management & Resource Materials Quality Program Management and Resource materials are essential to the maintenance of your drug and alcohol-testing program. IHSN offers additional quality program materials to make it easier for you to manage your testing program and maintain compliance with DOT regulations. See the page in this proposal titled “IHSN Program Materials” for more information. Substance Abuse Professional (SAP) Referral Services When an employee violates an FMCSA drug or alcohol testing program prohibition, FMCSA regulations require the employer to provide the employee with a referral to a qualified Substance Abuse Professional (SAP). IHSN can assist you with this requirement by making a referral to a qualified Substance Abuse Professional. IHSN’s SAP Referral service includes: 1) locating an appropriate facility and certified individual to perform the SAP evaluation and 2) providing you with documentation that the individual meets the criteria to act as an SAP per DOT regulations. I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . Drug Screen Collection & Alcohol Testing Services IHSN will work with your existing provider location(s) or will establish drug screen collection and alcohol testing sites for you. Below you will find our suggestion(s) for service providers in the areas you requested. If you prefer to work with a different facility than the site(s) listed below, please provide your representative with the name, address and phone number of the site of your choice. Fees for drug screen collection and alcohol testing services will be the usual and customary fees charged by the site. Unless otherwise noted below, all fees for services provided by your collection site will be billed to you directly by the provider site. The collection site service fees listed below are based on the collection site’s current fee schedule and are subject to change without notice. Please note that collection and alcohol testing fees are in addition to IHSN’s testing fees. Stillwater Medical Group - Workwell 1500 Curve Crest Blvd. Stillwater, MN 55082 Hours:M - F: 8am-4:15pm Appt not required but a call ahead is preferred for any service. Urine Specimen Collection Fee: $24.00 Phone:(651) 439-1234 DOT Physical Fee:$85.00 Fax:(651) 275-3395 Breath Alcohol Test Fee: $44.00 I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . IHSN Program Materials Cab Packs $5.90 A Cab Pack is a sealed collection kit that contains the specimen bottle kit, a custody and control form, an airway bill, and courier shipping bag. The pack is designed be kept aboard a vehicle for post accident or random on the road testing. We highly recommend having a cab pack for each of your vehicles to decrease the possibility of errors during post accident testing. DOT Program Materials FMCSA Drug & Alcohol Testing Forms Packet Paper Version: $34.95 CD Version: $39.95 The IHSN Drug & Alcohol Testing Forms Packet is designed to aid employers in complying with the record keeping requirements of the Federal Motor Carriers Safety Administration’s drug and alcohol testing program. Each of these time saving forms includes a guide at the bottom of each form listing to whom, and where copies of each form should be distributed. Additionally, each of the program checklists included features not only a list of required documents, but also the time period the form must be retained by the employer. Unlike the program forms sold by other companies, you do not need to buy our forms more than once! IHSN provides you with a packet of master forms that can be photocopied for your internal company use. This packet is also available on CD (Files are in pdf format). DOT Drug and Alcohol Testing Regulations: Part 382 $14.95 This guidebook provides you with a complete copy of the current Part 382 drug and alcohol testing rules. (A pdf version of this booklet is available to download for free in the “clients only” area of our web site.) DOT Drug and Alcohol Testing Regulations: Part 40 $14.95 This guidebook provides you with a complete copy of the current Part 40 drug and alcohol testing rules. (A pdf version of this booklet is available to download for free in the “clients only” area of our web site.) FMCSA Supervisor's Reasonable Suspicion Training Guide $64.95 This guide is designed to meet the supervisor training requirements of 382.603. This manual provides your supervisors with guidance concerning the physical, behavioral, speech and performance indicators of drug and alcohol abuse. Additionally, this manual provides guidance concerning how to approach employees when reasonable suspicion testing is required and how to document the request for testing (includes sample forms) Driver’s Guide to the FMCSA Drug & Alcohol Testing Rules $4.50 This booklet is designed to educate your employees about the dangers and health effects of the use and abuse of drugs and alcohol. This booklet meets the requirements of part 382.601(b) and is designed to be distributed to each of your drivers along with a copy of your company’s written drug and alcohol policy. FMCSA Complete Materials Package $172.00 Save 5%! This cost saving package includes all the basic program materials you need to implement your FMCSA testing program. This package includes 1 - Drug & Alcohol Testing Forms Packet (paper version), 1 - Supervisor’s Reasonable Suspicion Training Manual, 1 - DOT Drug and Alcohol Testing Regulations: Part 382 book, 1 - DOT Drug and Alcohol Testing Regulations: Part 40 book, 5 – FMCSA Driver’s Guidebooks, and 5 – Cab Pack Test Kits. (Don’t forget to order additional Driver’s Guides and cab packs for each additional driver!) I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . Service Fees - FMCSA IHSN Premier Service Program IHSN Services Guide SAMHSA Laboratory Testing DOT SAMHSA 5-panel Test Certified Medical Review Officer Services Automated Results Reporting Deluxe Result Reporting Options Next Day Reporting on Negative Test Results Positive Test Results Confirmed by GC/MS Specimen Collection Supplies Collection Site Referral Services & Account Set-Up Services (First 2 sites free, fee for each additional site) Premier Random Selection Services DOT Regulatory and Program Compliance Assistance Access to IHSN’s 24 hour Emergency Testing Services Access to IHSN’s Non-Emergency Over-The-Road Collection Site Set-Up Services IHSN’s Premier Customer Service Package Premier Specimen Status Tracking Expedited Correction of Correctable Custody and Control Form Errors Regular Customer Service Account Reviews Subscription to IHSNews Password Access to IHSN’s On-Line Regulation and Compliance Resource Center One Monthly Billing Statement for all Lab, MRO and IHSN Services Annual Service Fee:...............................................................................................................