HomeMy WebLinkAboutM-79-0251ti
Joseph Grassie
City Manager
Maurice A. Ferre
Mayor
4/2/79
Action Community renter, Inc.
r..
Attached please find 'a self-explanatory letter from
Executive Pirector of+ Action Community Center, Inc.
Would you please schedule this matter for the April
meeting.
cc: Honorable Members of the Cornnission
Mrs. Maria P. Albo,
19th, City Commission
79.251
900 S.W. 1ST STREET
BUILDING C•16
MIAMI, FLORIDA 33130
PHONE: 545-9299
545-9701
COMMUNITY CENTER, INC.
March 29, 1979
Hon. Maurice A. Ferro
Mayor, City of Miami
3500 Pan ,American Drive
Miami, Florida 53153
Dear Mayor Ferro:
This agency recently applied to the State of Florida Department of
Transportation for monies in order to purchase vehicles for our
program. We were recently informed that 11i11' approved our proposal
and was ,;ranting conditional to a local contribution of 514,5=0,
an award of S38,08I0. These 1non1vs till' he used to acquire the
following:
Foul' (-1) t 1 f toon-(!asserel' Vans (ono wheelchair)
One (1) .sc1))o1 bus -thirty passenger
Since, as you know, :Action Community Center does not have the
financial resources to comply with the local contribution by
means of this letter we are requesting that the City of Miami
provide the $1 1, 52O needed for us to acquire the aforementioned
vehicles.
Thanking you in advance for your attention to this most important
matter, I remain
Sincerely,
:,aria C. A1l o
1 ecut it'e Director
*The money from the City of Miami is needed before the 25th of
!April.
cc: Honorable Members of the City Connnission
TRANSPORTATION PROVIDED BY CITY OF MIAMI
III NUMBER
JOB NUMBER
FUNCTION
OBJECT CODE
COST CENTER
AGREEMENT
AGr:F::'•:ENT made and entered into this day of
197 , by and between the STATE OF FLOiZIDA DEPART: T O'r' 'i'i'.AP:SPOPTAT:G::, a
component acjency of the State of Florida, hereinafter caned the Depart-
ment, and Action Cormunit7 Cntcr
a private_, no:;p rolit oranization, estai.D-
lisaec: under the laws of the State of Florida and authorized to transact
business in the: State of Florida, hereinafter called the Grantee.
W I T H E S S E T :i:
;.;:;AS, Section 16 (b) (2) of the Urban ::ass Transportation Act of
1964 as amended hereinafter called the Act provides for Federal Capital
improvement grants to private nonprofit corporations and associations :.or
the specific purpose of assisting in providing transportation services
meeting, the special needs of the elderly and handicapped for whom mass
transportation services planned, designed and carried out pursuant to Sectio:
16 (a) (1) o:: said Mass Transportation Act are unavailable, insufficient or
inappropriate, and:
wi:::::':',: , the Governor of the State of Florida, in accordance with a
request al the Urban Mass Transportation Administration, has designated
the Department to administer. t he program and manacle the use of grant funds,
and:
S , the Department and the Grantee desire to secure and utilize
grant for the transportation needs of the elderly and handicapped
citizens of the State of Florida, and:
:C:::7J;AS, the Grantee has the authority to enter into said Agreement and
to underta d: the Project hereinafter described, and the Department has been
granted the authority to function adequately in all areas of appropriate
jurisdiction including providing transportation service to meet the special
needs of the elderly and handicapped.
NOW, ': i:ERE7OR , in consideration of the mutual covenants, premises
and representations herein, the parties agree as follows:
1. Pl:: poste of Agreement. The purpose of this Agreement is to provide
for the unaer ar:ing transportation services to the elderly and the hand-
icapped (hereinafter referred to as "Project") by the Grantee, and to state
the terms'.,, conditions and mutual understandings of the parties as to the
manner in which the Project, as more particularly described in Exhibit "A",
attached hereto and made a part hereof, will be undertaken and completed.
