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Agenda 10/14/2025 Item #16F 2 (Award RFP #25-8350 for Medical Director and Deputy Medical Director to James Augustine and Medical Director and S. Sandoval MD, LLC as Deputy Medical Director)10/14/2025 Item # 16.F.2 ID# 2025-4224 Executive Summary Recommendation to award Request for Proposal No. 25-8350, “Medical Director and Deputy Medical Director,” to James Augustine as Medical Director and S. Sandoval, MD, LLC as Deputy Medical Director, and authorize the Chair to sign the attached agreements. OBJECTIVE: To continue to provide exemplary Collier Emergency Medical Service (“EMS”) pre-hospital emergency medical care. CONSIDERATIONS: Florida Statutes require that every County operating a basic life support transportation service or advanced life support service employ or contract with a Medical Director and Deputy Medical Director. The Medical Director and Deputy Medical Director supervise and assume direct responsibility for the medical performance of the emergency medical technicians and paramedics employed by EMS. On February 7, 2025, the Procurement Services Division released Request for Proposal (“RFP”) No. 25-8350, “Medical Director and Deputy Medical Director,” and the County received eight (8) proposals by the March 10, 2025 deadline. All proposers were found to be responsive and responsible. The County extended the solicitation deadline one (1) week to allow staff to conduct additional vendor outreach. Company Name City County State Final Ranking Responsible / Responsive Medical Director James Augustine, M.D. Naples Collier FL 1 Yes/Yes Douglas S. Lee M.D. Naples Collier FL 2 Yes/Yes Antonio Gandia M.D. P.A. Deerfield Broward FL 3 Yes/Yes Deputy Medical Director S. Sandoval, M.D., LLC Naples Collier FL 1 Yes/Yes Travis Weber, M.D. Naples Collier FL 2 Yes/Yes Aldo Manresa D.O. Deerfield Broward FL 3 Yes/Yes Medicus Healthcare Solutions LLC Windham Rockingham NH Not Ranked Yes/Yes Sunshine Enterprise USA L.L.C. Maitland Orange FL Not Ranked Yes/Yes The selection committee met on July 22, 2025, and after reviewing the proposals and deliberating, the committee scored the proposals and shortlisted the top three proposals to advance to Step 2, Oral Presentations. On August 20, 2025, the selection committee reconvened for Step 2 Oral Presentations, which resulted in a Final Ranking reached by the selection committee as follows: Medical Director: James Augustine– Ranked #1 Douglas S. Lee MD – Ranked #2 Antonio Gandia MD P.A. – Ranked #3 Deputy Medical Director: S. Sandoval, MD, LLC – Ranked #1 Travis Weber, MD – Ranked #2 Aldo Manresa DO – Ranked #3 Page 4776 of 6526 10/14/2025 Item # 16.F.2 ID# 2025-4224 Staff is recommending awarding the attached Agreements to James Augustine for Medical Director and S. Sandoval, MD, LLC for Deputy Medical Director. The attached contracts include an initial three-year term, with three additional two-year renewal terms available upon the agreement of the parties. This item is consistent with the Collier County strategic plan objective to support and enhance our commitment to robust public safety services. FISCAL IMPACT: The funding for these positions is already budgeted under the Emergency Medical Services Fund (4050). GROWTH MANAGEMENT IMPACT: There is no growth management impact associated with this action. LEGAL CONSIDERATIONS: This item is approved as to form and legality and requires majority vote for Board approval. — SRT RECOMMENDATIONS: To award Request for Proposal No. 25-8350, “Medical Director and Deputy Medical Director,” to James Augustine as Medical Director and S. Sandoval, MD, LLC as Deputy Medical Director, and authorize the Chair to sign the attached agreements. PREPARED BY: Charles Kammerer, Supervisor – Accounting, Corporate Financial & Management Services ATTACHMENTS: 1. 25-8350 James Augustine Contract VS 2. 25-8350 S. Sandoval Contract VS 3. 25-8350 NORA 4. 25-8350 Final Ranking Medical Director 5. 25-8350 Final Ranking Deputy Medical Director 6. 25-8350 Solicitation 7. 25-8350 James Augustine Proposal 8. 25-8350 S. Sandoval Proposal Page 4777 of 6526 Page 4778 of 6526 Page 4779 of 6526 Page 4780 of 6526 Page 4781 of 6526 Page 4782 of 6526 Page 4783 of 6526 Page 4784 of 6526 Page 4785 of 6526 Page 4786 of 6526 Page 4787 of 6526 Page 4788 of 6526 Page 4789 of 6526 Page 4790 of 6526 Page 4791 of 6526 Page 4792 of 6526 Page 4793 of 6526 Page 4794 of 6526 Page 4795 of 6526 Page 4796 of 6526 Page 4797 of 6526 Page 4798 of 6526 Page 4799 of 6526 Page 4800 of 6526 Page 4801 of 6526 Page 4802 of 6526 Page 4803 of 6526 Page 4804 of 6526 Page 4805 of 6526 Page 4806 of 6526 Page 4807 of 6526 Page 4808 of 6526 Page 4809 of 6526 Page 4810 of 6526 Page 4811 of 6526 Page 4812 of 6526 Page 4813 of 6526 Page 4814 of 6526 Page 4815 of 6526 Page 4816 of 6526 Page 4817 of 6526 I f I FIRST WITNF.SS: ,\~~ s DEPUTY MEDICAL DIRECTOR L aricly Sandoval, M.D. Its Manager Page 11 of21 Page 4818 of 6526 Page 4819 of 6526 Page 4820 of 6526 Page 4821 of 6526 Page 4822 of 6526 Page 4823 of 6526 t I l l AfflDAVIT REGARDING LAIIOR AND SDVICIS AND CONTRAC11NG WITH ENTITIIS OJ JOR&IGN COUNTRIESOl'CONCIRN PROHIBrnD Effective July 1. 2024. punuant IO f 717.06(13), Florida Slalu1ea1 when I contract ls axcc=Ulod, renewed, o, extended between a wpemma,ta entity and a aowrnmeetaJ entity, the nanaOYerNnentat entity muss provide lbe ,ovemmen&al entity with an affldavk llped by an officer o, 1 repreaentatlw of tho IIClftl0¥Cl'llltal entity under penalty of perjury a1111tJn1 that tbe DCJIICO\fCfflfflenlll tntlcy doea not UN c:ocn:iall rcw labor o MMCel. EffcctiYC Jaa.-y I, 202~, 11ownncnlal entity anay not accept a bid cm, 1 propoul f«, « a reply to,« enter lnlo, a conaraa whit an entlt! which wowd paat die entity ICCCU lo 11ft .individual's penc,Ml ideatifyinc iafonutioa •lea the entity provldel the acmmmcnt wltb • amd1vit siped by an officer « ropraentetiw Wider peMlty or perjury IUe!tin, tue lhe entity doel not ,_.. any of the followln& crlttria: (1 tho entity ii owned by die pwmment of a forelp coumay of concern; (b) lhe l&M'•Wnt .,r I foreip COUDtry or conccn his I comrollini in&ertlt in the eatky. « (c:) die entity is orpnized UAdcr-the laws or« has its principal placo of buaioeu iD I beip coumry ol cc,ncem, RfTcc:dw July I, 202.S, when • entity cxteadl or renews a contraet with a aovem,nental c,ntily which would pant the entity acce11 to • indlvidual'a penonal idelllllyin& laf'ormatioll. tho entity mlllt provide the pvcmmenlll entity w~ • affidavit aiped by ., officer o ropn:sc,ntative oftbo entity UNer penalty of perjury anatinc dla the entity doCII not meet any of the criwla in paracraphl ClX•Hc:). f 217.131 Florida Statuea. Nongovemmontal &thy'a Name: S. Sandoval MD LLC Acldrcsa: 11665 Collier Blvd #786 Na les Fl Phone Number: Aldhol izied Representative's Name: Autho.md Represcntalive'a Title: BmallAddress: I, Sariety Sandoval (Name o( Authorbled Rep,111 .... iw), M Mhorized rep11entlllivt auat under penalty of~ that 5 Sandoval MD 11 C (Name ofNoqowmmeetal F.atity) doea not: (I) 1111 coerdoa ror labor o teriicel M defined in f 717.06, Flcirida Statutes, Mid (2) the ftOlt&C)YClfflfcntal entity is not (a) owned by a IOWll'lllnall of I forefp country o cooum, (b) that I foreip country of concern docs not hive I controllin& inaerCllt la &he efttity, and (e) tblt the entity ii not orpnlzed ander th& laws of or hll 111 principal place otbulineu in I foroip coun&ry of concern, all u prohibited Wldar f 217.131 1 Florida Statuta. Under ~f pcrj~l~haverad the fcncoifta Affl~vit •n~ diet the r.cts Uled in it an tnae. ~ 2 z-t:t11q12S (Si&neturcofauthoriad lllplCIOfthidYC) Dia / 1 STA TB OF __ ......,,,............--'_ COUNTY OP-~,A.J,-&,_L.L- l blfore Ill of pbyakal preamce Of a online notlriulion lhil by v 0.(' (Hime or Affiant), who produced his Florida Driwr'a Lk:cnle II ideotil\c:ation NotaryPu Uc ~fl Commluion Expires , P,nonally 1CMwD DOR Prodlacocl ldcnllllclll~ £/ r,7 Typo of ldeotlftcatlon Produced: Ci_ J/<._, Page 17 of21 --------- t l,;,~ -~ .4TT1U HEPP I 1 -~~~ Noury Public • Sutt cf Flond• fa~\X,'./J Comm,sston ~ HH 601539 1 ~°'-!'t' M.y Comm. ~j)trt) Jan t,, 2029 t !onct<S throu1h Nat1or11 Notary Assn I ( • /$J Page 4824 of 6526 Page 4825 of 6526 Page 4826 of 6526 Page 4827 of 6526 Page 4828 of 6526 Page 4829 of 6526 Page 4830 of 6526 Page 4831 of 6526 Page 4832 of 6526 Page 4833 of 6526 Page 4834 of 6526 BUSINF.SS ASSOCIA T8: S. Sandoval, M.D. LLC By: JJ $ a y Sandoval, M.D. Tide: 1ta Mnlcr Si ~ ~lJJt,..,t\_, Q l~ \M.'1:,~ PrintNamo hp.i&olll Page 4835 of 6526 Notice of Recommended Award Solicitation: #25-8350 Title: Medical Director and Deputy Medical Director Due Date and Time: March 26, 2025, at 3:00 pm EST Proposers: Company Name City County State Final Ranking Responsive/Responsible Medical Director James Augustine Naples Collier FL 1 Yes/Yes Douglas S. Lee MD Naples Collier FL 2 Yes/Yes Antonio Gandia MD P.A. Deerfield Broward FL 3 Yes/Yes Deputy Medical Director S. Sandoval, MD, LLC Naples Collier FL 1 Yes/Yes Travis Weber, MD Naples Collier FL 2 Yes/Yes Aldo Manresa DO Deerfield Broward FL 3 Yes/Yes Medicus Healthcare Solutions LLC Windham Rockingham NH Not Ranked Yes/Yes Sunshine Enterprise USA L.L.C. Maitland Orange FL Not Ranked Yes/Yes Utilized Local Vendor Preference: Yes No Recommended Proposers For Award: On February 7, 2025, the Procurement Services Division released Request for Proposal (“RFP”) No. 25 -8350, “Medical Director and Deputy Medical Director”, to two thousand eight hundred forty-six (2,846) vendors. Six hundred sixty (660) solicitation packages were viewed, and eight (8) submittals were received by the March 10, 2025, deadline. All proposers were found to be responsive and responsible. The solicitation deadline was extended for one (1) week, during which time staff conducted additional vendor outreach. The Selection Committee met on May 5, 2025. After reviewing the proposals and deliberation, the Committee scored the proposals and were shortlisted/final ranked. Due to an appearance of disregarded of Cone of Silence, the decision was made to reconvene the Selection Committee Meeting with a new committee. The Selection Committee reconvened on July 22, 2025. After reviewing the proposals and deliberation, the Committee scored the proposals and were shortlisted as noted below and the top three Proposers moved on to Step 2 Oral Presentations: Medical Director: Douglas S. Lee MD – Ranked #1 James Augustine – Ranked #2 Antonio Gandia MD P.A. – Ranked #3 Medicus Healthcare Solutions LLC – Ranked #4 Sunshine Enterprise USA L.L.C. – Ranked #5 Deputy Medical Director: S. Sandoval, MD, LLC – Ranked #1 Travis Weber, MD – Ranked #2 Aldo Manresa DO – Ranked #3 Sunshine Enterprise USA L.L.C. – Ranked #4 Medicus Healthcare Solutions LLC – Ranked #5 Docusign Envelope ID: D8184959-4321-4B38-B9E7-58E6FA0D872D Page 4836 of 6526 On August 20, 2025, the Selection Committee reconvened for Step 2 Oral Presentations and Final Ranking. The Committee ranked the proposers as follows: Medical Director: James Augustine– Ranked #1 Douglas S. Lee MD – Ranked #2 Antonio Gandia MD P.A. – Ranked #3 Deputy Medical Director: S. Sandoval, MD, LLC – Ranked #1 Travis Weber, MD – Ranked #2 Aldo Manresa DO – Ranked #3 Staff is recommending award to the top-ranked Proposer, James Augustine for Medical Director and S. Sandoval, MD, LLC for Deputy Medical Director. Contract Driven Purchase Order Driven Required Signatures Project Manager: Procurement Strategist: Procurement Services Division Director: __________________________________ _________________ Sandra Srnka Date Docusign Envelope ID: D8184959-4321-4B38-B9E7-58E6FA0D872D 8/25/2025 8/25/2025 8/25/2025 Page 4837 of 6526 Selection Committee Final Ranking Sheet Medical Director RFP #:25-8350 Title: Medical Director and Deputy Medical Director Name of Firm Chris Johnson John Dunnuck Michael Nieman Andrew Kelly Cormac Gilin Total Selection Committee Final Rank James Augustine 1 2 1 2 1 7 1.0000 Douglas S. Lee MD 2 1 2 1 2 8 2.0000 Antonio Gandia MD PA 3 3 3 3 3 15 3.0000 Procurement Professional Date 8/20/2025Barbara Lance Page 1 of 1 Page 4838 of 6526 Selection Committee Final Ranking Sheet Deputy Medical Director RFP #:25-8350 Title: Medical Director and Deputy Medical Director Name of Firm Chris Johnson John Dunnuck Michael Nieman Andrew Kelly Cormac Gilin Total Selection Committee Final Rank Sariely Sandoval, MD LLC 1 1 1 1 1 5 1.0000 Travis Weber, MD 2 2 2 2 2 10 2.0000 Aldo Manresa DO 3 3 3 3 3 15 3.0000 Procurement Professional Date 8/20/2025Barbara Lance Page 1 of 1 Page 4839 of 6526 COLLIER COUNTY BOARD OF COUNTY COMMISSIONERS REQUEST FOR PROPOSAL (RFP) FOR MEDICAL DIRECTOR AND DEPUTY MEDICAL DIRECTOR SOLICITATION NO.: 25-8350 BARBARA LANCE, PROCUREMENT STRATEGIST PROCUREMENT SERVICES DIVISION 3295 TAMIAMI TRAIL EAST, BLDG C-2 NAPLES, FLORIDA 34112 TELEPHONE: (239) 252-8998 Barbara.Laqnce@colliercountyfl.gov (Email) This solicitation document is prepared in a Microsoft Word format (Rev 8/7/2017). Any alterations to this document made by the Vendor may be grounds for rejection of proposal, cancellation of any subsequent award, or any other legal remedies available to the Collier County Government. Page 4840 of 6526 2 SOLICITATION PUBLIC NOTICE REQUEST FOR PROPOSAL (RFP) NUMBER: 25-8350 PROJECT TITLE: MEDICAL DIRECTOR AND DEPUTY MEDICAL DIRECTOR DUE DATE: MARCH 5, 2025, AT 3:00 PM EST PLACE OF RFP OPENING: PROCUREMENT SERVICES DIVISION 3295 TAMIAMI TRAIL EAST, BLDG C-2 NAPLES, FL 34112 All proposals shall be submitted online via the Collier County Procurement Services Division Online Bidding System: https://procurement.opengov.com INTRODUCTION As requested by the Emergency Medical Services Division (hereinafter, the “Division” and “EMS”), the Collier County Board of County Commissioners Procurement Services Division (hereinafter, “County”) has issued this Request for P roposal (hereinafter, “RFP”) with the intent of obtaining proposals from interested and qualified vendors (also referred to “firms” “contractors” and “proposers” in accordance with the terms, conditions and specifications stated or attached. The vendor, at a minimum, must achieve the requirements of the Specifications or Scope of Work stated. Collier County is soliciting for the positions of Medical Director and Deputy Medical Director . Historically, the County has spent approximately $300,000 annually; however, this may not be indicative of future buying patterns. BACKGROUND Per Florida Statutes, each County operating a basic life support transportation service or advanced life support service must employ or contract with a Medical Director and Deputy Medical Director. The Medical Director and Deputy Medical Director must be a licensed physician; a corporation, association, or partnership composed of physicians; or physicians employed by any hospital that delivers in-hospital emergency medical services and employs or contracts with physicians specifically for that pur pose. Such a hospital, physician, corporation, association, or partnership must designate one physician from that organization to be Medical Director or Deputy Medical Director at any given time. The Medical Director and/or Deputy Medical Director must supervise and assume direct responsibility for the medical performance of the emergency medical technicians and paramedics operating for th at emergency medical services system. TERM OF CONTRACT The contract term, if an award(s) is/are made is intended to be for three (3) years with three (3) two (2) year renewal options. Prices shall remain firm for the initial term of this contract. Surcharges will not be accepted in conjunction with this contract, and such charges should be incorporated into the pricing s tructure. The County Manager, or designee, may, at his discretion, extend the Agreement under all of the terms and conditions contained in this Agreement for up to one hundred eighty (180) days. The County Manager, or designee, shall give the Contractor written n otice of the County's intention to extend the Agreement term not less than ten (10) days prior to the end of the Agreement term the n in effect. All goods are FOB destination and must be suitably packed and prepared to secure the lowest transportation rates and to comply with all carrier regulations. Risk of loss of any goods sold hereunder shall transfer to the COUNTY at the time and place of delivery; provided that risk of loss prior to actual receipt of the goods by the COUNTY nonetheless remain with VENDOR. DETAILED SCOPE OF WORK In accordance with Section 401.265, Florida Statutes responsibilities for Medical Directors include: (1) The Medical Director's responsibility is to provide professional services as Medical Director for the County in accordanc e with Chapter 401, Florida Statutes and Chapter 64 -J-1, Florida Administrative Code, and the Rules of the Department of Health. Page 4841 of 6526 3 (2) Each basic life support transportation service or advanced life support service must employ or contract with a Medical Di rector. The Medical Director must be a licensed physician; a corporation, association, or partnership composed of physicians; or physicians employed by any hospital that delivers in-hospital emergency medical services and employs or contracts with physicians specifically for that purpose. Such a hospital, physician, corporation, association, or partnership must designate one physician from that organization to be medical director at any given time. The Medical Director must supervise and assume direct responsibility for the medical performance of the emergency medical technicians and paramedics operating for that emergency medical services system. The Medical Director must perform duties including advising, consulting, training, counseling, and overseeing of services, including appropriate quality assurance but not including administrative and manageri al functions. (3) Each Medical Director shall establish a quality assurance committee to provide for quality assurance review of all emerge ncy medical technicians and paramedics operating under his or her supervision. If the Medical Director has reasonable belief that conduct by an emergency medical technician or paramedic may constitute one or more grounds for discipline as provided by this part, he or she shall document facts and other information related to the alleged violation. The Medical Director shall report to the department any emergency medical technician or paramedic whom the medical director reasonably believes to have acted in a manner which might constitute grounds for disciplinary action. Such a report of disciplinary concern must include a statement and documentation of the specific acts of the disciplinary concern. Within 7 days after receipt of such a report, the department shall provide the emergency medical technician or paramedic a copy of the report of the disciplinary concern and documentation of the specific acts related to the disciplinary concern. If the department determines that the report is insufficient for disciplinary action against the emergency medical technician or paramedic pursuant to Section 401.411, Florida Statutes, the report shall be expunged from the record of the emergency medical technician or paramedic. (4) Any Medical Director who in good faith gives oral or written instructions to certified emergency medical services personn el for the provision of emergency care shall be deemed to be providing emergency medical care or treatment for the purposes of Section 768.13(2), Florida Statutes. (5) Each Medical Director who uses a paramedic or emergency medical technician to perform blood pressure screening, health promotion, and wellness activities, or to administer immunization on any patient under a protocol as specified in Section 401.272, Florida Statutes, which is not in the provision of emergency care, is liable for any act or omission of any paramedic or emergency medical technician acting under his or her supervision and control when performing such services. (6) The department shall adopt and enforce all rules necessary to administer this section. Requirements and Qualifications of the Medical Director include: 1. Medical Director shall implement such planning and coordination which may be necessary to deliver advanced life support by Paramedics (including EMS and Fire District personnel) trained to the level of advanced and basic medical technicians, which may require intravenous administration of emergency resuscitative drugs and the performance of sophisticated technical emergency procedures. 2. Medical Director shall perform a broad-based medical specialty such as emergency medicine, internal medicine, anesthesiology, or other surgical specialty, with demonstrated experience in pre-hospital care and hold an ACLS certification of successful course completion or be board certified in emergency medicine. 3. Medical Director shall demonstrate and have available for review documentation of active participation in a regional or state wide physician group involved in pre-hospital care. He/she shall supervise and accept direct responsibility for the medical performance of the paramedics working for Collier County EMS. 4. Medical Director shall supervise and accept direct responsibility for the medical performance of the paramedics working for Collier County EMS. 5. Medical Director shall develop medically correct standing orders or protocols relating to life support system procedures when communication cannot be established with a supervising physician or when any delay in patient care would potentially threaten the life or health of the patient. 6. Medical Director shall issue standing orders and protocols to Collier County EMS to ensure that it transports each of its pat ients to facilities that offer a type and level of care appropriate to the patient's medical condition if available within the se rvice region. 7. Medical Director shall provide continuous 24 -hour-per-day, 7-day-per-week of medical direction which shall include, in addition to the development of protocols and standing orders, direction to Collier County EMS personnel as to the availabilit y of "off-line" service to resolve problems, system conflicts, and provide services in an emergency as that term is defined by Section 252.34(4), Florida Statutes. 8. Medical Director shall establish a quality assurance committee to provide for quality assurance review of all paramedics operating under his supervision. 9. Medical Director shall audit the performance of system personnel by use of a quality assurance program that includes but is n ot limited to a prompt review of patient care records, direct observation, and comparison of performance standards for drugs, equipment, system protocols and procedures. 10. Medical Director shall participate in quality assurance programs that may be developed by the department. Page 4842 of 6526 4 11. Ensure and certify that security procedures of the Collier County EMS for medications, fluids and controlled substances are in compliance with Florida Statutes Chapters, 499 and 893, and Chapter 61N -1, of the Florida Administrative Code (F.A.C). 12. Medical Director shall create, authorize and ensure adherence to, detailed written operating procedures regarding all as pects of the handling of medications, fluids and controlled substances by the EMS personnel and comply with all requirements of Flo rida Statutes Chapters 401,499 and 893. 13. Medical Director shall notify the Florida Department of Health, (hereinafter the "Department") in writing when the use o f telemetry is not necessary. 14. Medical Director shall notify the department in writing of each substitution by Collier County EMS of equipment or medication . 15. Medical Director shall assume direct responsibility for the use by a Collier County paramedic of an automatic or semi -automatic defibrillator and the performance of esophageal intubation, and on routine interfacility transports, the monitoring and maintenance of non-medicated I.V.s. Ensure that the paramedic is trained to perform these procedures; establish written protocols for the performance of these procedures; and provide written evidence to the department documenting compliance with the provisions of this paragraph. 16. Medical Director shall ensure that all paramedics are trained in the use of the trauma scorecard methodologies as provid ed in Sections 64J-2.004 of the F.A.C., for adult trauma patients and Section 64J-2.0005, F.A.C., for pediatric trauma patients. 17. Medical Director shall participate as a crew member on an EMS vehicle for a minimum of 10 hours per year and complete a minimum of 10 hours per year of continuing medical education related to pre-hospital care or teaching or a combination of both. 18. Medical Director shall ensure that all Collier County paramedics have all proper certifications and receive all training nece ssary to maintain their certification. 19. Medical Director shall be physically present in the COUNTY EMS Administrative Offices on as needed basis; in order to confer with the EMS Chief and other designated staff. All official meetings attended by the Medical Director which have been approve d by the EMS Chief, will be recognized as part of the normal job duties of Medical Director. 20. As required under Chapter 401, Florida Statutes, and Chapter 64J-I, F.A.C., Medical Director shall develop, review and authorize use of ALS and BLS protocols which allow personnel to properly manage medical emergencies. Such protocols shall be specifi c in nature and shall provide for managing immediately life-threatening medical emergencies. As required by Section 401.265, Florida Statutes, and Rule 64J-1.004, F.A.C, the Medical Director shall supervise and assume direct responsibility for the medical performance of all EMT's and paramedics operating for COUNTY EMS, including both ground and aero medical personnel. Medical Director shall develop any other protocols as required by Chapter 401, Florida Statutes, or Chapter 64J -1, F.A.C., as they may be amended from time to time. 21. Medical Director shall provide the County Manager or designee with a quarterly report generally describing activities performed, with reference to the requirements of this Agreement. COUNTY shall provide administrative support in order for the Medical Director to meet the obligations of this paragraph. Back -up physicians may be used in lieu of the Medical Director and/or Deputy Medical Director upon approval of the County Manager or designee. Back -up physicians, when used, shall meet all of the qualifications for a medical director as set forth in Section 401.265, Florida Statutes, and shall be at no additional cost to the COUNTY. 22. Medical Director shall perform all other services required of a medical director and assume all legal duties and responsibili ties of a medical director, as provided by Chapter 401, Florida Statutes, Chapter 641 -1 F.A.C., and any other applicable laws and regulations, all as may be amended from time to time. 23. Medical Director shall be available for consultation with the Director of Emergency Management during activations of the County's Emergency Operations Center or eminent emergency situation to assist in a public health emergency, disaster, pandemic, or mass medical event. Such efforts shall be in coordination with the Public Health Director and not in conflict with public health statutory authority. 24. Medical Director shall receive prior approval from the County Manager or designee preceding any COUNTY communication with the media. 25. Medical Director shall maintain current instructor level training in Advanced Cardiac Life Support (ACLS), or equivalent, or Advanced Trauma Life Support (ATLS), maintain provider or instructor level training in International Trauma Life Support (ITLS), Prehospital Trauma Life Support (PHTLS), or Advanced Trauma Life Support (ATLS); and Advanced Pediatric Life Support (APLS), Pediatric Advanced Life Support (PALS), Pediatric Education for Prehospital Professionals (PEPP), or Emergency Pediatric Care (EPC). 26. Assist in the following duties: a) Interacting with the Medical Directors Coalition. b) Consulting in the planning for Emergency Medical Services Division to be provided by the County, including the design of vehicles, equipment, supplies, distribution resources, emergency medical service personnel training and medical policy, protocol, planning and development. c) Consulting in the coordination of training of paramedical personnel, including the determination of training criteria for certification. d) Organizing, coordinating and participating as an instructor for the in -service education programs and quality control of the patient care in day-to-day delivery of emergency medical services by the County. e) Serving as a liaison between the County and the appropriate community hospitals, medical societies, practicing physicians and training facilities in the area. f) Providing such assistance as may be required in the preparation and administration of any grant programs for the establishment and improvement of the system. g) Keeping adequate records and supporting documentation, which concern or reflect services under the resultant contract. Page 4843 of 6526 5 h) Representing that the consultant presently has no interest and shall acquire no interest, either direct or indirect, whic h would conflict in any manner with the performance of services required hereunder. In accordance with Section 401.265, Florida Statutes, responsibilities for Deputy Medical Director include: (1) The Deputy Medical Director’s responsibility is to provide professional services in conjunction with the Medical Director in accordance with Chapter 401, Florida Statues, and Chapter 64 -J-1, Florida Administrative Code, and the Rules of the Department of Health. (2) The scope of services for the Deputy Medical Director, shall be in support of and to further the duties of the Medical Di rector. If for any reason the Medical Director is unavailable whether by termination of his/her contract, scheduled vacation or per sonal emergency, the Deputy Medical Director shall assume the duties of the Medical Director until further notice. Requirement and Qualifications of the Deputy Medical Director include: 1. When the Medical Director is unavailable, the Deputy Medical Director must attend the quarterly scheduled emergency medical services meeting where discussions will involve patient care, quality, mandated Paramedic and EMT training. Paramedic requirements. addition or deletion of equipment available to Paramedics and EMT's. Ample notice for all such meetings will be supplied by the County Manager or designee. 