$229.00 Fee Per Drug Test:............................................................................................................... $44.90* Optional Services Collection Site Referral & Set-Up Services............First 2 sites free, $45 fee for each additional site Urine Specimen Collection Combined Billing Service ........................................................$5.00/test Non-Emergency Site Set-Up Services (regular office hours) .........................$45.00 per set-up plus testing and collection fees Emergency After Hours Site Set-Up Services ...............................................$75.00 per set-up plus testing and collection fees Split Specimen Re-test..........................................................................................$180.00 per test** SAP Referral Services........................................................................................$150.00 per referral Employee And Supervisor Training Programs.................................... See Program Materials Sheet Program Management and Resource Materials................................. See Program Materials Sheet *Test Fees are based upon a maximum positive rate of 5 % per year. Positive test results above the 5 % maximum annual rate will be subject to an additional $45.00 fee per test. If translation services are required for an MRO interview with a non-English speaking employee, the MRO will utilize the translation services of AT & T Language Line. The employer will be charged a per minute translation fee based upon the current rate charged by AT & T Language Line. ** Split Specimen re-test fees are billed to the employer and the employer is responsible for payment of all split specimen re-test fees. The employer may choose to seek reimbursement from the employee according to the employer’s company policy. I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . Service Agreement DURATION OF OFFER: This offer is open for 30 days from the date of this proposal DURATION OF PRICING: Annual fee and test fees are effective for term of this agreement. IHSN reserves the right to increase client’s annual fee or test fees due to regulation changes or unforeseen increases in laboratory, shipping or other costs. IHSN will provide Client a written notice of any mid term increase in the annual fee or test fees 30 days in advance. Fees at renewal will be IHSN’s present market price at the time of renewal. Fees for all other services are subject to change without notice. PAYMENT TERMS: Invoices are issued monthly and payment is due within 15 days of the invoice date. CUSTOMER SATISFACTION GUARANTEE: Subject to the conditions below, if customer is dissatisfied with IHSN’s quality of service or support, IHSN will, at customer’s written request: (i) cancel service and close the account, and (ii) cancel customer’s contract without liability for the termination fee. CONDITIONS TO SATISFACTION GUARANTEE: 1. IHSN must receive written notice of the issue from the customer. 2. The issue must be attributable to facilities or causes within IHSN’s reasonable control; for example problems caused by acts of God, natural disasters, inclement weather or third parties are not grounds to invoke the guarantee. 3. If the issue is due to the performance of a subcontracted or coordinated third party service provider (i.e. lab, MRO, collection site, etc.) IHSN must be reasonably given the opportunity to (i) resolve the problem with the existing service provider, or (ii) change service providers and pass through any corresponding differences in service provider fees. If there is no alternate service provider reasonably available or customer is unwilling to accept an alternate service provider, then the issue shall not be covered by this satisfaction guarantee. 4. IHSN is unable to resolve a covered problem to customer’s reasonable satisfaction within 30 days after receipt of written notice. 5. Customer’s account must be current (no balance older than 30 days). TERM AND TERMINATION: Client agrees that IHSN will be its sole provider of the drug and alcohol testing services covered by this agreement, unless those services are not available because of location, emergency or necessitated by regulations or government authorities. This agreement shall be for an Initial Term of 1 year from the date signed by the Customer. Upon expiration of the Initial Term, this agreement shall automatically renew for successive 1-year periods at IHSN’s present market price at the time of renewal. Customer or IHSN may terminate this Agreement at the end of any term by submitting a written notice to the other party at least thirty (30) days prior to the end of such term. If service is terminated prior to expiration of the current term, whether by IHSN for customer breach, or by Customer other than under the Customer Satisfaction Guarantee, Customer shall forfeit all annual fees paid and upon demand by IHSN pay a termination fee equal to either 1) the average monthly billing for all prior months of the current term multiplied by the number of months remaining on the current term or 2) the average monthly billing for the last 12 months multiplied by the number of months remaining on the current term, whichever is greater. AMENDMENTS: Changes in federal or state regulations or standard testing practices may necessitate periodic amendments to the terms of this agreement. In the event an amendment is necessary, IHSN will issue a written notice to the client which shall include a deadline by which client must notify IHSN of its refusal to accept the amended terms. Failure to provide notice by and/or continued use of IHSN services after the expiration of this deadline will constitute acceptance of the amendment by client. ACCEPTANCE: Acceptance may be made by email, mail or fax. Email and fax documents shall serve as originals. ENTIRE AGREEMENT: This written Agreement and the accompanying Service Fees sheet constitute the entire agreement between the parties and supersedes any prior or contemporaneous proposals, discussion or agreements, whether verbal or written. CHOICE OF LAW: This agreement shall be construed and controlled by the laws of the State of Wisconsin and both parties further consent to the jurisdiction of the state and federal courts sitting in that state. Customer hereby accepts and agrees to the terms, conditions and pricing as stated in this proposal. For: ___________________________________________ For Industrial Health Services Network, Inc. (Company Name) By ____________________________________________A (Name of Authorized Representative) Emily S. Battis, President VD010118 _______________________________________________ Date: _____________________________ (Signature of Authorized Representative) I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . Premier Service Enrollment Form - FMCSA Our Testing Program Is: Mandated by U.S. DOT Regulations Non-DOT/Company Policy (If you selected this option, please stop here