IFB_S92102551_-_RPP_Compliance_Services.pdf

State of California Department of Corrections and Rehabilitation

June 3, 2026

INVITATION FOR BID (IFB)

IFB No. S92102551

RESPIRATORY PERSONAL PROTECTION COMPLIANCE SERVICES

Notice to Prospective Contractors

The California Correctional Training and Rehabilitation Authority (CALCTRA) invites you to review and respond to this Invitation for Bid (IFB), entitled RESPIRATORY PERSONAL PROTECTION COMPLIANCE SERVICES, IFB NO. S92102551. In submitting your bid, you must comply with the instructions found herein and the Bidders Instructions REV-0925 located on the CALCTRA website (www.calctra.ca.gov, select About tab and then Doing Business with CALCTRA).

In the opinion of CALCTRA, this IFB is complete and without need of explanation. However, should you have questions, or need clarifying information, please contact the Contract Analyst indicated below.

Due Date/Time: June 23, 2026 by 3:00 PM CALCTRA Contact SUBMIT BID TO:

Rommel Disuanco, Contract Analyst Phone: (916) 358-1433

Email: Rommel.Disuanco@calctra.ca.gov

California Correctional Training and Rehabilitation Authority

Attention: Rommel Disuanco, Contract Analyst 560 East Natoma Street

Folsom, CA 95630

Please note that no verbal information given will be binding upon the CALCTRA unless such information is issued in writing as an official addendum to this IFB.

Term: CALCTRA anticipates that the proposed contract term will be for a period of two (2) years with the option to extend for an additional one (1) year.

The contract award will be made on the basis of BEST VALUE as determined by CALCTRA alone, under statutory authority (Penal Code 2808) considering the following criteria:

1. Cost: Fair, reasonable, and competitive price, and customer service commitments for goods and or services.

2. Performance: Past performance, including but not limited to, quality and/or reliability for the product or service as well as efficient billing practices; certification by the International Organization for Standardization (ISO).

http://www.calctra.ca.gov/ mailto:Rommel.Disuanco@calctra.ca.gov

California Correctional Training and Rehabilitation Authority (CALCTRA) IFB No. S92102551 Respiratory Personal Protection (RPP) Compliance Services

3. Experience: Length of time and/or number of instances the bidder has offered or produced the requested type of product and/or service.

CALCTRA may consider other factors deemed necessary to ensure that best value is achieved.

In the interest of achieving best value, CALCTRA does not grant Small Business, Disabled Veteran Business Enterprise (DVBE), Target Area Contract Preference Act (TACPA), Local Agency Military Base Recovery Act (LAMBRA), or Enterprise Zone Act (EZA) preferences in evaluating bids.

Employment of ex-offenders by the bidder is encouraged by CALCTRA as part of our ongoing mission to change lives through opportunities.

Any agreement resulting from this solicitation shall be of no force or effect until it is signed by both parties and approved by CALCTRA. The Contractor is not to begin work until a contract has been made, all approvals have been obtained, and the contract has been fully executed. Should work begin before all approvals are obtained, services shall be considered voluntary.

TABLE OF CONTENTS

SECTION

PAGE

A. Purpose and Description of Service 4 B. Bid Information 4 C. Bidder’s Submittal Requirements 5 D. Bid Evaluation 6 E. Licenses and Permits 6 F. Standard Language 6 G. Bid Attachments 6

Attachment 1: Bid Document Submittal Check List 7 Attachment 2: Sample Standard Agreement (STD 213), Statement of

Work and Payment Provisions 8

Attachment 3: Cost Sheet 20 Attachment 4A: Payee Data Record (STD 204) 21 Attachment 4B: Payee Data Record Supplement (STD 205) 23 Attachment 5: Darfur Certification 25 Attachment 6: Appropriate Attire Policy 26 Attachment 7: Experience/Past Performance (References) 28 Attachment 8: Contractor Certification Clauses (CCC’s) 29 Attachment 9: PREA Volunteer/Contractor Information Sheet 33 Attachment 10: Economic Sanctions Certification 36

Bid Submittal Documents:

Attachment 1: Bid Document Submittal Check List 1 page Attachment 3: Cost Sheet 1 page Attachment 4A: Payee Data Record (STD 204) 2 pages Attachment 4B: Payee Data Record Supplement (STD 205) 2 pages Attachment 5: Darfur Certification 1 page Attachment 7: Experience/Past Performance (References) 1 page Attachment 8: Contractor Certification Clauses (CCC’s) 4 pages Attachment 9: PREA Volunteer/Contractor Information Sheet 3 pages Attachment 10: Economic Sanctions Certification 1 page

Bidder Instructions and Contract Provisions:

Bidders Instructions REV-0925* 10 pages General Provisions REV-1025* 22 pages Security Provisions REV-0925* 5 pages

NOTE: Items shown with an Asterisk (*), are hereby incorporated by reference and are located on our website at the following link http://www.calctra.ca.gov select About tab, then select Doing Business with CALCTRA.

A. Purpose and Description of Service

1. Contractor agrees to provide the California Correctional Training and Rehabilitation Authority (CALCTRA) with Respiratory Personal Protection (RPP) Compliance services throughout the State of California.

Refer to the Sample STD 213, Statement of Work and Payment Provisions, attached to this IFB as Attachment 2.

CALCTRA reserves the right, before the conclusion of the contract term to extend the contract for an additional one-year period. A written and approved amendment will be required to extend the contract prior to contract expiration.

B. Bid Information

1. Time Schedule

It is recognized that time is of the essence. All bidders are hereby advised of the following schedule and will be expected to adhere to the required dates and times. All times are Pacific Standard Time (PST)/Pacific Daylight Time (PDT).