2. Be available as back-up, as needed, during times when the Medical Director is absent due to a scheduled vacation or personal emergency or schedule and ensure that an approved back-up physician is available. 3. Deputy Medical Director shall ride as a crew member on an EMS vehicle a minimum of ten (10) hours annually or as otherwise expressly required by state law to evaluate the skills and maintain a working relationship with EMT's, assigned Paramedics. and probationary Paramedics. 4. As part of the quality assurance committee, Deputy Medical Director shall assist the COUNTY with obtaining patient outcome information from local hospitals. 5. Deputy Medical Director shall participate in regular Quality Assurance meetings with Dispatch personnel. 6. Deputy Medical Director shall review and participate in the development of the Dispatch Protocols followed by COUNTY EMS. 7. Deputy Medical Director shall participate in and direct EMS Advanced Cardiac Life Support (.ACLS) classes and shall assist the County and EMS Chief in arranging additional training to meet the needs of the community and the standards of care for the industry. The Deputy Medical Director shall, upon request of the County Manager or designee, evaluate COUNTY EMTs and Paramedical personnel during training exercises. Deputy Medical Director shall review and approve the content of EMS training for medical correctness at the request of the County Manager or designee. 8. Deputy Medical Director shall be physically present in the COUNTY EMS Administrative Offices on as needed basis; in order to confer with the EMS Chief and other designated staff All official meetings attended by the Deputy Medical Director which have been approved by the EMS Chief, will be recognized as part of the normal job duties of Deputy Medical Director. 9. In the absence of the Medical Director, and as required under Chapter 401, Florida Statutes, and Chapter 64J l. FA.C. the Dep uty Medical Director shall develop, review and authorize use of ALS and BLS protocols which allow personnel to properly manage medical emergencies. Such protocols shall be specific in nature and shall provide for managing immediately life -threatening medical emergencies. In the absence of the Medical Director. and as required by Section 401.265, Florida Statutes, and Rule 64J-1.004, F.A.C. the Deputy Medical Director shall also supervise and assume direct responsibility for the medical performance of all EMTs and paramedics operating for COUNTY EMS, including both ground and aero medical personnel. 10. Deputy Medical Director shall assist the Medical Director in the supervision, implementation and maintenance of a quality assurance program as required by Section 401.265, Florida Statutes and Rule 641 -1.004 FA.C., to include spot-checking medical reports for completion and correctness. The quality assurance program must cover dispatch, field paramedics, EMT's and Flight Medics. 11. Deputy Medical Director may review and provide written affirmation of recertification training of COUNTY EMS EMT and Paramedic personnel in accordance with Section 401.2715(3), Florida Statutes, It is understood and agreed between the parties that all of the legal duties and responsibilities of a Medical Director as se t forth in Chapter 401, Florida Statutes, Rule 64J-1.004 F.A.C., and any other applicable laws and regulations, shall remain with t he Medical Director at all times except during scheduled vacations or personal emergencies, when the Deputy Medical Director or other approved back-up physician is available pursuant to and in accordance with Section 13 below. 12. Back-up physicians may be used in lieu of the Medical Director and/or Deputy Medical Director upon approval of the County Manager or designee. Back-up physicians, when used, shall meet all of the qualifications for a medical director as set forth in Section 401.265. Florida Statutes and shall be at no additional cost to the COUNTY. 13. In the absence of the Medical Director, the Deputy Medical Director will coordinate the provision of coverage at all times no t available during the term of this Agreement, during such times, backup coverage may include an approved back -up physician. 14. In support of the Medical Director, the Deputy Medical Director shall perform all other services required of a Medical Direct or and assume all legal duties and responsibilities of a Medical Director, as provided by Section 40 l, Florida Statutes, Chapt er Page 4844 of 6526 6 64J-1 F.A.C. and any other applicable laws and regulations, all as may be amended from time to time. 15. Deputy Medical Director shall be available for consultation with the Director of Emergency Management during activations of the County's Emergency Operations Center or eminent emergency situation to assist in a public health emergency, disaster, pandemic, or mass medical event. Such efforts shall be in coordination with the Public Health Director and not in conflict with public health statutory authority. 16. Deputy Medical Director shall receive prior approval from the County Manager or designee preceding any COUNTY communication with the media. 17. Deputy Medical Director shall maintain current instructor level training in Advanced Cardiac Life Support (ACLS), or equivalent, or Advanced Trauma Life Support (ATLS), maintain provider or instructor level training in International Trauma Life Support (ITLS), Prehospital Trauma Life Support (PHTLS), or Advanced Trauma Life Support (ATLS); and Advanced Pediatric Life Support (APLS), Pediatric Advanced Life Support (PALS), Pediatric Education for Prehospital Professionals (PEPP), or Emergency Pediatric Care (EPC). Firms Proposal Intent The prospective firm shall select a category or categories with the submission of their proposal. The prospective firms may propose up to two (2) categories by checking the box of each category. The prospective firms will only be awarded one (1) category. Category A – Medical Director Category B – Deputy Medical Director The prospective firm will rank each category in order of preference, if proposing on multiple categories. The prospective firm will enter one (1) for the most preferred to two (2) being least preferred. The prospective firms proposing on a single category shall not rank in an order of preference. Category A – Medical Director Category B – Deputy Medical Director REQUEST FOR PROPOSAL (RFP) PROCESS 1.1 The Proposers will submit a qualifications proposal which will be scored based on the criteria in Evaluation Criteria for Development of Shortlist, which will be the basis for short-listing firms. The Proposers will need to meet the minimum requirements outlined herein in or der for their proposal to be evaluated and scored by the COUNTY. The COUNTY will then score and rank the firms and enter into negotiations with the top ranked firm to establish cost for the services needed. The COUNTY reserves the right to issue an invitation for oral presentations to obtain additional information after scoring and before the final ranking. With successful negotiations, a contract will be developed with the selected firm, based on the negotiated price and scope of services and submitted for approval by the Board of County Commissioners. 1.2 The COUNTY will use a Selection Committee in the Request for Proposal selection process. 1.3 The intent of the scoring of the proposal is for respondents to indicate their interest, relevant experience, financial capability, staffing and organizational structure. 1.4 The intent of the oral presentations, if deemed necessary, is to provide the vendors with a venue where they can conduct discussions with the Selection Committee to clarify questions and concerns before providing a final rank. 1.5 Based upon a review of these proposals, the COUNTY will rank the Proposers based on the discussion and clarifying questions on their approach and related criteria, and then negotiate in good faith an Agreement with the top ranked Proposer. Page 4845 of 6526 7 1.6 If, in the sole judgment of the COUNTY, a contract cannot be successfully negotiated with the top-ranked firm, negotiations with that firm will be formally terminated and negotiations shall begin with the firm ranked second. If a contract cannot be successfully negotiated with the firm ranked second, negotiations with that firm will be formally terminated and negotiations shall begin with the third ranked firm, and so on. The COUNTY reserves the right to negotiate any element of the proposals in the best interest of the COUNTY. RESPONSE FORMAT AND EVALUATION CRITERIA FOR DEVELOPMENT OF SHORTLIST: 1.7 For the development of a shortlist, this evaluation criterion will be utilized by the COUNTY’S Selection Committee to score each proposal. Proposers are encouraged to keep their submittals concise and to include a minimum of marketing materials. Proposals must address the following criteria: Evaluation Criteria Maximum Points 1. Cover Letter / Management Summary 5 Points 2. Certified Woman and/or Minority Business Enterprise 5 Points 3. Qualifications 20 Points 4. Affiliations (Medical/Public Health/Public Safety) 20 Points 5. Cost of Services to the County 20 Points 6. Experience and Capacity of the Firm 20 Points 7. Local Vendor Preference 10 Points TOTAL POSSIBLE POINTS 100 Points Tie Breaker: In the event of a tie at final ranking, award shall be made to the proposer with the lower volume of work previously awarded. Volume of work shall be calculated based upon total dollars paid to the proposer in the twenty -four (24) months prior to the RFP submittal deadline. Payment information will be retrieved from the County’s financial system of record. The tie breaking procedure is only applied in the final ranking step of the selection process and is invoked by the Procurement Services Division Director or designee. In the event a tie still exists, selection will be determined based on random selection by the Procurement Services Director before at least three (3) witnesses. ---------------------------------------------------------------------------------------------------------------------------------------------------------- Each criterion and methodology for scoring is further described below. ***Proposals must be assembled, at minimum, in the order of the Evaluation Criteria listed or your proposal may be deemed non-responsive*** EVALUATION CRITERIA NO. 1: COVER LETTER/MANAGEMENT SUMMARY (5 Total Points Available) Provide a cover letter, signed by an authorized officer of the firm, indicating the underlying philosophy of the firm in providing the services stated herein. Include the name(s), telephone number(s) and email(s) of the authorized contact person(s) concerning proposal. Submission of a signed Proposal is Vendor's certification that the Vendor will accept any awards as a result of this RFP. EVALUATION CRITERIA NO. 2: CERTIFIED WOMAN AND/OR MINORITY BUSINESS ENTERPRISE (5 Total Points Available) Submit certification with the Florida Department of Management Service, Office of Supplier Diversity as a Certified Woman and/or Minority Business Enterprise. EVALUATION CRITERIA NO. 3: QUALIFICATIONS (20 Total Points Available) In this criteria, include but not limited to: • Provide Current licenses including o Current State of Florida Medical License (provide copy) o DEA License • Professional resume for either, or both, positions. • Provide evidence of: o Training in the field of emergency medicine • Provide Current Certifications including: o ACLS certificate or be board certified in emergency medicine o International Trauma Life Supports (ITLS) provider or International Trauma Life Supports (ITLS) Instructor, or Page 4846 of 6526 8 Prehospital Hospital Trauma Life Support (PHTLS) provider or Instructor, ATLS certification or ATLS Instructor, or Advanced Trauma Life Support (ATLS) o Advanced Pediatric Life Support (APLS) o Pediatric Advanced Life Support (PALS) o Pediatric Education for Prehospital Professionals (PEPP), or Emergency Pediatric Care (EPC). EVALUATION CRITERIA NO. 4: AFFILIATIONS (MEDICAL/PUBLIC HEALTH/PUBLIC SAFETY) (20 Total Points Available) In this criteria, include but not limited to: • Collier and Lee County hospital, medical, and other public health and safety affiliations (Sheriff, EMS, Fire Department, etc.); • Pharmaceutical and/or medical manufacturers or distributor affiliations; and • Any other company or organization that may pose a conflict -of-interest risk for the Collier County Board of County Commissioners. EVALUATION CRITERIA NO. 5: COST OF SERVICES TO THE COUNTY (20 Total Points Available) In this criteria, include but not limited to: Annual Cost of Service for Medical Director $ Annual Cost of Service for Deputy Medical Director $ Initial pricing is for grading purposes and are subject to change during negotiations with the selected vendor. EVALUATION CRITERIA NO. 6: SPECIALIZED EXPERTISE OF TEAM MEMBERS (20 Total Points Available) In this criteria, include but not limited to: • Provide experience in emergency medicine, advanced life support service, and basic life support transportation services. The County requests that the vendor submits no fewer than three (3) and no more than ten (10) completed reference forms from clients during a period of the last ten (10) years whose projects are of a similar nature to this solicitation as a part of their proposal. Provide information on the projects completed by the Proposer that best represent projects of similar size, scope and complexity of this project using form provided in Form 5. Proposers may include two (2) additional pages for each project to illustrate aspects of the completed project that provides the information to assess the experience of the Proposer on relevant project work. EVALUATION CRITERIA NO. 7: LOCAL VENDOR PREFERENCE (10 Total Points Available) Local business is defined as the vendor having a current Business Tax Receipt issued by the Collier or Lee County Tax Collector prior to proposal submission to do business within Collier County, and that identifies the business with a permanen t physical business address located within the limits of Collier or Lee County from which the vendor’s staff operates and performs business in an area zoned fo r the conduct of such business. VENDOR CHECKLIST ***Vendor should check off each of the following items as the necessary action is completed (please see, Vendor Check List)*** Page 4847 of 6526 County of Collier, FL Procurement -, - 3299 Tamiami Trail, East Naples, FL 34112 [JAMES AUGUSTINE] RESPONSE DOCUMENT REPORT GEN No. 25-8350 Medical Director and Deputy Medical Director RESPONSE DEADLINE: March 26, 2025 at 3:00 pm Report Generated: Wednesday, March 26, 2025 James Augustine Response CONTACT INFORMATION Company: James Augustine Email: jaugust23@gmail.com Contact: James Augustine Address: 7858 Classics Drive Naples, FL 34113 Phone: (404) 456-6211 Website: N/A Submission Date: Mar 10, 2025 7:27 PM (Eastern Time) Page 4848 of 6526 [JAMES AUGUSTINE] RESPONSE DOCUMENT REPORT GEN No. 25-8350 Medical Director and Deputy Medical Director [JAMES AUGUSTINE] RESPONSE DOCUMENT REPORT undefined - Medical Director and Deputy Medical Director Page 2 ADDENDA CONFIRMATION Addendum #1 Confirmed Mar 6, 2025 2:04 PM by James Augustine Addendum #2 Confirmed Mar 8, 2025 11:58 PM by James Augustine Addendum #3 Confirmed Mar 10, 2025 11:26 PM by James Augustine QUESTIONNAIRE 1. I certify that I have read, understood and agree to the terms in this solicitation, and that I am authorized to submit this r esponse on behalf of my company.* Confirmed 2. Request for Proposals (RFP) Instructions Form* Request for Proposals (RFP) Instructions have been acknowledged and accepted. Confirmed 3. Collier County Purchase Order Terms and Conditions* Collier County Purchase Order Terms and Conditions have been acknowledged and accepted. Confirmed Page 4849 of 6526 [JAMES AUGUSTINE] RESPONSE DOCUMENT REPORT GEN No. 25-8350 Medical Director and Deputy Medical Director [JAMES AUGUSTINE] RESPONSE DOCUMENT REPORT undefined - Medical Director and Deputy Medical Director Page 3 4. Insurance Requirements* Vendor Acknowledges Insurance Requirement and is prepared to produce the required insurance certificate(s) within five (5) da ys of the County's issuance of a Notice of Recommended Award. Confirmed 5. Collier County Required Forms PROPOSAL SUBMITTAL* Please submit a proposal per the Evaluation Criteria outlined in the Solicitation. Proposal_JJA_CCEMS.docx VENDOR DECLARATION STATEMENT (FORM 1)* Vendor_Declaration_Sttmt_LCEMS.tiff CONFLICT OF INTEREST CERTIFICATION (FORM 2)* COI_form_CCEMS.tiff IMMIGRATION LAW AFFIDAVIT CERTIFICATION (FORM 3)* Immigration_Affidavit.tiff CERTIFICATION FOR CLAIMING STATUS AS A LOCAL BUSINESS (FORM 4) IF APPLICABLE Please provide a business tax receipt. Local business is defined as the vendor having a current Business Tax Receipt issued b y the Collier or Lee County Tax Collector prior to proposal submission to do business within Collier County, and that identifies th e business with a permanent physical business address located within the limits of Collier or Lee County from which the vendor’s staff o perates and performs business in an area zoned for the conduct of such business. Please attach a Collier or Lee County B usiness Tax Receipt. Local_Vendor_Form.tiff REFERENCE QUESTIONNAIRE (FORM 5)* Page 4850 of 6526 [JAMES AUGUSTINE] RESPONSE DOCUMENT REPORT GEN No. 25-8350 Medical Director and Deputy Medical Director [JAMES AUGUSTINE] RESPONSE DOCUMENT REPORT undefined - Medical Director and Deputy Medical Director Page 4 The County requests that the vendor submits no fewer than three (3) and no more than ten (10) completed reference forms from clients during a period of the last ten (10) years whose projects are of a similar nature to this solicitation as a part of their proposal. Reference_for_CCEMS_Aguilera_325.pdf JJA_recc_form_Johnson_Colin.docx JJA_recc_form_Batiato_325.docx JJA_recc_form_Chf_Byrne_325.docx E-VERIFY - MEMORANDUM OF UNDERSTANDING* Vendor MUST be enrolled in the E-Verify - https://www.e-verify.gov/ at the time of submission of the proposal/bid. E-Verify Memorandum of Understanding or Company Profile page should be attached with your submittal. Everify_form_CCEMS.tiff W-9 FORM* W9_Naples_1224.pdf PROOF OF STATUS FROM DIVISION OF CORPORATIONS - FLORIDA DEPARTMENT OF STATE (SUNBIZ) http://dos.myflorida.com/sunbiz/ should be attached with your submittal* Proof_of_Status_from_Division_of_Corporations.docx LICENSE REQUIREMENT* Provide licenses and certifications as outlined in Evaluation Criteria 3: Qualifications. Licenses_and_certifications_CCEMS.docx ALL SIGNED ADDENDA (IF APPLICABLE) Addenda_LCEMS.tiff ALL OTHER DOCUMENTATION, AS APPLICABLE. No response submitted Page 4851 of 6526 Proposal per the Evaluation Criteria outlined in the Solicitation Cover Letter/Management Summary Provide a cover letter, signed by an authorized officer of the firm, indicating the underlying philosophy of the firm in providing the services stated herein. Include the name(s), telephone number(s) and email(s) of the authorized contact person(s) concerning proposal. Submission of a signed Proposal is Vendor's certification that the Vendor will accept any awards as a result of this RFP. This Proposal is for Category A – Medical Director James Augustine, MD is the candidate for Collier County EMS Medical Director He is applying as an individual. His contact information is: James Augustine, MD 7868 Classics Drive, Naples, FL 34113 Phone 404.456.6211 Email is jaugust23@gmail.com As outlined in his CV, he has served in the public safety industry since initial fire EMS training in 1982 and 1983. He completed his emergency medicine training in 1986, and has served as an emergency physician since then. His roles have included experience as an EMS Medical Director in Ohio, Georgia, Washington DC, and Florida. His longest continuous service is with Washington Township Fire Department, in metro Dayton Ohio, since 1987. This Summary will outline qualifications. Thank you, James Augustine, MD EVALUATION CRITERIA NO. 2: CERTIFIED WOMAN AND/OR MINORITY BUSINESS ENTERPRISE – I do not fulfill this criteria EVALUATION CRITERIA NO. 3: LICENSING AND CERTIFICATION – IN A SEPARATE DOCUMENT EVALUATION CRITERIA NO. 4: AFFILIATIONS (MEDICAL/PUBLIC HEALTH/PUBLIC SAFETY). In this criteria, include but not limited to: • Collier and Lee County hospital, medical, and other public health and safety affiliations (Sheriff, EMS, Fire Department, etc.); I CURRENTLY SERVE AS A CHIEF MEDICAL OFFICER FOR NORTH COLLIER FIRE RESCUE, LEE COUNTY EMS, CITY OF FORT MYERS FIRE DEPARTMENT, UPPER CAPTIVA FIRE DEPARTMENT, USEPPA FIRE DEPARTMENT, AND THE LEHIGH ACRES FIRE RESCUE DEPARTMENT • Pharmaceutical and/or medical manufacturers or distributor affiliations; I SERVE AS A CONSULTANT TO SEVERAL COMPANIES THAT MANUFACTURE MEDICAL DEVICES and Page 4852 of 6526 • Any other company or organization that may pose a conflict-of-interest risk for the Collier County Board of County Commissioners - EVALUATION CRITERIA NO. 5: COST OF SERVICES TO THE COUNTY This proposal is for the Medical Director Position The Annual Cost of Service for the Medical Director is for $200,000 EVALUATION CRITERIA NO. 6: SPECIALIZED EXPERTISE OF TEAM MEMBERS In this criteria, include but not limited to: • Provide experience in emergency medicine, advanced life support service, and basic life support transportation services James Augustine, MD began his career in EMS when he was in medical school in Dayton. He became a firefighter in 1982, then began his service as a Fire EMS medical director in the Dayton area in 1987. After serving as the President of the regional Fire EMS council, he became the first Chair of the Ohio EMS Board. He moved to Atlanta in 2001, and served as Medical Director for Atlanta Fire Rescue, including the Hartsfield Jackson Atlanta International Airport Fire Rescue division. He later served as Assistant Fire Chief and Medical Director for the District of Columbia Fire EMS Department. While there, he also served as Medical Director for the Metropolitan Police Department. His current roles include the responsibility of serving as Medical Director for the International Association of Fire Chiefs (IAFC). He also works with the International Association of Chiefs of Police Dr. Augustine is an emergency physician, and a Clinical Professor in the Department of Emergency Medicine at Wright State University in Dayton, Ohio. He is a member of National Association of EMS Physicians, and is a key member of the “Eagles” group of Fire EMS Medical Directors. He is an active member of the Florida Association of EMS Medical Directors. Dr. Augustine currently serves as the Medical Director for Lee County EMS in Fort Myers, Florida. His Medical Director roles include City of Fort Myers FD and the Lehigh Acres FD. He also is the Chief Medical Officer for North Collier Fire Rescue in Naples, Florida. Jim is the Medical Director for Washington Township Fire Rescue near Dayton, Ohio, where he has served since 1987. Jim has a long history of providing medical direction related to emergency medical services, from dispatch to first response to air and ground transport. He has developed medical protocols, major incident management and disaster guidelines, quality assurance programs and materials. He provides oversight of EMS providers, feedback and guidance, and personnel counseling. In his current roles, he delivers medical care on-scene by responding to scenes and over the radio. In his airport medical direction roles, he developed response plans with the Quarantine Station of the CDC, oversee planning and response with the Georgia Division of Public Health related to airport activities, and interacted with other airport agencies regarding All-Hazards Emergency Preparedness and emergency medical activities. Dr Augustine interacts frequently with the Florida Bureau of EMS. He is active in monitoring and reporting on emergency medicine drug shortages. His management philosophies are built around collaboration, cooperation, team-building, and customer service. He serves as Vice Chair of the Collier County Medical Directors’ Coalition. He has helped bring the southwest Florida EMS medical directors together to develop the SW Florida Regional EMS Guidelines, which reflect the regional health system that serves the population in this area. These are evidence-based and reflect collaborative approaches with the specialty physicians in the region. Page 4853 of 6526 Jim is known for being friendly, fair, approachable, and positive in approaches to emergency care. He and his wife Linda have been residents in Naples for the last 14 years. Their three adult children and four grandchildren are frequent visitors. Page 4854 of 6526 Page 4855 of 6526 Page 4856 of 6526 Page 4857 of 6526 Page 4858 of 6526 Page 4859 of 6526 Form 5 Reference Questionnaire (USE ONE FORM FOR EACH REQUIRED REFERENCE) Solicitation: EMS Medical Director Reference Questionnaire for: James Augustine, MD (Name of Company Requesting Reference Information) James Augustine, MD (Name of Individuals Requesting Reference Information) Name:Jorge Aguilera (Evaluator completing reference questionnaire) Company: North Collier Fire Rescue (Evaluator’s Company completing reference) Email: jaguilera@northcollierfire.com FAX: 239 597-9227 Telephone: 239 253-8589 Collier County has implemented a process that collects reference information on firms and their key personnel to be used in the selection of firms to perform this project. The Name of the Company listed in the Subject above has listed you as a client for which they have previously performed work. Please complete the survey. Please rate each criteria to the best of your knowledge on a scale of 1 to 10, with 10 representing that you were very satisifed (and would hire the firm/individual again) and 1 representing that you were very unsatisfied (and would never hire the firm/indivdiual again). If you do not have sufficient knowledge of past performance in a particular area, leave it blank and the item or form will be scored “0.” Project Description: EMS Medical Direction Completion Date: Project Budget: None Project Number of Days: ______Unknown_____ Item Criteria Score (must be completed) 1 Ability to manage the project costs (minimize change orders to scope). ------------------------------ 2 Ability to maintain project schedule (complete on-time or early). 10 3 Quality of work. 10 4 Quality of consultative advice provided on the project. 10 5 Professionalism and ability to manage personnel. 10 6 Project administration (completed documents, final invoice, final product turnover; invoices; manuals or going forward documentation, etc.)10 7 Ability to verbally communicate and document information clearly and succinctly. 10 8 Abiltity to manage risks and unexpected project circumstances. 10 9 Ability to follow contract documents, policies, procedures, rules, regulations, etc. 10 10 Overall comfort level with hiring the company in the future (customer satisfaction). 10 TOTAL SCORE OF ALL ITEMS 90 Page 4860 of 6526 Form 5 Reference Questionnaire (USE ONE FORM FOR EACH REQUIRED REFERENCE) Solicitation: Collier County EMS Medical Director Reference Questionnaire for: James Augustine, MD (Name of Company Requesting Reference Information) James Augustine, MD (Name of Individuals Requesting Reference Information) Name:Colin Johnson (Evaluator completing reference questionnaire) Company: Lee County Public Safety (Evaluator’s Company completing reference) Email: cajohnson@leegov.com Collier County has implemented a process that collects reference information on firms and their key personnel to be used in the selection of firms to perform this project. The Name of the Company listed in the Subject above has listed you as a client for which they have previously performed work. Please complete the survey. Please rate each criteria to the best of your knowledge on a scale of 1 to 10, with 10 representing that you were very sat isifed (and would hire the firm/individual again) and 1 representing that you were very unsatisfied (and would never hire the firm/indivdiual again). If you do not have sufficient knowledge of past performance in a particular area, leave it blank and the item or form will be scored “0.” Project Description: EMS Medical Direction Completion Date: Project Budget: None Project Number of Days: ______Unknown_____ Item Criteria Score (must be completed) 1 Ability to manage the project costs (minimize change orders to scope). 9 2 Ability to maintain project schedule (complete on-time or early). 10 3 Quality of work. 10 4 Quality of consultative advice provided on the project. 10 5 Professionalism and ability to manage personnel. 