and contact your IHSN representative to request a Non-DOT enrollment form) If your company is regulated by the US Department of Transportation, please indicate all DOT Modal Agency Drug and Alcohol Testing Regulations your company must comply with: Federal Motor Carrier Safety Administration (FMCSA) Other DOT Agency (please list agency name) ________________________________ Result Reporting Preferences Results should be directed to the following address: Mailing Address: ________________________________________________________ City. State, Zip: _________________________________________________________ Phone: (_____________) __________________________________________ Please list the names of the individuals authorized to receive test results (please list phone # if different than number listed above): Primary person________________________________________________________ 2nd person___________________________________________________________ 3rd Person____________________________________________________________ Desired reporting method: Auto Fax reporting is a computerized faxing system that immediately faxes test results to your secure fax upon release by the MRO. If auto fax is selected, you must have a secure fax with access to this fax limited to only those individuals authorized to receive test results. Notify Fax reporting is designed for clients who do not have a secure fax or who want to control their inbound faxes. A notice is faxed to you informing you when your tests are available for reporting. Then you simply call IHSN to have your test result reports released to your fax while you monitor your fax machine. Phone reporting is designed for clients who do not have a secure fax. A representative will call you with your test results and a written copy will be mailed to you the same day. Mail reporting is designed for clients who do not have a secure fax. When the result is released by the MRO for reporting, a written copy of the result is mailed to you. This is the least efficient way to receive results and is not recommended for clients who are anxiously awaiting test results. Select one: Auto Fax* Notify-Fax* Phone* Mail only If Auto fax or notify-fax reporting is selected, enter the fax number to report results: ( )_________-_________ * If fax or phone reporting is selected, the client will receive a preliminary result report via fax or phone. A final result report signed by the MRO is then sent via U.S. Mail. Newsletter Subscription: A copy of our newsletter publication, IHSNews, is provided to each client as part of their annual program fee. The newsletter is sent out by email. Please list the email address that you would like your newsletter sent to: ______________________________________@___________________________________ I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . Premier Service Enrollment Form - FMCSA Random Selections I want IHSN to complete our company drug & alcohol random selections?Yes No If yes, which quarter do you want IHSN to begin making these selections*? immediately for the current quarter (clients just starting a program or clients who have not completed random selections for the current quarter should check this option) 1st quarter(Jan.-March 31) 2nd Quarter(April 1-June 30) 3rd quarter(July 1-Sept. 30) 4th quarter(Oct. 1-Dec. 31) *IHSN standardly performs random selections on a quarterly basis. If your company’s operations are seasonal, please contact your representative to discuss the appropriate random selection schedule for your company. Selection Rate: Random selections are drawn at a rate equal to the minimum annual selection rate set by the applicable DOT agency. If you would like your selection rate set higher than the minimum annual selection rate, please enter the desired selection rate below, otherwise leave this section blank. Drug: ___________%/ calendar year Alcohol: _____________%/calendar year All random correspondence should be directed to: Random Selection Contact: _____________________________________________________ Phone: ____________________________ Fax: ________________________________ Email: _________________________________________________________________ Address: _______________________________________________________________ City, State, Zip: __________________________________________________________ All random correspondence should be sent by (please select one): mail fax email Billing Information Accounts Payable Contact: _________________________________________________ Phone: ( )____________________________ Fax: ( ) _____________________ Billing Address: ___________________________________________________________ City, State, Zip: __________________________________________________________ _ Physical/Shipping Address Street Address: ___________________________________________________________ City, State, Zip: __________________________________________________________ _ I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . Premier Service Enrollment Form - FMCSA Program Supplies Item Description Quantity Unit Price Total Annual Service Fee 1 $229.00 $229.00 Collection Site Referral & Set-Up Services (first 2 sites free) $45.00 Cab packs $5.90 FMCSA Drug & Alcohol Testing Forms Packet (printed)$34.95 FMCSA Drug & Alcohol Testing Forms Packet (CD) $39.95 DOT Drug and Alcohol Testing Regulations: Part 382 $14.95 DOT Drug and Alcohol Testing Regulations: Part 40 $14.95 FMCSA Supervisor’s Reasonable Suspicion Training Guide $64.95 Driver’s Guide to the FMCSA Drug & Alcohol Testing Rules $4.50 Complete FMCSA Training Package $172.00 Subtotal Sales Tax (WI residents add 5.5% sales tax. SD residents add 4% state sales tax plus the applicable city sales tax.) Shipping & Handling: Introductory Materials 1 $14.95 $ 14.95 Shipping & Handling: Additional Program Materials: (Based on weight. Please call for quote if paying by check. IHSN will automatically calculate for credit card orders.) Total Please mail your check to IHSN (or complete the credit card authorization below) for this amount at the time you mail your acceptance. If you are faxing your acceptance please complete the credit card authorization form below. Credit Card Payment Authorization Please charge my credit card for the annual program fee and any supplies ordered above Card: VISA MASTERCARD Card Number: ______________________________________________ 3-Digit Security Code (found on the backside of card): ______________ Card Expiration Date: ________________________________________ Cardholder Name: ___________________________________________ Card Billing Address: _________________________________________________________ City, State, Zip: ______________________________________________________________ Cardholder Phone Number: ___________________________________ Cardholder Signature: ________________________________________ To establish Your Account, Please submit the following by fax or mail to: Industrial Health Services Network, Inc. Attn: Account Setup P.O. Box 490, Hudson, WI 54016 Fax: (715) 386-9308 1. Your signed Service Agreement 2. Your completed Enrollment Form 3. A List of your current collection facilities (please include the site name, complete address, phone number, fax number and contact person) or a list of the locations where sites are needed, 4. If you have requested random selection services, a complete list of the names and social security numbers of your employees for random selections. You must submit a computer file or use the form provided. 