*estimated timeframes

2. Bid Submittal

Bids must be received via U.S. Mail, common carrier, or hand delivered; no other method of response will be accepted. Bids not submitted under sealed cover may be rejected. Submit one (1) copy of the bid to the address and Contract Analyst on page 1 of this document. The interior sealed envelope must be plainly marked with the IFB number and title, must show your firm name and address, and must be marked with “DO NOT OPEN”, as shown in the following example:

EVENT DATE

TIME

(Pacific STD /Daylight Time)

IFB available to prospective bidders 6/3/26 Final Date for Bid Submission/Bid Opening 6/23/26 By 3:00 PM Successful Bidder Letter and Posting of Intent to Award* 6/24/26 5:00 PM Last Day to Appeal Intent to Award* 7/1/26 5:00 PM Proposed Start Date of Agreement* 9/1/2026

Company Name Company Address

IFB Number: 92102551 IFB Name: Respiratory Personal Protection (RPP) Compliance services Attention: ROMMEL DISUANCO

BID SUBMITTAL – DO NOT OPEN

C. Bidder’s Submittal Requirements

Experience: Contractor must provide proof of two (2) years of experience with services similar in nature to the services identified in the attached Scope of Work. Experience will be determined by documentation submitted by the Contractor and further information provided by the references submitted under the Past Performance requirement below. Experience is defined as the kind and amount of work a Contractor has done relevant to the work contemplated by this procurement.

Past Performance: Contractor will be evaluated on prior performance through Contractor’s references (Attachment 7), on three (3) projects similar in nature within the last three (3) years.

Past performance is defined as the Contractor’s record of conforming to standards of good workmanship; Contractor’s record of forecasting and controlling costs; Contractor’s adherence to contract schedules, including the administrative aspects of performance; Contractor’s history of reasonable and cooperative behavior and commitment to customer satisfaction; and the Contractor’s business-like concern for the interest of the customer.

Licenses/Permits: The Contractor shall provide copies of all required license(s) and permit(s) as required by the city, county, or both as determined by bidder’s place of business.

Executive Order N-6-22 – Russia Sanctions:

CALCTRA requires Bidders to include a completed Economic Sanctions Certification form (BSS-F069) as required by Executive Order N-6-22 in order to be eligible to conduct business with the State of California.

Executive Order N-12-23 – Generative Artificial Intelligence (GenAI):

The State of California seeks to realize the potential benefits of GenAI, through the development and deployment of GenAI tools, while balancing the risks of these new technologies.

Bidder / Offeror must notify the State in writing if it: (1) intends to provide GenAI as a deliverable to the State; or (2), intends to utilize GenAI, including GenAI from third parties, to complete all or a portion of any deliverable that materially impacts: (i) functionality of a State system, (ii) risk to the State, or (iii) Contract performance. For avoidance of doubt, the term “materially impacts” shall have the meaning set forth in State Administrative Manual (SAM) §

4986.2 Definitions for GenAI.

Failure to report GenAI to the State may result in disqualification. The State reserves the right to seek any and all relief to which it may be entitled to as a result of such non-disclosure.

Upon notification by a Bidder / Offeror of GenAI as required, the State reserves the right to incorporate GenAI Special Provisions into the final contract or reject bids/offers that present an unacceptable level of risk to the State.

Government Code 11549.64 defines “Generative Artificial Intelligence (GenAI)” as an artificial intelligence system that can generate derived synthetic content, including text, images, video, and audio that emulates the structure and characteristics of the system’s training data.

D. Bid Evaluation

Award of a contract resulting from this IFB will be based on the contractor providing the best value. The Contractor must meet or exceed the minimum requirements of the following criteria:

Category – Description Cost Past Performance Experience

E. Licenses and Permits

During the term of the contract, the Contractor must maintain all required licenses and/or permits in full force and effect. If and when the State learns that the Contractor has failed to do so, the State may, in addition to any other remedy it may have, immediately terminate this contract without any cost or liability to the State. If, after bid submission, the Contractor replaces or renews a required license or permit or obtains a newly-applicable license or permit, the Contractor shall provide the State with a copy of the renewed or replaced or newly-obtained license or permit within 20 days following the Contractor's receipt of same.

F. Standard Language

CALCTRA does not accept alternate contract language from a prospective contractor. A bid with such language will be considered a counter proposal and will be rejected. CALCTRA’s General Provisions (GP’s) are not negotiable.

G. Bid Attachments

Refer to the following pages for additional required attachments that are a part of this IFB.

ATTACHMENT 1

BID DOCUMENT SUBMITTAL CHECK LIST

A complete bid or bid package will consist of the items identified below.

Complete this checklist to confirm the items listed below have been included in your bid. Place a check mark or “X” next to each item that you are submitting. For your bid to be responsive, all required attachments must be returned. This checklist should be returned with your bid package.

NAME OF BIDDER:

COMPANY NAME:

Attachment Name/Description

_____ Attachment 1: Bid Document Submittal Check List _____ Attachment 3: Cost Sheet

_____ Attachment 4A: Payee Data Record (STD 204) NOTE: If company is incorporated, Payee’s Legal business name on the STD 204 must match the name registered with the Secretary of State of California.

_____ Attachment 4B: Payee Data Record Supplement (STD 205) NOTE: For use if additional remittance addresses are needed or if additional authorized representatives need to be identified.