10 6 Project administration (completed documents, final invoice, final product turnover; invoices; manuals or going forward documentation, etc.) 10 7 Ability to verbally communicate and document information clearly and succinctly. 10 8 Abiltity to manage risks and unexpected project circumstances. 9 9 Ability to follow contract documents, policies, procedures, rules, regulations, etc. 10 10 Overall comfort level with hiring the company in the future (customer satisfaction). 10 TOTAL SCORE OF ALL ITEMS 108 Page 4861 of 6526 Form 5 Reference Questionnaire (USE ONE FORM FOR EACH REQUIRED REFERENCE) Solicitation: Collier County EMS Medical Director Reference Questionnaire for: James Augustine, MD (Name of Company Requesting Reference Information) James Augustine, MD (Name of Individuals Requesting Reference Information) Name: David Batiato, Chief of Training & Safety (Evaluator completing reference questionnaire) Company: Immokalee Fire Control District (Evaluator’s Company completing reference) Email: Dbatiato@immfire.com Collier County has implemented a process that collects reference information on firms and their key personnel to be used in t he selection of firms to perform this project. The Name of the Company listed in the Subject above has listed you as a client for which they have previously performed work. Please complete the survey. Please rate each criteria to the best of your knowledge on a scale of 1 to 10, with 10 representing that you were very satisifed (and would hire the firm/individual again) and 1 repres enting that you were very unsatisfied (and would never hire the firm/indivdiual again). If you do not have sufficient knowledge of past performance in a particular area, leave it blank and the item or form will be scored “0.” Project Description: EMS Medical Direction Completion Date: Project Budget: None Project Number of Days: ______Unknown_____ Item Criteria Score (must be completed) 1 Ability to manage the project costs (minimize change orders to scope). 2 Ability to maintain project schedule (complete on-time or early). 10 3 Quality of work. 10 4 Quality of consultative advice provided on the project. 10 5 Professionalism and ability to manage personnel. 10 6 Project administration (completed documents, final invoice, final product turnover; invoices; manuals or going forward documentation, etc.) 10 7 Ability to verbally communicate and document information clearly and succinctly. 10 8 Abiltity to manage risks and unexpected project circumstances. 10 9 Ability to follow contract documents, policies, procedures, rules, regulations, etc. 10 10 Overall comfort level with hiring the company in the future (customer satisfaction). 10 TOTAL SCORE OF ALL ITEMS 90 Page 4862 of 6526 Form 5 Reference Questionnaire (USE ONE FORM FOR EACH REQUIRED REFERENCE) Solicitation: Collier County EMS Medical Director Reference Questionnaire for: James Augustine, MD (Name of Company Requesting Reference Information) James Augustine, MD (Name of Individuals Requesting Reference Information) Name:Chris Byrne (Evaluator completing reference questionnaire) Company: City of Marco Island Fire Rescue Department (Evaluator’s Company completing reference) Email: cbyrne@cityofmarcoisland.com Collier County has implemented a process that collects reference information on firms and their key personnel to be used in the selection of firms to perform this project. The Name of the Company listed in the Subject above has listed you as a client for which they have previously performed work. Please complete the survey. Please rate each criteria to the best of your knowledge on a scale of 1 to 10, with 10 representing that you were very sat isifed (and would hire the firm/individual again) and 1 representing that you were very unsatisfied (and would never hire the firm/indivdiual again). If you do not have sufficient knowledge of past performance in a particular area, leave it blank and the item or form will be scored “0.” Project Description: EMS Medical Direction Completion Date: March 10, 2025 Project Budget: None Project Number of Days: ______Unknown_____ Item Criteria Score (must be completed) 1 Ability to manage the project costs (minimize change orders to scope). 10 2 Ability to maintain project schedule (complete on-time or early). 10 3 Quality of work. 10 4 Quality of consultative advice provided on the project. 10 5 Professionalism and ability to manage personnel. 10 6 Project administration (completed documents, final invoice, final product turnover; invoices; manuals or going forward documentation, etc.) 10 7 Ability to verbally communicate and document information clearly and succinctly. 10 8 Abiltity to manage risks and unexpected project circumstances. 10 9 Ability to follow contract documents, policies, procedures, rules, regulations, etc. 10 10 Overall comfort level with hiring the company in the future (customer satisfaction). 10 TOTAL SCORE OF ALL ITEMS 100 Page 4863 of 6526 Page 4864 of 6526 Page 4865 of 6526 Page 4866 of 6526 Form W-9 (Rev. October 2018) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification ▶ Go to www.irs.gov/FormW9 for instructions and the latest information. Give Form to the requester. Do not send to the IRS.Print or type. See Specific Instructions on page 3.1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. 2 Business name/disregarded entity name, if different from above 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes. Individual/sole proprietor or single-member LLC C Corporation S Corporation Partnership Trust/estate Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ▶ Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner. Other (see instructions) ▶ 4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3): Exempt payee code (if any) Exemption from FATCA reporting code (if any) (Applies to accounts maintained outside the U.S.) 5 Address (number, street, and apt. or suite no.) See instructions. 6 City, state, and ZIP code Requester’s name and address (optional) 7 List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter. Social security number –– or Employer identification number – Part II Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later. Sign Here Signature of U.S. person ▶Date ▶ General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099-INT (interest earned or paid) • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X Form W-9 (Rev. 10-2018) Page 4867 of 6526 Form W-9 (Rev. 10-2018)Page 2 By signing the filled-out form, you: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and 4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting, later, for further information. Note: If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: • An individual who is a U.S. citizen or U.S. resident alien; • A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States; • An estate (other than a foreign estate); or • A domestic trust (as defined in Regulations section 301.7701-7). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners’ share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner is a foreign person, and pay the section 1446 withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid section 1446 withholding on your share of partnership income. In the cases below, the following person must give Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States. • In the case of a disregarded entity with a U.S. owner, the U.S. owner of the disregarded entity and not the entity; • In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and • In the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a grantor trust) and not the beneficiaries of the trust. Foreign person. If you are a foreign person or the U.S. branch of a foreign bank that has elected to be treated as a U.S. person, do not use Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign Entities). Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a “saving clause.” Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes. If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items. 1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien. 2. The treaty article addressing the income. 3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions. 4. The type and amount of income that qualifies for the exemption from tax. 5. Sufficient facts to justify the exemption from tax under the terms of the treaty article. Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption. If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form W-8 or Form 8233. Backup Withholding What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 24% of such payments. This is called “backup withholding.” Payments that may be subject to backup withholding include interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, payments made in settlement of payment card and third party network transactions, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding. You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return. Payments you receive will be subject to backup withholding if: 1. You do not furnish your TIN to the requester, 2. You do not certify your TIN when required (see the instructions for Part II for details), 3. The IRS tells the requester that you furnished an incorrect TIN, 4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or 5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only). Certain payees and payments are exempt from backup withholding. See Exempt payee code, later, and the separate Instructions for the Requester of Form W-9 for more information. Also see Special rules for partnerships, earlier. What is FATCA Reporting? The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all United States account holders that are specified United States persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code, later, and the Instructions for the Requester of Form W-9 for more information. Updating Your Information You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account; for example, if the grantor of a grantor trust dies. Penalties Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect. Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty. Page 4868 of 6526 Form W-9 (Rev. 10-2018)Page 3 Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment. Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties. Specific Instructions Line 1 You must enter one of the following on this line; do not leave this line blank. The name should match the name on your tax return. If this Form W-9 is for a joint account (other than an account maintained by a foreign financial institution (FFI)), list first, and then circle, the name of the person or entity whose number you entered in Part I of Form W-9. If you are providing Form W-9 to an FFI to document a joint account, each holder of the account that is a U.S. person must provide a Form W-9. a. Individual. Generally, enter the name shown on your tax return. If you have changed your last name without informing the Social Security Administration (SSA) of the name change, enter your first name, the last name as shown on your social security card, and your new last name. Note: ITIN applicant: Enter your individual name as it was entered on your Form W-7 application, line 1a. This should also be the same as the name you entered on the Form 1040/1040A/1040EZ you filed with your application. b. Sole proprietor or single-member LLC. Enter your individual name as shown on your 1040/1040A/1040EZ on line 1. You may enter your business, trade, or “doing business as” (DBA) name on line 2. c. Partnership, LLC that is not a single-member LLC, C corporation, or S corporation. Enter the entity's name as shown on the entity's tax return on line 1 and any business, trade, or DBA name on line 2. d. Other entities. Enter your name as shown on required U.S. federal tax documents on line 1. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on line 2. e. Disregarded entity. For U.S. federal tax purposes, an entity that is disregarded as an entity separate from its owner is treated as a “disregarded entity.” See Regulations section 301.7701-2(c)(2)(iii). Enter the owner's name on line 1. The name of the entity entered on line 1 should never be a disregarded entity. The name on line 1 should be the name shown on the income tax return on which the income should be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a single owner that is a U.S. person, the U.S. owner's name is required to be provided on line 1. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on line 2, “Business name/disregarded entity name.” If the owner of the disregarded entity is a foreign person, the owner must complete an appropriate Form W-8 instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN. Line 2 If you have a business name, trade name, DBA name, or disregarded entity name, you may enter it on line 2. Line 3 Check the appropriate box on line 3 for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box on line 3. IF the entity/person on line 1 is a(n) . . . THEN check the box for . . . • Corporation Corporation • Individual • Sole proprietorship, or • Single-member limited liability company (LLC) owned by an individual and disregarded for U.S. federal tax purposes. Individual/sole proprietor or single- member LLC • LLC treated as a partnership for U.S. federal tax purposes, • LLC that has filed Form 8832 or 2553 to be taxed as a corporation, or • LLC that is disregarded as an entity separate from its owner but the owner is another LLC that is not disregarded for U.S. federal tax purposes. Limited liability company and enter the appropriate tax classification. (P= Partnership; C= C corporation; or S= S corporation) • Partnership Partnership • Trust/estate Trust/estate Line 4, Exemptions If you are exempt from backup withholding and/or FATCA reporting, enter in the appropriate space on line 4 any code(s) that may apply to you. Exempt payee code. • Generally, individuals (including sole proprietors) are not exempt from backup withholding. • Except as provided below, corporations are exempt from backup withholding for certain payments, including interest and dividends. • Corporations are not exempt from backup withholding for payments made in settlement of payment card or third party network transactions. • Corporations are not exempt from backup withholding with respect to attorneys’ fees or gross proceeds paid to attorneys, and corporations that provide medical or health care services are not exempt with respect to payments reportable on Form 1099-MISC. The following codes identify payees that are exempt from backup withholding. Enter the appropriate code in the space in line 4. 1—An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2) 2—The United States or any of its agencies or instrumentalities 3—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities 4—A foreign government or any of its political subdivisions, agencies, or instrumentalities 5—A corporation 6—A dealer in securities or commodities required to register in the United States, the District of Columbia, or a U.S. commonwealth or possession 7—A futures commission merchant registered with the Commodity Futures Trading Commission 8—A real estate investment trust 9—An entity registered at all times during the tax year under the Investment Company Act of 1940 10—A common trust fund operated by a bank under section 584(a) 11—A financial institution 12—A middleman known in the investment community as a nominee or custodian 13—A trust exempt from tax under section 664 or described in section 4947 Page 4869 of 6526 Form W-9 (Rev. 10-2018)Page 4 The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 13. IF the payment is for . . .THEN the payment is exempt for . . . Interest and dividend payments All exempt payees except for 7 Broker transactions Exempt payees 1 through 4 and 6 through 11 and all C corporations. S corporations must not enter an exempt payee code because they are exempt only for sales of noncovered securities acquired prior to 2012. Barter exchange transactions and patronage dividends Exempt payees 1 through 4 Payments over $600 required to be reported and direct sales over $5,0001 Generally, exempt payees 1 through 52 Payments made in settlement of payment card or third party network transactions Exempt payees 1 through 4 1 See Form 1099-MISC, Miscellaneous Income, and its instructions. 2 However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys’ fees, gross proceeds paid to an attorney reportable under section 6045(f), and payments for services paid by a federal executive agency. Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account you hold in the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial institution is subject to these requirements. A requester may indicate that a code is not required by providing you with a Form W-9 with “Not Applicable” (or any similar indication) written or printed on the line for a FATCA exemption code. A—An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37) B—The United States or any of its agencies or instrumentalities C—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities D—A corporation the stock of which is regularly traded on one or more established securities markets, as described in Regulations section 1.1472-1(c)(1)(i) E—A corporation that is a member of the same expanded affiliated group as a corporation described in Regulations section 1.1472-1(c)(1)(i) F—A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any state G—A real estate investment trust H—A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940 I—A common trust fund as defined in section 584(a) J—A bank as defined in section 581 K—A broker L—A trust exempt from tax under section 664 or described in section 4947(a)(1) M—A tax exempt trust under a section 403(b) plan or section 457(g) plan Note: You may wish to consult with the financial institution requesting this form to determine whether the FATCA code and/or exempt payee code should be completed. Line 5 Enter your address (number, street, and apartment or suite number). This is where the requester of this Form W-9 will mail your information returns. If this address differs from the one the requester already has on file, write NEW at the top. If a new address is provided, there is still a chance the old address will be used until the payor changes your address in their records. Line 6 Enter your city, state, and ZIP code. Part I. Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below. If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. If you are a single-member LLC that is disregarded as an entity separate from its owner, enter the owner’s SSN (or EIN, if the owner has one). Do not enter the disregarded entity’s EIN. If the LLC is classified as a corporation or partnership, enter the entity’s EIN. Note: See What Name and Number To Give the Requester, later, for further clarification of name and TIN combinations. How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local SSA office or get this form online at www.SSA.gov. You may also get this form by calling 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at www.irs.gov/Businesses and clicking on Employer Identification Number (EIN) under Starting a Business. Go to www.irs.gov/Forms to view, download, or print Form W-7 and/or Form SS-4. Or, you can go to www.irs.gov/OrderForms to place an order and have Form W-7 and/or SS-4 mailed to you within 10 business days. If you are asked to complete Form W-9 but do not have a TIN, apply for a TIN and write “Applied For” in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester. Note: Entering “Applied For” means that you have already applied for a TIN or that you intend to apply for one soon. Caution: A disregarded U.S. entity that has a foreign owner must use the appropriate Form W-8. Part II. Certification To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if item 1, 4, or 5 below indicates otherwise. For a joint account, only the person whose TIN is shown in Part I should sign (when required). In the case of a disregarded entity, the person identified on line 1 must sign. Exempt payees, see Exempt payee code, earlier. Signature requirements. Complete the certification as indicated in items 1 through 5 below. Page 4870 of 6526 Form W-9 (Rev. 10-2018)Page 5 1. Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification. 2. Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form. 3. Real estate transactions. You must sign the certification. You may cross out item 2 of the certification. 4. Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. “Other payments” include payments made in the course of the requester’s trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments made in settlement of payment card and third party network transactions, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations). 5. Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), ABLE accounts (under section 529A), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification. What Name and Number To Give the Requester For this type of account:Give name and SSN of: 1. Individual The individual 2. Two or more individuals (joint account) other than an account maintained by an FFI The actual owner of the account or, if combined funds, the first individual on the account1 3. Two or more U.S. persons (joint account maintained by an FFI) Each holder of the account 4. Custodial account of a minor (Uniform Gift to Minors Act) The minor2 5. a. The usual revocable savings trust (grantor is also trustee) b. So-called trust account that is not a legal or valid trust under state law The grantor-trustee1 The actual owner1 6. Sole proprietorship or disregarded entity owned by an individual The owner3 7. Grantor trust filing under Optional Form 1099 Filing Method 1 (see Regulations section 1.671-4(b)(2)(i) (A)) The grantor* For this type of account:Give name and EIN of: 8. Disregarded entity not owned by an individual The owner 9. A valid trust, estate, or pension trust Legal entity4 10. Corporation or LLC electing corporate status on Form 8832 or Form 2553 The corporation 11. Association, club, religious, charitable, educational, or other tax- exempt organization The organization 12. Partnership or multi-member LLC The partnership 13. A broker or registered nominee The broker or nominee For this type of account:Give name and EIN of: 14. Account with the Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments The public entity 15. Grantor trust filing under the Form 1041 Filing Method or the Optional Form 1099 Filing Method 2 (see Regulations section 1.671-4(b)(2)(i)(B)) The trust 1 List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished. 2 Circle the minor’s name and furnish the minor’s SSN. 3 You must show your individual name and you may also enter your business or DBA name on the “Business name/disregarded entity” name line. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN. 4 List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Also see Special rules for partnerships, earlier. *Note: The grantor also must provide a Form W-9 to trustee of trust. Note: If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed. Secure Your Tax Records From Identity Theft Identity theft occurs when someone uses your personal information such as your name, SSN, or other identifying information, without your permission, to commit fraud or other crimes. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund. To reduce your risk: • Protect your SSN, • Ensure your employer is protecting your SSN, and • Be careful when choosing a tax preparer. If your tax records are affected by identity theft and you receive a notice from the IRS, respond right away to the name and phone number printed on the IRS notice or letter. If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet, questionable credit card activity or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit Form 14039. For more information, see Pub. 5027, Identity Theft Information for Taxpayers. Victims of identity theft who are experiencing economic harm or a systemic problem, or are seeking help in resolving tax problems that have not been resolved through normal channels, may be eligible for Taxpayer Advocate Service (TAS) assistance. You can reach TAS by calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD 1-800-829-4059. Protect yourself from suspicious emails or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business emails and websites. The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft. Page 4871 of 6526 Form W-9 (Rev. 10-2018)Page 6 The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers, passwords, or similar secret access information for their credit card, bank, or other financial accounts. If you receive an unsolicited email claiming to be from the IRS, forward this message to phishing@irs.gov. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration (TIGTA) at 1-800-366-4484. You can forward suspicious emails to the Federal Trade Commission at spam@uce.gov or report them at www.ftc.gov/complaint. You can contact the FTC at www.ftc.gov/idtheft or 877-IDTHEFT (877-438-4338). If you have been the victim of identity theft, see www.IdentityTheft.gov and Pub. 5027. Visit www.irs.gov/IdentityTheft to learn more about identity theft and how to reduce your risk. Privacy Act Notice Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. Page 4872 of 6526 Proof of Status from Division of Corporations - Florida Department of State (SunBiz) http://dos.myflorida.com/sunbiz/ should be attached with your submittal* I AM NOT A CORPORATION. I AM AN INDIVIDUAL Page 4873 of 6526 Page 4874 of 6526 Page 4875 of 6526 Licenses and certifications as outlined in Evaluation Criteria 3: Qualifications. Documents: Provide Current licenses including o Current State of Florida Medical License BELOW o DEA License BELOW Professional resume for either, or both, positions. BELOW Provide evidence of: o Training in the fleld of emergency medicine BELOW • Provide Current Certiflcations including: o Board certifled in emergency medicine BELOW o International Trauma Life Supports (ITLS) provider or International Trauma Life Supports (ITLS) Instructor, Prehospital Hospital Trauma Life Support (PHTLS) provider or Instructor, ATLS certiflcation or ATLS Instructor, or Advanced Trauma Life Support (ATLS) – I SERVED AS AN ATLS AND BTLS INSTRUCTOR FOR MANY YEARS. MY LAST CARD IS BELOW. I WAS AN AUTHOR FOR THE SPINAL TRAUMA CHAPTER IN THE BTLS TEXTBOOK ACROSS MANY EDITIONS o Pediatric Advanced Life Support (PALS) – I WAS A PROVIDER FOR MANY YEARS. LAST CARD IS BELOW Page 4876 of 6526 Page 4877 of 6526 Page 4878 of 6526 PROFESSIONAL CURRICULUM VITAE James J. Augustine, M.D. PERSONAL Contact Information: JAugustine@LeeGov.com CURRENT POSITIONS: Page 4879 of 6526 Clinical Professor, Department of Emergency Medicine, Wright State University. Dayton, OH Vice Chair, Board of Governors, Emergency Medicine Data Institute, American College of Emergency Physicians Vice President, Emergency Department Benchmarking Alliance Medical Director, Lee County EMS, Fort Myers, FL Medical Director, Washington Township (OH) Fire Department Chief Medical Officer, North Collier Fire District, Naples, FL Medical Director, Lehigh Acres Fire District, Lehigh Acres, FL Medical Director, Fort Myers Fire Department, Fort Myers, FL Medical Director, RSW International Airport Fire Department, Fort Myers, FL Equalizer Technology, LLC - Chief Medical Officer/EMS Retired Chair Emeritus, National Clinical Governance Board, US Acute Care Solutions EDUCATION and TRAINING: July 1986 - June 1987 Post-Residency Administrative Fellow in Emergency Medicine Miami Valley Hospital Emergency & Trauma Center Dayton, Ohio July 1983 - June 1986 Residency Integrated Residency in Emergency Medicine Wright State University School of Medicine Dayton, Ohio Sept 1979 - June 1983 Medical School Doctor of Medicine Page 4880 of 6526 Wright State University School of Medicine Dayton, Ohio Sept 1975 - June 1979 Undergraduate B.A. in Business Administration. Graduate: Cum Laude Ohio State University, Columbus, Ohio LICENSURE: Medical Licenses: Ohio 35-050643 Georgia 50125 Florida ME 111185 Fellow, American College of Emergency Physicians American Board of Emergency Medicine - 1987 Certiflcate #860653 - Recertifled in 1997 - Recertifled in 2007 – Recertifled in 2017 Diplomate of the National Board of Medical Examiners - June 1984 PUBLICATIONS: Two hundred eighty-two to here “Post-attack Bystander Action Guide”. Thompson, Adam and Augustine, James. EMS1. Feb 2025. Access at https://www.ems1.com/community-awareness/post-attack-bystander-action-guide “The Invisible Hand of the Patient: ED Volumes Keep Climbing as Patients Demand Acute, Unscheduled Care”. ED Volume growth CDC data. Augustine, James. ACEP NOW 43(12) Dec 2024. Pg 22 “Transfer Capabilities Still Pose Major Issues”. Transfer data. Augustine, James. ACEP NOW 43(6) June 2024. Pg 21 “The Clinical Emergency Data Registry: Structure, Use, and Limitations for Research.” Lin MP, Sharma D, Venkatesh AK, Epstein SK, Janke A, Genes N, Mehrotra A, Augustine J, Malcom B, Goyal P, Griffey RT. Jan 2024 AnnalsEM. https://doi.org/10.1016/j.annemergmed.2023.12.014 “A Sobering Year for ED’s and Their Patients”. Boarding times in 2022 EDBA data. Augustine, James. ACEP NOW 42(12) Dec 2023. Pg 19 Page 4881 of 6526 “Changes in the Number of United States Emergency Departments and Their Annual Visit Volumes Since 2001”. Boggs, Krislyn; Augustine, James; Sullivan, Ashley; Espinola; Janice, Camargo, Carlos. AnnalsEM. 