5. A check or completed credit card billing authorization for the annual program fee and any program supplies ordered. (NOTE: Please do not send credit card information by email. Please mail, fax or call in your credit card information) I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . Premier Service Program – Non-DOT IHSN’s Premier Service Program is a high service model designed for employers who want a comprehensive solution for their drug and alcohol testing program needs. This service package is ideal for employers who want the assistance and experience of knowledgeable staff to coordinate their testing services and assist with the administration of their program. Clients who enroll in our Premier Service program receive the following Superior Quality and Value Added Service Package: IHSN Services Guide Upon enrollment each IHSN client receives our valuable IHSN Services Guide. Our IHSN Services Guide provides: • An introduction to our service program, • Answers to your common service questions, • A listing of your designated service providers (Lab, MRO & collection sites), • Program Management Resources, • Sample Forms, • Sample Company Policy Information, and • Tabbed sections for you to store your service contracts and copies of our monthly newsletter, IHSNews. This handy ring-bound guidebook is divided into convenient tabbed sections for easy reference and convenient storage of your important program documents. Laboratory and MRO Services IHSN makes using or changing to our services a snap by making all the arrangements for establishing your laboratory testing and Medical Review Officer (MRO) accounts. IHSN will set-up your account with one of our contracted top quality SAMHSA certified labs and establish your MRO services account with our MRO Services Department. IHSN also takes care of ordering and arranging for the laboratory to ship the initial supply of drug testing materials directly to you or to each of your designated collection sites, making a change to IHSN services a breeze! Test Panel Employers who enroll in our Premier service program receive their choice of testing panels. Employers can select our standard 5-panel, 7-panel, 10-panel or a custom panel drug screen. Our standard 5-panel drug screen tests for THC/Marijuana, Cocaine, Amphetamines/Methamphetamines, Opiates and PCP. Our standard 7-panel drug screen tests for all substances included on the 5-panel test plus benzodiazepines and barbiturates. Our standard 10-panel drug screen tests for all substances included on the 7-panel test plus methadone, methaqualone and propoxyphene. Rapid Result Reporting IHSN understands that drug test results cannot come too soon. Your company’s critical personnel and operations decisions depend on them. Our MRO Services Department is dedicated to providing the rapid, top quality service you need. Negative test results are generally reported the afternoon following specimen collection (provided the collection facility ships the sample the same day it is collected and faxes a copy of the MRO copy of the custody and control form to our offices the day of collection). Positive laboratory test results are handled immediately upon receipt from the laboratory ensuring minimal wait times for your MRO verified result. Deluxe Result Reporting Options IHSN recognizes that some companies may require test results to be reported to multiple locations or require varying levels of access to test results. Our sophisticated result reporting system has the ability to report test results to multiple locations and to accommodate varying access levels to result data. I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . Premier Service Program – Non-DOT Specimen Collection Supplies IHSN provides all specimen collection supplies needed for drug testing including: ♦ Specimen collection and bottle containers ♦ Custody and Control Forms (CCF) pre-printed with your company’s account information; and, ♦ Courier overnight shipping envelope and airbill for sending specimens to your designated SAMHSA-certified lab IHSN will order and ship the initial supply of testing materials to you or directly to your collection site(s). Collection Site Location and Account Set-Up Our Premier service clients receive IHSN’s Collection Site Locator & Account Set-up Service. Locating and establishing urine specimen collection and alcohol testing sites is critical to the success of your Drug and Alcohol Testing Program. Using our vast collection site database and collection site locator resources, we will locate collection sites in your designated testing areas and help you determine which sites best meet your unique service needs. We will then coordinate the set-up of your account at each chosen collection site by providing the site with detailed instructions concerning the establishment of your account, including: ♦ Your company name, address, phone numbers and authorized contacts ♦ The names, addressees and phone numbers of your testing lab and MRO ♦ Specimen shipping instructions ♦ Instructions concerning how to order additional testing supplies, ♦ Instructions concerning the disbursement of testing paperwork, and ♦ Billing instructions Additionally we will also order and ship the initial supply of specimen collection materials to each collection site or if you prefer we will ship the supplies directly to you for distribution to your sites or employees. IHSN will also act as a liaison between the employer and the collection site on an ongoing basis. Premier Random Selection Services IHSN’s drug and alcohol random selection services are included at no extra charge for clients enrolled in our Premier service program. IHSN’s sophisticated computerized random selection service is designed to simplify the management and employee list maintenance duties of your random selection program. IHSN creates an individual random selection pool for each client enrolled in our Premier service program. To help you keep your employee list up to date, each quarter IHSN sends you a reminder to submit changes to your employee list. Our easy to complete update forms or electronic submission procedures make updating your employee list quick and painless! Our random computer system automatically calculates the number of random selections required for the