_____ Attachment 5: Darfur Certification _____ Attachment 7: Experience/Past Performance (References) _____ Attachment 8: Contractor’s Certification Clauses _____ Attachment 9: PREA Volunteer/Contractor Information Sheet _____ Attachment 10: Economic Sanctions Certification

ADD OR DELETE AS NEEDED Additional Items Description (If Applicable)

_____ PLHCP credentials and Medical Director information

STATE OF CALIFORNIA

STANDARD AGREEMENT

STD 213 (Rev 6/21/06) AGREEMENT NUMBER S92102551

REGISTRATION NUMBER

RESPIRATORY PERSONAL PROTECTION COMPLIANCE SERVICES

1. This Agreement is entered into between the State Agency and the Contractor named below:

STATE AGENCY'S NAME

CALIFORNIA CORRECTIONAL TRAINING AND REHABILITATION AUTHORITY

CONTRACTOR'S NAME

TBD

2. The term of this

Month, Day, 2026 or upon approval, whichever is the later, through Month, Day, 2028

Agreement is:

3. The maximum amount $ 0.00 of this Agreement is: Dollars and No Cents

4. The parties agree to comply with the terms and conditions of the following exhibits that by this reference made a part of the Agreement.

Attachment 2 - Scope of Work and Payment Provisions 6 pages Appendix A- OSHA Respirator Medical Evaluation Questionnaire 5 pages Attachment 3 – Cost Sheet 1 page General Provisions REV-1025* 22 pages Security Provisions REV-0925* 5 pages NOTE: Items shown with an Asterisk (*), are hereby incorporated by reference and made part of this agreement as if attached

These documents can be viewed at http://www.calctra.ca.gov, (select About tab, then select Doing Business with CALCTRA).

IN WITNESS WHEREOF, this Agreement has been executed by the parties hereto.

CONTRACTOR

CONTRACTOR’S NAME (if other than an individual, state whether a corporation, partnership, etc.)

BY (Authorized Signature)

DATE SIGNED(Do not type)

PRINTED NAME AND TITLE OF PERSON SIGNING

ADDRESS

STATE OF CALIFORNIA

AGENCY NAME

California Correctional Training and Rehabilitation Authority BY (Authorized Signature)

DATE SIGNED(Do not type)

PRINTED NAME AND TITLE OF PERSON SIGNING

ADDRESS

560 East Natoma Street Folsom, CA 95630

SCOPE OF WORK AND PAYMENT PROVISIONS

I. SCOPE OF WORK

1. Contractor agrees to provide the California Correctional Training and Rehabilitation Authority

(CALCTRA) with Respiratory Personal Protection (RPP) Compliance services throughout the State of California.

A. The Contractor shall furnish all labor, including travel and per diem, materials, non-consumable supplies, parking fees and bridge tolls, insurance, transportation, equipment and every other item of expense necessary to perform services.

2. The services shall be performed at CALCTRA facilities throughout the State of California.

3. The services shall be provided during regular business hours, Monday through Friday, except

State holidays, or as directed by the CALCTRA Project Representative, or designee.

4. Service shall be available not later than the express date set by CALCTRA and the

Contractor, after all approvals have been obtained, the agreement is fully executed, and a Sage X3 Tracking Number is issued. Should the Contractor fail to commence work at the agreed upon time, the CALCTRA, upon five (5) days’ written notice to the Contractor, reserves the right to terminate the agreement effective immediately. In addition, the Contractor shall be liable to the CALCTRA for the difference between Contractor's bid price and the actual cost of performing work by another best value contractor.

5. The Project Representatives during the term of this agreement will be:

State Agency: CALCTRA Contractor:

Section/Unit: Section/Unit:

Attention: Attention:

Address: Address:

Phone: Phone:

Email: Email:

Note: No formal amendment of this agreement is needed to change the contact information. Changes will be made by written or electronic notification.

6. Contractor shall furnish to the CALCTRA a certificate of insurance, stating that there is Commercial General Liability, Worker’s Compensation, and Automotive Liability. The certificate of insurance shall include the following three (3) provisions in their entirety:

A. The insurer will not cancel the insured’s coverage without 30 days prior written notice to the State and will provide the State with a written 10-day notice for Contractor’s non-payment of premiums.

B. Under Contractor’s General Liability and Automobile Liability insurance CALCTRA and the State of California, its officers, agents, employees, and servants are included as additional insured, but only insofar as the operations under this contract are concerned.

C. The State will not be responsible for any premiums or assessment of the policy.

7. Contractor shall provide the following:

A. Provide RPP compliance services for the Occupational Safety and Health Administration

(OSHA) Medical Clearance Certificates (Medical Certificate) under Title 29 of the Code of Federal Regulations (CFR) Standard Number 1910.134 (OSHA Standard) for CALCTRA Employees.

B. Services include conducting Medical Questionnaires (Questionnaires, see Appendix A § 1910.134: OSHA Respirator Medical Evaluation Questionnaire) under the Standard, issuing Medical Certificates signed by a Physician or Licensed Healthcare Provider (PLHCP), providing further evaluation of employees by PLHCPs as necessary, Health Insurance Portability and Accountability Act (HIPAA) compliant storage of Medical Certificates, Fit Test Certificates, administrative and employee internet-based portals.

C. The service does not include Fit Testing or issuing Fit Test Certificates.

D. These services shall be provided for approximately 550 employees annually operating across 31 CALCTRA facilities throughout the State of California.

8. Vendor Requirements:

A. Vendor is to provide Software as a Service platform via an internet-browser-based portal

(Portal) with password protection.

B. Vendor shall annually provide OSHA Standard Number 1910.134 (OSHA Standard) compliant medical questionnaires (Questionnaires) to employees.

C. Portal shall allow the assignment of a unique CALCTRA site code (Site Code) and unique

CALCTRA employee identification number (Employee ID) to each employee.

D. Vendor is to provide differentiated Questionnaires and Medical Certificates to Employees for Respirator Types including Half-Face, Particulate, Powered air-purifying respirator (PAPR), and Supplied Air as defined in the OSHA Standard.

