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HomeMy WebLinkAboutNADESouthold Town Board -Letter y~~yifIXt !~ ~m©~, ~_...w `~ ~,~- Board Meeting of May 20, 2008 RESOLUTION 2008-525 Item # DOC ID: 3903 ADOPTED THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION N0.2008-525 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON MAY 20, 2008: RESOLVED that the Town Board of the Town of Southold hereby authorizes and directs Supervisor Scott Russell to execute an addendum agreement with The National Association of Drug-Free Employees, lnc. (NADE), to provide drug and alcohol collection services to the Town of Southold for the period from July 1, 2008 to June 30, 2009, with the option to extend the contract in one (1)-year increments, said agreement subject to the approval of the Town Attorney. Elizabeth A. Neville Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Albert Krupski Jr., Councilman SECONDER: Vincent Orlando, Councilman AYES: Ruland, Orlando, Krupski Jr., Wickham, Evans, Russell Generated May 22, 2008 Page 31 Jul U1 Ut1 11:34a MYKNA SHAMF'ANIE=K 803 802-9824 p.4 ORIGINAL CONTRACT FOR SERVICES Th"s Contrail For Services b entered into as of the Date day of Month, 2007 by and between MADE a wholly owned subsidiary of Perrrbrooke Ocapa6orel Health, Inc. ('NADE7, and Itre Client whose name is subscribed below (hereirrener referred to as "Client"). 1. Services and Fees. NADE wit provide CfeM with the services listed in the attacfled fee sritedule. 2. Term and Tormirratlon of Contrail. This Contrail will exist for an ingial period of ono (t) year from the effective data set fodh above, and unless sooner terminated pursuant to the terms hereof, will au[omagcally renew for successive periods of one (1) year. Eglrw party may cancel tips Contrail at the end of the Initial [enn or any mnewal farm by givkrg the other party wrigen notice of its intent not to renew al least thirty (30) days prar b the expbation of the then wneM term. The pricing it efleil at gre renewal date will be adjusted to regail the dtarrge in the Comumer Price Index for the most recent lwehre month period. If a party has violated arty law w regulation regarding the performance of the CoMrect, the other party may terminate the CorMred Immedieley upon wdgen notice. g a party's in matedal txriadt of tlris Contrail and fats to cure the bleach wlWn thfny (30) days a/1er written notice, the oNier party may :r.redbley tertTrinale this Contrail. 3. Automatle TerrMrnaon. This Contrail will automatira/y terminate on and as of the date arty of the folbwing occur: 1. The fL'ng of a petitlon yr bankruptq by either paAy; 2. The making by either party of an aasiganenl for the benafd of creditors; 3. The filing of arty involuntary penl'on in banknsitry or for en arranganeM pursuant to the U.S. Bantouptcy Code agalrrsl eifrar Party: 4. The apliointrnent of a receirer for Ne business of ether party; or 5. The orssagon of operations by eigrer Pady, for arty reason whatsoever. 4. &IIMa Payment terms are net itirly (30) days 1 K CYent farts to pay any imroice from kl4DE vdren it becorrres due, MADE (in addition re arty and all ilhw right and rertredies h may have against GbM) may decine service to CYrent under this Contrail rad7 such default has been erred. H arty such defaua shad cerdhrue for a pedod of tliirty (30) addiliorral days, MADE may Oarrrrinate this Contrail upon tan (10) days wrilen nogce b CAenl Terminagon of this Contred shalt not atteil ClknYs obggation to pay for proper charges inwned prior to termination. 