quarter and then selects the appropriate number of employees for random drug and/or alcohol testing. We also automatically select a percentage of alternates in addition to the primary selections. These alternates are provided for your convenience to be used in cases when the original employees selected are not available for testing due to termination, medical leave, etc. I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . Premier Service Program – Non-DOT Premier service clients also receive the following additional random selection service and reporting benefits. • For Premier service clients, our computer system tracks your drug tests as they enter our test results system and matches the selections made to the random tests you have completed. If a test enters our test results system labeled as a random test, but does not match a selection in our system, (i.e. the test was marked as a random, but is actually a different category of test; or the SS# on the paperwork does not match the SS# in our data base; etc.) we automatically contact you to determine the cause of the discrepancy and then submit any necessary data changes to the testing laboratory. This process ensures that all of your random testing is properly completed and labeled so that your IHSN random progress and laboratory statistical reports will reflect the correct data. • Premier service clients are sent a progress report just prior to the end of each selection period detailing the status of the random drug testing for the current period. This report includes a summary of the number of selections made, the number of drug tests completed to date and the number of drug tests remaining to be completed for the selection period. This value added report is a timely management tool providing either a confirmation that you have completed all the required drug testing for the period or a friendly reminder that you still have testing to complete before the period ends. • Premier Service Clients who fail to complete their random testing by the end of the selection period are issued a notice of non-completion each month until the testing has been completed. These friendly reminders are designed to assist you in maintaining compliance with your company policy or vendor contracts and serve as a gentle reminder that you still have outstanding tests that need to be completed. Our Premier random selection system makes managing your random selection program as easy as 1-2-3! Please Note: If a client does not complete all the required random selections for two successive selection periods, IHSN reserves the right to cancel random selection services on the account. Access to IHSN’s 24 hour Emergency Testing Assistance Because accidents do not occur just on weekdays or during regular office hours, IHSN has staff on call 24 hours a day, 365 days a year to assist our Premier service Clients with post-accident or other emergency testing situations. To utilize this service simply call our toll free number day or night and we will locate a test site and make all the arrangements with the clinic for the required testing. When you are dealing with an accident or other emergency testing situation the last thing you want to worry about is locating a competent site to perform drug and alcohol testing. We make arranging for emergency testing worry free! Access to IHSN’s Non-Emergency Over-The-Road Collection Site Set-up Services Because it is not always possible or convenient to use your permanent collection sites for pre- employment, random or other testing, IHSN offers our Premier service Clients our IHSN “Over- the-Road” Collection Site Set-Up Service. To use this service simply call our toll free number during regular office hours. We will locate a collection site in the requested area and make all the arrangements for the required testing. We then call you back with the facility information so you can direct your employee to the test site. This service is a great tool for completing random testing on-the-road or pre-employment testing on applicants who live far distances from your place of business, saving you travel and lodging expenses when qualifying applicants. I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . Premier Service Program – Non-DOT Premier Specimen Status Tracking & Expedited Result Reporting IHSN understands that drug test results cannot come too soon, your critical personnel decisions depend on them. If you are particularly anxious about the status of a pending test result simply call our offices. Our MRO staff will contact the lab to 1) verify that the lab has received the specimen, 2) determine the testing status of the specimen and, 3) obtain an estimate of when the lab is expected to release the result to the MRO for review. In addition to contacting the lab to verify the status of your test results, for Premier service clients, our MRO staff will also contact your collection site to verify that the employee did complete the test, we will verify when the sample was shipped, and track the specimen with the courier service responsible for transporting the specimen to the testing laboratory. If you are particularly anxious about a specific result, for Premier service clients, our MRO staff can also enter a “flag” in our computer system that will automatically notify the staff member the minute that specific result is received into our computer system. The result can then be flagged for “priority or emergency” processing to further expedite the MRO review and reporting process. Expedited Correction of Custody and Control Form errors Some MRO’s simply cancel specimens that are submitted to the lab with minor Custody and Control Form Errors (i.e. missing date, missing collector signature, collector failed to mark test type, etc.) rather than taking the time to correct them. Other MRO’s leave it up to the laboratory to obtain the necessary documentation required to correct paperwork errors. These practices cost the employer not only time and lost revenue, but also the cost and hassle of arranging for a second collection if the sample must be re-collected. IHSN, however, takes an active role in the correction process. When a correctable Custody and Control form error occurs, the laboratory notifies our MRO of any errors for your account. Our MRO administrative staff then expedites the correction process by coordinating with the collector to correct the error. Our MRO staff contacts the collector to inform the collector of the error, review the proper procedures to ensure that the error does not happen again, and obtain the necessary corrective paperwork. This involvement in the correction process to expedite the correction of custody and control form errors is not common practice for most MRO organizations. Our MRO Services Department is committed to going the extra mile, ensuring that you receive your test results as rapidly as