E. Based on employee responses to questionnaires, Vendor shall provide consultation from a PLHCP to employees, as needed, within 5 business days either via video conference such as Microsoft Teams or similar.

F. Vendor shall issue digital Medical Certificates in Portable Document Format (PDF) that include Employee ID, Site Code, Respirator Type, expiration date, and PLHCP signature.

G. Portal shall show a filterable compliance dashboard for all Employees including date of last Medical Clearance, date of last Fit Test, next Medical Clearance due date, next Fit Test Due date, employee active status, CALCTRA site code, Employee ID and overall compliance status.

H. Portals shall allow export of reports as digital files digital files as Comma Separated

Values (CSV[RD1.1] [DH1.2]) or in Microsoft Excel (Excel) format.

I. Platform shall send automatic email notifications to Employee and Administrator at intervals set by the Administrator prior to Medical Certificate and Fit Test Certificate due dates such as 30-days and 14-days prior.

J. Platform shall allow Administrator to upload Employee Fit Test certificates in Portable Document Format (PDF).

K. Platform shall allow Administrator to upload external Employee Medical Certificates from PLHCP not affiliated with Vendor and provide status and notifications for these certificates that are the same internal Certificates.

L. Platform shall support the migration of between 3,000 and 4,000 Medical and Fit Test Certificates from current vendor.

M. Vendor shall provide fully HIPAA and OSHA compliant retention of all Medical and Fit Test Certificates for a period of 30 years from employee’s termination date.

N. Portal shall allow bulk enrollment of employees CSV or Microsoft Excel format and including Respirator Type and Site Code.

O. Vendor will provide Employee and records management (view records, initiate evaluations, upload external clearances, reassign location) via portal or via email within 24 hours.

P. Portal will provide role-based access controls with audit logging (Administrator and HIPAA restricted role).

Q. Vendor will provide email or phone customer service response to Administrator inquiries within 4 hours during regular business hours.

R. Vendor shall offer training to Administrators on how to use the Portal.

S. All vendor services shall comply with the following regulations: US Title 29 CFR 1910.134

(OSHA Respiratory Protection), US Title 29 CFR 1910.1020 (Access to Medical Records), US HIPAA/ Health Information Technology for Economic and Clinical Health Act (HITECH) Title 45 CFR Parts 160 and 164.

T. Vendor shall enter into a Business Associate Agreement (BAA) prior to any Protected Health Information (PHI) transmission with CALCTRA.

U. All Vendor systems shall use Transport Layer Security (TLS) 1.2+ in transit, Advanced Encryption Standard (AES)-256 at rest.

V. Vendor will notify CALCTRA of any data breaches within 48 hours.

W. Vendor guarantees Portal uptime of 99%.

X. Platform screenshots including dashboard, compliance reporting showing multi-site support, external clearance upload.

Y. Workflow describing referral process for medical evaluation by PLHCP.

9. Executive Order N-6-22 – Russia Sanctions

On March 4, 2022, Governor Gavin Newsom issued Executive Order N-6-22 (the EO) regarding Economic Sanctions against Russia and Russian entities and individuals.

“Economic Sanctions” refers to sanctions imposed by the U.S. government in response to Russia’s actions in Ukraine, as well as any sanctions imposed under state law. The EO directs state agencies to terminate contracts with, and to refrain from entering into any new contracts with, individuals or entities that are determined to be a target of Economic Sanctions. Accordingly, should the State determine Contractor is a target of Economic

Sanctions or is conducting prohibited transactions with sanctioned individuals or entities, that shall be grounds for termination of this agreement. The State shall provide Contractor advance written notice of such termination, allowing Contractor at least 30 calendar days to provide a written response. Termination shall be at the sole discretion of the State.

10. Executive Order N-12-23 – Generative Artificial Intelligence (GenAI)

GenAI Technology Use & Reporting

During the term of the contract, Contractor must notify the State in writing if their services or any work under this contract includes, or makes available, any previously unreported GenAI technology, including GenAI from third parties or subcontractors. At the direction of the State, Contractor shall discontinue the use of any new or previously undisclosed GenAI technology that materially impacts functionality, risk or contract performance, until use of such GenAI technology has been approved by the State.

The State reserves the right to amend the contract, without additional cost, to incorporate GenAI Special Provisions into the contract at its sole discretion and/or terminate any contract that presents an unacceptable level of risk to the State.

11. CALCTRA reserves the right to amend the agreement, prior to expiration, in writing on the STD 213A. CALCTRA may adjust the terms of the agreement, including but not limited to the following:

A. Term extension up to one (1) year.

B. Decreasing the amount of the contract’s original value.

C. Increasing the contract amount by up to 30% of the original value.

II. PAYMENT PROVISIONS

1. Invoicing and Payment

A. For services satisfactorily rendered, and upon receipt and approval of the invoices, CALCTRA agrees to compensate the Contractor in accordance with the amount specified in the Cost Sheet , Attachment 3, which is attached hereto and made part of this agreement.

B. Invoices shall be itemized and include the time period covered by the invoice, work completed for the period (detailed statement of services) and number of hours worked (if applicable). Invoices shall include the six-digit Purchase Order (Sage X3) Number and the Agreement Number referenced in the executed contract cover letter. Invoices shall be submitted in triplicate not more frequently than once every 30 days in arrears to:

CALCTRA -

Attention: XXXX Address: XXXX

C. All invoice packages must contain original documents and be legible. Failure to provide original, legible documents will delay payment at Contractor’s expense.