2. Scor,o of Protect. The Grantee whall undertake the conduct of t:he
Project as chi._ crlb'cd in Exhibit "A" with all practicable dispatch, in a
sound economical and efficient manner, and in compliance with all applicable
laws.
1
3. Cost of irn_iect. Ti';tcost of the Project shale be in the amount
indicated in i_ne a'ro jeer budget (E::i1ibit "11") and shall be borne in the
Manner described therein. In no event shall the Department be liable to LIiC_'
Grantee for any portion of the Federal or non-1't.c:era1 nhare of the: L'rOl'.CL
Cost.
Further, Lilo Grantee al<jrutl.`; that. it Will i!i:ovide from sources Oti1Cr
than S ta1Lt` uf' Ft.'i:l.'i'.i.a. Lined., ,.iL:c:., in the sufficient, to,;ether WLt.11
t.hc grant to a1:;.:urc' payment o: the actual i?I:o: jet co:;t. In cases where
•.l:..a2, lit)::l al:l'f + aunty, school l:.L .:tril.t, :i.L :..:. C.♦j,a1l. .a l_, 1', s'1)•:Ciail (.:: ..�t.i.l�L '-/C.'
,._7,ency of nny th i.l aar'c t.0 be lia;i'a. With the G' not to a s:;ure payment Cif `a;C
.lc a a.a11. cu.: t , al ; L o u a -..on t_ho .(ody an to the
a)ui;)O::c o1: the :)LC sect. alnd an offi ::..aal 1.i.af'-11. o:,in on of court:-3c`1 Of .;a11C:
governing boa.'.' i...:.:nti ll(:j the .a.o;•'c'a: is Of as .1uf=ici'._nt: and r1 Cia1 Cy
purpose and t`::[+cnt11turc of said public funds 1s allowable unalr provisions
of Article VI:" :-,ection 10 of a...;Q 1''1l.)1 ..Gal CQ: .i-..Ceti-lUa arc to be 1nC.ulaeC1
ir1 this c:ol;tr.act. It is further understood an C.: agreed by the Gri1ntee that
no :c_u:.a1 or reduction of the cca.1 contr .fpuc.it'.l 1. 11. 1. be ..laa at any time
unless t;1r!re i:; at the same time a refund or reduction of 0 proportional
amount o; �.:t. " ` ' :still Grant._ ai:;i:.
tne Grantee a1C`ree a...at: ul::..cr no circumstances or c:.inclit1C;.s
will said Grantee use the i:Cjra. e;;;ent :or the pa :;o:;t`. of bOrrC'..1:13 Ii1Unoy,
obtaining c:._...it., receiving preferential a,rt'...t':.;_n 't or sLjecial C0:.a;i.C:e1 c.tiOla.
In effect, it
i:understood and agreed by the Grantee that this Agreement as
not to :+i' used or construed in .:r ' firm or manner a:; a pledge of the credit
01 the :i i:.:te of 'Florida which is prohibited by Article VII, Section 10 of
the Florida Constitution of
l`1uu.
4 ....'L-.C. :tio.. The Department's ,•._s1c..Sii:llii;.y as
agent ..or J. . . . _'t?ci:. a_.:;cnt o: T a':nsport:: ion is ti C coordination and proces-
sing of a..ic Crnntee's t-:'.'j 1ica.l..ion, development ofnecl�s sary vehicle s-:a::C1:.lama.
tian s, the pr:c<'L_ ing of�procurement documents, purchasing of vehicles and
equipment, aii... provision of technical assistance and project mon itcri.l:c: to
insure the implementation and continuing provision of transportation service
for the eit:'criy and i;n:;C:.11ap c:i..a as described in Z:1nibit "A".