possible. This commitment to excellence speeds up the processing time for Custody and Control form errors saving you time and money. Regular Customer Service Account Reviews All Premier service clients receive regular account reviews. Our friendly, dedicated staff will contact you to review your account history and point out any changes in testing activity that may indicate a service or compliance concern. This personalized service helps you identify and correct compliance issues before they become a problem. Subscription to IHSNews Our monthly newsletter, IHSNews provides articles on a variety of drug and alcohol testing topics. One subscription to IHSNews is provided to each IHSN client as part of their service program. IHSN’s on-line Resource Center Premier service Clients have access to our on-line Resource Center. This Resource Center located on IHSN’s web site (www.ihsn.com) provides access to: ♦ Program Management Tools ♦ Past issues of IHSNews, and ♦ Links to Variety of useful DOT, Government and Industry Drug and Alcohol Testing Web Sites. I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . Premier Service Program – Non-DOT Drug and/or Alcohol Free Workplace Policies IHSN recommends that any employer requiring employee drug and alcohol testing have a written drug and/or alcohol testing policy for their company. Due to the fact that testing regulations vary from state to state, it is not possible for IHSN to provide a model policy that would comply with the laws of all 50 states. IHSN recommends that you engage the services of a competent attorney to develop a testing policy specific to your state law and individual company needs. Listed below are some sources for information concerning state drug testing laws that may assist you with the development of your company policy. • Your company legal counsel: Your company legal counsel should be able to assist you in identifying any state drug testing laws that you must comply with as well as assist you in writing your company policy. • Your State Attorney General’s Office: Your State Attorney General’s Office should be able to provide you with information regarding your state’s drug testing laws. • U.S. Department of Labor: This web site features a variety of information and resources concerning how to develop a drug free workplace policy, including a policy builder module. http://www.dol.gov/elaws/drugfree.htm • Substance Abuse and Mental Health Services Administration: This site provides information and tools regarding drug-free workplace programs. You can access this web site at http://www.samhsa.gov/workplace • Drug Free Workplace – Office of National Drug Control Policy: This web site offers a variety of information and resources regarding drug free workplace programs including links to state and local drug offices and publications. http://www.whitehousedrugpolicy.gov/prevent/workplace/index.html • The National Clearinghouse for Alcohol and Drug Information: This web site features publications for workplace drug testing programs. http://www.health.org/workplace • DTState Laws: This is a multimedia subscription information service that offers subscribers access to state statutes, court decisions, issues forums, state news, and employer notes concerning workplace drug and alcohol testing. For more information visit http://www.dtstatelaws.com/ • Institute for a Drug Free Workplace: This organization provides a variety of publications to assist employers in implementing and maintaining their drug free work place programs including a guide to state and federal drug testing laws. http://store.drugfreeworkplace.org/publications.aspx Optional Services Employee Information and Supervisor Training Programs Employee Information and Supervisor Training Programs are key to maintaining an effective drug and alcohol testing program. It is essential that employees understand not only what is expected of them, but also what to expect when they submit to drug and alcohol testing. Our employee guide is packed with easy to read information and includes a certificate of receipt for your personnel files. Supervisors play a crucial role in an effective drug and alcohol-testing program. More than anyone else, they are in a position to recognize changes in an employee’s job performance. Our supervisor-training guide gives your supervisors the tools they need to make reasonable suspicion determinations. This training guide is packed with valuable information and includes sample forms and a certificate of completion. I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . Drug Screen Collection & Alcohol Testing Services IHSN will work with your existing provider location(s) or will establish drug screen collection and alcohol testing sites for you. Below you will find our suggestion(s) for service providers in the areas you requested. If you prefer to work with a different facility than the site(s) listed below, please provide your representative with the name, address and phone number of the site of your choice. Fees for drug screen collection and alcohol testing services will be the usual and customary fees charged by the site. Unless otherwise noted below, all fees for services provided by your collection site will be billed to you directly by the provider site. The collection site service fees listed below are based on the collection site’s current fee schedule and are subject to change without notice. Please note that collection and alcohol testing fees are in addition to IHSN’s testing fees. Stillwater Medical Group - Workwell 1500 Curve Crest Blvd. Stillwater, MN 55082 Hours:M - F: 8am-4:15pm Appt not required but a call ahead is preferred for any service. Urine Specimen Collection Fee: $24.00 Phone:(651) 439-1234 DOT Physical Fee:$85.00 Fax:(651) 275-3395 Breath Alcohol Test Fee: $44.00 I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . IHSN Program Materials Cab Packs $5.90 A Cab Pack is a sealed collection kit that contains the specimen bottle kit, a chain of custody form, an airway bill, an MRO envelope and courier shipping bag. The pack is designed to be kept aboard a company vehicle for post accident or random on the road testing. Supervisor's Reasonable Suspicion Training Guide $64.95 This manual is designed to provide your supervisors with information concerning the physical, behavioral, speech and performance indicators of drug and alcohol abuse. Additionally this manual offers guidance concerning how to approach employees when reasonable suspicion testing is required and how to document the request for testing (sample forms included). Employee Drug & Alcohol Testing Information Guide $4.50 This booklet is designed to educate your employees about the dangers and health effects of the use and abuse of drugs and alcohol as well as information regarding what to expect when they submit to drug and alcohol testing. I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . Service Fees – Non-DOT IHSN Premier Service Program IHSN Services Guide SAMHSA Laboratory Testing Choice of Test Panel (5, 7, 10 Panel) Certified Medical Review Officer Services Automated Results Reporting Deluxe Result Reporting Options Next Day Reporting on Negative Test Results Positive Test Results Confirmed by GC/MS Specimen Collection Supplies Premier Random Selection Services Access to IHSN’s 24 hour Emergency Testing Services Access to IHSN’s Non-Emergency Over-The-Road Collection Site Set-Up Services IHSN’s Premier Customer Service Package Premier Specimen Status Tracking Expedited Correction of Correctable Custody and Control Form Errors Regular Customer Service Account Reviews Subscription to IHSNews Password Access to IHSN’s On-Line Resource Center One Monthly Billing Statement for all Lab, MRO and IHSN Services Annual Service Fee:...............................................................................................