D. Accurate/correct invoice packages must be submitted for review and payment in a timely manner subject to the following:

i. All invoices, including revised/amended/corrected invoices, must be received by

CALCTRA within 60 days from the date services were rendered.

ii. Invoices received by CALCTRA more than 60 days after the date services were rendered will be denied, deemed a forfeiture of payment by Contractor, and no payment will be issued.

a. It is Contractor’s responsibility to ensure invoices are received by CALCTRA by the deadline. No exceptions will be allowed for invoice packages lost in transit unless supported by documentation that they should have arrived on time (i.e., proof of overnight delivery).

b. If a revision/amendment/correction of a timely submitted invoice is requested by

CALCTRA, payment will not be forfeited if the requested invoice is received more than 60 days after the date services were rendered.

iii. All invoices received shall be deemed accurate/correct unless Contractor provides

CALCTRA with written notice of any error(s) within 60 days from the date services were rendered. Written notice must include a written explanation of the change, a revised/amended/corrected invoice, and supporting documentation.

iv. Invoices received by CALCTRA on the 60th day from the date services were rendered cannot be revised/amended/corrected by Contractor except at the request of

CALCTRA.

E. Contractors unable to provide accurate/correct invoice packages in a timely manner may receive a vendor performance report for failure to meet contract needs. Patterns related to failed vendor performance may result in termination of contract at any time.

F. Contractor is to provide a monthly report showing billed, paid, and outstanding invoices.

2. Availability of Funds

All financial obligations of CALCTRA for the fiscal year(s) encompassed by the term of this agreement are subject to the availability and approval of funding by the California Correctional Training and Rehabilitation Board and/or the presence of sufficient funds to cover those obligations in the fund from which those obligations are to be paid. If such obligations are, or become contingent, on funding by and/or through the CALCTRA budget or on the availability of federal funds or on the action of any Legislative body, said obligations are contingent on the appropriation and availability of funds for the purpose of meeting those obligations. If insufficient funds are approved or appropriated or otherwise available in order to meet CALCTRA’s obligations under this agreement, CALCTRA may immediately terminate this agreement.

3. Prompt Payment Clause

Payment will be made in accordance with, and within the time specified in, Government Code Chapter 4.5, commencing with Section 927. Unless expressly exempted by statute, the Act requires State agencies to pay properly submitted, undisputed invoices not more than 45 days after (a) the date of acceptance of goods or performance of services or (b) receipt of an undisputed invoice, whichever is later.

4. Cash Discounts

CALCTRA has a history of taking cash discounts and intends to take advantage of cash discounts offered when they are in the best interest of the CALCTRA.

Appendix A

§ 1910.134: OSHA Respirator Medical Evaluation Questionnaire

To the employer: Answers to questions in Section 1, and to question 9 in Section 2 of part A, do not require a medical examination.

To the employee:

Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers, and your employer must tell you how to deliver or send this questionnaire to the health care professional who will review it.

Part A. Section 1. (Mandatory) The following information must be provided by every employee who has been selected to use any type of respirator (please print).

1. Today's date:_______________________________________________________

2. Your name:__________________________________________________________

3. Your age (to nearest year):_________________________________________

4. Sex (circle one): Male/Female

5. Your height: __________ ft. __________ in.

6. Your weight: ____________ lbs.

7. Your job title:_____________________________________________________

8. A phone number where you can be reached by the health care professional who reviews this questionnaire (include the Area Code): ____________________

9. The best time to phone you at this number: ________________

10. Has your employer told you how to contact the health care professional who will review this questionnaire (circle one): Yes/No

11. Check the type of respirator you will use (you can check more than one category):

a. ______ N, R, or P disposable respirator (filter-mask, non-cartridge type only).

b. ______ Other type (for example, half- or full-facepiece type, powered-air purifying, supplied-air, self-contained breathing apparatus).

12. Have you worn a respirator (circle one): Yes/No

13. If "yes," what type(s):___________________________________________________________

14. Part A. Section 2. (Mandatory) Questions 1 through 9 below must be answered by every employee who has been selected to use any type of respirator (please circle "yes" or "no").

15. Do you currently smoke tobacco, or have you smoked tobacco in the last month: Yes/No

16. Have you ever had any of the following conditions?

a. Seizures: Yes/No

b. Diabetes (sugar disease): Yes/No

c. Allergic reactions that interfere with your breathing: Yes/No

d. Claustrophobia (fear of closed-in places): Yes/No

e. Trouble smelling odors: Yes/No

17. Have you ever had any of the following pulmonary or lung problems?

a. Asbestosis: Yes/No

b. Asthma: Yes/No

c. Chronic bronchitis: Yes/No

d. Emphysema: Yes/No

e. Pneumonia: Yes/No

f. Tuberculosis: Yes/No

g. Silicosis: Yes/No

h. Pneumothorax (collapsed lung): Yes/No

i. Lung cancer: Yes/No

j. Broken ribs: Yes/No

k. Any chest injuries or surgeries: Yes/No

l. Any other lung problem that you've been told about: Yes/No

18. Do you currently have any of the following symptoms of pulmonary or lung illness?

a. Shortness of breath: Yes/No

b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline: Yes/No

c. Shortness of breath when walking with other people at an ordinary pace on level ground:

Yes/No

d. Have to stop for breath when walking at your own pace on level ground: Yes/No

e. Shortness of breath when washing or dressing yourself: Yes/No

f. Shortness of breath that interferes with your job: Yes/No

g. Coughing that produces phlegm (thick sputum): Yes/No

h. Coughing that wakes you early in the morning: Yes/No

i. Coughing that occurs mostly when you are lying down: Yes/No

j. Coughing up blood in the last month: Yes/No

k. Wheezing: Yes/No

l. Wheezing that interferes with your job: Yes/No

m. Chest pain when you breathe deeply: Yes/No

n. Any other symptoms that you think may be related to lung problems: Yes/No

19. Have you ever had any of the following cardiovascular or heart problems?

a. Heart attack: Yes/No

b. Stroke: Yes/No

c. Angina: Yes/No

d. Heart failure: Yes/No

e. Swelling in your legs or feet (not caused by walking): Yes/No

f. Heart arrhythmia (heart beating irregularly): Yes/No

g. High blood pressure: Yes/No

h. Any other heart problem that you've been told about: Yes/No

20. Have you ever had any of the following cardiovascular or heart symptoms?

a. Frequent pain or tightness in your chest: Yes/No

b. Pain or tightness in your chest during physical activity: Yes/No

c. Pain or tightness in your chest that interferes with your job: Yes/No

d. In the past two years, have you noticed your heart skipping or missing a beat: Yes/No

e. Heartburn or indigestion that is not related to eating: Yes/No

f. Any other symptoms that you think may be related to heart or circulation problems:

Yes/No

21. Do you currently take medication for any of the following problems?

a. Breathing or lung problems: Yes/No

b. Heart trouble: Yes/No

c. Blood pressure: Yes/No

d. Seizures: Yes/No

22. If you've used a respirator, have you ever had any of the following problems? (If you've never used a respirator, check the following space and go to question 9:)

a. Eye irritation: Yes/No

b. Skin allergies or rashes: Yes/No

c. Anxiety: Yes/No

d. General weakness or fatigue: Yes/No

e. Any other problem that interferes with your use of a respirator: Yes/No

23. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire: Yes/No

24. Questions 10 to 15 below must be answered by every employee who has been selected to use either a full-facepiece respirator or a self-contained breathing apparatus (SCBA). For employees who have been selected to use other types of respirators, answering these questions is voluntary.

25. Have you ever lost vision in either eye (temporarily or permanently): Yes/No

26. Do you currently have any of the following vision problems?

a. Wear contact lenses: Yes/No

b. Wear glasses: Yes/No

c. Color blind: Yes/No

d. Any other eye or vision problem: Yes/No

27. Have you ever had an injury to your ears, including a broken ear drum: Yes/No

28. Do you currently have any of the following hearing problems?

a. Difficulty hearing: Yes/No

b. Wear a hearing aid: Yes/No

c. Any other hearing or ear problem: Yes/No

29. Have you ever had a back injury: Yes/No

30. Do you currently have any of the following musculoskeletal problems?

a. Weakness in any of your arms, hands, legs, or feet: Yes/No

b. Back pain: Yes/No

c. Difficulty fully moving your arms and legs: Yes/No

d. Pain or stiffness when you lean forward or backward at the waist: Yes/No

e. Difficulty fully moving your head up or down: Yes/No

f. Difficulty fully moving your head side to side: Yes/No

g. Difficulty bending at your knees: Yes/No

h. Difficulty squatting to the ground: Yes/No

i. Climbing a flight of stairs or a ladder carrying more than 25 lbs: Yes/No

j. Any other muscle or skeletal problem that interferes with using a respirator: Yes/No

31. Part B Any of the following questions, and other questions not listed, may be added to the questionnaire at the discretion of the health care professional who will review the questionnaire.

32. In your present job, are you working at high altitudes (over 5,000 feet) or in a place that has lower than normal amounts of oxygen: Yes/No

33. If "yes," do you have feelings of dizziness, shortness of breath, pounding in your chest, or other symptoms when you're working under these conditions: Yes/No

34. At work or at home, have you ever been exposed to hazardous solvents, hazardous airborne chemicals (e.g., gases, fumes, or dust), or have you come into skin contact with hazardous chemicals: Yes/No

35. If "yes," name the chemicals if you know them:_________________________

36. Have you ever worked with any of the materials, or under any of the conditions, listed below:

a. Asbestos: Yes/No

b. Silica (e.g., in sandblasting): Yes/No

c. Tungsten/cobalt (e.g., grinding or welding this material): Yes/No

d. Beryllium: Yes/No

e. Aluminum: Yes/No

f. Coal (for example, mining): Yes/No

g. Iron: Yes/No

h. Tin: Yes/No

i. Dusty environments: Yes/No

j. Any other hazardous exposures: Yes/No

37. If "yes," describe these exposures:____________________________________

38. List any second jobs or side businesses you have:___________________

39. List your previous occupations:_____________________________________

40. List your current and previous hobbies:________________________________

41. Have you been in the military services? Yes/No

42. If "yes," were you exposed to biological or chemical agents (either in training or combat): Yes/No

43. Have you ever worked on a HAZMAT team? Yes/No

44. Other than medications for breathing and lung problems, heart trouble, blood pressure, and seizures mentioned earlier in this questionnaire, are you taking any other medications for any reason (including over-the-counter medications): Yes/No

45. If "yes," name the medications if you know them:_______________________

46. 10. Will you be using any of the following items with your respirator(s)?

a. HEPA Filters: Yes/No

b. Canisters (for example, gas masks): Yes/No

c. Cartridges: Yes/No

47. 11. How often are you expected to use the respirator(s) (circle "yes" or "no" for all answers that apply to you)?:

a. Escape only (no rescue): Yes/No

b. Emergency rescue only: Yes/No

c. Less than 5 hours per week: Yes/No

d. Less than 2 hours per day: Yes/No

e. 2 to 4 hours per day: Yes/No

f. Over 4 hours per day: Yes/No

48. During the period you are using the respirator(s), is your work effort:

a. Light (less than 200 kcal per hour): Yes/No

49. If "yes," how long does this period last during the average shift:____________hrs.____________mins.

50. Examples of a light work effort are sitting while writing, typing, drafting, or performing light assembly work; or standing while operating a drill press (1-3 lbs.) or controlling machines.