5. Costs and Altomevs' Fees. In addition to any other rights w remedies of NADE, in the event of Client's default under gds Contact, NADE shall be entitled to mower from Cient al maswrable fees, ircludirg attorneys' fees, costs, damages and lost profits arising out of default 6. IndemNlleation. MADE agrees to defend, indemnify and hold CfieM harmless from all vests, losses and damages, indrrding without linitation reasonable attorneys' teas, adsing out of any n neglgrnt ads or amesions, (i) violation of laws or regulations or (in) broach of this Contrail by MADE. Cfient agrees to defend, indemnify and hold MADE harmless from ag rxrsls, losses and damages, iirdutling without limitation reasonable attorneys' fees, arisig out of arty () negligent ads or omissions, (Ii) violation of laws or egulatlons or (ip breach of this Contrail by Client In Ilre event an indemnified Haim is made, the irlderttnified party shall-give the indemngying party Prompt wdtlen nilice of any claim d the indemnified party hams of the same, and stroll provide the indermrifying paAy with all reasonable inforrnMiorr and assistance; Provided, however, tlnt the ktdemnlhed partys faiWre to provide notice of any dakn shag not in any way effect the obtlgation to Mdamnify. Tha inderrxtalying party shall have the dghf, at ks sole expanse. to diced and control the defense andrw settlement of airy such claim, but the indemnfed party shat bare the dgM to rnorrkor the case w clam through its own counsel and al its awn expense, and to approve any setdanent that does not include a tuil and uncendgarral release of the indemnified parry. IN NO EVENT SHALL EITI$R PARTY BE LIABLE FOR ANY INCIDENTAL, CONSEI]UENTIAL, EXEMPLARY, SPECIAL OR PUNITNE DAMAGES OR EXPENSES (REL3tiRDLESS OF HOW CHARACTERIZED AND EVEN IF SUCH PARTY iiA,S BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES) UNDER OR IN CONNECTION WfTH THIS AGREEMENT, REGARDLESS OF THE FORM OR ACTION (WHETHER IN CONTRACT, TORT, NEGLIGENCE, STRICT LIABILITY, STAMORY LIABILITY OR OTHERWISE). 7. Other Rastrirdions. In the event that the services, or thedata accessed (hereby, are restricted arrdlw prohidted by third party providers of Information, krdustry prstciples, MADE Adidas, laws or regulations, NADE shall have the dghk in rls sob discretion, to either (a) immediately discontinue provk6rg, or modiy, any arM all of the affected Services; (b) InxrtMlaley terminate this Contrail g the mstdctions and/or protnbaiorrs make NADE's perfornarrce under gris Contrail Impractlcabk w unlawful; w (c) impose restrictions andbr prohibitions on the use of the data w Sarices, to the extent they am imposed on NADE. & Uss of Information. Client agrees not to sell, assign, or ottrerwise transfer any information or portions of Information obtained pursuant tc tlds Contra:[ to any thins parry. Client also represents and Rev. Ot-76-20oe Corrtrad Page 1 of 4 Jul 01 08 11:35a MYRNA SHAMPANIER werroMS the arty records obtained purwaM to ID's Controawll be used foremploymen[ purposes only. 9. Eraire Contract Thk Comrad cons0tutes the entire understanding and agreement between the ponies GorlCeming its subject ma8er. The Contrail supersedes all prior, contemporaneous ar subsequent oral comnamications between the parties wlh rasped to its subjad metlar. This Contrail may onty be amended ormodified in a vvdtlng signed by all parties. 10. Notices. All notices under the Contrail shall ba given in writing 6y (I) fast Gass marl, DosM9a DreWid, (II) personal tleWery, (i~ ovantgM caabr or (w) by email (onty with proof of ddhrery and followed wi0r a hard copy delivered try one of the oMer aulhoraed methods) to the addresses eat forth below M b such other addresses as a party desigrratm In writing. 