J. (-).: t.... aa%...a_. Except as otherwise authorized in writing
by the De >aar.,ment, the Grantee shall not execute any contract, amendment
or change o:a..)r thereto, Cr obligate itself 111 any :tar;1Cr with any third
party with re , ect to its rights and responsibilities under this Agreement
without the 1J r written approval of the Department.'
6. ..lei:: t ,..^.+: Tnneetion. The Grantee shall permit the Department, the
Socrry ....c' a,;lia_t'.G S-taa_a::, :Deportment of Transportation, and the
Cad:,':)t..'o11er General of the United States or their authorized representatives,
to inspect alll vehicles, equipment, parts and materials purchased for the
Grnntce an part of the Project; all transportation services rendered by
♦.:all
the Grantee by the UL:c: of such Vvehicles,ia1C:.l2L1C.':i and Ct1U.1�`•:I1t:Ilti and
relevant :'I'o jucL d atai and fiI.ancial, administrative, aIld operational records
with ti special right to audit the books, records and accounts of the Grantee
pertaiIling to tile: Project.
7. 1) rJ7 1'toot the Pz•C) 'l' ..
(al) '..:1' purcna ie 01 all project vehicles and equipment financed in
whole cr in pslrt pursuanty1: b
to this . Agreement Si;.. :....'.�<'. undertaken `i the
Oepart:,.cnt on ;e:lallf of the United .`:hates Department Of Transportation in
accordance with state and federal procedures, regulations and statutes.
:)) Title to any eCC' iii.' nt, vehicles, parts and materials purchased
Project - lDepartments
with .:f;a.., :ih:a11 be vested i11 the as a1cjC'I1L for the
United elates D,:partl;lent. of Tr aannportaltion. Grantee understands and agrees
it does not have 1e<;a1 title to any of the above and under no circumstances
in Grantee to :;e11, lease or land same. Upon termination of the Agreement
for any reason the Grantee Will :urrendor ponsesSiOn of any item purchased
with Project fandLi upon effcc ivo date of said termination.
-2- 9-1-77
(c) The Grantee shall keep satisfactory records, as described in
Exhibit "C" , with regard to the use of the property and submit to the
Department upon requc:;t such information as is required in order to a:;:.ure
compliance with this Section and shall immediately notify the Department
in all cases where Project vehicles or equipment are used in a manner
substantially different from that described in the Project Description.
An annual certification as described in Exhibit "E", shall be submitted
to the Department.
(d) The Grantee agrees not to use the bus equipment in violation
of Federal, State or Municipal Statute Law, regulation, ruling, order or
ordinance.
(c) The Grantee agrees to maintain the project vehicles anc:
equipment at a high level of cleanlincn s, safety and mechanical soundness
during the period of contract performance. Manufacturer's recommended
maintenance program will be followed by the Grantee. Required records
and reports to assure compliance with this section are delineated in
Exhibit "C".
The Grantee agrees not to make any alterations or modifications
to the vehicles and equipment except with the written consent of the
Department.
(f) All drivers operating Project vehicles and equipment shall
possess a valid Florida chauffeur's license. In addition, all drivers
will undergo an annual physical exem. The Grantee shall maintain the
physical exam reports as shown in Exhibit "D", in the Project file. In
no case shall a driver operate a Project vehicle more than 45 days without
the requires: 7Thysica1 exam. If more restrictive local driver requirements
apply, this section shall not constitute an exemption.
G. Teroinntien bv the Department. The Department may, by written
notice to t e Grantee, terminate the Project and cancel this Agreement
for any of the following reasons:
(a) The Grantee discontinues the use of the Project vehicles or
couipment goring their useful lives for the purpose of providing transpor-
tation services to the elderly and the handicapped;
•
The useful life of vehicles is considered to be five (5) years
for vehicles costing less than $30,000 and ten (10) years for vehicles
costing $30,000 o:.more. These periods may be shortened if detailed
maintenance and repair informaticn is provided to document that the useful
life has terminated in a lesser period of time.