a. Moderate (200 to 350 kcal per hour): Yes/No

51. If "yes," how long does this period last during the average shift:____________hrs.____________mins.

52. Examples of moderate work effort are sitting while nailing or filing; driving a truck or bus in urban traffic; standing while drilling, nailing, performing assembly work, or transferring a moderate load (about 35 lbs.) at trunk level; walking on a level surface about 2 mph or down a 5-degree grade about 3 mph; or pushing a wheelbarrow with a heavy load (about 100 lbs.) on a level surface.

a. Heavy (above 350 kcal per hour): Yes/No

53. If "yes," how long does this period last during the average shift:____________hrs.____________mins.

54. Examples of heavy work are lifting a heavy load (about 50 lbs.) from the floor to your waist or shoulder; working on a loading dock; shoveling; standing while bricklaying or chipping castings; walking up an 8-degree grade about 2 mph; climbing stairs with a heavy load (about 50 lbs.).

55. Will you be wearing protective clothing and/or equipment (other than the respirator) when you're using your respirator: Yes/No

56. If "yes," describe this protective clothing and/or equipment:__________

57. Will you be working under hot conditions (temperature exceeding 77 °F): Yes/No

58. Will you be working under humid conditions: Yes/No

59. Describe the work you'll be doing while you're using your respirator(s):

60. Describe any special or hazardous conditions you might encounter when you're using your respirator(s) (for example, confined spaces, life-threatening gases):

61. Provide the following information, if you know it, for each toxic substance that you'll be exposed to when you're using your respirator(s):

62. Name of the first toxic substance:___________________________________________

63. Estimated maximum exposure level per shift:__________________________________

64. Duration of exposure per shift:______________________________________________

65. Name of the second toxic substance:__________________________________________

66. Estimated maximum exposure level per shift:__________________________________

67. Duration of exposure per shift:______________________________________________

68. Name of the third toxic substance:___________________________________________

69. Estimated maximum exposure level per shift:__________________________________

70. Duration of exposure per shift:______________________________________________

71. The name of any other toxic substances that you'll be exposed to while using your respirator:

72. ____________________________________________________________________________

73. Describe any special responsibilities you'll have while using your respirator(s) that may affect the safety and well-being of others (for example, rescue, security):

[63 FR 1152, Jan. 8, 1998; 63 FR 20098, April 23, 1998; 76 FR 33607, June 8, 2011; 77 FR 46949, Aug. 7, 2012]

ATTACHMENT 3

COST SHEET

The estimated quantities indicated below will be used solely for computing the cost to determine the best value bidder and is not binding upon the contracting agency. However, the actual costs quoted by the bidder shall be binding for the term of the Agreement. CALCTRA is not obligated to purchase any quantity of services from the contractor.

Under no circumstances will the contractor be allowed to use a subcontractor for more than 50% of the contract dollar amount. For all services where a subcontractor is used, the contractor will be required to provide a minimum of 50% of the staffing for the project including project contact person.

It is unlawful for any person engaged in business within this state to sell or use any article or product as a “loss leader” as defined in Section 17030 of the Business and Professions Code.

Item No. Description of Work Details Unit Quoted Cost

1 Medical Clearance Certificate EA

2 Setup Fee / Initiation Fee EA

TOTAL

See Bidders Instructions Item 26 for complete instructions on offering Cash Discounts.

_____% Cash discount for payment within __________ days of receipt.

For accounting reporting purposes, please provide the following information: Are you certified with the California Department of General Services, Office of Small Business Certification and Resources (OSBCR) as:

a. California Small Business Micro Business

Yes No Yes No If yes, enter certification number: __________ Expiration Date: __________

b. Disabled Veteran Business Enterprise Yes No

If yes, enter your service code: __________

NAME OF

BIDDER:

COMPANY NAME

ADDRESS:

PHONE: FAX:

EMAIL:

AUTHORIZED

NAME:

PLEASE PRINT

AUTHORIZED

SIGNATURE DATE:

TITLE:

STATE OF CALIFORNIA – DEPARTMENT OF FINANCE

PAYEE DATA RECORD

(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 03/2021)

Section 1 – Payee Information NAME (This is required. Do not leave this line blank. Must match the payee’s federal tax return)

BUSINESS NAME, DBA NAME or DISREGARDED SINGLE MEMBER LLC NAME (If different from above)

MAILING ADDRESS (number, street, apt. or suite no.) (See instructions on Page 2)

CITY, STATE, ZIP CODE E-MAIL ADDRESS

Section 2 – Entity Type Check one (1) box only that matches the entity type of the Payee listed in Section 1 above. (See instructions on page 2)

CORPORATION (see instructions on page 2)SOLE PROPRIETOR / INDIVIDUAL MEDICAL (e.g., dentistry, chiropractic, etc.)SINGLE MEMBER LLC Disregarded Entity owned by an individual

PARTNERSHIP

ESTATE OR TRUST

LEGAL (e.g., attorney services)

EXEMPT (e.g., nonprofit)

ALL OTHERS

Section 3 – Tax Identification Number Enter your Tax Identification Number (TIN) in the appropriate box. The TIN must match the name given in Section 1 of this form. Do not provide more than one (1) TIN.

The TIN is a 9-digit number. Note: Payment will not be processed without a TIN.

For Individuals, enter SSN.

If you are a Resident Alien, and you do not have and are not eligible to get an SSN, enter your ITIN.

Grantor Trusts (such as a Revocable Living Trust while the grantors are alive) may not have a separate FEIN. Those trusts must enter the individual grantor’s SSN.

For Sole Proprietor or Single Member LLC (disregarded entity), in which the sole member is an individual, enter SSN (ITIN if applicable) or FEIN (FTB prefers SSN).