11. CorrfldeMial Mormadtrrt CieM and NADE will maintain sMd confidentially with reaped la empkryee iMortnaffon and drug test reslue and wit ensure that this Itdormatlon a not diadoaed to arty other party e>tcept as pennihed by law. 12. Uae of Narks. Fach party arkrwwledges and agrees That it nehher augWres, nor ran H convoy, arty right, ilk or interest in and b Me other party's trademarks, services marks, trade names, logos, cepyrghts, IMelladual property rghfs or any other assd used b identify and d'degueh the other party's goods, services or business, as They eakt mday end as they maybe amended or e~arakd ti the future, all of which shall be colk+c8vely referred to herein as the 'Marks.' Each party must revlaw end approve in wrklrg, prior to use or publieallon, ant all use of the omets Marks. Upon temrkr of 8rs CorNad, each party shat immediatey ue the use of the oNefs Marks. 13. Asafvrment lJc party stroll assgn, transfer, convey or otherwise depose of its right, bib or interest in the Cadres whhout the prior wrkten consent d Me other party, whkh consent shall rat be unreasonabry wlhheld; Provided, spun wrflbn ndico, eitlrer Party may assign the Cordrad b a sucsassor to Ik 803 802-9824 p.5 business or to all orsubstardially all of ib easels, or b a firm that wntrob, k controlled by, or a under common conhvl wlh the party. This Contrail shed be binding upon and inure to the Dertefd of the parties and their successors and pemdttetl assignees. 14. Force Naieure_ The obligation of either party to perform under this Contract shall be exwsed during each period of delay caused by maaers beyond such party's reasonable coMroL including witltout imitation, government regulatlon or law, war or insurretliorr, civil oonarrotion, destruc8on of production hdl~es or materials by earthquake, fire, flood, slonn, or other natural disaster, WDor disturbances, epidemk or hibre of suppiers, pubic WlRies or comnan arriers. 18. Severebllflr. The terms ant wrdtlons of this Contrail are severable. IF any term or mndilion oT the Corarad a deemed b ba itegel or unerdorceable under any rule oT law, ail ogler leans shat remain In force. Further, the tens or condition that is held b be iiegel or uneMorceable shall remain N e8eil as fat a9 possbb in accordance wlh the 'vrterdbn of the portico. 18, ERed of Waiver. Falure by a party b enforce arty proviabn of this Contrail shat nil be deemed a waiver oT that proviskm a of any other provision oT ibis Contrail. 17. Oovemina Law. Thb Contract abet ba gwenred by arW cemkued in aaonlance wlh the laws of the Comnamveahh of Yaginla wlhout respect to is cho'xe of law provisions. The partlea further agree that any claim Drought under thk Contract shall De (led and maintained onty in a roan in the Comrtamvealh of tfaginia. 18. SBrvlval. Provsions o(tNS Contract that, by gleh nature, survive ma termkretion a e~iration of Ihls Contrail, sl~ll so survive. 19. CounMroarts. The Contract may be eaecubd in multiple oandarparls, eadr of whist sha0 be deemed to be an original, and both of which together shall cana0tute one and the same insWment. Agreed to by the parties as evidenced by the atgrrolwes belew of Yreir authonrsd reproves. NADE, a wholly owned subsidiary of Ptsrrtbrooke Occupational Health, Inc. TOWN OF SOUTHOLD client Full Legal Name CorporationlYirgi nia Type of Entity/State of Incorporation 2307 N. Parham Road Municipal Corporation/New York Type of EntitylState of Incorporation P.O. Box 1179, 53095 Main Road Richmond, VA 23229 southola, NY 11971-0959 Address Address Rev. 01-16-2008 Contras Page 2 of 4 Jul 01 08 11:35a MYRNA SHAMPANIER Signature /~)~ Domenica Philli s Printed Name Operations Coordinator Title 803 802-9824 p.6 Signature Printed Name Supervisor ime 6/13108 July 2, 2008 Date Date Rev. 07-16-2008 ConUaci Page 3 of 4 Jul 01 08 11:358 MYRNA SHAMPANIER NADE FEE SCHEDULE: 803 802-9824 p.7 NADE r4T10X4.AS5D~Fr1IX1 r/DAbAR nO1D/EFS • rt,uF00EE CASI.M' Descr~tlon Berre(ils/ Comments POH Price Dru 8 Alcohol Teati Services 