$179.00*WAIVED One Time Account Set-Up Fee ...............................................................................................$50.00 Fee Per Drug Test:..............................................................................................................$44.90** *Annual fee is waived as long as the client has an active DOT account with IHSN. An annual fee will be implemented for this non-DOT testing account if the client should close its DOT account or request that either random selection services or separate billing statements be provided for the non-DOT account. Optional Services Collection Site Referral & Set-Up Services.................................................$45.00 per collection site Urine Specimen Collection Combined Billing Service ........................................................$5.00/test Non-Emergency Site Set-Up Services (regular office hours) .........................$45.00 per set-up plus testing and collection fees Emergency After Hours Site Set-Up Services ...............................................$75.00 per set-up plus testing and collection fees Split Specimen Re-test........................................................................................ $180.00 per test*** SAP Referral Services........................................................................................$150.00 per referral Employee And Supervisor Training Programs.................................... See Program Materials Sheet **Test Fees are based upon a maximum positive rate of 5 % per year. Positive test results above the 5 % maximum annual rate will be subject to an additional $35.00 fee per test. If translation services are required for an MRO interview with a non-English speaking employee, the MRO will utilize the translation services of AT & T Language Line. The employer will be charged a per minute translation fee based upon the current rate charged by AT & T Language Line. ** *Split Specimen re-test fees are billed to the employer and the employer is responsible for payment of all split specimen re-test fees. The employer may choose to seek reimbursement from the employee according to the employer’s company policy. I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . Service Agreement DURATION OF OFFER: This offer is open for 30 days from the date of this proposal DURATION OF PRICING: Annual fee and test fees are effective for term of this agreement. IHSN reserves the right to increase client’s annual fee or test fees due to regulation changes or unforeseen increases in laboratory, shipping or other costs. IHSN will provide Client a written notice of any mid term increase in the annual fee or test fees 30 days in advance. Fees at renewal will be IHSN’s present market price at the time of renewal. Fees for all other services are subject to change without notice. PAYMENT TERMS: Invoices are issued monthly and payment is due within 15 days of the invoice date. CUSTOMER SATISFACTION GUARANTEE Subject to the conditions below, if customer is dissatisfied with IHSN’s quality of service or support, IHSN will, at customer’s written request: (i) cancel service and close the account, and (ii) cancel customer’s contract without liability for the termination fee. CONDITIONS TO SATISFACTION GUARANTEE: 1. IHSN must receive written notice of the issue from the customer. 2. The issue must be attributable to facilities or causes within IHSN’s reasonable control; for example problems caused by acts of God, natural disasters, inclement weather or third parties are not grounds to invoke the guarantee. 3. If the issue is due to the performance of a subcontracted or coordinated third party service provider (i.e. lab, MRO, collection site, etc.) IHSN must be reasonably given the opportunity to (i) resolve the problem with the existing service provider, or (ii) change service providers and pass through any corresponding differences in service provider fees. If there is no alternate service provider reasonably available or customer is unwilling to accept an alternate service provider, then the issue shall not be covered by this satisfaction guarantee. 4. IHSN is unable to resolve a covered problem to customer’s reasonable satisfaction within 30 days after receipt of written notice. 5. Customer’s account must be current (no balance older than 30 days). TERM AND TERMINATION Client agrees that IHSN will be its sole provider of the drug and alcohol testing services covered by this agreement, unless those services are not available because of location, emergency or necessitated by regulations or government authorities. This agreement shall be for an Initial Term of 1 year from the date signed by the Customer. Upon expiration of the Initial Term, this agreement shall automatically renew for successive 1 year periods at IHSN’s present market price at the time of renewal. Customer or IHSN may terminate this Agreement at the end of any term by submitting a written notice to the other party at least thirty (30) days prior to the end of such term. If service is terminated prior to expiration of the current term, whether by IHSN for customer breach, or by Customer other than under the Customer Satisfaction Guarantee, Customer shall forfeit all annual fees paid and upon demand by IHSN pay a termination fee equal to either 1) the average monthly billing for all prior months of the current term multiplied by the number of months remaining on the current term or 2) the average monthly billing for the last 12 months multiplied by the number of months remaining on the current term, whichever is greater. AMENDMENTS Changes in federal or state regulations or standard testing practices may necessitate periodic amendments to the terms of this agreement. In the event an amendment is necessary, IHSN will issue a written notice to the client which shall include a deadline by which client must notify IHSN of its refusal to accept the amended