(b) The Grantee takes any action pertaining to this Agreement
without the app rcvnl of the Department and which under the procedures of
this Agreement would have required the approval of the Department;
(c) The commencement, prosecution or timely completion of the
Project by the Grantee is, for any reason, rendered improbable, impossible
or illegal;
(d) The Grantee shall be in default under any provision,of this
Agreement.
(e) The Department may suspend or terminate the financial
asnist.ance of this grant if the U.S. Department Of Transportation determines
that the purposes of the Act would not be adequately served by continuation
of Federal financial assistance to the Project.
(f) Any failure to make progress which significantly endangers
substantial performance of the Project within a reasonable time shall be
deemed to be a violation of the terms of this contract.
Termination of any part of the grant will not invalidate obliga-
tions pro 'L r:y incurred by the Grantee and concurred in by the Department
and u:•:T;► prior to the date of termination, to the extent they are noncance11a.
-3- 9-1-77
Theacceptance of a remittance by the Department of any or all Project
Funds previously received by the Grantee or the closing out of ?ederal.
financial participation in the Project shall not constitute a waiver c)
any claim which the Department may otherwise have arising out of this
Contract.
9. Ac.tion 1.',2on Termination. In the event of a termination of
cancellatIon pursuant oi Item j a..)ove, the parties hereto will proceed
in accordance with the ;following in regard to property provided under
this grant:
• () All -2roject vehicles, ec;uipeht, pro2crty, records,
and files are Lo be turned over to the Department upon effective date 0;.
termination.
(b) In the event cf any ety or interest of the Grantee in
vehicles, e(:uipmont and property, it will be reimbursed only after the
assuption 6.j obligations under the terms and conditions of this Agreement
by another Granto or disposal of said items by sale by the Department.
The DepartmDht shall mae, the sole determination of the Grantee's interest
and reimburseent.
10. Ihsuran. Tho Granteeshall agree to carry insurance on
vehicles aha e,,juiment specified in Exhibit "A", and to include the
Dcpartment CAS an additional insu:I.cd, guarantee liability and provide
evidence of said insurance for minimum coverage as follows;
(a) Liability covora,:e in an amount of n5c-„nors, for the death or
injury of one (1) person, $100,C)CO in the event of in5ury or death of two
or more per:::-)ns in a single accident including liability to any employees
engaged in operation of the vehicles, and S50,000 for property damage.
(b) Collision, fire, theft, and comprehensive coverages in an
amount reciuire'.1 to pav for any damages to the vehicles and ecluipment
specified in Exhibit "A" and to restore it to its then market value.
(c) The above required insurance will be primLry to any other
ir:surance or coveragc that may be applicable.
in.-;unce reciuirements will be reviewed periodically and upon
written noticc by the Department, the Grantee agrees to acquire additional
coverage and provide evidence of same.
11. Tn::::nficion The Grantee does hereby agree to indemnify
nolu harmless Dopartmeat from all claims, demand:7,
liabilitos, and suits of any nature whatsoever arising out of, becauz;e of,
or duo to the breach of this Agreement by tho Grantee, its agents or employee:
or due to any act or occurrence of omission or commission of the Grantee,
its agent:1, or employees. It is specifically understood and agreed that this
indemnificatic)n cl.luse does not cover or indemnify the Department for its
own negligence or breach of contract.
12. InL,!rents of of or Deleontor, to Conc:rc5. No member of
or delegate to the Congress o. the United States shail be admitted to any
share or p,irt of this contract or to any benefit arising therefrom.
13. Prc'hibt.ed Interest. No member, officer, or employee of the
Grantee during hls LO:'1111: or ono yoar thereafter sha:1 have any interest,
direct or indlrect, in this Agreement or the proceeds thereoi.
14.. The Grantee hereby agrees to comply with all
the requIreents ..m:A,sed by Title VI of the Civil 1:ights AcL of 1c_i64 nhd
legulations of the United States Department of Transportation issued there-
under as evidenced by the Grantee's Assurance of Compliance in the Project
Application.