5 Panel DOT/Norr~DOT Urkle D Screen krcludes lab, MRO, administration and a0 cdlegion fees S1i0.00 cech " Breath Alcohol Test ud ~ BAT, retrieve and enter data tram BAT forms, wlbdlon costs, 538,001 teal record kee ' and re orUn ,DOT rod annual summa OnShe Dru TesU Fee incudes IraveE tine. wail Yrtle mi and an other fees intoned 550.00 each OnSite Akrotiol Testin Fce includes travel tine, wail' Dnie, mi and an other fees inverted 530.00 each OrlShe Emergency/Oq-tbw Dng and Alcohol Prke covers cornlHrred drug and alcohol test 5250.00, plus drug Testin and akohd test fee Collegion Site OuaBficaUon 5100.00 site. Audit Support NADE wi0 assist the Giant in aWi preparallon antl will a0end the audit, when Travel expenses pennited veil be billed at cost Data Enhy NADE will tirarge a one time dais entry fee to add each employee to the WA detalxise Management Fees StiO Per Morrtlt Wait Fee NADE Collector tyA Contraq Collector Spot Specirlen Tests When the donor requesb a re-feat of a verified positive, adulterated or S 150.00 substituted test, the MRO veil arrarrga fix the specinen fo be transported to a sewnd laboratory for tectit0. Fees for spit spedmen lasts call be Dlied to u onl fl the donor refuses to for the retest. D 8 L Isomer Test for Mettrarnphetamine A lest to t1"atirguish between Vicks inhaler and iltiat and prescriptions forms of 550,00 each Posiives am helamines. Laboratory Litigation Package Includes a complete set of file IaDOratorys anaytical data, chain of astody S 150.00 records and other admin'lstraUve rloclerlents assocatad w%h a s 'men. State Notices for Postive ResuUs• to employee AdminislratHe fee. Some steles require that all positive resuhs be reported to 55.00 for non- Meted em rs on the individual em donor in vrr - ~ Stale Notices for Positive Resuhs- to slate Admiiistretive fee. Some slates require that all positive resuis be reported to 5 5.00 a for FMCSA and FTA em on the state a n the wslorner. Physicals- Administration Fee Cost covers administrative fees. S 10.00 (plus the acwal cost o! h cal Expert Wdriess Fees As charged to NADE Motor Yehiele a Back round Chstlt Services Per Snrch Si Court Criminal Seartlr Researchers Moan record searches at the hi hest court withit a Doan 5 15.00 Federal Cr'rriinal Search Searches for violations of federal law. Federal Eximirtal recoro searches are S 20.00 contlucted at Ne specific U.S. Distriq Corxi cevering the region where an a Ileam has resided. State Crkninal Search Searches crininal record databases try state, where avaiable. Release form S 6.00 uirenrerib and turnaround time va b aWte. National Criminal Database Search Searches miliorrs of criminal records from ntmerous sourkxs, including: stale 5 11.00 and county raiminal record repositories, lederaly wanted persons seardr, terrorist watch Gst, pr"son, parole and release files, sex o}fender regatries, and other slate ncies Basic EmpbymeM Reference An appacem's refermices are kxxAadetl by telephone and Dy letter to verily S 15.00 em to aril dates and sale Erderded Fsriployment Reference investlgalors conduq an Interview with fom~er employers for a more delaied S 24.00 work hi E d u cat io n V e ri fi c~ t io n Verifies iMomralion ovided b a licanls r and' de reel obtained. S 16.00 ~ J ~ ap ~ ~g ~ [ e ~ g II g g I A trained staff of professional researchers wit mndud telephone inoerviews to S 24.00 NAVE hE~ S .MEDULE: obtain information from rsona! refarerlces. Stale MVR 1 Provides infomratiori about an a licard's drwin Irsto for the last 5 ears. S 5.00 Sex Offender Check Seartlies a state's Sex Offender R and re orts an findin s. 5 10.00 M-I5/ OIG Lill of F~rcluded Individuals A thorough check of a database maintained by Healthy E Fltman Services! i 1200 Olfiw d Inspegor General