82(6) Nov 2023. Pp 760-1 https://doi.org/10.1016/j.annemergmed.2023.07.005 “A First Look at Emergency Department Data for 2022”. First look at 2022 EDBA data. Augustine, James. ACEP NOW 42(6) June 2023. Pg 19 “Diagnostic Test Turnaround Times are Improving Across EDs”. Augustine, James. ACEP NOW 42(4) April 2023. Pg 18-19 “CEDR Transforms into the EM Data Institute”. Augustine, James and Goyal, Pawan. ACEP NOW 42(3) March 2023. Pg 10 “First Look: Emergency Department Operations in the Pandemic Year 2021”. Augustine, James J; and Jouriles, Nicholas MD. ACEP NOW 43(1) January 6, 2023. Page 3 “ED Patient Challenges to Come“ Augustine, James. ACEP NOW 41(11) Nov 2022. Pg 15 NHAMCS 2019 data rpt. “The Big Recovery: Emergency Department Operations in 2021” Augustine, James. ACEP NOW 41(8) August 2022. First look at 2021 data “Where are all the Children Going? ED Pediatric Patients are Decreasing”. Augustine, James. ACEP NOW. 41(4) Apr 2022. Pg 10. ED Pediatric volume decreases “Another COVID Casualty: The ED Transfer Process” ACEP NOW. 41(2) Feb 2022. Pg 1. ED Transfer increases “EMS and the ED: What Should the Relationship Look Like Going Forward?” ACEP NOW. 40(11) Nov 21. EMS Arrivals and Admission Trends “Development of a Qualified Clinical Data Registry for Emergency Medicine” Epstein, Stephen K, Augustine, James J, et al. JACEP Open. August, 2021 “Where will ED Volume go Post Pandemic?” ACEP NOW. 40(8) Aug 2021. Pg 10. First publication of 2020 data Page 4882 of 6526 “ED Redesigns must Incorporate Recent Lessons Learned”. Augustine, James J. ACEP NOW. 40(5) May 2021. Pg 12. “The Relationship of Large City Out-of-hospital Cardiac Arrests and the Prevalence of COVID-19”. K.E. McVaney Augustine, James J, et al. EClinicalMedicine part of The Lancet Discovery Science. April 2021. https://doi.org/10.1016/j.eclinm.2021.100815 “Statistical Trends of Diagnostic Testing in the ED”. Augustine, James J. ACEP NOW. 40(2) Feb 2021. Pg 12. “Fair Play: Application of Normalized Scoring to Emergency Department Throughput Quality Measures in a National Registry”. Arjun Venkatesh, MD, MBA*; Shashank Ravi, MD, MBA; Craig Rothenberg, MPH; Jeremiah Kinsman, MPH; Jean Sun, MD; Pawan Goyal, MD; James Augustine, MD; Stephen K. Epstein, MD, MPP* Ann Emerg Med. 2020;-:1-10.] .https://doi.org/10.1016/j.annemergmed.2020.10.021 “Emergency Considerations in COVID-19 Vaccine Administration”. Ashleigh Chuah, BS , James J. Augustine , Ray Fowler, MD. JEMS On-line Dec 16, 2020 “Optimal Level of Training for Emergency Call-Takers: Ensuring the Best Outcome in Cardiac Arrest” Colin Danko, MD, Robert B. Dunne, MD, FACEP, FAEMS, Veer Vithalani, MD, FACEP, FAEMS, James J. Augustine, MD, FACEP, Hunter Pyle, BS and Raymond L. Fowler, MD | JEMS Nov 27, 2020 “Pre-COVID ED Trends Suggest More Challenges Lie Ahead”. Augustine, James J. ACEP NOW. 39(11) Nov 2020. Pg 16 “Managing and Measuring Emergency Department Care: Results of the Fourth Emergency Department Benchmarking Definitions Summit.” Maame Y. A. B. Yiadom MD, MPH, MSCI Anthony Napoli MD, EMHL Michael Granovsky MD Rebecca B. Parker MD Randy Pilgrim MD Jesse M. Pines MD, MSCE, MBA Jeremiah Schuur MD, MHS James Augustine MD Nicholas Jouriles MD Shari Welch MD AcademicEM. May 2020. Publication online May 8, 2020. doi.org/10.1111/acem.13978 “Help Prevent Coronavirus Spread by Reevaluating ED Flow”. Welch, Shari and Augustine, James J. ACEP NOW. 39(6) Jun 2020. Pg 5 “ED Usage Trends Before COVID-19”. Augustine, James J. ACEP NOW. 39(5) May 2020. Pg 21.. 3 source data and chart “The 20 Numbers of ED Management”. Augustine, James J. ACEP NOW. 39(3) Mar 2020. Pg 15 Page 4883 of 6526 “By the Numbers: Mental Health Visits are Increasing”. Augustine, James J. ACEP NOW. 39(3) Mar 2020. Pg 3 “Latest Data Reveal the ED’s Role as Hospital Admission Gatekeeper”. Augustine, James J. ACEP NOW. 38(12) Dec 2019. Pg 26 “The Latest ED Utilization Numbers are in” Augustine, James J. ACEP NOW. 38(10). Oct 2019. Pg 36. “Annotated guidance and recommendations for the role and actions of emergency medical services systems in the current opioid epidemic.” Keseg DP, Augustine JJ, Fowler, RL, Scheppke KA, Farcy DA, Pepe PE for the metropolitan cities’ emergency medical services medical directors’ coalition. J Emerg Med 2019:56 Epub: S0736-4679(19)30325-7. PMID: 31109831 “New Out-Of-Hospital Care Models Could Affect Your Emergency Dept”. Augustine, James J. ACEP NOW. 38(5) May 2019. Pg 19 “Optimizing Emergency Department Workspace to Promote Wellness”. Lim, David; Mosinski, Nicolette; Perfetti, Joyce; Powers, Evelyn; Augustine, James. ACEP NOW. 38(4). April 2019 “Variabilities in the Use of IV Epinephrine in the Management of Cardiac Arrest Patients”. Lokesh, Nidhish; Fowler, Raymond; Cabanas, Jose; Augustine James J. JEMS. 43(10) October 2018. Pp 39- 42 ‘Botulism Outbreak in a Regional Community Hospital: Lessons Learned in Transfer and Transport Considerations’. Krebs, William, Higgins, Terri, Buckley, Martha, Augustine, James J, Raetzke Bradley, & Werman, Howard. Prehospital Emergency Care, September, 2018 https://doi.org/10.1080/10903127.2018.1476636 “Identify and Plan for Your Emergency Department’s Particular Patient Mix. Augustine, James J. ACEP NOW. Feb 2019. 38(2). Pg 21-22 “ED Inefficiency Drive Poor Quality” Augustine, James J. ACEP NOW. Nov 2018. 37(11). Pg 21-22 “Injury in the Mix: Changing Nature of ED Patients” Augustine, James J. ACEP NOW. July 2018. 37(7). Pg 21 “Hospital Strategies for Reducing Emergency Department Crowding: A Mixed-Methods Study”. Chang AM, Cohen D, Lin A, Augustine J, Handel D, Howell E, Kim H, Pines J, Schuur J, McConnell KJ, Sun BC. AnnalsEM 71(4), Apr, 2018. Pp 497-505 Page 4884 of 6526 “Return ED Visits: Poor Performance or Flawed Metric” Augustine, James J. ACEP NOW. March 2018. 37(3). Pg 21 “Emergency Department Volume Increase Trend Continues Into 2014” Augustine, James J. ACEP NOW. November 2017. 36(10). Pg 10 “The Next Body Blow: Rising Drug Prices” Augustine, JJ and Abes, Ben. JEMS. October 18, 2017 “More Advanced Practice Providers in ED’s” Augustine, James J. ACEP NOW. September 2017. 36(12). Pg 8 “ED’s Need Plan to Deal with Drug Shortages” Augustine, James J. ACEP NOW. August 2017. 36(8). Pg 20 “Diagnostic Testing in the ED Supports Development of New Metrics as Quality Indicators” Augustine, James J. ACEP NOW. May 2017. 34(7). Pg 21-2 “Long-Term Trends in Emergency Department Visits, Patient Care Highlighted in National Reports” Augustine, James J. ACEP NOW. January 2017. 34(1). Pg 21-2 “Design ED’s to Boost Patient, Staff Satisfaction” Augustine, James J. ACEP NOW. December 2016. 33(12). Pg 1 “2015 Emergency Department Survey Shows Spike in Volume, Structural Changes, Patient Boarding Concerns” Augustine, James J. ACEP NOW. November 2016. 33(11). Pg 16 “Implementing Data Deflnition Consistency for ED Operations Benchmarking and Research.” Yiadom MY, Schuelen J, McWade C, Augustine JJ. Academic EM. 2016;23(7): 796–802 “Long ED Boarding Times Drive Walkaways, Revenue Losses” Augustine, James J. ACEP NOW. July 2016. 33(7). Pg 16 “Lifesaving Field Amputation”. Cortez, Eric; Keseg, David; Augustine James J. JEMS. 41(6) June 2016. Pp 39- 42 Page 4885 of 6526 “National Surveys on Emergency Department Trends Bring Future Improvements Into Focus” Augustine, James J. ACEP NOW. April 2016. 33(4). Pg 12 “Bleeding Control: The role of tourniquets in the field”. White, Elisabeth; Cash, Carla; Augustine James J.; Fowler, Raymond. JEMS. 41(4) April 2016. Pp 45- 47 “Emergency Department Benchmarking Alliance Releases 2014 Data on Staffing, Physician Productivity” Augustine, James J. ACEP NOW. January 2016. 33(1). Pg 14 Spinal Trauma and Patient-Centered Spinal Motion Restriction, chapter 11. Trauma Life Support for Emergency Care Providers. International Trauma Life Support. Eighth Edition. Published by Pearson Education, Inc. 2016 Pp 208-234 Case Study 17 on Trauma Center Design. Saint Francis Hospital. Emergency Department Design: A Practical Guide to Planning for the Future, 2nd Edition. ACEP, Dallas, TX. Pp 371-376. “Reducing Boarding Time in the Emergency Department Can Improve Patient Care” Augustine, James J. ACEP NOW. December 2015. 34(12). Pg 18 “Crash and Compression” Bacon, Chuck and Augustine, James J. JEMS. October 2015. 40(10), pp 26-30 Prehospital Rounds, monthly column in EMSWorld Magazine. “Suburban Plane Crash”. September 2015. 44(9). 18-26 “Pot (Bad) Luck. The Botulism Incident” Augustine, James J. and Scott, John ACEP NOW. August 2015. 34(8). Pg 1 “Emergency Department Flow, Patient Walkaway Key Performance Measures” Augustine, James J. ACEP NOW. July 2015. 34(7). Pg 9 “Risk Adjusted Variation for Publicly Reported Emergency Department Timeliness Measures.” Sun B, Laurie A, Prewitt L, Fu R, Chang AM, Augustine J, Reese C, McConnell KJ. Annals of Emergency Medicine. June 2015 Epub ahead of print. Prehospital Rounds, monthly column in EMSWorld Magazine. “STEMI’s and Other Sources of Chest Pain”. August 2015. 44(8). 12-20 Page 4886 of 6526 Prehospital Rounds, monthly column in EMSWorld Magazine. “Dry Decontamination”. July 2015. 44(7). 12-21 Prehospital Rounds, monthly column in EMSWorld Magazine. “Severe Heat Illness”. June 2015. 44(6). 15- 19 Prehospital Rounds, monthly column in EMSWorld Magazine. “Infectious Disease Outbreak” EMS Patient Management of Public Health Exposures. May 2015. 44(5). 12-15 Prehospital Rounds, monthly column in EMSWorld Magazine. “Bariatric Patient Care” EMS Patient Management of Very Large Patients and their Equipment. Apr 2015. 44(4). 14-20 Prehospital Rounds, monthly column in EMSWorld Magazine. “Officer Down” EMS Patient Management of MCIs in Active Shooter Incidents. Mar 2015. 44(3). 12-22 “ACEP’s Clinical Emergency Data Registry to Measure, Report Health Care Quality, Outcomes” Augustine, JJ, et al ACEP NOW. May 2015. 34(5). “Diagnostic Testing Usage Data can Help Emergency Physicians Manage Utilization” Augustine, James J. ACEP NOW. April 2015. 34(4). “How EMS Systems can Prepare for the Next Outbreak”. Augustine, James J. JEMS March 2015. 40(3). 18- 19 “The Growing Evidence of the Value of Emergency Care”. Rosenau, AM, Augustine, JJ, Jones, S, and Glickman, SW. Academic Emergency Medicine. Feb 2015. 22(2). Pp 224-226. “Measles Outbreak Highlights the Need for Infectious Disease Containment Protocols in the Emergency Department” Augustine, James J. ACEP NOW. February 2015. 34(2). Prehospital Rounds, monthly column in EMSWorld Magazine. “Tech Support” EMS Patient Management of Accidental Hypothermia, and Ice Rescue. Feb 2015. 44(2). 16-24 Prehospital Rounds, monthly column in EMSWorld Magazine. “Air Traffic Control” EMS Patient Management of Trauma Airways, and Drone Problems. Jan 2015. 44(1). 18-28 Page 4887 of 6526 “National Hospital Ambulatory Medical Care Survey Data Show Increase in Emergency Department Visits” Augustine, James J. ACEP NOW. January 2015. 34(1). Pg 6 “EMS Arrivals, Admission Rates to the ED Analyzed” Augustine, JJ. ACEP NOW. December 2014. 34(1). 22. Prehospital Rounds, monthly column in EMSWorld Magazine. “Hands Down” EMS Patient Management of Severe Hand Injuries. Dec 2014. 43(12). 20-24 Prehospital Rounds, monthly column in EMSWorld Magazine. “Arms and ‘The Man”” EMS Management of Violent Patients with Law Enforcement. Nov 2014. 43(11). 26-30 Prehospital Rounds, monthly column in EMSWorld Magazine. “Crash Deconstruction” EMS Patient Safety in Evaluating Trauma Patient Scenarios. Oct 2014. 43(10). 14-17 Two Hundred to here Prehospital Rounds, monthly column in EMSWorld Magazine. “Germs of Service” EMS Patient Safety in At- Risk Patients for Nosocomial Infections. Sept 2014. 43(9). 16-20 “Emergency Department Benchmarking Alliance Reports on Data Survey for Next-Generation ED Design ” Augustine, JJ. ACEP NOW. August 2014. 33(8). 22. “Managing Another Emergency Medication Challenge: The Severe Saline Shortage”. News You Can Use. Augustine, James J. JEMS June 2014. 39(6). 20-21 Prehospital Rounds, monthly column in EMSWorld Magazine. “X Vials” EMS Patient Safety Regarding Medication Shortage. Aug 2014. 43(8). 14-19 Prehospital Rounds, monthly column in EMSWorld Magazine. “Leg Lock” EMS Patient Safety Regarding High Angle Rescue. July 2014. 43(7). 20-25 Prehospital Rounds, monthly column in EMSWorld Magazine. “Passing the Boards” EMS Patient Safety Regarding Pediatric Spinal Motion Restriction . June 2014. 43(6). 18-22 “Expanded Diagnostic Testing in the Emergency Department Raises Need for Cohort Data” Augustine, JJ. ACEP NOW. May 2014. 33(5). Pg 16 Page 4888 of 6526 Prehospital Rounds, monthly column in EMSWorld Magazine. “Stock Options” EMS Equipment Safety in use of Cardiac Monitors. May 2014. 43(5). 20-22 Prehospital Rounds, monthly column in EMSWorld Magazine. “Things that go Bump in the Night” EMS Vehicle Safety in Scene Operations . April 2014. 43(4). 18-22 “What ED Measure Performance Measures Should Mean to You” Augustine, JJ. ACEP NOW. March 2014. 33(3). Pg 14 Prehospital Rounds, monthly column in EMSWorld Magazine. “Homebody” EMS Management of Bariatric Patients. March 2014. 43(3). 14-19 Prehospital Rounds, monthly column in EMSWorld Magazine. “Toxic Avoider” EMS Management of Patients with Unknown Contamination. February 2014. 43(2). 18-25 “The Cost of a Click” Augustine, JJ. and Holstein, John G. Emerg Physicians Monthly. February 2014. 21(2). 26. Prehospital Rounds, monthly column in EMSWorld Magazine. “Sidetracked” EMS Management of a Fire Rescue MCI. January 2014. 43(1). 10-18 Prehospital Rounds, monthly column in EMSWorld Magazine. “Fragile Load” EMS Management of Pain in Patients with Compression Fractures. December 2013. 42(12). 24-27 “The True Cost of Ambulance Diversion” Augustine, JJ. Emerg Physicians Monthly. December 2013. 20(12). 27. “Four Metrics that can Change Medicine” Augustine, JJ. Emerg Physicians Monthly. November 2013. 20(11). 9. Prehospital Rounds, monthly column in EMSWorld Magazine. “Breath Wish” EMS Management of Pulmonary Embolism Complicating a Fracture. November 2013. 42(11). 18-21 Chapter X: Operational Issues. Casey, John, Lowe, Robert, Augustine, James. Ohio ACEP EMS Medical Directors’ Course. 3rd edition Oct, 2013. Columbus, Ohio. Editor Ann Dietrich, MD, FAAP, FACEP Page 4889 of 6526 Prehospital Rounds, monthly column in EMSWorld Magazine. “Unhealthy Diet” EMS Management of Anaphylactic Reactions to Food. October 2013. 42(10). 16-20 “Healthcare Preparedness-The Resilience Challenge”. Augustine, JJ, Domestic Preparedness Jnl. Oct 2013;9(10):8-9. “Survey: The ED is the Nexus of Care” Augustine, JJ. Emerg Physicians Monthly. October 2013. 20(10). 26-7. Prehospital Rounds, monthly column in EMSWorld Magazine. “Head to Head” EMS Management of Pediatric Head Injuries. September 2013. 42(9). 28-34 “Befriending Big Data” Augustine, JJ. Emerg Physicians Monthly. August 2013. 20(8). 1, 3. Prehospital Rounds, monthly column in EMSWorld Magazine. “Fight-Picker” EMS Management of Penetrating Chest Wounds. August 2013. 42(8). 22-28 Prehospital Rounds, monthly column in EMSWorld Magazine. “Time Management” EMS Management of Time Management in Acute Strokes. July 2013. 42(7). 20-26 Prehospital Rounds, monthly column in EMSWorld Magazine. “Stutter Steps” EMS Management of Acute MI with Atypical Presentation and Uncertain Onset. June 2013. 42(6). 20-23 Prehospital Rounds, monthly column in EMSWorld Magazine. “What’s in Your All Hazards Plan?” EMS Review of Boston Explosions and Planning. May 2013. 42(5). 18-23 Prehospital Rounds, monthly column in EMSWorld Magazine. “History’s Mysteries.” EMS Management of a Person without Identity and a History. Apr 2013. 42(4). 19-22 Prehospital Rounds, monthly column in EMSWorld Magazine. “Outbreak Hotel.” EMS Management of an Infiuenza Outbreak. Mar 2013. 42(3). 16-22 “Drug Shortages and Emergency Care: Your Action is Needed”. Augustine, JJ. Pt Safety & Quality Healthcare. Nov/Dec2012;9(6): 60–61 Page 4890 of 6526 Prehospital Rounds, monthly column in EMSWorld Magazine. “Unexpected Drop-ins.” EMS Management of a College Bus Crash with Multiple Fatalities. Dec 2012. 41(12). 22-25 “Designing a National Infectious-Agent Detection System”. Augustine, JJ, Domestic Preparedness Jnl. Nov 2012;8(11):7-8. “It Costs the Pharmacy About $6.00 per Patient for Medicines Administered in the ED”. Augustine, JJ. Joint Comm J Qual Pat Safety (online) Prehospital Rounds, monthly column in EMSWorld Magazine. “Seizure Secrets.” EMS Management of Obstetrical Complications. Nov 2012. 41(11).26-30 “Procedural safety in emergency care: A conceptual model and recommendations”. Pines JM, Kelly JJ, Meisl H, Augustine J, Broida RI, Clarke JR, Farley H, Franklin M, Fuller D, Klauer K, Phelan MP, Schuur JD, Stone- Griffith S, Thallner E, Wears RL. Jt Comm J Qual Patient Saf. 2012;38(11):516–526 Prehospital Rounds, monthly column in EMSWorld Magazine. “Pregnant Pause.” EMS Management of Obstetrical Complications. Oct 2012. 41(10).22-26 “Volume-Related Difference in Emergency Department Performance”. Shari J. Welch, MD, James J. Augustine, MD, Li Dong, MD, Lucy Savitz, PhD, Gregory Snow, PhD, and Brent James, MD, MStat. Jt Comm J Qual Patient Saf. 2012;38(9):395–401 Prehospital Rounds, monthly column in EMSWorld Magazine. “Cancer Complications.” EMS Management of Cancer Complications. Sept 2012. 41(9).20-22 Prehospital Rounds, monthly column in EMSWorld Magazine. “Pierced Ear.” EMS Management of Ambulance ENT Emergencies. Aug 2012. 41(8).20-25 Prehospital Rounds, monthly column in EMSWorld Magazine. “Crash Course.” EMS Management of Ambulance Crash MCIs. July 2012. 41(7).24-30 Prehospital Rounds, monthly column in EMSWorld Magazine. “Running into Trouble.” EMS Manag ement of Heat-Related MCIs. June 2012. 41(6).14-18 Prehospital Rounds, monthly column in EMSWorld Magazine. “Fence Splitter.” EMS Management of Genital Trauma. May 2012. 41(5).24-26 Page 4891 of 6526 “Fundamental Principles of Disaster Management: Decontamination”. Chapter in The Oxford American Handbook of Disaster Medicine. Edited by Robert Partridge, Lawrence Proano, and David Marcozzi. Oxford University Press. 2012 Prehospital Rounds, monthly column in EMSWorld Magazine. “Target Audience.” EMS Management of Mass Casualty Shooting. Apr 2012. 41(4).26-30 Prehospital Rounds, monthly column in EMSWorld Magazine. “Mystery Stick.” EMS Management of Needles and Hepatitis C. Mar 2012. 41(3).18-22 “Extreme Bleeds: Recommendations for Tourniquets in Civilian EMS” Risk, Gregory, and Augustine, JJ,. JEMS. 33 (3): 76-81. March 2012 Prehospital Rounds, monthly column in EMSWorld Magazine. “When it Rains, It Pours.” EMS Management of Elderly Patients on Blood Thinners. Feb 2012. 41(2).18-19 Prehospital Rounds, monthly column in EMSWorld Magazine. “Special Delivery.” EMS Management of a Pregnant Patient in a Blizzard. Jan 2012. 41(1).28-32 Prehospital Rounds, monthly column in EMSWorld Magazine. “House Arrest.” EMS Management of a Major Emergency Involving a Crew Member. Dec 2011. 40(12).22-28 Prehospital Rounds, monthly column in EMSWorld Magazine. “Eye-catcher.” EMS Management of Patients with Penetrating Eye Injuries. Nov 2011. 40(11).26-28 Prehospital Rounds, monthly column in EMSWorld Magazine. “Just Say No.” EMS Management of Patients who may Need Drug Screening. Oct 2011. 40(10).24-25 “The Reform-Ready ED” Part One. Welch, Shari, Augustine, JJ, Asplin, Brent. Emerg Medicine News. 33 (10): 33-34. October 2011 Prehospital Rounds, monthly column in EMSWorld Magazine. “Disarmed.” EMS Management of Patients with Amputations. Sept 2011. 40(9).26-32 Prehospital Rounds, monthly column in EMSWorld Magazine. “Families to the Left.” EMS Management of Victims and Families of an Unknown Chemical Incident. August 2011. 40(8).21-26 Page 4892 of 6526 Prehospital Rounds, monthly column in EMSWorld Magazine. “The Gravity of the Situation.” EMS Management of Law Enforcement Incidents. July 2011. 40(7).28-34 “Emergency Department Operational Metrics, Measures, and Deflnitions:: Results of the Second Performance Measures and Benchmarking Summit”. Shari J. Welch, MD, Brent Asplin, MD, MPH, Suzanne Stone-Griffith, RN, Steven Davidson, MD, MBA, James Augustine, MD, and Jeremiah D. Schuur, MD,MHS,. Annals EM 2011; 58(1): 33–40. July 2011 Prehospital Rounds, monthly column in EMSWorld Magazine. “The Near-Death Patient.” EMS Management of Patients at End of Life. June 2011. 40(6).24-26 “Mixed Messages on Cardiac Arrest” Augustine, JJ. Emerg Physicians Monthly. June 2011. 18(6). 34. “Emergency Department Operations Dictionary: Results of the Second Performance Measures and Benchmarking Summit”. Shari J. Welch, MD, Suzanne Stone-Griffith, RN, Brent Asplin, MD, MPH, Steven Davidson, MD, MBA, James Augustine, MD, and Jeremiah D. Schuur, MD,MHS, on behalf of The Second Performance Measures and Benchmarking Summit and the Emergency Department Benchmarking Alliance. Academic EM 2011; 18:1–6 “Expect uptick in emergency volume”. Welch, Shari and Augustine, James. Modern Healthcare news, January 5, 2011 Prehospital Rounds, monthly column in EMSWorld Magazine. “After the Storm.” EMS Response to a Tornado Event. May 2011. 40(5).28-31 Prehospital Rounds, monthly column in EMSWorld Magazine. “Priority Calls.” Cell phone Technology Improves Emergency Medical Care. April 2011. 40(4).24-26 Prehospital Rounds, monthly column in EMSWorld Magazine. “Feel it Kick.” Management of Patients with Automated Implanted Cardiac Deflbrillators. March 2011. 40(3).26-30 Prehospital Rounds, monthly column in EMSWorld Magazine. “The Quiet Ones Dying.” Management of IED Incident Patients. February 2011. 40(2).26-27 Prehospital Rounds, monthly column in EMSWorld Magazine. “A Bolt from the Blue.” Management of Lightning Strike Patients. January 2011. 40(1).20-21 Page 4893 of 6526 Prehospital Rounds, monthly column in EMSWorld Magazine. “Hold your Fire.” Assuring Safe Application of Deflbrillation. December 2010. 39(12).24-28 Prehospital Rounds, monthly column in EMSWorld Magazine. “Uneasy Rider.” Managing Trauma and Personal Property. November 2010. 39(11).18-22 “The New Vital Sign Parameter. Co-oximetry should be in the BLS Toolkit”. Augustine, JJ. JEMS. 35(10) October 2010. Suppl pp 24-28 Prehospital Rounds, monthly column in EMSWorld Magazine. “An Especially Difficult Airway.” Managing Airways using Alternate Airway Procedures. October 2010. 39(10).28-30 Prehospital Rounds, monthly column in EMS Magazine. “Running on Empty.” Understanding the Most Important Patient Medications. September 2010. 39(9).24-28 Prehospital Rounds, monthly column in EMS Magazine. “Down in the Mouth.” Prehospital management of anaphylactic reaction with intralingual injection. August 2010. 39(8).18-20 Prehospital Rounds, monthly column in EMS Magazine. “Put in Her Place.” Prehospital management of dislocated joints. July 2010. 39(7).22-24 Prehospital Rounds, monthly column in EMS Magazine. “Man vs. Machine.” Prehospital management of farm accidents and difficult extrications. June 2010. 39(6).18-21 Prehospital Rounds, monthly column in EMS Magazine. “Responding to Special Needs.” Prehospital management of unusual medical devices. May 2010. 39(5).26-27 Prehospital Rounds, monthly column in EMS Magazine. “Belly Bump.” Non-trauma causes of shock related to abdominal bleeding. April 2010. 39(4).20-24 Prehospital Rounds, monthly column in EMS Magazine. “A Clear Mandate.” Patients Refusing Spinal Immobilization. March 2010. 39(3).24-28 Prehospital Rounds, monthly column in EMS Magazine. “Don’t Come Around Here.” ED Diversion Issues for EMS. February 2010. 39(2).24-26 Page 4894 of 6526 Prehospital Rounds, monthly column in EMS Magazine. “Describing What Happened”. A new method for documenting a complicated unresponsive-child call. January 2010. 39(1).26-28 Augustine JJ, McGinnis K. Chapter 47: Communications. In Bass RR, Brice JH, Delbridge, TR, Gunderson MR. Medical Oversight of EMS. Volume 2 of Cone DC, O’Connor, Fowler. Emergency Medical Service: Clinical Practice and Systems Oversight. Kendall Hunt Publishing. 2009. Prehospital Rounds, monthly column in EMS Magazine. “Don’t Care for Mama”. Limited Treatment Orders. December 2009. 38(12).28-30 Prehospital Rounds, monthly column in EMS Magazine. “No History, No Meds”. Management of Elderly Patients with Hip Fractures. November 2009. 38(11).18-19 Prehospital Rounds, monthly column in EMS Magazine. “Not Like Herself at All”. Managing Acute Presentations of Acute Intracranial Bleeding. October 2009. 38(10).26-29 Prehospital Rounds, monthly column in EMS Magazine. “Hold that Epi”. Atypical Presentation of ACS. September 2009. 38(9).20-25 Prehospital Rounds, monthly column in EMS Magazine. “Backseat Baby”. Managing Precipitant Delivery. August 2009. 38(8).20-24 Prehospital Rounds, monthly column in EMS Magazine. “Belly Full of Trouble”. Managing Major Trauma in Young Adults. July 2009. 38(7).26-27 Prehospital Rounds, monthly column in EMS Magazine. “Drinking Herself to Death”. Managing Altered Level of Consciousness Presentations in College-Aged Patients. June 2009. 38(6).20-23 Prehospital Rounds, monthly column in EMS Magazine. “Out at Home”. Injuries to Young Athletes. May 2009. 38(5).18-22 Prehospital Rounds, monthly column in EMS Magazine. “Potty Mouth”. Proper us of Poison Control Center Resources. April 2009. 38(4).18-20 Page 4895 of 6526 Prehospital Rounds, monthly column in EMS Magazine. “The Value of Restraint”. Immobilizing Children during Transport. March 2009. 38(3).34-39 Prehospital Rounds, monthly column in EMS Magazine. “Baby Stopped Breathing”. Infants with ALTEs. February 2009. 38(2).22-24 Prehospital Rounds, monthly column in EMS Magazine. “Two -Way Flow”. Managing Emergencies Involving Stomas. January 2009. 38(1).22-26 Prehospital Rounds, monthly column in EMS Magazine. “Intervene-ous Line”. When a Doctor’s Order Exceed your Scope, What’s a Provider to do?. December 2008. 37(12).34-37 Prehospital Rounds, monthly column in EMS Magazine. “Unmasked”. Improving Consistency of Infectious Disease Practices. November 2008. 37(11).30-31 Prehospital Rounds, monthly column in EMS Magazine. “Swingers and Spitters”. Restraint Policies and Management of Violent Patients. October 2008. 37(10).34-35 Prehospital Rounds, monthly column in EMS Magazine. “Thanks, I'll Stay Here. A hypoglycemic episode is quickly resolved-but what about transport?”. Management of Hypoglycemic Patients. September 2008. 37(9).36-37 “RAES Bring Hope”, Augustine, JJ. ACEP EMS Prehospital Care Section News 10(2): September 2008. page 20-21 Prehospital Rounds, monthly column in EMS Magazine. “The Mess in the Garage”. Management of a Mangled Extremity, with Customer Service Priorities. August 2008. 37(8).44-47 “The Care and Feeding of Fireflghters” Fire and EMS and NFPA 1584. Augustine, JJ. EMS. July 2008;37(7):39-52 Prehospital Rounds, monthly column in EMS Magazine. “Needle in a Racetrack”. Management of an eyelid amputation. July 2008. 37(7). 28-34 One Hundred Publications to here Page 4896 of 6526 Prehospital Rounds, monthly column in EMS Magazine. “Industrial Entrapment”. Management of patient trapped in a machine. June 2008. 37(6). 26-28 “More than Just a Standard: NFPA 1584 Deflnes the Rehab Process.” Augustine, JJ. JEMS. 2008 May;33(5):106-117 Prehospital Rounds, monthly column in EMS Magazine. “The Whole Family’s Sick”. Recognition of Carbon Monoxide poisoning. May 2008. 37(5). 36-38 Prehospital Rounds, monthly column in EMS Magazine. “Under Parental Control”. Managing a Patient with Seizures using Parental Assistance. April 2008. 37(4). 26-28 “The Hope of RAES”. Augustine, JJ. EMS Magazine. March 2008. 37(3). 53 Prehospital Rounds, monthly column in EMS Magazine. “Don’t Put That Tube In!”. Managing a Patient using CPAP. March 2008. 37(3). 40-44 Prehospital Rounds, monthly column in EMS Magazine. “Skating to Patients”. Managing a Community Multiple Casualty Incident. February 2008. 37(2). 34-41 Prehospital Rounds, monthly column in EMS Magazine. “Man Ill on the Incoming Flight”. Managing Contagious Exposures in Public Transport System. January 2008. 37(1). 28-30 Prehospital Rounds, monthly column in EMS Magazine. “Truly Bleeding to Death”. Managing Airway Hemorrhage. December 2007. 36(12). 28-30 “Seeing the Glass Half Full: ED-EMS Partnerships Achieve Success in Emergency Care” Augustine, JJ. Urgent Matters Patient Flow Newsletter. 4(4): pg 5-6. Oct/Nov 2007 Prehospital Rounds, monthly column in EMS Magazine. “Overseas Delivery”. Managing Contagious Diseases in the Airport. November 2007. 36(11). 28-34 Prehospital Rounds, monthly column in EMS Magazine. “Any Position you Please”. Managing Airways with Careful Positioning. October 2007. 36(10). 48-52 Page 4897 of 6526 “Logic model use in Developing a Survey Instrument for Program Evaluation: Emergency Preparedness Summits for Schools of Nursing in Georgia.” Torghele, K, Augustine, J, et al. Public Health Nursing. Sept 2007. 24(5): 472-9. Prehospital Rounds, monthly column in EMS Magazine. “Why won’t He Wake Up?”. Managing Medication Mishaps. September 2007. 36(9). 25-27 Prehospital Rounds, monthly column in EMS Magazine. “How Many can You Take?”. Medical MCI Requires Coordination for Transportation. August 2007. 36(8). 23-27 Prehospital Rounds, monthly column in EMS Magazine. “Patient Tracking at an MCI”. Critical Needs for Tracking to Facilitate Customer Service. July 2007. 36(7). 26-29 Prehospital Rounds, monthly column in EMS Magazine. “Wreck with Entrapment”. Customer Service Priorities in EMS. June 2007. 36(6). 26-33 “Noninvasive CO Measurement; A Transformation in Prehospital Care using the Pulse CO-Oximeter.” Augustine, JJ. JEMS. 2007 May;32(5):64-71. Prehospital Rounds, monthly column in EMS Magazine. “Sit Up for a Pulse”. Management of CHF and Respiratory Distress. May 2007. 36(5). 28-30 Prehospital Rounds, monthly column in EMS Magazine. “You Take my Breath Away”. Management of Pediatric Respiratory Distress. April 2007. 36(4). 76-77 Prehospital Rounds, monthly column in EMS Magazine. “It’s Not the Pulse, It’s the Perfusion”. Heart rate and the Ability to Pump Blood. March 2007. 