-4- 9-1-77 •
15. Minority nuni.ness Enterprise. In connection with the ,performance
of this contract, the Crantce will coo,:crato with the iiL'par t-monL in meet 1llt%
his co;v.mi t.ments and goals with regard to the m txL;: u r uti . 1 i:ation of minority
business enterprises and will use its best: efforts to insure that minority
.business enterprises snu1.1 have the maximum practicable opportunity to co pet'-'
for subcontract wor under this contract.
IN WT'..:::._., Wiil;.iEO ', the parties hereto have caused these presents to
be CXt CUtt_U, the llu1 and year first above written.
S':ITN:S: : STATE OF FLORIDA DEPARTMENT OF
TRANSPORTATION
APP :COVED :
Director oz Public BY:
Transportation Operations Director of Administration
APPROVED: ATTEST:
Department Comptroller
Executive Secretary
AP:1 RO :'::D AS TO 0:::: , LEGALITY AND
• E OF PRIVATE NONPROFIT
ORGANIZATION)
Assistant Attorney
As to Grantee
•
BY: (Seal)
TITLE:
ATTEST:
TITLE:
(Seal)
9-1-77
•
Exhibit "A"
PROJECT DESCRIPTION
Agency: .fiction Community Center
Address:
900 S. W. 1st Street
l:il dir. C-16
Miami, Florida 33130
Area St rued : From City of Miami to County Wide Areas
Services Provided: Free transportation for elderly and the handi-
capped, to doctors', rehabilitation center, Government offices,
social activities, and other needs.
Pro: ec t
--:���• e•• Four (4) fifteen -passenger vans
0ne (1) School Bus -thirty passenger
Protect Description: To provide a daily free transportation service
for elderly and handicapped individuals which they can count on to
attend doctors' appointments, rehabilitation centers, goverment
offices, shopping centers, hospitals, dentists' offices, labora-
tories, senior centers, nursing homes, and social activities, which'
help tl.cm to feel a part of the Community.
me
3
11 0.7 ;CT 3UDGI..
;z
The t.ota1 cost of the project for the cquilii:ient itemized in
s:tihihi "A' is $ 7^,cGO
:.
to participate up to 80'. of 4
� � d..ra1 C;ov.,r.:;;,ica;. :�� nci:i •rc`c: -e
net project cost which is $
The locai contribution 02 o: cn` net ;pro;cct cost is S ,, ';,E._ ,
L .;i.'ai:c will .:. ....:i .; . :i1 2U, o. .:he net project cost arc?.'.1..
1.20 4::..:c th _ DepaI t'z ui-Jon t.hG execution of
l_veci ._ t;le aL ..1 cost of t..l..' _ s fro: ,
the Grantee will i;:,::,,T ri'tejy pay to the ✓l.'"ii:: ti,':::.t Cr
the i"), .1: ._.. .....t to the (r ir'tec, .his the ciic Li:. • be, siucii Sue", of :c. n C.y .,..
-i ter-, O ) F /+
Ilc_C�. �._ �t� .' t� ,,,,�,1 �. i,:� 4,ii' rruili.E:e pai is iClp:.ii:.i:,Cj to the c}.t.e::i. of c:
23': o:: actual costs.
It 1:: i;'.i: ti.:ur understood that :c rEfunci or roc:uc::l on of the_ local
C. o:: .~.r i :J u tii>.. s.. ... .: be icicl C:h U .. any t1...._ unless there is at the same t:::7e a
rufuhd of u amount .i G:
proportional of the � lliC: �. ..� .. t•
sO, ... ..
The following listings are the sources of local funds:
•
1
BI NUMBER
EXHIIBIT "C"
REPORTING REQUIREMENTS
Each driver will keep a record of passengers carried and the num'eor
of wheelchair passengers carried. An example of such a format is shown
in Item CL. A passenger is counted whenever £ person enters the vehicle.