that Ifsts individuals excluded frwn partic'Qation n the Medicare, Medicaid and all Federal FieaRh care rams. Rev. 01-16-2008 Conirad Page 4 of 4 Jul 01 08 11:36a MYRNA SHAMPANIER 803 802-9824 p.8 GSA List of Parties Excluded! Fed. Prog. A thorough check of the Gerrerel Services Administratlon Ilst of parties S 7200 excluded from rewlvirtg federal contrecls, oeAain subcorrtracts, and oertaln s of federal finandal and non-financial assistance and benefits. Slate MVR-3 1 Provides irdama0on about an icant's drivi hilt for the last 3 acs ; 8.00 Worker's Compensation Chedr A workers' compensation search will hey idrngfy previous wnditions or i 30.00 injuries, enabFng an employer to make reasonable axorrvnoda0orrs and in a Ica61e slate second fords Employee Credll Check Reveals bankruptcies, debt levels, Judgments, or other information that may S 5.00 be bdicative of oor finandal "ud ment. Sortial Sawn Trace Verifaes an individuals socal secud number. ;3-00 Professional License Verifxatbn Verifies information provided by appOcanls regarding pharmaceutical, S 16.00 FAAIFCC nursin , insurence, teachln and other rofessiorral licenses. Unlimied County Criminal Search w/ Trace A search for crininal adivily in speci0c counties based on resu0s from a ;75.00 social trace. 3 Basic Empbyment Rekrence Check Discounkd pdoe for frequerwy d requesting 3 employment reference chedrs S A0.00 at a time instead of a sin le check. Scored Resuk- Criminal Checks Criminal Check results are reviewed ant scored based on pre-set paromekrs S 5.00 by the wstomer. (!n addrlion to search Scored Resui-Traces Traces are reviewed and scored (ex. Pass, Fad, Review grades) based on S 5.001 produet customer criteria. (In aatimon ro search IIX Motor Vehicb- Nonfiated IM/R (1) ProvMae irdormatbn about an applicam's driving history wihout using a S 4.00 scerin National Criminal Search USIS S 20-00 (USWS) Searches milbns of erhninai recoms from numerous sources, indudtng: state and county crininai record repositories, federally wanted persons search, terrorist watch list, prison, parole and release Oles, sex offender regisVies, and other slate agexies. Any tuts on USWS are verihed by oondudmg a County Criminal Search. National Cruninal Search, plus County Criminal USIS ; 25.00 (USWP) Searches milrons of criminal records from numerous sources, irxiWing: state and county criminal record repositorbs, fedarely wanted persons search, terrorist watch list, prison, parole and reease Oles, sex offender reg'stries, and other state agencies. Any hits on USWP are verified by conducting a County Criminal Search and a Social Sewdry trace. AN courdies rearmed on a Social Sever' tram will Ire checked. FCRA LeOer for Feted BG Checks Two copies (Pre-Adverse and Adverse) of the Fair Credd Reporting Ad letter S 5.00 an: sent to an applicant if Ire a she b not hired based on results from a back round roves' ation_ ' Collection fees ran vary, deperrdrg on whether the dierd uses a laboratory's Patient Service Confer, a preferred NADE cellegion Bile, an Independent third party eoiedion sie or an orFS6e colledor. To arriv0 at the qudetl fee, IJADE's ealculaled the weighted average cast of colbdion for the geographic area(s) in which the diem is beefed, and made assumptions about the type of collection faciiaes the [lard wit use. Each.quarter, NADE wiA re-rakatlate the price usng the diem's adual vreigFrbd average cdbc0on oust for the preceding quarter. MADE is mrrarNted b providing Me most competitive price la your orerall program, and through Mk analysis w61 work cbsery vn6r your program administrator to ensure Mat the most ceN e6edive colbdion tadli0es are being used. Rev. 01-iCi2006 Conlrad Page 5 of 4 Jul 01 OS 11:36a MYRNA SHAMPANIER MADE NATIONAL A55(x]A'IDN OF DRUG-FREE EMPLOYEES A PEMB0.0p(E COMPANY CONSORTIUM 51GN-UP QUESTIONNAIRE 66 Commack Road, Suite 100 Commack, NY 71725 (631)462-0735 phone (631) 462-0978 fax COMPANY INFORMATION Com an !O erator Name: iowr \o DBA if a livable Address: O. l t~l Cit. ,~T+4<~u-p Staie: pJ Zi Code: 1l°{7J Phone: te31 - `ll~~ ~ 333 Fax: (a31 - ~S - i ~J~n Secure? YES NO `~ PROGRAM ADMINISTRATOR Name Prima o 1'~ \~S~v~.aw Title: 1aw~ Cciv,~ -}-rol\~ E-mail: 11n,evsl-,v„a, r .Sw-rr~oti. .