terms. Failure to provide notice by and/or continued use of IHSN services after the expiration of this deadline will constitute acceptance of the amendment by client. ACCEPTANCE Acceptance may be made by email, mail or fax. Email and fax documents shall serve as originals. ENTIRE AGREEMENT This written Agreement and the accompanying Service Fees sheet constitute the entire agreement between the parties and supersedes any prior or contemporaneous proposals, discussion or agreements, whether verbal or written. CHOICE OF LAW This agreement shall be construed and controlled by the laws of the State of Wisconsin and both parties further consent to the jurisdiction of the state and federal courts sitting in that state. Customer hereby accepts and agrees to the terms, conditions and pricing as stated in this proposal. For: ___________________________________________ For Industrial Health Services Network, Inc. (Company Name) By ____________________________________________A (Name of Authorized Representative) Emily S. Battis, President VND040116 _______________________________________________ Date: _____________________________ (Signature of Authorized Representative) I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . Premier Service Enrollment Form – Non-DOT Our Testing Program Is: Non-DOT/Company Policy Mandated by Government Regulations (If you selected this option, please stop here and contact your IHSN representative to request the correct enrollment form) Test panel choice: 5 panel(standard) 5 panel(DOT Look-A-Like) 7 panel 10 panel Result Reporting Preferences Results should be directed to the following address: Mailing Address: ________________________________________________________ City. State, Zip: _________________________________________________________ Phone: (_____________) __________________________________________ Please list the names of the individuals authorized to receive test results (please list phone # if different than number listed above): Primary person________________________________________________________ 2nd person___________________________________________________________ 3rd Person____________________________________________________________ Desired reporting method: Auto Fax reporting is a computerized faxing system that immediately faxes test results to your secure fax upon release by the MRO. If auto fax is selected, you must have a secure fax with access to this fax limited to only those individuals authorized to receive test results. Notify Fax reporting is designed for clients who do not have a secure fax or who want to control their inbound faxes. A notice is faxed to you informing you when your tests are available for reporting. Then you simply call IHSN to have your test result reports released to your fax while you monitor your fax machine. Phone reporting is designed for clients who do not have a secure fax. A representative will call you with your test results and a written copy will be mailed to you the same day. Mail reporting is designed for clients who do not have a secure fax. When the result is released by the MRO for reporting, a written copy of the result is mailed to you. This is the least efficient way to receive results and is not recommended for clients who are anxiously awaiting test results. Select one: Auto Fax Notify-Fax Mail Only Phone followed by mailed copy If fax or notify-fax reporting is selected, enter the fax number to report results: ( )_________-___________ Newsletter Subscription: A copy of our newsletter publication, IHSNews, is provided to each client as part of their annual program fee. The newsletter is sent out by email. Please list the email address that you would like your newsletter sent to: ______________________________________@___________________________________ I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . Premier Service Enrollment Form – Non-DOT Random Selections Does your company have a random testing program? Yes No Billing Information Accounts Payable Contact: _________________________________________________ Phone: ( )____________________________ Fax: ( ) _____________________ Billing Address: ___________________________________________________________ City, State, Zip: __________________________________________________________ _ Physical/Shipping Address Street Address: ___________________________________________________________ City, State, Zip: __________________________________________________________ _ I N D U S T R I A L H E A L T H S E R V I C E S N E T W O R K , I N C . Premier Service Enrollment Form – Non-DOT Program Supplies Item Description Quantity Unit Price Total Annual Service Fee 1 $179.00 waived One Time Account Set-Up Fee 1 $50.00 $50.00 Collection Site Referral & Set-Up Services 1 $45.00 $45.00 Cab packs $5.90 Supervisor’s Reasonable Suspicion Training Guide (Non-DOT Version) $64.95 Employee Drug & Alcohol Testing Information Guide (Non-DOT Version) $4.50 Subtotal Sales Tax (WI residents add 5.5% sales tax. SD residents add 4% state sales tax plus the applicable city sales tax.) Shipping & Handling: Introductory Materials 1 $14.95 $ 14.95 Shipping & Handling: Additional Program Materials: (Based on weight. Please call for quote if paying by check. IHSN will automatically calculate for credit card orders.) Total Please mail your check to IHSN (or complete the credit card authorization below) for this amount at the time you mail in your acceptance. If you are faxing your acceptance please complete the credit card authorization form below. Credit Card Payment Authorization Please charge my credit card for the annual program fee and any supplies ordered above Card: VISA MASTERCARD Card Number: ______________________________________________ 3-Digit Security Code (found on the backside of card): ______________ Card Expiration Date: ________________________________________ Cardholder Name: ___________________________________________ Card Billing Address: _________________________________________________________ City, State, Zip: ______________________________________________________________ Cardholder Phone Number: ___________________________________ Cardholder Signature: ________________________________________ To establish Your Account, Please submit the following by fax or mail to: Industrial Health Services Network, Inc. Attn: Account Setup P.O. Box 490, Hudson, WI 54016 Fax: (715) 386-9308 1. Your signed Service Agreement 2. Your completed Enrollment Form 3. If you have requested random selection services, a complete list of the names and social security numbers of your employees for random selections. You must submit a computer file or use the form provided. 4. A check or completed credit card billing authorization for the annual program fee and any program supplies ordered. (NOTE: Please do not send credit card information by email. Please mail, fax or call in your credit card information)