Thus a person making a round trip consistinc3 of2 one-way person trips
would be counted as 2 passenger trip..
A Vehicle Log will be maintained according to the format in Item C2.
Any repairs or maintenance will be noted under the "Remarks" section and
detailed on the norm item C3 - Repairs on Vehicle.
Monthly reports on each -Vehicle will be forwarded to the Department
within 30 days of the end of the month. The report will be in the format
shown in Item C4.
Driver Tally Sheets, Vehicle Logs 1 .ye..airs on Vehicle Reports, and
maintenance work orders shall be maintained by the Grantee in a Project
File on each vehicle and will be subject to periodic audit.
3I NUMBER
DATE'
DRIVER John Doe
VEHICLE NO. 10-4
ITEM "CI"
DRIVER TALLY SI:EET
RUN OR iZOL:.:. 1 PASSr:N=S
(Elapsed T.ne)
PASS NGS IN
a .J
V ♦ Vii:_17: C:;AiRS
FARE REVENUE
1 (2 hrs.)
7,3,3
1,1
TOTALS
•
A run is a complete vehicle trip from an initial stating point
and the return to this point or travel along a defined route or some
defined interval of travel.
EXAMPLE:
A driver named John Doe leaves the Agency at 7:30 A.M. and proceeds .
to 3 different hoc addresses to pick up a total of 8 persons, one of
whom is in a wheelchair. These individuals arc dropped off at 2
seperate dostiI ations. Ile then proceed:; to pick up 3 persons at their
homes and delivers them,to the Health Department. The driver then
recurss to the earlier d`stin:ttions and picks up 4 of the original
8 persons, including the wheelchair client, and returns them to their
homes. i:e then returns to the Acjency at 9:30 A.M. for a few hours
before picking, up other clients or returning, these clients home.
The driver notes this as run l and has an elapsed time oi 2 hours.
Note that persons were counted as passengers when they boarded the
vehicle.
•
VEHICLE trO.
VEHICLE LOG
Month
Dote
MILEAGE
TIME 1- Tool :us Add i Total Oil Add
REMARKS , LRryr
I 1IIT:".
Oegin 1 End Bailin
End f Gals. , Cost
Ors. 4 Cost
I 1
i ,
1
i
f 3
A
;
I 1
S .
}
6
1
71 1
l
91 Ir
I
1
10 i !
1
1
11
13
lu
15
Sub•
Total
Romoths:
•
EhICLE ;;o. VE:1:CL LOG
Month
MILEAGE TIME Toro' Gas .add I Totul Oii Add
Jute ' 1 �----
! Begin I End I Begin End I Guis. I Cost t O's. I Cost
REMARKS
DRIVE
INI;IG_
16
I I
17 ! I I 1
IS
20 1
211
?: j
23 7
1
!
(
1
! -
24 1
I
!
26 !
. I
�1
I
=1 1
;a 1
,
I
4
17
1
1
,
c
31
'
.31I
1
1
„
-
Dotal
ii•mur�s:
1
01: V titCLL-
MIL k' AGI:
{'[7'Al f7 OP.SCUII'1IGN
)TIHf:I.n cn-n• t 101 Fl.
{
i
ITEM "C4"
IIi NUMBER
MONTHLY REPORTING FORM FOR PRIVATE
NON-PROFIT ORGANIZATIONS,RECEIVING 1G (b) (2) FUNDS
DATE OF PREPARATION
FOR MONTH OF
VEUICL1 NO. LICENSE NO.
NAME OF PRIVATE NON-PROFIT ORGANIZATION
1. Total Number of Passengers
Carried by Passenger Classification (See Note)
Minority Other
* 1
Elderly
Physically Handicapped.
In Wheelchair
Not in Wheelchair
Other
Total
Total.