36(3). 28-30 “Heavy Subjects: The Delivery of Emergency Care to Obese Patients.” Augustine, JJ. JEMS. 2007 March;32(3):74-85. ”Today’s Opportunity to Create Solutions for EDs” Augustine, JJ. EM News 29(2). 4. February 2007 Prehospital Rounds, monthly column in EMS Magazine. “On-Scene Decon”. Management of Multiple Casualty Contamination Incidents. February 2007. 36(2). 30-34 Page 4898 of 6526 Prehospital Rounds, monthly column in EMS Magazine. “Extraordinary Extrication”. Conflned space rescue and medical decision making. January 2007. 36(1). 22-25 Prehospital Rounds, monthly column in EMS Magazine. “Cold, Wet, and Hurt”. Hypothermia complicates trauma when a hunter falls from a tree. December 2006. 35(12). 36-38 Prehospital Rounds, monthly column in EMS Magazine. “The Pregnant MVA Victim”. Managing the late trimester pregnant woman after trauma. November 2006. 35(11). 22-29 “The ED Major Incident Center. A Perfect Reflt”. Augustine, JJ. EMS Magazine. October 2006. 35(10). 40-50 Prehospital Rounds, monthly column in EMS Magazine. “Cleaning up the Mess”. Hazardous Materials issues with a Contaminated Patient. October 2006. 35(10). 28-30 Prehospital Rounds, monthly column in EMS Magazine. “All Abuzz”. Managing a Multiple Casualty Incident with a Medical Etiology (Multiple Patients with Beestings). September 2006. 35(9). 50 -53 Emergency Department Performance Measures and Benchmarking Summit. Welch S, Augustine J, Camargo CA, et al. Acad Emerg Med (United States), 2006 Oct;13(10):1074-80. Epub 2006 Aug 31. PMID: 16946283 “Point of view: how you can use the IOM report to improve EMS.” Augustine, JJ. Emerg Med Serv. 2006 Aug;35(8):51. Prehospital Rounds, monthly column in EMS Magazine. “Right Patient, Right Place, Right Time”. Managing Victim with Abdominal Aortic Aneurysm. August 2006. 35(8). 26-27 Prehospital Rounds, monthly column in EMS Magazine. “Next Victim”. Managing Incidents with Escalating Numbers of Victims. July 2006. 35(7). 28-29 Prehospital Rounds, monthly column in EMS Magazine. “Driver Down”. M anaging Shock of Unknown Etiology. June 2006. 35(6). 30-31 Prehospital Rounds, monthly column in EMS Magazine. “Fast Thinking”. Improving the Delivery of Stroke Care. May 2006. 35(5). 32-33 Page 4899 of 6526 Prehospital Rounds, monthly column in EMS Magazine. “Keep the Kids Together”. Triage for Incidents Involving Children. April 2006. 35(4). 30-32 Prehospital Rounds, monthly column in EMS Magazine. “Burn Baby Burn”. Managing Victims of Unexpected Hazmat Incidents . March 2006. 35(3). 34-36. Prehospital Rounds, monthly column in EMS Magazine. “Managing Your Scene”. ICS Utilization of Major EMS Incidents . February 2006. 35(2). 36-38. Prehospital Rounds, monthly column in EMS Magazine. “The ABCs of Scene Size-Up”. EMS Management of Major Incidents . January 2006. 35(1). 34-36. Prehospital Rounds, monthly column in EMS Magazine. “He keeps Falling Out”. EMS Management of Syncope . November 2005. 34(11). 32-34. “The Onus on Hospitals” Augustine, JJ. Hospitals and Health Networks. Letters to th e Editor. October 2005. 79(10). Pg 10. Prehospital Rounds, monthly column in EMS Magazine. “Mom, I Think I am Really Sick”. EMS Management of Highly Communicable Disease . October 2005. 34(10). 34-37. Hospital Evacuation: Philosophies of Patient Management. Augustine, JJ. ACEP Disaster Section Newsletter. 14(3) August 2005. Pg 4. Prehospital Rounds, monthly column in EMS Magazine. “Is There Someone on Board?”. EMS Provision of Care for Acute Myocardial Infarction. September 2005. 34(9). Pp 40-41. “Pre-Event Willingness to Receive Smallpox Vaccination among Physicians and Public Safety Personnel” Silk, Benjamin J, Augustine, James J, et al. Southern Medical Journal 98(9). Sept 2005. Pp 876-882 “ED Design: Form, Function, and a Friendly Front Door”, Augustine, JJ. ACEP News 24(8): August 2005. page iv The Future of Prehospital Care. EMS Magazine. August 2005. 34(8). 179 Page 4900 of 6526 Prehospital Rounds, monthly column in EMS Magazine. “Everyone Out: Managing an Evacuation”. EMS Operations at an Evacuation. August 2005. 34(8). 70-71. Prehospital Rounds, monthly column in EMS Magazine. “Minty Fresh and Unconscious”. Managing Poisoning in a Toddler. July 2005. 34(7). 48-49. Evacuation of a Rural Community Hospital: Lessons Learned From an Unplanned Event”. Augustine, J and Schoettmer, JT. Disaster Management & Response. Volume 3(3) , July-September 2005, Pp 68-72 Prehospital Rounds, monthly column in EMS Magazine. “Just the Flu”. Carbon monoxide poisoning at the worksite. June 2005. 34(6). 50-51. Prehospital Rounds, monthly column in EMS Magazine. “Triage at a Major Incident?”. Tough decisions in Triage. June 2005. 34(6). 46-49. Prehospital Rounds, monthly column in EMS Magazine. “Work Injury”. Severe Work-Related Injuries. May 2005. 34(5). 41-42. Prehospital Rounds, monthly column in EMS Magazine. “Barrels of Bad News?”. Toxic exposures combined with Multiple Trauma. April 2005. 34(4). 41-42. Prehospital Rounds, monthly column in EMS Magazine. “Can we Leave the Scene?”. Managing Underaged Patients. February 2005. 34(2). 44 Prehospital Rounds, monthly column in EMS Magazine. “A Call to the Hall”. Managing Multiple Casualties Exposure Incidents. January 2005. 34(1). 44 Prehospital Rounds, monthly column in EMS Magazine. “Senior Tour”. Geriatric Trauma Priorities. October 2004. 33(10). 64 Prehospital Rounds, monthly column in EMS Magazine. “Burn Triage”. Managing Major Incidents with large numbers of Burn Casualties. September 2004. 33(9). 32-35 Prehospital Rounds, monthly column in EMS Magazine. “Too Quiet”. Assessing Pediatric Patients. July 2004. 33(7). 32 Page 4901 of 6526 Prehospital Rounds, monthly column in EMS Magazine “There is Someone on the Ramp”. Documentation of Patient Care. June 2004. 33(6). 40 Prehospital Rounds, monthly column in EMS Magazine “Failure on the Board”. Trauma Patients with Underlying Medical Problems. May 2004. 33(5). 52-53 “Enhancing Assessment Senses: A look at the Past, Present, and Future of Emergency Patient Monitoring.” Augustine, JJ, JEMS 29(3) March 2004. 84-94 “System Redesign and Information Technology Implementation”. Augustine J.J Advances in Information Technology. 8(1) January 2004. 41-44. “America’s Emergency Care System and Severe Acute Respiratory Syndrome: Are We Ready?” Augustine JJ, Kellermann AL, Koplan JP. Ann Emerg Med. 43(1) January 2004. 23-26. Also serial online. Available at: http://www.mosby.com/AnnEmergMed. “Developing a Highly Contagious Disease Readiness Plan: The SARS Experience”, Augustine, JJ, Emergency Medical Services. July, 2003. 77-83. "A Model for Community Investment in Regional Emergency System Preparedness." Augustine, JJ. National Association of EMS Physicians News. 12(2): 4-7. May/June 2003. “SARS: The Implications for Fire and EMS”, Augustine, JJ, Emergency Medical Services, June, 2003. pg 30. “Quality in Clinical Practice” Cone, DC, Nedza, SM, Augustine, JJ, and Davidson, SJ. Academic Emergency Medicine pp 1085-90, Vol 9 (11) 2002. “Silent Assassin: Managing Exposure Incidents of Unknown Origin.” Augustine, JJ, JEMS, April 2002 “The Emergency Medicine Workforce Study: More Questions than Answers.” Augustine, JJ, and Kellermann, A. Annals Emergency Med 40:1 July 2002, 16-18. “Multiple Casualty Incidents and the Pediatric Patient.” Pediatric BTLS course textbook second edition. BTLS International, Oak Brook, IL 60681. pp 165-172. 2002 “Perspectives on Bioterrorism: Understanding the Threat.” Augustine, JJ, and Pesik, N. Emory Momentum Magazine. Winter 2001-2, pg 30-31. “Good Planning Needed for Tragedies”, Augustine, JJ, McKnight’s Long-term Care News, August 27, 2001, Pg 25. Page 4902 of 6526 “Evaluation of Missed Diagnoses for Patients Admitted from the ED” Chellis,M , Olson JE, Augustine, JJ, Hamilton, GC, Academic Emergency Medicine, pp 125-130, Vol 8(2), Feb, 2001 “Model of the Clinical Practice of Emergency Medicine” Hockberger, RS, Augustine, JJ, and others, Academic Emergency Medicine, 2001. Same reference in Annals of Emergency Medicine, PP 745-770, Vol 37, No. 6, June 2001 “Spinal Cord Trauma.” BTLS course textbook, Second edition, 1988, Third edition, 1994, and Fourth edition, 1999 “Unconventional Patient Positioning”, Augustine, JJ, Emergency Medical Services. May 1998. pp 60-64 “Evacuation Operations: A Race Against Time”, Augustine, JJ, DeLorenzo, RA: EMS Rescue Technology, Vol 1(1). January 1998. pp 24-29 “Best Practices in the Best Places: Benchmarking in the Emergency Department”, Augustine, JJ, McClay J: Best Practices and Benchmarking in Healthcare. Nov/Dec 1997. pp 274-278 “Emergency Medicine in a Managed Care Environment” Augustine, JJ and Dietrich, A. Managed Care Interface. 11(2). Feb 1998. 58-62, 67. “Patient Position and Airway Maintenance in Trauma Patients” Augustine, JJ. Ohio BTLS. December 1997. Pp 5-6. “Managed Care and Triage”, Mayer,T, Augustine JJ: Topics in Emergency Medicine. Vol 19(2). June 1997. pp 12-18 "Lessons in Emergency Evacuation From The Miamisburg Train Derailment" DeLorenzo RA, Augustine, JJ. Prehospital and Disaster Medicine, Vol 11(4).Oct-Dec 1996. pp 270-275 “Patient Positioning: Laying out the Options” De Lorenzo RA, Augustine, JJ. JEMS 21(2). September, 1996. Pp 72-84. “Optimal Positioning for Cervical Immobilization” DeLorenzo RA, Olson JE, Boska M, Johnston, R, Hamilton, GC, Augustine, JJ, Barton, Rhonda. Annals of Emergency Medicine.Vol 28(3). September, 1996. pp 301-308 “The ED Dilemma: Are Ohio’s Living Will Laws Working?” O’Daniel, J, Augustine, JJ. Ohio Medicine. April 1996. Pg 30 “Pediatric Trauma Triage and Major Incident Management.” Pediatric BTLS course textbook first edition. BTLS International, Oak Brook, IL 60681. pp108-113. 1995 "Priorities in Extrication" Augustine JJ. Emergency Medical Services. Vol 23(6) June 1994. 53-61 “Cardiopulmonary Arrest” in Present Signs and Symptoms in the E.D: Evaluation and Treatment." Hamilton, GC: Williams & Wilkins, 1993 "Priorities Only Please" Augustine JJ. ACEP Disaster Medicine Newsletter.Vol. 3. July, 1992. 7-9. "Penetrating Intracranial Trauma From a Fishhook" Swanson J. Augustine JJ. Annals of Emergency Medicine. Vol 21(5) May, 1992. Pp 568-571. Page 4903 of 6526 "Objectives to Direct the Training of Emergency Medicine Residents on Off-Service Rotations: Administration" Augustine JJ, Boyle M, Guttman TG, Hamilton, GC. The Journal of Emergency Medicine Vol 10. March/April, 1992. pp 209-219 "In Search of Fatigue Predictors." Augustine JJ. FIRE COMMAND. 57(11). November 1990. Pp 13-17 "EMS Communications." EMS Medical Directors Textbook, National Association of EMS Physicians, 1989, 1993. "Ventilation Performance During Cardiopulmonary Resuscitation." Augustine JJ, Seidel DR, McCabe JB. American Journal of Emergency Medicine. January 1988. "Administrative and EMS Outline for Emergency Medicine." Augustine JJ. American Journal of Emergency Medicine. January, 1988. "Physician at the Scene of an Emergency." Augustine JJ, McCabe JB, Singer JI. Southern Medical Journal. 78: 1985. 1074-1077. "Overview of Emergency Medical Services in Montgomery County." McCabe J. Augustine JJ. Dayton Medicine. September, 1984. 243-244. “The OSMA's medical student section (or what are we going to do with all these medical students?). Augustine, JJ and Papay, F. Ohio State Med J. 78(10). 1982 Oct. 699-700, 703. EDITORIAL POSITIONS: Senior Reviewer, Annals of Emergency Medicine Former Executive Editor, Emergency Department Management, an AHC Journal Associate editor and contributor to Strauss and Mayer’s Emergency Department Management Textbook, Second Edition, 2021 Section editor and contributor to Strauss and Mayer’s Emergency Department Management Textbook, First Edition, 2014 Editorial Board, ACEP Now Journal Page 4904 of 6526 Editorial Board, EMSWorld Magazine Editorial Board, JEMS Magazine Former Executive Editor, Emergency Physicians Monthly CERTIFICATIONS: Certifled Instructor, Advanced Trauma Life Support (ATLS) 1988 - Present Certifled Instructor, Basic Trauma Life Support (BTLS) 1985 - Present Certifled Instructor, Advanced Cardiac Life Support (ACLS) 1984 – Present Certifled Provider, Pediatric Advanced Life Support (PALS) 2002- Present Certifled Fireflghter, State of Ohio 1982 – Present EMT-A Certifled, State of Ohio, 1985 – 1999 ACTIVITIES/AWARDS: Recipient of the ACEP “James D. Mills Outstanding Contribution to Emergency Medicine Award” in 2021 Street Medicine Society. “John P Pryor Award” for exemplary service by a street medicine physician. February 2015. Multiple Service Awards. Atlanta Fire Rescue Department. 2003 to 2017. Liaison from the American College of Emergency Physicians to The Joint Commission, Hospital Professional and Technical Advisory Committee, and Roundtable on the Hospital of the Future Annals of Emergency Medicine “Top Consultant” for 2002-5, and 2007- 2010 for Excellence in Peer Review and Critical Analysis of Scientiflc Manuscripts Page 4905 of 6526 Beta Gamma Sigma Honor Society Phi Eta Sigma Honor Society Wright State University School of Medicine Student Council Treasurer Wright State University School of Medicine Faculty Curriculum Committee AMA - Medical Student Section, School Representative Ohio State Medical Association Planning Committee Member OSMA - Medical Student Section, Governing Council Externship, Dayton Power & Light Co. Performed comprehensive study of medical dept. Alpha Omega Alpha, 1983 Academy of Medicine Award, 1981 Chief Resident, Department of Emergency Medicine, 1985 - 1986 Ohio State Medical Association, Committee on Emergency and Disaster Medical Care Ohio State Medical Association, Committee on Legislation American College of Emergency Physicians, EMS Committee PAST ACTIVITIES AND Page 4906 of 6526 LEADERSHIP POSITIONS: Medical Director, Atlanta Fire Rescue Department Faculty Member, “Emergency Department of the Future” Harvard University School of Design, Cambridge, MA Past Chair, Hospital Professional Technical Advisory Committee Member, Hospital Advisory Council Board of Commissioners The Joint Commission, Oakbrook Terrace, IL 2004 to 2011 Medical Director, Emergency Department, Mercy Anderson Hospital, Cincinnati, OH. July 2010 to July 2011. 50,000 volume full-service Emergency Department. Intense focus on recruiting a whole new set of ED staff physicians • Initiated programs for improving patient satisfaction, which resulted in Press Ganey scores improving above 90% and recognition by Press Ganey for largest improvement in the U.S. • Finalized plans for an interim Department re-design • Served as Chair of the Hospital Preparedness Committee, and assisted in revamping Disaster programs and education • Consolidated efforts of an ED transition team to reduce ED walkaway rates, which then decreased to a rate below 1% • Led development of communication scripts to improve patient understanding of the ED process • Facilitated staffing model changes to improve physician and PA effectiveness • Participated in process to improve effectiveness of the Primary Cardiac Intervention Program at Mercy Anderson Hospital • Improved interface with regional trauma and stroke intervention programs • Development of program to manage cardiac arrests and other emergencies across the hospital campus Physician-in-Chief and Chair of the Department of Emergency Medicine, Stamford Health System, West Broad St at Shelburne, Stamford, CT 06904. February to July, 2004. 58,000 volume full-service Emergency Department and freestanding urgent care center. Level II Trauma Center and academic teaching site. Intense focus on recruiting new ED leadership and staff physicians • Initiated programs for improving patient satisfaction • Finalized plans for an interim Department re-design and long-term ED replacement Page 4907 of 6526 • Served as Chair of the Hospital Preparedness Committee, and assisted in revamping Disaster programs and education • Participated in Connecticut programs for Bioterrorism preparedness • Consolidated efforts to reduce ED walkaway rates. • Led development of communication scripts to improve patient understanding of the ED process • Facilitated staffing model changes to improve physician and PA effectiveness • Participated in process to allow air ambulance access to the City and the hospital campus • Leadership in hospital hearings which successfully developed a Primary Cardiac Intervention Program at Stamford Hospital • Improved interface with Trauma Program • Development of program to manage cardiac arrests and other emergencies across the hospitals’ campuses Chair, Department of Emergency Medicine, Miami Valley Hospital. Served as emergency physician in the Emergency and Trauma Center at Miami Valley Hospital from 1986-2000. During that time, accomplishments included: • Served as Associate Medical Director of the Emergency and Trauma Center • Served on Medical Staff Executive Committee • Served on Organizational Process Improvement Committee • Served as Chair, Disaster Committee • Served on the Trauma Committee • Served as interim Director of the hospital Trauma Program, which is a verifled Level I program. • Served as Director of EMS • This busy metropolitan hospital served as the Level I Trauma Center and Regional Burn Center. ED volume in this interval doubled. Patients arriving by EMS tripled. A regional referral network was established and a transportation program established with an air ambulance and then a critical care ground transport progra m. The ED was redesigned several times. A complete hospital critical care service tower addition was accomplished in the year 2000, including a new Emergency and Trauma Center, new inpatient surgical unit, new recovery area, new Trauma ICU, new parking, central receiving and supply, and a heliport were elements of this addition. Chief Executive Officer, Premier Health Care Services. 1986 -2001 One of four founders of a physician practice corporation, and served continuously on the Board of Directors. Developed a startup company of 4 physicians into a corporation of about 200 full time physicians and 500 total employees, with revenues of $60 million. When business conditions necessitated, developed an LLC model for the physician practice, and served as Chair of the LLC Board of New Century Physicians, Ltd Medical Director and Assistant Fire Chief, DC Fire & EMS May 2008 to Feb, 2010 1923 Vermont Ave, NW. Washington, DC 20001. Page 4908 of 6526 Medical Director, Atlanta Fire Rescue Department 2001-2009 And Atlanta Hartsfield Jackson International Airport 675 Ponce de Leon Ave, NE Atlanta, GA 30308-1829 Medical Director, Forest Park Fire Department, Riverdale Fire Department, City of Morrow Fire Division, and Fayetteville Fire Department 2003-2009 Chair, ASTM Task Group E54.02.01 Standards for Hospital Preparedness Under Committee E54 on Homeland Security Applications Clinical Assistant Professor, Emory University Department of Emergency Medicine Clifton Road Atlanta, GA Chair, Atlanta Metropolitan Medical Response System Atlanta Fulton County Emergency Management Agency Chair, Ohio EMS Board (the oversight body for EMS in the State of Ohio) Liaison from the Ohio EMS Board to the Ohio Trauma Subcommittee President, Ohio Chapter, American College of Emergency Physicians Board of Directors, Ohio Chapter, American College of Emergency Physicians Chair, Montgomery County EMS Task Force Medical Advisor, Dayton Regional Hazardous Materials Team Medical Advisor, Huber Heights Fire Department Page 4909 of 6526 Medical Advisor, West Carrollton Fire Department Medical Advisor, Washington Township Fire Department Chair, Ohio State Medical Association Emergency & Disaster Medical Care Committee Member, Trauma workgroup for developing statewide trauma system, Ohio State Medical Association Chair, Ohio Chapter ACEP, EMS Committee Montgomery County Medical Society Emergency & Disaster Committee Affiliate Faculty, State BTLS Committee President, Greater Miami Valley Regional EMS Council Ohio State Medical Association - 1980 Montgomery County Medical Society - 1980 Emergency Medicine Residents of Ohio – 1983 Montgomery County EMS Council - 1984 MEMBERSHIPS: American College of Physician Executives - 1990 American College of Emergency Physicians - 1983 State Chapters, American College of Emergency Physicians, Ohio and Georgia – 1983 Society Academic Emergency Medicine Alpha Omega Alpha - 1983 Page 4910 of 6526 American Medical Association Honorary Life Member, Montgomery County Fire Chief’s Association Association for the Advancement of Automotive Medicine (AAAM) PRESENTATIONS: This list of more then 500 national and international presentations on topics related to Emergency Medicine and Emergency Medical Service is available on request. REFERENCES: Available on request. Page 4911 of 6526 County of Collier, FL Procurement -, - 3299 Tamiami Trail, East Naples, FL 34112 [S SANDOVAL, MD LLC] RESPONSE DOCUMENT REPORT GEN No. 25-8350 Medical Director and Deputy Medical Director RESPONSE DEADLINE: March 26, 2025 at 3:00 pm Report Generated: Wednesday, March 26, 2025 S Sandoval, MD LLC Response CONTACT INFORMATION Company: S Sandoval, MD LLC Email: sarisand3@gmail.com Contact: Sariely Sandoval Address: 11665 Collier Blvd #786 Naples, FL 34116 Phone: (805) 223-3205 Website: N/A Submission Date: Mar 3, 2025 4:47 PM (Eastern Time) Page 4912 of 6526 [S SANDOVAL, MD LLC] RESPONSE DOCUMENT REPORT GEN No. 25-8350 Medical Director and Deputy Medical Director [S SANDOVAL, MD LLC] RESPONSE DOCUMENT REPORT undefined - Medical Director and Deputy Medical Director Page 2 ADDENDA CONFIRMATION Addendum #1 Confirmed Mar 6, 2025 2:23 PM by Sariely Sandoval Addendum #2 Confirmed Mar 8, 2025 12:10 PM by Sariely Sandoval Addendum #3 Confirmed Mar 10, 2025 1:38 PM by Sariely Sandoval QUESTIONNAIRE 1. I certify that I have read, understood and agree to the terms in this solicitation, and that I am authorized to submit this r esponse on behalf of my company.* Confirmed 2. Request for Proposals (RFP) Instructions Form* Request for Proposals (RFP) Instructions have been acknowledged and accepted. Confirmed 3. Collier County Purchase Order Terms and Conditions* Collier County Purchase Order Terms and Conditions have been acknowledged and accepted. Confirmed Page 4913 of 6526 [S SANDOVAL, MD LLC] RESPONSE DOCUMENT REPORT GEN No. 25-8350 Medical Director and Deputy Medical Director [S SANDOVAL, MD LLC] RESPONSE DOCUMENT REPORT undefined - Medical Director and Deputy Medical Director Page 3 4. Insurance Requirements* Vendor Acknowledges Insurance Requirement and is prepared to produce the required insurance certificate(s) within five (5) da ys of the County's issuance of a Notice of Recommended Award. Confirmed 5. Collier County Required Forms PROPOSAL SUBMITTAL* Please submit a proposal per the Evaluation Criteria outlined in the Solicitation. Cover_Letter_-_Proposal.pdf VENDOR DECLARATION STATEMENT (FORM 1)* Form_1_-_Vendor_Declaration_Statement.pdf CONFLICT OF INTEREST CERTIFICATION (FORM 2)* Form_2_-_Conflict_of_Interest.pdf IMMIGRATION LAW AFFIDAVIT CERTIFICATION (FORM 3)* Form_3_-_Immigration_Affidavit.pdf CERTIFICATION FOR CLAIMING STATUS AS A LOCAL BUSINESS (FORM 4) IF APPLICABLE Please provide a business tax receipt. Local business is defined as the vendor having a current Business Tax Receipt issued b y the Collier or Lee County Tax Collector prior to proposal submission to do business within Collier County, and that identifies the business with a permanent physical business address located within the limits of Collier or Lee County from which the vendor’s staff o perates and performs business in an area zoned for the conduct of such business. Please attach a Collier or Lee County Business Tax Receipt. Form_4_-_Local_Vendor_Preference.pdf REFERENCE QUESTIONNAIRE (FORM 5)* Page 4914 of 6526 [S SANDOVAL, MD LLC] RESPONSE DOCUMENT REPORT GEN No. 25-8350 Medical Director and Deputy Medical Director [S SANDOVAL, MD LLC] RESPONSE DOCUMENT REPORT undefined - Medical Director and Deputy Medical Director Page 4 The County requests that the vendor submits no fewer than three (3) and no more than ten (10) completed reference forms from clients during a period of the last ten (10) years whose projects are of a similar nature to this solicitation as a part of t heir proposal. Reference_-_Tina.pdf Reference_-_Jorge.pdf Reference_-_Hunter.pdf Reference_-_Hunt.pdf E-VERIFY - MEMORANDUM OF UNDERSTANDING* Vendor MUST be enrolled in the E-Verify - https://www.e-verify.gov/ at the time of submission of the proposal/bid. E-Verify Memorandum of Understanding or Company Profile page should be attached with your submittal. e-verify_MOU.pdf W-9 FORM* W9.pdf PROOF OF STATUS FROM DIVISION OF CORPORATIONS - FLORIDA DEPARTMENT OF STATE (SUNBIZ) http://dos.myflorida.com/sunbiz/ should be attached with your submittal* Annual_Report_Filing_-_2025.pdf LICENSE REQUIREMENT* Provide licenses and certifications as outlined in Evaluation Criteria 3: Qualifications. Florida_Medical_License_(2024-2027).pdf 2025-2028_DEA_License_.pdf Curriculum_Vitae_(Updated_02.24.2025).pdf Beaumont_Residency_Diploma.pdf ABEM_EM_Certificate_.pdf EMS_Fellowship_Diploma_.pdf ICS100_Intro_to_Incident_Command_Certificate.pdf Page 4915 of 6526 [S SANDOVAL, MD LLC] RESPONSE DOCUMENT REPORT GEN No. 25-8350 Medical Director and Deputy Medical Director [S SANDOVAL, MD LLC] RESPONSE DOCUMENT REPORT undefined - Medical Director and Deputy Medical Director Page 5 IS-200_Basic_Incident_Command_System_.pdf 300.pdf ICS-G400.pdf IS-700.An_Introduction_to_the_National_Incident_Management_System.pdf 800.pdf BDLS_2022.pdf ADLS_2023.pdf ALL SIGNED ADDENDA (IF APPLICABLE) No response submitted ALL OTHER DOCUMENTATION, AS APPLICABLE. Vendor_Check_List.pdf Proposal_Intent.pdf Page 4916 of 6526 February 24, 2025 Barbara Lance Collier County EMS 3295 Tamiami Tr East, Bldg C-2 East Naples, Florida 34112 Subject: Application for Deputy Medical Director Position To Whom It May Concern: I am writing to express my strong interest in the position of Deputy Medical Director for Collier County EMS. With a deep passion for prehospital emergency care, a strong background in emergency medicine, and proven leadership in EMS medical oversight, I am eager to contribute my expertise to enhance the quality and efficiency of our county’s EMS system. As a board-certified emergency physician with experience in prehospital medicine, I have had the privilege to work closely with EMS providers and Medical Directors to develop evidence- based protocols, implement skills training, and ensure optimal patient outcomes. In my current role as Medical Director for Immokalee Fire Control District and Associate Medical Director for North Collier Fire Control and Rescue, I have provided medical oversight, conducted training programs, and collaborated with local agencies to improve emergency response effectiveness. Key highlights of my qualifications include: • EMS Medical Oversight: In addition to my current positions, served as medical control for Washtenaw and Livingston County EMS (Michigan) where I enforced protocols aligned with state and national EMS standards. • Clinical and Operational Leadership: Involved in quality assurance programs, conducted case reviews, and implemented new training methodologies that improved field performance and patient care. • Interagency Collaboration: Worked closely with fire departments, law enforcement, and emergency management agencies to enhance response coordination and disaster preparedness. • Education and Training: Involved in skills training for paramedics and EMTs, ensuring adherence to the latest medical advancements and best practices. • Regulatory Compliance: Ensured compliance with state and federal EMS regulations while advocating for policies that support prehospital care advancements. • Commitment to Communication: Dedicated to fostering open communication with paramedics and EMTs to ensure their voices are heard and their concerns addressed, while also building strong relationships with the administration to promote cohesive leadership and operational efficiency. • Regional and Interagency Commitment: Committed to continuing work on a Southwest Florida Regional Guideline while fostering close collaboration with hospitals and fire departments to provide the best medical care for our community. Page 4917 of 6526 • Medical Director Coalition Involvement: An active member of the Medical Director Coalition since its formation in 2024, committed to continuing collaborative efforts with fellow medical directors and serving as a voice for our EMS system and the well-being of our community. I am committed to fostering a culture of excellence, innovation, and patient-centered care within your EMS system. My goal is to enhance clinical outcomes, improve provider training, and strengthen interagency collaboration to ensure that the residents of Collier County receive the highest standard of emergency medical care. I welcome the opportunity to discuss how my experience and vision align with your county’s EMS objectives. Thank you for your time and consideration. I look forward to the possibility of contributing to your team. Sincerely, Sariely Sandoval, MD 7848 Martino Cir, Naples, Florida 34112 sarisand3@gmail.com (805) 223-3205 Page 4918 of 6526 Form 1: Vendor Declaration Statement BOARD OF COUNTY COMMISSIONERS Collier County Government Complex Naples, Florida 34112 Dear Commissioners: The undersigned, as Vendor declares that this response is made without connection or arrangement with any other person and this proposal is in every respect fair and made in good faith, without collusion or fraud. The Vendor hereby declares the instructions, purchase order terms and conditions, requirements, and