~ Name ARemate : 4~avc~ ~ ci~o,~-L, Title: .v~. ~v0.`~-eve I~S 5-~-.~ E-maiC 1~wn.,yud3c,r@-~-own.SoJ~~lA.ti Vs ~ Address: •~ . \ \'"tq C" 'C~1v,.~p State: ~ Zi Code: 1lq"1 ) Phone: lea ~ rlta~~ ~133~ Fax: bbl. ~1b S- Lilo Secure? YES NO+~ Ma we send ou documents/inFomTation via a-mail? t/YES NO PLEASE INCLUDE A LIST OF ALL COVERED EMPLOYEES WITH THIS FI THE EMPLOYEE'S NAME, SOCUIL SECURITY NUMBER AND JOB CODE UPDATES SHOULD BE PROVIDED 6Y THE CLIENT AS CHANGES TAKE 803 802-9824 p.9 DESCRIPTION OF POSITION). ~E. Rev. Oi-1fi-2008 Jul 01 08 11:34a MYRNA SHAMPANIER 803 802-9824 p.2 PROPOSAL FOR EMPLOYMENT-SCREENING SOLUTIONS NADE Corporate History: Established in 1989, NADE is a national third party administrator and provider of full-service drug and alcohol fesdng program management services. NADE is presently a wholly owned subsidiary of Pembrooke Occupational Health, Inc. Pembrooke is based in Richmond, vrginia and acquired NADE in 1999. Clients: NADE has the e>~erience and resources tD otter a wide range of employee screening and risk management services to large and small companies nationwide. NADE's 2900 DOT-regulated clients represent all DOT modalities: FAA, FMCSA, FRA, PHMSA, FTA and USCG. In addition, NADE provides non-regulated testing to more than 1,000 corporate accounts nationwide. Testing: NADE administers more than 350,000 tests per year and uses i.abCorp as its SAMHSA~ertified laboratory facility. We also have a network of over 4,000 approved specimen collection sites throughout the United States. Innovative Empbyees: Our team of innovative, forward thinkers consistently delivers on the promise of accurate and timely results through rotting edge tedmology. Data Management: Our robust computer applications ensure real-time access to critical information that is accurate, timely and secure. Our system features include the ability to view test resuMs in multiple formats, generate customized reports, manage employee lists, review and monitor random selection and compliance, limit user access according to function andfor lotxtions, enter data for alcohol tests, and receive random selections and invoices eleclron~ally. Drug ~ NADE will select cdledion sites from its e>ostirg network of Thousands of providers or, if Setup necessary, wBl dentify new sites to meet your speafic needs. We wig also provide required inkxmation to Iaboratorles, and configure our irtemal data management system to maintain your mount. NADE will contract directly with collection sites and wlll work with them to ensure that a0 tests are collected accurately and are performed in accordance with applicable laws Collection Sites andfor regulations, inckrding 49 CFR Pan 40 (the federal govemmenrs Procedures for Transporta5on Wodrptace Drug and Ncobo/Testing Programs) and your company's spedfic requirements. NADE roil pay collection sites diredty, which removes you from this burden. Collection Kits NADE wip provide urine specimen colection kits and chain of custody forms at no additional cost to you. Rev. D1-16-2008 Proposal -Page 1 of 2 Jul 01 08 11:34a MYRNA SHAMPANIER 803 802-9824 p.3 Drug and Alcohd Testing Services {continued): NADE will: 1. Assume responsibility for the ovemigM trarwportation o-aY speetimens to the designated NIDAISAMHSA certified laboratory; 