2. Trip Purpose, by Number of Passengers
Using Each Specific Trip Category
3. Total Miles Driven
Total Days Operated
4. Average Miles Per Day
5. Average Number of Hours
Vehicle in Service Per
Day
Medical
Employment
Nutrition.
Social/
Recreation
Education
Other
TOTAL
6. Operating Expenses Salary
Fuel & Oil
Preventive
Maintenance
Repairs
7. Total Fare Fox Revenue (if any)
8. Operating Revenue Collected:
Insurance
TOTAL
Source Amount
I
i3I NUMBER
ITEM "C4"
9. Comments (Include identification of Minority Passengers indicated
in Item 1)
*Note:
Minority is defined by the Department of Justice as:
(1) Slac':, not of -ispo nic origin. A person having origins in any
of the black racial grou'Ds o:: Africa.
(2) .1 person of :lexicon, Puerto Rican, Cuban, Central or
Sourti iw:.crican or other culture or origin, reggardiess
o: race.
(3) Asian o; Pacific Isl':iccr, A person having origins in any cf
the original people 01 tnc Far East, Southeast Asia, the
Indian Subcontinent, or the Pacific Islands. (e.g. China, japan,
Korea, Philippine Islands, and Samoa;..
(4) American Indi n. COY Al aska n Native?, A person :laving Or iC.:ns
any of tail: original peoples of North Amcr : ca , and who maintain
cultural identification through tribal affiliation or com.m:::ity
recognition.
u� ►�v..u.:��
Exhibit „D„
APPLICATION TO DRIVE A VEHICLE TRANSPORTING THE ELDERLY AND HANDICAPPED.
1. Name in Full
2. Mailing Address
3. a. Male
b.' Female
Aye
Age
4. How many years have you driven a motor vehicle?
5. Yes No Have you completed a col:rse in school bus driver training conducted
by the Department of Education?
6. Yes No Have you been employed previously as driver of a school bus?
When? Where?
How many months?
7. Yes No Have you ever been involved in a chargeable motor' vehicle accident
in which any person was injured or killed?
If so, where? When?
8. Yes No Have you ever been convicted of a violuior., misdemeanor, or felony
(underscore which) of any Federal, state, county, or city law or
city law or ordinance? If so, state when
Where and what court
If selected a:; an applicant to drive a vehicle, I acjree, at i 1 then, to keep informed c
all traffic rules and State and District regulations; to observe such rules and regu-
lations; to b tdln from the use of intoxican ; to attend any driver training
course sponsored by the Agency; and to undergo a physical examination and be subject
to the finciiu:in of the physician duly designated by the Agency to make said examination.
I hereby certify the above answers to be correct and that to the best of Tiny knowledge
and belief I am free from any disease or physical impairment that would interfere with
my duties as 4 driver.
Date To be signed by applicant in the presence of the Agency
Director or his agent.
AGENCY CERTI7ICATION
To be signed after report on applicant's physical examination
THIS IS TO CERTIFY That this applicant has been examined and found hhy nically fit by
a physician and fulfills all requirements for a bus driver, has been recommended by
me i,:; a driver of vehicles transporting the elderly and handicapped. •
Date Signed
.7 ;•: z1cy director or Agent
Applicant will begin work , 197
(Thi:: form is issued by the Florida Department of Transportation, Tallahassee, Fla.)
PHYSICAL. EXAMINATION rOit DRIVER APPLICANT OF
VEHICLES TRANSPORTING THE ELDERLY AND HANDICAPPED
Attention Examining Physician: This form, when completed, should be returned
directly to ( ) by the examining physician, not the applicant.
I. The examining physician should use the answers to the following questions A through
G in an evaluation of items 1 through 15 below.
A. What serious illness has the applicant had in thu past five years?
13. What injuries has the applicant had?
C. Does the applicant take drugs regularly? If so, naive and give reason.
D. Is the applicant required to wear glasses or contact lenses?
so, aro they worn regularly or for reading only?
last checked?