specifications/scope of work of this solicitation have been fully examined and accepted. The Vendor agrees, if this solicitation submittal is accepted by Collier County, to accept a Purchase Order as a form of a formal contract or to execute a Collier County formal contract for purposes of establishing a contractual relationship between the Vendor and Collier County, for the performance of all requirements to which this solicitation pertains. The Vendor states that the submitted is based upon the documents listed by the above referenced solicitation. The Vendor agrees to comply with the requirements in accordance with the terms, conditions and specifications denoted herein and according to the pricing submitted as a part of the Vendor’s bids. Further, the Vendor agrees that if awarded a contract for these goods and/or services, the Vendor will not be eligible to compete, submit a proposal, be awarded, or perform as a sub-vendor for any future associated work that is a result of this awarded contract. IN WITNESS WHEREOF, WE have hereunto subscribed our names on this 27th_ day of __February______, 2025_ in the County of _Collier___________, in the State of __Florida________ Firm’s Legal Name: S Sandoval, MD, LLC Address: 11665 Collier Blvd #786 City, State, Zip Code: Naples, Florida, 34116 Florida Certificate of Authority Document Number Federal Tax Identification Number *CCR # or CAGE Code *Only if Grant Funded __93-2657916____________________________________________________________________ Telephone: (805) 223-3205 Email: Sarisand3@gmail.com Signature by: (Typed and written) Sariely Sandoval Title: Physician Page 4919 of 6526 Additional Contact Information Send payments to: (required if different from above) 7848 Martino Cir, Naples, Florida, 34112 Company name used as payee Contact name: Sariely Sandoval Title: Physician Address: 7848 Martino Cir City, State, ZIP Naples, Florida, 34112 Telephone: (805) 223-3205 Email: Sarisand3@gmail.com Office servicing Collier County to place orders (required if different from above) Contact name: Title: Address: City, State, ZIP Telephone: Email: Page 4920 of 6526 e Collier County Form 2: Conflict of Inter-en Certification Affidavit The Vendor certifies that to the best of its knowledge nnd belief, t11e past and current work on any Collier County project affiliated with this solicitation does not pose an organii.alional conflict as described by one of the three categories below: Biased ground nalcs -The finn has not set the "ground mlcs" for affiliated past or current ColJier County project identified above (e.g., writing a procuremetlt's statement of work, specifications, or performing systems engineering and technical direction for the procurement) which appears to skew tlte competition in favor of my firm. Impaired objectivity -The fitm has not pcrfonncd work on an affilfated past or current CollieT County project identified above to evaluate proposals / past pelformance of .itself or a competitor, whJch cans into question the contractor's ability to render impartial advice to the government. Unequal actta to infonnation -1be firm bas not had access to no~blic infonnation as part of its performance of a Collier County project identified above which may have provided the cont13Ctor (or an affiliate) with an unfair competitive advantage in current or future solicitations and contracts. In addition to this signed affidavit, the contractor / vendor must provide the following: 1. All documents produced as a result of the work completed in the past or currently being wotked on for the above-mentioned project; am, 2. Indicate if the information produced was obtained as a matter of public record (in the "sumhine") or through non-public ( not in the "sumhine") conversation (s), meeting(s), document(s) and/or other means. Failure to disclose all material or having an organiz.atlonal conflict in one or more of the three categories above be identified, may result in the disqualification for future solicitations affiliated with the above referenced project(s). By the signature below, the finn ( employees, officers and/or agents) certifies, and hereby discloses, that, to the best of their koow ledge and belief, all relevant facts concerning past, present, or currently planned interest or activity (financial, contractual, organizational or otherwise) which relates to the project identified above has been fully disclosed and does not pose an organi731ional conflict 1J-cSoY1dOJC-\./, MD LL~ Company Name £~. Signature Jav-ieLy Sr<vi.dwu¾ ~D Print Name and Title Stateof ~(]q_ County of Co [ [ ( lC ~~~lllf ~ instrument was ~';wledged before,,ipe by~ e or D online ootari23tion, ~ day of ~-_ _,._!UQ_\..,-4-=---A.-, (month), f)~ (year), by --==~::::;.___::.....;r-J..Jo~-;-..;;;;;;._--=-......... ,o:;J,,Ll~..,_,,== _ _:(name of peison acknowledging). (Signature of Notary Public) / (PQ t. Type, or Stamp Commi~ioned Name ofNoouy Public) Personally Known OR Produced Identification £fer ( (, <k-DL-- Type of Identification Produced .l''" '",••,,,, SHAWN MICHAEL OESEAR {~ ~ Notary Publtc • State of Florida \ :,) Commission II HH 455578 ·,. .. . ,,, My Comm. Exptr,s Oct 18, 2027 aondtd throuah National Notary Assn. Page 4921 of 6526 £) Collier County Fol'm 3: Immigration Affidavit Certification This Affidmit is required and should be signed. by an Authorized principal of the firm and submitted with formal solicitation submiuals. Further. Vendors are required to be enrolled in the E-Vcrify program (https://www.e-verffy.goyh. at the time of the submission of the Vendor's proposal/bid. Acceptable evidence of your enrollment comists of a copy of the properly completed E-Verify Company Profile p.,gc or a copy of the fully executed E-Verify Memorandum of Understanding for the company which wit be produced at the time of tire submission of the Vendor's proposal/bid or within five (5) day of the County's Notice of Recommend Award. FAILURE TO EXECUTE THIS AFFIDAVIT CERTIFICATION AND SUBMIT WITH VENDOR'S PROPOSAL/BID MAY DEEM THE VENDOR'S AS NON-RESPONSIVE. Collier County "ill not intentionally award County contracts to any Vendor who knowingly employs unauthorized alien workers. constituting a violation of the employment provision contained ins U.S.C. Section 1324 a(e) Section 274A(e) of the Immigration and Nationality Act ('INA"). Collier County may consider the employment by any Vendor of unauthoriz.ed aliens a violation of Section 274A (e) of the INA. Such Violation by the recipient of the Employment Provisions contained in Section 274A (e) of the INA shall be grounds for unilateral termination of the contract by Collier CoWlty. Vendor attests that they are fully compliant with all applicable immigration laws (specifically to the 1986 Immigration Act and subsequent Amendment(s), that it is aware of and in compliance with the requirements set forth in Florida Statutes §448.093, and agrees to comply with the provisions of the Memorandum of Understanding with E-Verify and to provide proof of emollment in The Employment Eligibility Verification System (E-Verify), operated by the Department of Homeland Security in partnership with the Social Security Administration at the time of submission of the Vendor's proposal/bid s. Se-tv'\dW~l, M \), LL(, s ,)) µName Signature Sar;ely Sav1dw4) , Mb Print Name ind Title Stale of /tu'd c;_ County of C (5 l I ~eL I The~ instrument was ackllowledged bef~ me !lY ~ans of t{p~sical pre~ or Do • of 01 (month)~ P:();6 (year), by~Cf e 'Y :;a a <l-ov: < ~rlZ;t:·. on, this ..S day Personally Known OR Produced Identification dee&_ :u~ Type of Identification Produced .' Public) (Print, Type, or Stamp Commissioned Name of Notal)' Public) .. <J}'ii<i:--... SHAWN MICHAEL DESEAR (f~\:\ Notary Public • State of Florida ,\.~I/ Commission# HH 455578 '"?io,r-.i.: My Comm. Expires Oct 18, 2027 .......... Bonded throu11h National Notary Assn. Page 4922 of 6526 Form 4: Vendor Submittal – Local Vendor Preference Certification (Check Appropriate Boxes Below) State of Florida (Select County if Vendor is described as a Local Business) Collier County Lee County Vendor affirms that it is a local business as defined by the Procurement Ordinance of the Collier County Board of County Commissioners and the Regulations Thereto. As defined in Section Fifteen of the Collier County Procurement Ordinance: Local business means the vendor has a current Business Tax Receipt issued by the Collier County Tax Collector prior to bid or proposal submission to do business within Collier County, and that identifies the business with a permanent physical business address located within the limits of Collier County from which the vendor’s staff operates and performs business in an area zoned for the conduct of such business. A Post Office Box or a facility that receives mail, or a non-permanent structure such as a construction trailer, storage shed, or other non-permanent structure shall not be used for the purpose of establishing said physical address. In addition to the foregoing, a vendor shall not be considered a "local business" unless it contributes to the economic development and well-being of Collier County in a verifiable and measurable way. This may include, but not be limited to, the retention and expansion of employment opportunities, support and increase to the County's tax base, and residency of employees and principals of the business within Collier County. Vendors shall affirm in writing their compliance with the foregoing at the time of submitting their bid or proposal to be eligible for consideration as a "local business" under this section. A vendor who misrepresents the Local Preference status of its firm in a proposal or bid submitted to the County will lose the privilege to claim Local Preference status for a period of up to one year under this section. Vendor must complete the following information: Year Business Established in Collier County or Lee County: _2023___ Number of Employees (Including Owner(s) or Corporate Officers):___1______ Number of Employees Living in Collier County or Lee (Including Owner(s) or Corporate Officers):___1____ If requested by the County, Vendor will be required to provide documentation substantiating the information given in this certification. Failure to do so will result in vendor’s submission being deemed not applicable. Sign and Date Certification: Under penalties of perjury, I certify that the information shown on this form is correct to my knowledge. Company Name: ____S Sandoval, MD LLC_______________________ Date: ___2/27/2025__________________ Address in Collier or Lee County: __11665 Collier Blvd #786, Naples, Fl 34116________________________________ Signature: ____________________________________________ Title: ____Physician__________________ Page 4923 of 6526 Page 4924 of 6526 Page 4925 of 6526 Page 4926 of 6526 Form 5 Reference Questionnaire (USE ONE FORM FOR EACH REQUIRED REFERENCE) Solicitation: Reference Questionnaire for: (Name of Company Requesting Reference Information) (Name of Individuals Requesting Reference Information) Name: Nathaniel Hunt (Evaluator completing reference questionnaire) Company: University of Michigan (Evaluator’s Company completing reference) Email: FAX: Telephone: Collier County has implemented a process that collects reference information on firms and their key personnel to be used in the selection of firms to perform this project. The Name of the Company listed in the Subject above has listed you as a client for which they have previously performed work. Please complete the survey. Please rate each criteria to the best of your knowledge on a scale of 1 to 10, with 10 representing that you were very satisifed (and would hire the firm/individual again) and 1 representing that you were very unsatisfied (and would never hire the firm/indivdiual again). If you do not have sufficient knowledge of past performance in a particular area, leave it blank and the item or form will be scored “0.” Project Description: ___________________________ Completion Date: _____________________________ Project Budget: _______________________________ Project Number of Days: _______________________ Item Criteria Score (must be completed) 1 Ability to manage the project costs (minimize change orders to scope). 2 Ability to maintain project schedule (complete on-time or early). 3 Quality of work. 4 Quality of consultative advice provided on the project. 5 Professionalism and ability to manage personnel. 6 Project administration (completed documents, final invoice, final product turnover; invoices; manuals or going forward documentation, etc.) 7 Ability to verbally communicate and document information clearly and succinctly. 8 Abiltity to manage risks and unexpected project circumstances. 9 Ability to follow contract documents, policies, procedures, rules, regulations, etc. 10 Overall comfort level with hiring the company in the future (customer satisfaction). TOTAL SCORE OF ALL ITEMS S Sandoval, MD LLC Sariely Sandoval EMS Fellowship June 30, 2025 365 nateryan@med.umich.edu 734-323-7213 N/A 10 10 10 10 10 10 10 10 10 90/90 Page 4927 of 6526 Company ID Number: THE E-VERIFY MEMORANDUM OF UNDERSTANDING FOR EMPLOYERS ARTICLE I PURPOSE AND AUTHORITY The parties to this agreement are the Department of Homeland Security (DHS) and (Employer). The purpose of this agreement is to set forth terms and conditions which the Employer will follow while participating in E-Verify. E-Verify is a program that electronically confirms an employee’s eligibility to work in the United States after completion of Form I-9, Employment Eligibility Verification (Form I-9). This Memorandum of Understanding (MOU) explains certain features of the E-Verify program and describes specific responsibilities of the Employer, the Social Security Administration (SSA), and DHS. Authority for the E-Verify program is found in Title IV, Subtitle A, of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (IIRIRA), Pub. L. 104-208, 110 Stat. 3009, as amended (8 U.S.C. § 1324a note). The Federal Acquisition Regulation (FAR) Subpart 22.18, “Employment Eligibility Verification” and Executive Order 12989, as amended, provide authority for Federal contractors and subcontractors (Federal contractor) to use E-Verify to verify the employment eligibility of certain employees working on Federal contracts. ARTICLE II RESPONSIBILITIES A. RESPONSIBILITIES OF THE EMPLOYER 1.The Employer agrees to display the following notices supplied by DHS in a prominent place that is clearly visible to prospective employees and all employees who are to be verified through the system: a.Notice of E-Verify Participation b.Notice of Right to Work 2.The Employer agrees to provide to the SSA and DHS the names, titles, addresses, and telephone numbers of the Employer representatives to be contacted about E-Verify. The Employer also agrees to keep such information current by providing updated information to SSA and DHS whenever the representatives’ contact information changes. 3.The Employer agrees to grant E-Verify access only to current employees who need E-Verify access. Employers must promptly terminate an employee’s E-Verify access if the employer is separated from the company or no longer needs access to E-Verify. Page 1 of 17 E-Verify MOU for Employers | Revision Date 06/01/13 S Sandoval, MD, LLC 2632016 Page 4928 of 6526 Company ID Number: 4.The Employer agrees to become familiar with and comply with the most recent version of the E-Verify User Manual. 5.The Employer agrees that any Employer Representative who will create E-Verify cases will complete the E-Verify Tutorial before that individual creates any cases. a.The Employer agrees that all Employer representatives will take the refresher tutorials when prompted by E-Verify in order to continue using E-Verify. Failure to complete a refresher tutorial will prevent the Employer Representative from continued use of E-Verify. 6.The Employer agrees to comply with current Form I-9 procedures, with two exceptions: a.If an employee presents a "List B" identity document, the Employer agrees to only accept "List B" documents that contain a photo. (List B documents identified in 8 C.F.R. § 274a.2(b)(1)(B)) can be presented during the Form I-9 process to establish identity.) If an employee objects to the photo requirement for religious reasons, the Employer should contact E-Verify at 888-464-4218. b.If an employee presents a DHS Form I-551 (Permanent Resident Card), Form I-766 (Employment Authorization Document), or U.S. Passport or Passport Card to complete Form I-9, the Employer agrees to make a photocopy of the document and to retain the photocopy with the employee’s Form I-9. The Employer will use the photocopy to verify the photo and to assist DHS with its review of photo mismatches that employees contest. DHS may in the future designate other documents that activate the photo screening tool. Note: Subject only to the exceptions noted previously in this paragraph, employees still retain the right to present any List A, or List B and List C, document(s) to complete the Form I-9. 7.The Employer agrees to record the case verification number on the employee's Form I-9 or to print the screen containing the case verification number and attach it to the employee's Form I-9. 8.The Employer agrees that, although it participates in E-Verify, the Employer has a responsibility to complete, retain, and make available for inspection Forms I-9 that relate to its employees, or from other requirements of applicable regulations or laws, including the obligation to comply with the anti- discrimination requirements of section 274B of the INA with respect to Form I-9 procedures. a.The following modified requirements are the only exceptions to an Employer’s obligation to not employ unauthorized workers and comply with the anti-discrimination provision of the INA: (1) List B identity documents must have photos, as described in paragraph 6 above; (2) When an Employer confirms the identity and employment eligibility of newly hired employee using E-Verify procedures, the Employer establishes a rebuttable presumption that it has not violated section 274A(a)(1)(A) of the Immigration and Nationality Act (INA) with respect to the hiring of that employee; (3) If the Employer receives a final nonconfirmation for an employee, but continues to employ that person, the Employer must notify DHS and the Employer is subject to a civil money penalty between $550 and $1,100 for each failure to notify DHS of continued employment following a final nonconfirmation; (4) If the Employer continues to employ an employee after receiving a final nonconfirmation, then the Employer is subject to a rebuttable presumption that it has knowingly Page 2 of 17 E-Verify MOU for Employers | Revision Date 06/01/13 2632016 Page 4929 of 6526 Company ID Number: employed an unauthorized alien in violation of section 274A(a)(1)(A); and (5) no E-Verify participant is civilly or criminally liable under any law for any action taken in good faith based on information provided through the E-Verify. b.DHS reserves the right to conduct Form I-9 compliance inspections, as well as any other enforcement or compliance activity authorized by law, including site visits, to ensure proper use of E-Verify. 9.The Employer is strictly prohibited from creating an E-Verify case before the employee has been hired, meaning that a firm offer of employment was extended and accepted and Form I-9 was completed. The Employer agrees to create an E-Verify case for new employees within three Employer business days after each employee has been hired (after both Sections 1 and 2 of Form I-9 have been completed), and to complete as many steps of the E-Verify process as are necessary according to the E-Verify User Manual. If E-Verify is temporarily unavailable, the three-day time period will be extended until it is again operational in order to accommodate the Employer's attempting, in good faith, to make inquiries during the period of unavailability. 10.The Employer agrees not to use E-Verify for pre-employment screening of job applicants, in support of any unlawful employment practice, or for any other use that this MOU or the E-Verify User Manual does not authorize. 11.The Employer must use E-Verify for all new employees. The Employer will not verify selectively and will not verify employees hired before the effective date of this MOU. Employers who are Federal contractors may qualify for exceptions to this requirement as described in Article II.B of this MOU. 12.The Employer agrees to follow appropriate procedures (see Article III below) regarding tentative nonconfirmations. The Employer must promptly notify employees in private of the finding and provide them with the notice and letter containing information specific to the employee’s E-Verify case. The Employer agrees to provide both the English and the translated notice and letter for employees with limited English proficiency to employees. The Employer agrees to provide written referral instructions to employees and instruct affected employees to bring the English copy of the letter to the SSA. The Employer must allow employees to contest the finding, and not take adverse action against employees if they choose to contest the finding, while their case is still pending. Further, when employees contest a tentative nonconfirmation based upon a photo mismatch, the Employer must take additional steps (see Article III.B. below) to contact DHS with information necessary to resolve the challenge. 13.The Employer agrees not to take any adverse action against an employee based upon the employee's perceived employment eligibility status while SSA or DHS is processing the verification request unless the Employer obtains knowledge (as defined in 8 C.F.R. § 274a.1(l)) that the employee is not work authorized. The Employer understands that an initial inability of the SSA or DHS automated verification system to verify work authorization, a tentative nonconfirmation, a case in continuance (indicating the need for additional time for the government to resolve a case), or the finding of a photo mismatch, does not establish, and should not be interpreted as, evidence that the employee is not work authorized. In any of such cases, the employee must be provided a full and fair opportunity to contest the finding, and if he or she does so, the employee may not be terminated or suffer any adverse employment consequences based upon the employee’s perceived employment eligibility status Page 3 of 17 E-Verify MOU for Employers | Revision Date 06/01/13 2632016 Page 4930 of 6526 Company ID Number: (including denying, reducing, or extending work hours, delaying or preventing training, requiring an employee to work in poorer conditions, withholding pay, refusing to assign the employee to a Federal contract or other assignment, or otherwise assuming that he or she is unauthorized to work) until and unless secondary verification by SSA or DHS has been completed and a final nonconfirmation has been issued. If the employee does not choose to contest a tentative nonconfirmation or a photo mismatch or if a secondary verification is completed and a final nonconfirmation is issued, then the Employer can find the employee is not work authorized and terminate the employee’s employment. Employers or employees with questions about a final nonconfirmation may call E-Verify at 1-888-464-4218 (customer service) or 1-888-897-7781 (worker hotline). 14.The Employer agrees to comply with Title VII of the Civil Rights Act of 1964 and section 274B of the INA as applicable by not discriminating unlawfully against any individual in hiring, firing, employment eligibility verification, or recruitment or referral practices because of his or her national origin or citizenship status, or by committing discriminatory documentary practices. The Employer understands that such illegal practices can include selective verification or use of E-Verify except as provided in part D below, or discharging or refusing to hire employees because they appear or sound “foreign” or have received tentative nonconfirmations. The Employer further understands that any violation of the immigration-related unfair employment practices provisions in section 274B of the INA could subject the Employer to civil penalties, back pay awards, and other sanctions, and violations of Title VII could subject the Employer to back pay awards, compensatory and punitive damages. Violations of either section 274B of the INA or Title VII may also lead to the termination of its participation in E-Verify. If the Employer has any questions relating to the anti-discrimination provision, it should contact OSC at 1-800-255-8155 or 1-800-237-2515 (TDD). 15.The Employer agrees that it will use the information it receives from E-Verify only to confirm the employment eligibility of employees as authorized by this MOU. The Employer agrees that it will safeguard this information, and means of access to it (such as PINS and passwords), to ensure that it is not used for any other purpose and as necessary to protect its confidentiality, including ensuring that it is not disseminated to any person other than employees of the Employer who are authorized to perform the Employer's responsibilities under this MOU, except for such dissemination as may be authorized in advance by SSA or DHS for legitimate purposes. 16.The Employer agrees to notify DHS immediately in the event of a breach of personal information. Breaches are defined as loss of control or unauthorized access to E-Verify personal data. All suspected or confirmed breaches should be reported by calling 1-888-464-4218 or via email at E-Verify@uscis.dhs.gov. Please use “Privacy Incident – Password” in the subject line of your email when sending a breach report to E-Verify. 17.The Employer acknowledges that the information it receives from SSA is governed by the Privacy Act (5 U.S.C. § 552a(i)(1) and (3)) and the Social Security Act (42 U.S.C. 1306(a)). Any person who obtains this information under false pretenses or uses it for any purpose other than as provided for in this MOU may be subject to criminal penalties. 18.The Employer agrees to cooperate with DHS and SSA in their compliance monitoring and evaluation of E-Verify, which includes permitting DHS, SSA, their contractors and other agents, upon Page 4 of 17 E-Verify MOU for Employers | Revision Date 06/01/13 2632016 Page 4931 of 6526 Company ID Number: reasonable notice, to review Forms I-9 and other employment records and to interview it and its employees regarding the Employer’s use of E-Verify, and to respond in a prompt and accurate manner to DHS requests for information relating to their participation in E-Verify. 19.The Employer shall not make any false or unauthorized claims or references about its participation in E-Verify on its website, in advertising materials, or other media. The Employer shall not describe its services as federally-approved, federally-certified, or federally-recognized, or use language with a similar intent on its website or other materials provided to the public. Entering into this MOU does not mean that E-Verify endorses or authorizes your E-Verify services and any claim to that effect is false. 20.The Employer shall not state in its website or other public documents that any language used therein has been provided or approved by DHS, USCIS or the Verification Division, without first obtaining the prior written consent of DHS. 21.The Employer agrees that E-Verify trademarks and logos may be used only under license by DHS/USCIS (see M-795 (Web)) and, other than pursuant to the specific terms of such license, may not be used in any manner that might imply that the Employer’s services, products, websites, or publications are sponsored by, endorsed by, licensed by, or affiliated with DHS, USCIS, or E-Verify. 22.The Employer understands that if it uses E-Verify procedures for any purpose other than as authorized by this MOU, the Employer may be subject to appropriate legal action and termination of its participation in E-Verify according to this MOU. B. RESPONSIBILITIES OF FEDERAL CONTRACTORS 1.If the Employer is a Federal contractor with the FAR E-Verify clause subject to the employment verification terms in Subpart 22.18 of the FAR, it will become familiar with and comply with the most current version of the E-Verify User Manual for Federal Contractors as well as the E-Verify Supplemental Guide for Federal Contractors. 