For Single Member LLC (disregarded entity), in which the sole member is a business entity, enter the owner entity’s FEIN. Do not use the disregarded entity’s FEIN.

For all other entities including LLC that is taxed as a corporation or partnership, estates/trusts (with FEINs), enter the entity’s FEIN.

Social Security Number (SSN) or Individual Tax Identification Number (ITIN)

OR

Federal Employer Identification Number

(FEIN)

Section 4 – Payee Residency Status (See instructions)

CALIFORNIA RESIDENT – Qualified to do business in California or maintains a permanent place of business in California.

CALIFORNIA NONRESIDENT – Payments to nonresidents for services may be subject to state income tax withholding.

No services performed in California

Copy of Franchise Tax Board waiver of state withholding is attached.

Section 5 – Certification I hereby certify under penalty of perjury that the information provided on this document is true and correct.

Should my residency status change, I will promptly notify the state agency below.

NAME OF AUTHORIZED PAYEE REPRESENTATIVE TITLE E-MAIL ADDRESS

SIGNATURE DATE TELEPHONE (include area code)

Section 6 – Paying State Agency Please return completed form to:

STATE AGENCY/DEPARTMENT OFFICE UNIT/SECTION

MAILING ADDRESS FAX TELEPHONE (include area code)

CITY STATE ZIP CODE E-MAIL ADDRESS

California Prison Industry Authority (CALPIA) Business Services Section (BSS)

560 East Natoma Street (916) 358-1811 (916) 358-2755

Folsom CA 95630 bsshelpdesk@calpia.ca.gov

Print Form Reset Form

California Correctional Training and Rehabilitation Authority (CALCTRA) Respiratory Personal Protection (RPP) Compliance Services

ATTACHMENT 4A

STATE OF CALIFORNIA – DEPARTMENT OF FINANCE

PAYEE DATA RECORD

(Required when receiving payment from the State of California in lieu of IRS W-9 or W-7) STD 204 (Rev. 03/2021)

GENERAL INSTRUCTIONS

Type or print the information on the Payee Data Record, STD 204 form. Sign, date, and return to the state agency/department office address shown in Section 6.

Prompt return of this fully completed form will prevent delays when processing payments.

Information provided in this form will be used by California state agencies/departments to prepare Information Returns (Form1099).

NOTE: Completion of this form is optional for Government entities, i.e. federal, state, local, and special districts.

A completed Payee Data Record, STD 204 form, is required for all payees (non-governmental entities or individuals) entering into a transaction that may lead to a payment from the state. Each state agency requires a completed, signed, and dated STD 204 on file; therefore, it is possible for you to receive this form from multiple state agencies with which you do business.

Payees who do not wish to complete the STD 204 may elect not to do business with the state. If the payee does not complete the STD 204 and the required payee data is not otherwise provided, payment may be reduced for federal and state backup withholding. Amounts reported on Information Returns (Form 1099) are in accordance with the Internal Revenue Code (IRC) and the California Revenue and Taxation Code (R&TC).

Section 1 – Payee Information Name – Enter the name that appears on the payee's federal tax return. The name provided shall be the tax liable party and is subject to IRS TIN matching (when applicable).

Sole Proprietor/Individual/Revocable Trusts – enter the name shown on your federal tax return.

Single Member Limited Liability Companies (LLCs) that is disregarded as an entity separate from its owner for federal tax purposes - enter the name of the individual or business entity that is tax liable for the business in section 1. Enter the DBA, LLC name, trade, or fictitious name under Business Name.

Note: for the State of California tax purposes, a Single Member LLC is not disregarded from its owner, even if they may be disregarded at the Federal level.

Partnerships, Estates/Trusts, or Corporations – enter the entity name as shown on the entity’s federal tax return. The name provided in Section 1 must match to the TIN provided in section 3. Enter any DBA, trade, or fictitious business names under Business Name.

Business Name – Enter the business name, DBA name, trade or fictitious name, or disregarded LLC name.

Mailing Address – The mailing address is the address where the payee will receive information returns. Use form STD 205, Payee Data Record Supplement to provide a remittance address if different from the mailing address for information returns, or make subsequent changes to the remittance address.

Section 2 – Entity Type If the Payee in Section 1 is a(n)… THEN Select the Box for…

Grantor (Revocable Living) Trust disregarded for federal tax purposes Sole Proprietor/Individual Limited Liability Company (LLC) owned by an individual and is disregarded for federal tax purposes Single Member LLC-owned by an individual Partnerships Limited Liability Partnerships (LLP) and, LLC treated as a Partnership Partnerships Estate Trust (other than disregarded Grantor Trust) Estate or Trust Corporation that is medical in nature (e.g., medical and healthcare services, physician care, nursery care, dentistry, etc. LLC that is to be taxed like a Corporation and is medical in nature

Corporation-Medical

Corporation that is legal in nature (e.g., services of attorneys, arbitrators, notary publics involving legal or law related matters, etc.) LLC that is to be taxed like a Corporation and is legal in nature

Corporation-Legal

Corporation that qualifies for an Exempt status, including 501(c) 3 and domestic non-profit corporations. Corporation-Exempt Corporation that does not meet the qualifications of any of the other corporation types listed above LLC that is to be taxed as a Corporation and does not meet any of the other corporation types listed above

Corporation-All Other

Section 3 – Tax Identification Number The State of California requires that all parties entering into business transactions that may lead to payment(s) from the state provide their Taxpayer Identification Number (TIN). The TIN is required by R&TC sections 18646 and 18661 to facilitate tax compliance enforcement activities and preparation of Form 1099 and other information returns as required by the IRC section 6109(a) and R&TC section 18662 and its regulations.

Section 4 – Payee Residency Status Are you a…