If
When were they
E. DOCG the applicant wear a hearing aid?
F. Is the applicant excessively overweight?
G. Name and address of family physician:
Name
Address
I1. This examination was formulated upon the advice of the State Board of Health and
an Advisory Committee of the Florida Medical Association.
1. Record vision without glasses in every case and with glasses when glasses arc
required. Visual acuity must not be leas than 20/20 in one eye and 2G/40 in
the other or 20/30 in each eye separately either with or without glasses.
Vision test based on Right eye 20/ Right eye 20/
Snelien'S Test Chart Without glasses With glasses
at twenty feet
Loft eye 20/ Left eye 20/
Without glasses With glasses
2. Yes No Color perception inadequate for rod or green (using Standard Skein:;
or other approved ck vice) .
3. Yes No Absence of normal functioning hand or fool, or loss of sight in one oye.
4. Yes No Imp ai.r.ed' hearinc (inability to :,ear the usual waispered voice at
fifteen feet, facing away from the examiner, and/or normal range
audometric test) .
5. Yes No Tubcrculor test positive (shall bo determined by x-ray; 70 nun
screening by county -health dep:ar.tr,est or mobile unit acceptable or
determination by tuberculin skin test).
G. Yes No (a) heart.disease. (b) If positive, fully compensated. Yes No
7. Yes NoAny mental libnormality (known or suspected) or emotional instability
which would interfere with proper judgment in the operation of a
school bus.
8. Yaps NoAny history of seizure::, convulsions, epilepsy or blackout::.
9. Yes t:o_— Islood pra.ssuro: Systolic above 170 or below 100. Diastolic above 100.
10. Yes }:J Lack of coordination or neurological disorders which would interfere
in the operation of a bus.
11. Ye; No Any communicable disease including venereal disease.
12. Yes Na "Diabetes, or evidence of sugar in urine.
13. Yes t:o *Hernia.
14. Yes No Other physical conditions or factors that would interfere with
applicant's performance of duty as a bu:, driver. Remarks
'These it(( . (only) may be waived sport r(COonii:atian O. it CO;UGalttee consisting Or the
examlninq physician, the health of ii::ar or ono other qualified physician; and the
Director of t)-.o Privalt e, Nonprofit Aa,cncy.
Note: If deaii'ed, thole calestions answered "yes" may be more fully explained by the
use of an additional Sheet.
I
RECOM::► NDAT1t);: DV .;AIv&;;:
It is our )ur]tle,1Iunt that the physi.ua1 con(iit Lun(s) noted in iturv. (check) 12 13�
:above will not handicap the applicant in the satisfactory performance of duties as a
bus driver. It is therefore reco7.tmended that this defect he waived.
Examining Physician Health Officer or Other Qualified Phys,irian
Agency Director
PHYSICIAN'S CERTIFICATION
THIS IS. TO CE}TIPY That on . 19
was t'x dined by me and his physicali condition wcis found to Iii as indicated above, and
is satisfactory for the operation of a vehicle transporting passengers.
Remarks:
•
.xaoininy Physician
EXHIBIT "L"
ANNUAL CERTIFICATION OF USE OF
PROJECT :;QUI.MEN
DI NUWF3L
At the beginning of each calencl r year the Grantee shall submit to
the Department a certification for year just ended attesting that:
1. The vehicles and equipment acquired under the project
continue to be used for the purpose for which the grant was
approved.
2. The vehicles and equipment do not exceed that which is
needed for operations.
3. None of the vehicles and equipment have been sold, damaged
or of erwise taken out of service.
4. There has not been a reduction in the local contribution
made to the project.
The certification should make specific reference to all four of the
above items. If tile Gr nt. e cannot: certify to oi:c�'-- Gr Inore of them, please
eNpla:nn fully in writing. In the case o: project equipment which consists
of vehicles, each vehicle- should be itemized by year, serial number and
tag number.
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