2. Manage the laboratories that conduct testing for our com Laboratories y pany; 3• Work with laboratories to rectify, to your company's sa6sfad'ron, any problems ex complaints Ihat may arise; and 4. Pay the laboratories in a timely fashion, using a reconUliation process tttal eledroniplty matches laboratory irwoices with speearnen test resuhs. NADE will immediately pay aY reconaled invdces, artd send Ifwse that remain unmatdted to an irnestigation file to be promptly researched. NADE wYl provide Medical Review Officer ("MRO'~ services in compliance wNh all applicable federal and state laws and regulations. Such services will inUude: 1. Interpreting drug bast results That the laboratory has ident~ed as aduBereled, substituted, or inva5d MRO ~~ 2. Detexrnining if positive dnrg test results indicate prescription medidne use or have other alternative medical et~lanalions; 3. Reviewing applicable fonts for possible errors; and 4. Providing feedback to employers, collection sites, laboratories, end federal agendas as needed. NADE's program administraYon wYl be conducted in accordance with applicable law, DOT Regulations and the regulations of specific DOT agertrdes, as applicable. NADE's administration duties will inUude, but not be limited to: 1. Adding the Client's covered employees to NADE's consortium pool or p~m setting uP a Client-speafic pool at the Client's election. Administratiar 2- Updating the selection pod, as directed by the employer; 3. Providing Company wHh the idbwing reports far each seled'ron period: a. Selection Run Information Sheet b. Employees Selected Form Random records will be rrtaintained for a mininum of Wvo (2) years for statistical purposes or as requested by Company. &irtd Specimen NADE wiN purchase blind performance speamens, which wiY be prepared for split Testing specanen testing. Record-Keeping NADE wiY retain aY positve drug test results for a period of five (5) years antl all negative drug test results for a period of two (2) years. Annual Reports NADE will prepare aY DOTanandated annual statistical reports for the Client. Pembrooke has contracted with a network of Substance Atxise Professionals (SAPS) to SAP Referre! help CFents ensure that employees and applicants who fail a DOT drug or aloohd test are provided the proper infortnafion. Return to Duty and Upon request. NADE will assist the Client in determining whether an applicant or Fellow-Up Programs empbyee has completed the SAP's requirements. ~ Audit Support in the event Uient is audited t>y a state or federal agency, NADE will provide audit support to assist the Client in aetdi preparation. Rev. 07-16-20oa Proposal -Page 2 of 2 Jul 01 08 11:37a MYRNA SHAMPANIER NADE NATIONAL ASSOCIATION OF DRUG-FREE EMPLOYEES A PEMBROOKE COMPANY EMPLOYEE ENROLLMENT FORM p.10 66 Commack Road, Suite 100 Commack, NY 11725 (631) 462-0735 phone (631)462-0978 fax Em to ee Information Last Name: Date of Birth: First Name: Male/Female: Middle Name: Social 5ecurit Number: Home Address: Cit : State: Zi Code: Home Tele hone Number: Work Tele hone Number: i Telephone Code Word: Choose en ~!, code woN that u wiN remember such es ur mothers maiden name. Company Infolmation Company: Job Code: Location (City, State): Company Employee #: NADE Account #/Loc Code: FAA FMCSA CIRCLE TYPE OF PROGRAM FRA PHMSA FTA USCG Corp Em to ee Certification By sigrnn9 bNaw, I certify that: (a) the irdormation above is true and correct; (b) I edcnowledge the requirement d being drug and alcohol tested by my empkryer, (c) I understand lhal I will De tested for madjuana, cocaine, phencycidina, opiates, amphetamines, and akohd; and (d) I understand that al information wit be kept confKlential per 49 CFR Part40. Em to ee Si nature: Date: Rev. 01-1 E2008 803 802-9824