2.In addition to the responsibilities of every employer outlined in this MOU, the Employer understands that if it is a Federal contractor subject to the employment verification terms in Subpart 22.18 of the FAR it must verify the employment eligibility of any “employee assigned to the contract” (as defined in FAR 22.1801). Once an employee has been verified through E-Verify by the Employer, the Employer may not create a second case for the employee through E-Verify. a.An Employer that is not enrolled in E-Verify as a Federal contractor at the time of a contract award must enroll as a Federal contractor in the E-Verify program within 30 calendar days of contract award and, within 90 days of enrollment, begin to verify employment eligibility of new hires using E-Verify. The Employer must verify those employees who are working in the United States, whether or not they are assigned to the contract. Once the Employer begins verifying new hires, such verification of new hires must be initiated within three business days after the hire date. Once enrolled in E-Verify as a Federal contractor, the Employer must begin verification of employees assigned to the contract within 90 calendar days after the date of enrollment or within 30 days of an employee’s assignment to the contract, whichever date is later. Page 5 of 17 E-Verify MOU for Employers | Revision Date 06/01/13 2632016 Page 4932 of 6526 Company ID Number: b.Employers enrolled in E-Verify as a Federal contractor for 90 days or more at the time of a contract award must use E-Verify to begin verification of employment eligibility for new hires of the Employer who are working in the United States, whether or not assigned to the contract, within three business days after the date of hire. If the Employer is enrolled in E-Verify as a Federal contractor for 90 calendar days or less at the time of contract award, the Employer must, within 90 days of enrollment, begin to use E-Verify to initiate verification of new hires of the contractor who are working in the United States, whether or not assigned to the contract. Such verification of new hires must be initiated within three business days after the date of hire. An Employer enrolled as a Federal contractor in E-Verify must begin verification of each employee assigned to the contract within 90 calendar days after date of contract award or within 30 days after assignment to the contract, whichever is later. c.Federal contractors that are institutions of higher education (as defined at 20 U.S.C. 1001(a)), state or local governments, governments of Federally recognized Indian tribes, or sureties performing under a takeover agreement entered into with a Federal agency under a performance bond may choose to only verify new and existing employees assigned to the Federal contract. Such Federal contractors may, however, elect to verify all new hires, and/or all existing employees hired after November 6, 1986. Employers in this category must begin verification of employees assigned to the contract within 90 calendar days after the date of enrollment or within 30 days of an employee’s assignment to the contract, whichever date is later. d.Upon enrollment, Employers who are Federal contractors may elect to verify employment eligibility of all existing employees working in the United States who were hired after November 6, 1986, instead of verifying only those employees assigned to a covered Federal contract. After enrollment, Employers must elect to verify existing staff following DHS procedures and begin E-Verify verification of all existing employees within 180 days after the election. e. The Employer may use a previously completed Form I-9 as the basis for creating an E-Verify case for an employee assigned to a contract as long as: i.That Form I-9 is complete (including the SSN) and complies with Article II.A.6, ii.The employee’s work authorization has not expired, and iii.The Employer has reviewed the Form I-9 information either in person or in communications with the employee to ensure that the employee’s Section 1, Form I-9 attestation has not changed (including, but not limited to, a lawful permanent resident alien having become a naturalized U.S. citizen). f.The Employer shall complete a new Form I-9 consistent with Article II.A.6 or update the previous Form I-9 to provide the necessary information if: i.The Employer cannot determine that Form I-9 complies with Article II.A.6, ii.The employee’s basis for work authorization as attested in Section 1 has expired or changed, or iii.The Form I-9 contains no SSN or is otherwise incomplete. Note: If Section 1 of Form I-9 is otherwise valid and up-to-date and the form otherwise complies with Page 6 of 17 E-Verify MOU for Employers | Revision Date 06/01/13 2632016 Page 4933 of 6526 Company ID Number: Article II.C.5, but reflects documentation (such as a U.S. passport or Form I-551) that expired after completing Form I-9, the Employer shall not require the production of additional documentation, or use the photo screening tool described in Article II.A.5, subject to any additional or superseding instructions that may be provided on this subject in the E-Verify User Manual. g.The Employer agrees not to require a second verification using E-Verify of any assigned employee who has previously been verified as a newly hired employee under this MOU or to authorize verification of any existing employee by any Employer that is not a Federal contractor based on this Article. 3. The Employer understands that if it is a Federal contractor, its compliance with this MOU is a performance requirement under the terms of the Federal contract or subcontract, and the Employer consents to the release of information relating to compliance with its verification responsibilities under this MOU to contracting officers or other officials authorized to review the Employer’s compliance with Federal contracting requirements. C. RESPONSIBILITIES OF SSA 1.SSA agrees to allow DHS to compare data provided by the Employer against SSA’s database. SSA sends DHS confirmation that the data sent either matches or does not match the information in SSA’s database. 2.SSA agrees to safeguard the information the Employer provides through E-Verify procedures. SSA also agrees to limit access to such information, as is appropriate by law, to individuals responsible for the verification of Social Security numbers or responsible for evaluation of E-Verify or such other persons or entities who may be authorized by SSA as governed by the Privacy Act (5 U.S.C. § 552a), the Social Security Act (42 U.S.C. 1306(a)), and SSA regulations (20 CFR Part 401). 3.SSA agrees to provide case results from its database within three Federal Government work days of the initial inquiry. E-Verify provides the information to the Employer. 4.SSA agrees to update SSA records as necessary if the employee who contests the SSA tentative nonconfirmation visits an SSA field office and provides the required evidence. If the employee visits an SSA field office within the eight Federal Government work days from the date of referral to SSA, SSA agrees to update SSA records, if appropriate, within the eight-day period unless SSA determines that more than eight days may be necessary. In such cases, SSA will provide additional instructions to the employee. If the employee does not visit SSA in the time allowed, E-Verify may provide a final nonconfirmation to the employer. Note: If an Employer experiences technical problems, or has a policy question, the employer should contact E-Verify at 1-888-464-4218. D. RESPONSIBILITIES OF DHS 1.DHS agrees to provide the Employer with selected data from DHS databases to enable the Employer to conduct, to the extent authorized by this MOU: a.Automated verification checks on alien employees by electronic means, and Page 7 of 17 E-Verify MOU for Employers | Revision Date 06/01/13 2632016 Page 4934 of 6526 Company ID Number: b. Photo verification checks (when available) on employees. 2. DHS agrees to assist the Employer with operational problems associated with the Employer's participation in E-Verify. DHS agrees to provide the Employer names, titles, addresses, and telephone numbers of DHS representatives to be contacted during the E-Verify process. 3. DHS agrees to provide to the Employer with access to E-Verify training materials as well as an E-Verify User Manual that contain instructions on E-Verify policies, procedures, and requirements for both SSA and DHS, including restrictions on the use of E-Verify. 4.DHS agrees to train Employers on all important changes made to E-Verify through the use of mandatory refresher tutorials and updates to the E-Verify User Manual. Even without changes to E-Verify, DHS reserves the right to require employers to take mandatory refresher tutorials. 5.DHS agrees to provide to the Employer a notice, which indicates the Employer's participation in E-Verify. DHS also agrees to provide to the Employer anti-discrimination notices issued by the Office of Special Counsel for Immigration-Related Unfair Employment Practices (OSC), Civil Rights Division, U.S. Department of Justice. 6.DHS agrees to issue each of the Employer’s E-Verify users a unique user identification number and password that permits them to log in to E-Verify. 7.DHS agrees to safeguard the information the Employer provides, and to limit access to such information to individuals responsible for the verification process, for evaluation of E-Verify, or to such other persons or entities as may be authorized by applicable law. Information will be used only to verify the accuracy of Social Security numbers and employment eligibility, to enforce the INA and Federal criminal laws, and to administer Federal contracting requirements. 8.DHS agrees to provide a means of automated verification that provides (in conjunction with SSA verification procedures) confirmation or tentative nonconfirmation of employees' employment eligibility within three Federal Government work days of the initial inquiry. 9.DHS agrees to provide a means of secondary verification (including updating DHS records) for employees who contest DHS tentative nonconfirmations and photo mismatch tentative nonconfirmations. This provides final confirmation or nonconfirmation of the employees' employment eligibility within 10 Federal Government work days of the date of referral to DHS, unless DHS determines that more than 10 days may be necessary. In such cases, DHS will provide additional verification instructions. ARTICLE III REFERRAL OF INDIVIDUALS TO SSA AND DHS A. REFERRAL TO SSA 1. If the Employer receives a tentative nonconfirmation issued by SSA, the Employer must print the notice as directed by E-Verify. The Employer must promptly notify employees in private of the finding and provide them with the notice and letter containing information specific to the employee’s E-Verify case. Page 8 of 17 E-Verify MOU for Employers | Revision Date 06/01/13 2632016 Page 4935 of 6526 Company ID Number: The Employer also agrees to provide both the English and the translated notice and letter for employees with limited English proficiency to employees. The Employer agrees to provide written referral instructions to employees and instruct affected employees to bring the English copy of the letter to the SSA. The Employer must allow employees to contest the finding, and not take adverse action against employees if they choose to contest the finding, while their case is still pending. 2.The Employer agrees to obtain the employee’s response about whether he or she will contest the tentative nonconfirmation as soon as possible after the Employer receives the tentative nonconfirmation. Only the employee may determine whether he or she will contest the tentative nonconfirmation. 3.After a tentative nonconfirmation, the Employer will refer employees to SSA field offices only as directed by E-Verify. The Employer must record the case verification number, review the employee information submitted to E-Verify to identify any errors, and find out whether the employee contests the tentative nonconfirmation. The Employer will transmit the Social Security number, or any other corrected employee information that SSA requests, to SSA for verification again if this review indicates a need to do so. 4.The Employer will instruct the employee to visit an SSA office within eight Federal Government work days. SSA will electronically transmit the result of the referral to the Employer within 10 Federal Government work days of the referral unless it determines that more than 10 days is necessary. 5.While waiting for case results, the Employer agrees to check the E-Verify system regularly for case updates. 6.The Employer agrees not to ask the employee to obtain a printout from the Social Security Administration number database (the Numident) or other written verification of the SSN from the SSA. B. REFERRAL TO DHS 1.If the Employer receives a tentative nonconfirmation issued by DHS, the Employer must promptly notify employees in private of the finding and provide them with the notice and letter containing information specific to the employee’s E-Verify case. The Employer also agrees to provide both the English and the translated notice and letter for employees with limited English proficiency to employees. The Employer must allow employees to contest the finding, and not take adverse action against employees if they choose to contest the finding, while their case is still pending. 2.The Employer agrees to obtain the employee’s response about whether he or she will contest the tentative nonconfirmation as soon as possible after the Employer receives the tentative nonconfirmation. Only the employee may determine whether he or she will contest the tentative nonconfirmation. 3.The Employer agrees to refer individuals to DHS only when the employee chooses to contest a tentative nonconfirmation. 4.If the employee contests a tentative nonconfirmation issued by DHS, the Employer will instruct the Page 9 of 17 E-Verify MOU for Employers | Revision Date 06/01/13 2632016 Page 4936 of 6526 Company ID Number: employee to contact DHS through its toll-free hotline (as found on the referral letter) within eight Federal Government work days. 5.If the Employer finds a photo mismatch, the Employer must provide the photo mismatch tentative nonconfirmation notice and follow the instructions outlined in paragraph 1 of this section for tentative nonconfirmations, generally. 6.The Employer agrees that if an employee contests a tentative nonconfirmation based upon a photo mismatch, the Employer will send a copy of the employee’s Form I-551, Form I-766, U.S. Passport, or passport card to DHS for review by: a.Scanning and uploading the document, or b.Sending a photocopy of the document by express mail (furnished and paid for by the employer). 7.The Employer understands that if it cannot determine whether there is a photo match/mismatch, the Employer must forward the employee’s documentation to DHS as described in the preceding paragraph. The Employer agrees to resolve the case as specified by the DHS representative who will determine the photo match or mismatch. 8.DHS will electronically transmit the result of the referral to the Employer within 10 Federal Government work days of the referral unless it determines that more than 10 days is necessary. 9.While waiting for case results, the Employer agrees to check the E-Verify system regularly for case updates. ARTICLE IV SERVICE PROVISIONS A. NO SERVICE FEES 1. SSA and DHS will not charge the Employer for verification services performed under this MOU. The Employer is responsible for providing equipment needed to make inquiries. To access E-Verify, an Employer will need a personal computer with Internet access. ARTICLE V MODIFICATION AND TERMINATION A. MODIFICATION 1. This MOU is effective upon the signature of all parties and shall continue in effect for as long as the SSA and DHS operates the E-Verify program unless modified in writing by the mutual consent of all parties. 2. Any and all E-Verify system enhancements by DHS or SSA, including but not limited to E-Verify checking against additional data sources and instituting new verification policies or procedures, will be covered under this MOU and will not cause the need for a supplemental MOU that outlines these changes. Page 10 of 17 E-Verify MOU for Employers | Revision Date 06/01/13 2632016 Page 4937 of 6526 Company ID Number: B. TERMINATION 1.The Employer may terminate this MOU and its participation in E-Verify at any time upon 30 days prior written notice to the other parties. 2.Notwithstanding Article V, part A of this MOU, DHS may terminate this MOU, and thereby the Employer’s participation in E-Verify, with or without notice at any time if deemed necessary because of the requirements of law or policy, or upon a determination by SSA or DHS that there has been a breach of system integrity or security by the Employer, or a failure on the part of the Employer to comply with established E-Verify procedures and/or legal requirements. The Employer understands that if it is a Federal contractor, termination of this MOU by any party for any reason may negatively affect the performance of its contractual responsibilities. Similarly, the Employer understands that if it is in a state where E-Verify is mandatory, termination of this by any party MOU may negatively affect the Employer’s business. 3.An Employer that is a Federal contractor may terminate this MOU when the Federal contract that requires its participation in E-Verify is terminated or completed. In such cases, the Federal contractor must provide written notice to DHS. If an Employer that is a Federal contractor fails to provide such notice, then that Employer will remain an E-Verify participant, will remain bound by the terms of this MOU that apply to non- Federal contractor participants, and will be required to use the E-Verify p rocedures to verify the employment eligibility of all newly hired employees. 4.The Employer agrees that E-Verify is not liable for any losses, financial or otherwise, if the Employer is terminated from E-Verify. ARTICLE VI PARTIES A.Some or all SSA and DHS responsibilities under this MOU may be performed by contractor(s), and SSA and DHS may adjust verification responsibilities between each other as necessary. By separate agreement with DHS, SSA has agreed to perform its responsibilities as described in this MOU. B.Nothing in this MOU is intended, or should be construed, to create any right or benefit, substantive or procedural, enforceable at law by any third party against the United States, its agencies, officers, or employees, or against the Employer, its agents, officers, or employees. C.The Employer may not assign, directly or indirectly, whether by operation of law, change of control or merger, all or any part of its rights or obligations under this MOU without the prior written consent of DHS, which consent shall not be unreasonably withheld or delayed. Any attempt to sublicense, assign, or transfer any of the rights, duties, or obligations herein is void. D.Each party shall be solely responsible for defending any claim or action against it arising out of or related to E-Verify or this MOU, whether civil or criminal, and for any liability wherefrom, including (but not limited to) any dispute between the Employer and any other person or entity regarding the applicability of Section 403(d) of IIRIRA to any action taken or allegedly taken by the Employer. Page 11 of 17 E-Verify MOU for Employers | Revision Date 06/01/13 2632016 Page 4938 of 6526 Company ID Number: E. The Employer understands that its participation in E-Verify is not confidential information and may be disclosed as authorized or required by law and DHS or SSA policy, including but not limited to, Congressional oversight, E-Verify publicity and media inquiries, determinations of compliance with Federal contractual requirements, and responses to inquiries under the Freedom of Information Act (FOIA). F. The individuals whose signatures appear below represent that they are authorized to enter into this MOU on behalf of the Employer and DHS respectively. The Employer understands that any inaccurate statement, representation, data or other information provided to DHS may subject the Employer, its subcontractors, its employees, or its representatives to: (1) prosecution for false statements pursuant to 18 U.S.C. 1001 and/or; (2) immediate termination of its MOU and/or; (3) possible debarment or suspension. G. The foregoing constitutes the full agreement on this subject between DHS and the Employer. To be accepted as an E-Verify participant, you should only sign the Employer’s Section of the signature page. If you have any questions, contact E-Verify at 1-888-464-4218. Page 12 of 17 E-Verify MOU for Employers | Revision Date 06/01/13 2632016 Page 4939 of 6526 Company ID Number: Approved by: Employer Name (Please Type or Print) Title Signature Date Department of Homeland Security – Verification Division Name (Please Type or Print) Title Signature Date Page 13 of 17 E-Verify MOU for Employers | Revision Date 06/01/13 USCIS Verification Division 02/20/2025 Sariely Sandoval Electronically Signed S Sandoval, MD, LLC 02/24/2025 Electronically Signed 2632016 Page 4940 of 6526 Company ID Number: Information Required for the E-Verify Program Information relating to your Company: Company Name Company Facility Address Company Alternate Address County or Parish Employer Identification Number North American Industry Classification Systems Code Parent Company Number of Employees Number of Sites Verified for Page 14 of 17 E-Verify MOU for Employers | Revision Date 06/01/13 S Sandoval, MD, LLC COLLIER 622 1 to 4 2632016 7848 Martino Cir Naples, FL 34112 932657916 1 site(s) Page 4941 of 6526 Company ID Number: Are you verifying for more than 1 site? If yes, please provide the number of sites verified for in each State: Page 15 of 17 E-Verify MOU for Employers | Revision Date 06/01/13 FL 1 2632016 Page 4942 of 6526 Company ID Number: Information relating to the Program Administrator(s) for your Company on policy questions or operational problems: Page 16 of 17 E-Verify MOU for Employers | Revision Date 06/01/13 Email 8052233205 Sariely Sandoval 2632016 Name Phone Number Fax sarisand3@gmail.com Page 4943 of 6526 Company ID Number: This list represents the first 20 Program Administrators listed for this company. Page 17 of 17 E-Verify MOU for Employers | Revision Date 06/01/13 2632016 Page 4944 of 6526 Form W-9 (Rev. March 2024) Request for Taxpayer Identification Number and Certification Department of the Treasury Internal Revenue Service Go to www.irs.gov/FormW9 for instructions and the latest information. Give form to the requester. Do not send to the IRS. Before you begin. For guidance related to the purpose of Form W-9, see Purpose of Form, below.Print or type. See Specific Instructions on page 3.1 Name of entity/individual. An entry is required. (For a sole proprietor or disregarded entity, enter the owner’s name on line 1, and enter the business/disregarded entity’s name on line 2.) 2 Business name/disregarded entity name, if different from above. 3a Check the appropriate box for federal tax classification of the entity/individual whose name is entered on line 1. Check only one of the following seven boxes. Individual/sole proprietor C corporation S corporation Partnership Trust/estate LLC. Enter the tax classification (C = C corporation, S = S corporation, P = Partnership) . . . . Note: Check the “LLC” box above and, in the entry space, enter the appropriate code (C, S, or P) for the tax classification of the LLC, unless it is a disregarded entity. A disregarded entity should instead check the appropriate box for the tax classification of its owner. Other (see instructions) 3b If on line 3a you checked “Partnership” or “Trust/estate,” or checked “LLC” and entered “P” as its tax classification, and you are providing this form to a partnership, trust, or estate in which you have an ownership interest, check this box if you have any foreign partners, owners, or beneficiaries. See instructions . . . . . . . . . 4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3): Exempt payee code (if any) Exemption from Foreign Account Tax Compliance Act (FATCA) reporting code (if any) (Applies to accounts maintained outside the United States.) 5 Address (number, street, and apt. or suite no.). See instructions. 6 City, state, and ZIP code Requester’s name and address (optional) 7 List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. Note: If the account is in more than one name, see the instructions for line 1. See also What Name and Number To Give the Requester for guidelines on whose number to enter. Social security number –– or Employer identification number – Part II Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and, generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later. Sign Here Signature of U.S. person Date General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9. What’s New Line 3a has been modified to clarify how a disregarded entity completes this line. An LLC that is a disregarded entity should check the appropriate box for the tax classification of its owner. Otherwise, it should check the “LLC” box and enter its appropriate tax classification. New line 3b has been added to this form. A flow-through entity is required to complete this line to indicate that it has direct or indirect foreign partners, owners, or beneficiaries when it provides the Form W-9 to another flow-through entity in which it has an ownership interest. This change is intended to provide a flow-through entity with information regarding the status of its indirect foreign partners, owners, or beneficiaries, so that it can satisfy any applicable reporting requirements. For example, a partnership that has any indirect foreign partners may be required to complete Schedules K-2 and K-3. See the Partnership Instructions for Schedules K-2 and K-3 (Form 1065). Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS is giving you this form because they Cat. No. 10231X Form W-9 (Rev. 3-2024) Page 4945 of 6526 Form W-9 (Rev. 3-2024)Page 2 must obtain your correct taxpayer identification number (TIN), which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099-INT (interest earned or paid). • Form 1099-DIV (dividends, including those from stocks or mutual funds). • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds). • Form 1099-NEC (nonemployee compensation). • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers). • Form 1099-S (proceeds from real estate transactions). • Form 1099-K (merchant card and third-party network transactions). • Form 1098 (home mortgage interest), 1098-E (student loan interest), and 1098-T (tuition). • Form 1099-C (canceled debt). • Form 1099-A (acquisition or abandonment of secured property). Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. Caution: If you don’t return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. By signing the filled-out form, you: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued); 2. Certify that you are not subject to backup withholding; or 3. Claim exemption from backup withholding if you are a U.S. exempt payee; and 4. Certify to your non-foreign status for purposes of withholding under chapter 3 or 4 of the Code (if applicable); and 5. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting is correct. See What Is FATCA Reporting, later, for further information. Note: If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: • An individual who is a U.S. citizen or U.S. resident alien; • A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States; • An estate (other than a foreign estate); or • A domestic trust (as defined in Regulations section 301.7701-7). Establishing U.S. status for purposes of chapter 3 and chapter 4 withholding. Payments made to foreign persons, including certain distributions, allocations of income, or transfers of sales proceeds, may be subject to withholding under chapter 3 or chapter 4 of the Code (sections 1441–1474). Under those rules, if a Form W-9 or other certification of non-foreign status has not been received, a withholding agent, transferee, or partnership (payor) generally applies presumption rules that may require the payor to withhold applicable tax from the recipient, owner, transferor, or partner (payee). See Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign Entities. The following persons must provide Form W-9 to the payor for purposes of establishing its non-foreign status. • In the case of a disregarded entity with a U.S. owner, the U.S. owner of the disregarded entity and not the disregarded entity. • In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, the U.S. grantor or other U.S. owner of the grantor trust and not the grantor trust. • In the case of a U.S. trust (other than a grantor trust), the U.S. trust and not the beneficiaries of the trust. See Pub. 515 for more information on providing a Form W-9 or a certification of non-foreign status to avoid withholding. Foreign person. If you are a foreign person or the U.S. branch of a foreign bank that has elected to be treated as a U.S. person (under Regulations section 1.1441-1(b)(2)(iv) or other applicable section for chapter 3 or 4 purposes), do not use Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see Pub. 515). If you are a qualified foreign pension fund under Regulations section 1.897(l)-1(d), or a partnership that is wholly owned by qualified foreign pension funds, that is treated as a non-foreign person for purposes of section 1445 withholding, do not use Form W-9. Instead, use Form W-8EXP (or other certification of non-foreign status). Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a saving clause. Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes. If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items. 1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien. 2. The treaty article addressing the income. 3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions. 4. The type and amount of income that qualifies for the exemption from tax. 5. Sufficient facts to justify the exemption from tax under the terms of the treaty article. Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if their stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first Protocol) and is relying on this exception to claim an exemption from tax on their scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption. If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form W-8 or Form 8233. Backup Withholding What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 24% of such payments. This is called “backup withholding.” Payments that may be subject to backup withholding include, but are not limited to, interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, payments made in settlement of payment card and third-party network transactions, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding. You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return. Payments you receive will be subject to backup withholding if: 1. You do not furnish your TIN to the requester; 2. You do not certify your TIN when required (see the instructions for Part II for details); 3. The IRS tells the requester that you furnished an incorrect TIN; 4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only); or 5. You do not certify to the requester that you are not subject to backup withholding, as described in item 4 under “By signing the filled- out form” above (for reportable interest and dividend accounts opened after 1983 only). Page 4946 of 6526 Form W-9 (Rev. 3-2024)Page 3 Certain payees and payments are exempt from backup withholding. See Exempt payee code, later, and the separate Instructions for the Requester of Form W-9 for more information. See also Establishing U.S. status for purposes of chapter 3 and chapter 4 withholding, earlier. What Is FATCA Reporting? The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all U.S. account holders that are specified U.S. persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code, later, and the Instructions for the Requester of Form W-9 for more information. Updating Your Information You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you are no longer tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account, for example, if the grantor of a grantor trust dies. Penalties Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect. Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty. Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment. Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties. Specific Instructions Line 1 You must enter one of the following on this line; do not leave this line blank. The name should match the name on your tax return. If this Form W-9 is for a joint account (other than an account maintained by a foreign financial institution (FFI)), list first, and then circle, the name of the person or entity whose number you entered in Part I of Form W-9. If you are providing Form W-9 to an FFI to document a joint account, each holder of the account that is a U.S. person must provide a Form W-9. • Individual. Generally, enter the name shown on your tax return. If you have changed your last name without informing the Social Security Administration (SSA) of the name change, enter your first name, the last name as shown on your social security card, and your new last name. Note for ITIN applicant: Enter your individual name as it was entered on your Form W-7 application, line 1a. This should also be the same as the name you entered on the Form 1040 you filed with your application. • Sole proprietor. Enter your individual name as shown on your Form 1040 on line 1. Enter your business, trade, or “doing business as” (DBA) name on line 2. • Partnership, C corporation, S corporation, or LLC, other than a disregarded entity. Enter the entity’s name as shown on the entity’s tax return on line 1 and any business, trade, or DBA name on line 2. • Other entities. Enter your name as shown on required U.S. federal tax documents on line 1. This name should match the name shown on the charter or other legal document creating the entity. Enter any business, trade, or DBA name on line 2. • Disregarded entity. In general, a business entity that has a single owner, including an LLC, and is not a corporation, is disregarded as an entity separate from its owner (a disregarded entity). See Regulations section 301.7701-2(c)(2). A disregarded entity should check the appropriate box for the tax classification of its owner. Enter the owner’s name on line 1. The name of the owner entered on line 1 should never be a disregarded entity. The name on line 1 should be the name shown on the income tax return on which the income should be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a single owner that is a U.S. person, the U.S. owner’s name is required to be provided on line 1. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity’s name on line 2. If the owner of the disregarded entity is a foreign person, the owner must complete an appropriate Form W-8 instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN. Line 2 If you have a business name, trade name, DBA name, or disregarded entity name, enter it on line 2. Line 3a Check the appropriate box on line 3a for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box on line 3a. IF the entity/individual on line 1 is a(n) . . . THEN check the box for . . . • Corporation Corporation. • Individual or • Sole proprietorship Individual/sole proprietor. • LLC classified as a partnership for U.S. federal tax purposes or • LLC that has filed Form 8832 or 2553 electing to be taxed as a corporation Limited liability company and enter the appropriate tax classification: P = Partnership, C = C corporation, or S = S corporation. • Partnership Partnership. • Trust/estate Trust/estate. Line 3b Check this box if you are a partnership (including an LLC classified as a partnership for U.S. federal tax purposes), trust, or estate that has any foreign partners, owners, or beneficiaries, and you are providing this form to a partnership, trust, or estate, in which you have an ownership interest. You must check the box on line 3b if you receive a Form W-8 (or documentary evidence) from any partner, owner, or beneficiary establishing foreign status or if you receive a Form W-9 from any partner, owner, or beneficiary that has checked the box on line 3b. Note: A partnership that provides a Form W-9 and checks box 3b may be required to complete Schedules K-2 and K-3 (Form 1065). For more information, see the Partnership Instructions for Schedules K-2 and K-3 (Form 1065). If you are required to complete line 3b but fail to do so, you may not receive the information necessary to file a correct information return with the IRS or furnish a correct payee statement to your partners or beneficiaries. See, for example, sections 6698, 6722, and 6724 for penalties that may apply. Line 4 Exemptions If you are exempt from backup withholding and/or FATCA reporting, enter in the appropriate space on line 4 any code(s) that may apply to you. Exempt payee code. • Generally, individuals (including sole proprietors) are not exempt from backup withholding. • Except as provided below, corporations are exempt from backup withholding for certain payments, including interest and dividends. • Corporations are not exempt from backup withholding for payments made in settlement of payment card or third-party network transactions. • Corporations are not exempt from backup withholding with respect to attorneys’ fees or gross proceeds paid to attorneys, and corporations that provide medical or health care services are not exempt with respect to payments reportable on Form 1099-MISC. The following codes identify payees that are exempt from backup withholding. Enter the appropriate code in the space on line 4. 1—An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2). Page 4947 of 6526 Form W-9 (Rev. 3-2024)Page 4 2—The United States or any of its agencies or instrumentalities. 3—A state, the District of Columbia, a U.S. commonwealth or territory, or any of their political subdivisions or instrumentalities. 4—A foreign government or any of its political subdivisions, agencies, or instrumentalities. 5—A corporation. 6—A dealer in securities or commodities required to register in the United States, the District of Columbia, or a U.S. commonwealth or territory. 7—A futures commission merchant registered with the Commodity Futures Trading Commission. 8—A real estate investment trust. 9—An entity registered at all times during the tax year under the Investment Company Act of 1940. 10—A common trust fund operated by a bank under section 584(a). 11—A financial institution as defined under section 581. 12—A middleman known in the investment community as a nominee or custodian. 13—A trust exempt from tax under section 664 or described in section 4947. The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 13. IF the payment is for . . .THEN the payment is exempt for . . . • Interest and dividend payments All exempt payees except for 7. • Broker transactions Exempt payees 1 through 4 and 6 through 11 and all C corporations. S corporations must not enter an exempt payee code because they are exempt only for sales of noncovered securities acquired prior to 2012. • Barter exchange transactions and patronage dividends Exempt payees 1 through 4. • Payments over $600 required to be reported and direct sales over $5,0001 Generally, exempt payees 1 through 5.2 • Payments made in settlement of payment card or third-party network transactions Exempt payees 1 through 4. 1 See Form 1099-MISC, Miscellaneous Information, and its instructions. 2 However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys’ fees, gross proceeds paid to an attorney reportable under section 6045(f), and payments for services paid by a federal executive agency. Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account you hold in the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial institution is subject to these requirements. A requester may indicate that a code is not required by providing you with a Form W-9 with “Not Applicable” (or any similar indication) entered on the line for a FATCA exemption code. A—An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37). B—The United States or any of its agencies or instrumentalities. C—A state, the District of Columbia, a U.S. commonwealth or territory, or any of their political subdivisions or instrumentalities. D—A corporation the stock of which is regularly traded on one or more established securities markets, as described in Regulations section 1.1472-1(c)(1)(i). E—A corporation that is a member of the same expanded affiliated group as a corporation described in Regulations section 1.1472-1(c)(1)(i). F—A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any state. G—A real estate investment trust. H—A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940. I—A common trust fund as defined in section 584(a). J—A bank as defined in section 581. K—A broker. L—A trust exempt from tax under section 664 or described in section 4947(a)(1). M—A tax-exempt trust under a section 403(b) plan or section 457(g) plan. Note: You may wish to consult with the financial institution requesting this form to determine whether the FATCA code and/or exempt payee code should be completed. Line 5 Enter your address (number, street, and apartment or suite number). This is where the requester of this Form W-9 will mail your information returns. If this address differs from the one the requester already has on file, enter “NEW” at the top. If a new address is provided, there is still a chance the old address will be used until the payor changes your address in their records. Line 6 Enter your city, state, and ZIP code. Part I. Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. If you are a resident alien and you do not have, and are not eligible to get, an SSN, your TIN is your IRS ITIN. Enter it in the entry space for the Social security number. If you do not have an ITIN, see How to get a TIN below. If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. If you are a single-member LLC that is disregarded as an entity separate from its owner, enter the owner’s SSN (or EIN, if the owner has one). If the LLC is classified as a corporation or partnership, enter the entity’s EIN. Note: See What Name and Number To Give the Requester, later, for further clarification of name and TIN combinations. How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local SSA office or get this form online at www.SSA.gov. You may also get this form by calling 800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at www.irs.gov/EIN. Go to www.irs.gov/Forms to view, download, or print Form W-7 and/or Form SS-4. Or, you can go to www.irs.gov/OrderForms to place an order and have Form W-7 and/or Form SS-4 mailed to you within 15 business days. If you are asked to complete Form W-9 but do not have a TIN, apply for a TIN and enter “Applied For” in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, you will generally have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester. Note: Entering “Applied For” means that you have already applied for a TIN or that you intend to apply for one soon. See also Establishing U.S. status for purposes of chapter 3 and chapter 4 withholding, earlier, for when you may instead be subject to withholding under chapter 3 or 4 of the Code. Caution: A disregarded U.S. entity that has a foreign owner must use the appropriate Form W-8. Page 4948 of 6526 Form W-9 (Rev. 3-2024)Page 5 Part II. Certification To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if item 1, 4, or 5 below indicates otherwise. For a joint account, only the person whose TIN is shown in Part I should sign (when required). In the case of a disregarded entity, the person identified on line 1 must sign. Exempt payees, see Exempt payee code, earlier. Signature requirements. Complete the certification as indicated in items 1 through 5 below. 1. Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification. 2. Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form. 3. Real estate transactions. You must sign the certification. You may cross out item 2 of the certification. 4. Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. “Other payments” include payments made in the course of the requester’s trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments made in settlement of payment card and third-party network transactions, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations). 5. Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), ABLE accounts (under section 529A), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification. What Name and Number To Give the Requester For this type of account:Give name and SSN of: 1. Individual The individual 2. Two or more individuals (joint account) other than an account maintained by an FFI The actual owner of the account or, if combined funds, the first individual on the account1 3. Two or more U.S. persons (joint account maintained by an FFI) Each holder of the account 4. Custodial account of a minor (Uniform Gift to Minors Act) The minor2 5. a. The usual revocable savings trust (grantor is also trustee) The grantor-trustee1 b. So-called trust account that is not a legal or valid trust under state law The actual owner1 6. Sole proprietorship or disregarded entity owned by an individual The owner3 7. Grantor trust filing under Optional Filing Method 1 (see Regulations section 1.671-4(b)(2)(i)(A))** The grantor* For this type of account:Give name and EIN of: 8. Disregarded entity not owned by an individual The owner 9. A valid trust, estate, or pension trust Legal entity4 10. Corporation or LLC electing corporate status on Form 8832 or Form 2553 The corporation 11. Association, club, religious, charitable, educational, or other tax-exempt organization The organization 12. Partnership or multi-member LLC The partnership 13. A broker or registered nominee The broker or nominee 14. Account with the Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments The public entity 15. Grantor trust filing Form 1041 or under the Optional Filing Method 2, requiring Form 1099 (see Regulations section 1.671-4(b)(2)(i)(B))** The trust 1 List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished. 2 Circle the minor’s name and furnish the minor’s SSN. 3 You must show your individual name on line 1, and enter your business or DBA name, if any, on line 2. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN. 4 List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) * Note: The grantor must also provide a Form W-9 to the trustee of the trust. ** For more information on optional filing methods for grantor trusts, see the Instructions for Form 1041. Note: If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed. Secure Your Tax Records From Identity Theft Identity theft occurs when someone uses your personal information, such as your name, SSN, or other identifying information, without your permission to commit fraud or other crimes. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund. To reduce your risk: • Protect your SSN, • Ensure your employer is protecting your SSN, and • Be careful when choosing a tax return preparer. If your tax records are affected by identity theft and you receive a notice from the IRS, respond right away to the name and phone number printed on the IRS notice or letter. If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet, questionable credit card activity, or a questionable credit report, contact the IRS Identity Theft Hotline at 800-908-4490 or submit Form 14039. For more information, see Pub. 5027, Identity Theft Information for Taxpayers. Page 4949 of 6526 Form W-9 (Rev. 3-2024)Page 6 Victims of identity theft who are experiencing economic harm or a systemic problem, or are seeking help in resolving tax problems that have not been resolved through normal channels, may be eligible for Taxpayer Advocate Service (TAS) assistance. You can reach TAS by calling the TAS toll-free case intake line at 877-777-4778 or TTY/TDD 800-829-4059. Protect yourself from suspicious emails or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business emails and websites. The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft. The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers, passwords, or similar secret access information for their credit card, bank, or other financial accounts. If you receive an unsolicited email claiming to be from the IRS, forward this message to phishing@irs.gov. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration (TIGTA) at 800-366-4484. You can forward suspicious emails to the Federal Trade Commission at spam@uce.gov or report them at www.ftc.gov/complaint. You can contact the FTC at www.ftc.gov/idtheft or 877-IDTHEFT (877-438-4338). If you have been the victim of identity theft, see www.IdentityTheft.gov and Pub. 5027. Go to www.irs.gov/IdentityTheft to learn more about identity theft and how to reduce your risk. Privacy Act Notice Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and territories for use in administering their laws. The information may also be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payors must generally withhold a percentage of taxable interest, dividends, and certain other payments to a payee who does not give a TIN to the payor. Certain penalties may also apply for providing false or fraudulent information. Page 4950 of 6526 State of Florida Department of State I certify from the records of this office that S.SANDOVAL,MD,LLC is a limited liability company organized under the laws of the State of Florida,filed on June 30,2023,effective June 24,2023. The document number of this limited liability company is L23000313824. I further certify that said limited liability company has paid all fees due this office through December 31,2025,that its most recent annual report was filed on February 27,2025,and that its status is active. Given under my hand and the Great Seal of the State of Florida at Tallahassee,the Capital,this the Twenty-seventh day of February,2025 Tracking Number:2553285615CC To authenticate this certificate,visit the following site,enter this number,and then follow the instructions displayed. https://services.sunbiz.org/Filings/CertificateOfStatus/CertificateAuthentication Page 4951 of 6526 Page 4952 of 6526 Page 4953 of 6526 Addendum # 1 Date: March 5, 2025 From: Barbara Lance, Procurement Strategist To: Interested Bidders Subject: Addendum # 1 Solicitation # 25-8350 – Medical Director and Deputy Medical Director The following clarifications are being made in response to questions posted on the County’s bidding platform, and are hereby incorporated into the bid: ADDITION: Uploaded 25-8350 Everify Registration Waiver Affidavit Form 12.12.23 In response to Question 4: Hello, I look forward to submitting my application this week. I currently work not as an independent contractor but as a w2 employee. The majority of these forms in the vendor questionnaire appear to more related to a business submitting a work proposal to the county rather than a physician applying for a directorship role. In particular submitting verification on e-verify, submitting a w9 form, or submitting proof of status to the Fl dept of state. The general proposal requirements will all be submitted that are required for the county commissioners grading system, but is it okay to leave these above questions blank? Thanks! Answer: Please list your name on the required forms in place of the Firm/Company Name. A copy of a W-9 and proof of status to the Florida Department of State (SunBiz) is required. Regarding the E-Verify requirement, per Addendum 1, please see the attachments section in OpenGov, for the following document has been uploaded. If waiver applies, please complete and upload in place of an E-Verify MOU/Company Profile: 25-8350 Attachment - Everify Registration Waiver Affidavit Form 12.12.23 If you require additional information, please post a question on our OpenGov (https://procurement.opengov.com) bidding platform under the solicitation for this project. Please sign below and return a copy of this Addendum with your submittal for the above referenced solicitation. (Signature) Date (Name of Firm) Email: Barbara.Lance@colliercountyfl.gov Telephone: (239) 252-8998 S Sandoval, MD LLC 4/6/2025 Page 4954 of 6526 Addendum # 1 Date: March 5, 2025 From: Barbara Lance, Procurement Strategist To: Interested Bidders Subject: Addendum # 1 Solicitation # 25-8350 – Medical Director and Deputy Medical Director The following clarifications are being made in response to questions posted on the County’s bidding platform, and are hereby incorporated into the bid: ADDITION: Uploaded 25-8350 Everify Registration Waiver Affidavit Form 12.12.23 In response to Question 4: Hello, I look forward to submitting my application this week. I currently work not as an independent contractor but as a w2 employee. The majority of these forms in the vendor questionnaire appear to more related to a business submitting a work proposal to the county rather than a physician applying for a directorship role. In particular submitting verification on e-verify, submitting a w9 form, or submitting proof of status to the Fl dept of state. The general proposal requirements will all be submitted that are required for the county commissioners grading system, but is it okay to leave these above questions blank? Thanks! Answer: Please list your name on the required forms in place of the Firm/Company Name. A copy of a W-9 and proof of status to the Florida Department of State (SunBiz) is required. Regarding the E-Verify requirement, per Addendum 1, please see the attachments section in OpenGov, for the following document has been uploaded. If waiver applies, please complete and upload in place of an E-Verify MOU/Company Profile: 25-8350 Attachment - Everify Registration Waiver Affidavit Form 12.12.23 If you require additional information, please post a question on our OpenGov (https://procurement.opengov.com) bidding platform under the solicitation for this project. Please sign below and return a copy of this Addendum with your submittal for the above referenced solicitation. (Signature) Date (Name of Firm) Email: Barbara.Lance@colliercountyfl.gov Telephone: (239) 252-8998 S Sandoval, MD LLC 4/6/2025 Page 4955 of 6526 Page 4956 of 6526 FS1198476 FS1198476 02-29-2028 02-29-2028 $888 $888 2,2N,3, 3N,4,5 2,2N,3, 3N,4,5 PRACTITIONER PRACTITIONER 01-03-2025 01-03-2025 SANDOVAL, SARIELY 6101 PINE RIDGE RD NAPLES, FL 34119 SANDOVAL, SARIELY 6101 PINE RIDGE RD NAPLES, FL 34119 Page 4957 of 6526 FS1198476 02-29-2028 $888 2,2N,3, 3N,4,5 PRACTITIONER 01-03-2025 SANDOVAL, SARIELY 6101 PINE RIDGE RD NAPLES, FL 34119 Page 4958 of 6526 Sariely Sandoval – 7848 Martino Cir, Naples, FL 34112 – sarisand3@gmail.com – (805) 223-3205 1 Sariely Sandoval 7848 Martino Cir, Naples, Florida 34112 (805) 223-3205 – sarisand3@gmail.com EDUCATION/TRAINING University of Michigan 07/2022 – 06/2023 1500 E Medical Center Dr, Ann Arbor, MI 48109 Emergency Medicine Services Fellowship Beaumont Royal Oak 07/2019 – 06/2022 3601 W 13 Mile Rd, Royal Oak, MI 48073 Emergency Medicine Residency Indiana University School of Medicine 08/2015 – 05/2019 340 W 10th St, Indianapolis, IN 46202 Doctor of Medicine Spanish Track Pepperdine University 08/2009 – 05/2013 24255 Pacific Coast Hwy, Malibu, CA 90263 Bachelor of Science, Sports Medicine – Cum Laude PROFESSIONAL EXPERIENCE – Emergency Medicine Services Medical Director 12/2024 – Present • Immokalee Fire Control District - Immokalee, Florida o Provide overall medical oversight for Fire District. Duties include establishing medical treatment protocols, overseeing provider training and certification, involvement in QI/QA, and providing representation for District at Medical Directors Coalition Associate Medical Director 04/2024 – Present • North Collier Fire Control and Rescue District - Naples, Florida o Work with rest of Fire District medical directors to provide overall medical oversight for this Fire District. Duties include establishing medical treatment protocols, overseeing provider training and certification, involvement in QI/QA, and providing representation for District at Medical Directors Coalition PROFESSIONAL EXPERIENCE – Emergency Medicine Attending Emergency Physician, Board Certified 08/2023 – Present • Physicians Regional Healthcare System - Naples, Florida o Diagnose, treat, and manage patients of all ages with acute life-threatening conditions. Duties include caring for acutely ill and injured patients with diverse disease processes. Experienced in history taking and physical exam techniques, interpretation of diagnostic tests, and performing advanced lifesaving procedures. Page 4959 of 6526 Sariely Sandoval – 7848 Martino Cir, Naples, FL 34112 – sarisand3@gmail.com – (805) 223-3205 2 Attending Emergency Physician, Board Eligible 12/2022 – 06/2023 • ProMedica Coldwater Regional Hospital - Coldwater, Michigan o Diagnose, treat, and manage patients of all ages with acute life-threatening conditions. Duties include caring for acutely ill and injured patients with diverse disease processes. Experienced in history taking and physical exam techniques, interpretation of diagnostic tests, and performing advanced lifesaving procedures. Attending Emergency Physician, Board Eligible 07/2022 – 06/2023 • Veteran Affairs Ann Arbor Healthcare System - Ann Arbor, Michigan o Diagnose, treat, and manage patients with acute life-threatening conditions. Duties include caring for acutely ill and injured veteran patients with diverse disease processes. Experienced in history taking and physical exam techniques, interpretation of diagnostic tests, and performing advanced lifesaving procedures. • Beaumont Health – Livonia and Lenox, Michigan o Freestanding emergency department o Provide emergency care as above for patients of all ages RESEARCH/PUBLICATIONS/PR ESENTATIONS/SPEAKING ENGAGEMENTS Research: • Ultrasound Guided Peripheral IV Placement by Community Paramedics o PI: Woody Sams, MD and Nathan Louras, MD – University of Michigan • Clinician Accuracy in Predicting Sources of Infection for Septic Patients in the Emergency Department o PI: Ronny Otero, MD – Beaumont Royal Oak • Credentialing of Point of Care Cardiac Ultrasound o PI: Dr. Audrey Herbert, MD – Indiana University School of Medicine Publications: • Frawley, J., Goyal, A., Gappy, R., Sandoval, S., Chen, NW., Crowe, R., Swor, R. (2023) A Comparison of Prehospital Pediatric Analgesic Use of Ketamine and Opioids. Prehospital Emergency Care, DOI: 10.1080/10903127.2023.2183295 • Sandoval, S., Goyal, A., Frawley, J., Gappy, R., Chen, NW., Crowe, R., Swor, R. (2023) Prehospital Use of Ketamine versus Benzodiazepines for Sedation among Pediatric Patients with Behavioral Emergencies. Prehospital Emergency Care, DOI: 10.1080/10903127.2022.2163326 • Goyal, A., Frawley, J., Gappy, R., Sandoval, S., Chen, NW., Crowe, R., Swor, R. (2022) Prehospital Ketamine Use in Pediatrics. Prehospital Emergency Care, DOI: 10.1080/10903127.2022.2096161 • Beaghler, M., Leo, M., Gass, J., March, J., Sandoval, S., et al. (2017) Initial Experience with New High Powered 120 W Holmium for Vaporization of the Prostate. Urology and Nephrology Open Access Journal 4(2):00119. Presentations: • Should Paramedics Place ETT in the Prehospital Setting? Presented at: University of Michigan Emergency Medicine Residency Didactics, Ann Arbor, MI on March 8, 2023 • Ultrasound Guided IV Access. Presented at: Survival Flight “On the Road” Emergency and Critical Care Conference; November 7, 2022; Frankenmuth, Michigan • Wilderness Dentistry. Presented during the Wilderness Medicine elective, University of Michigan, Ann Arbor, MI on September 13, 2022 • Survival Gear and Shelters. Presented during the Wilderness Medicine elective, University of Michigan, Ann Arbor, MI on August 30, 2022 • Sandoval, S., Keene, S., Berger, D., Klausner, H., Otero, R. Clinician Accuracy in Predicting Sources of Infection for Septic Patients in the Emergency Department. Poster presented at: Society for Academic Emergency Medicine Annual Meeting, 2022; May 13, 2022; New Orleans, Louisiana. Page 4960 of 6526 Sariely Sandoval – 7848 Martino Cir, Naples, FL 34112 – sarisand3@gmail.com – (805) 223-3205 3 • Sandoval, S., Goyal, A., Gappy, R., Crowe, R., Frawley, J., Chen, NW., Swor, R. Prehospital Use of Ketamine vs Benzodiazepines for Sedation Among Pediatric Patients With Behavioral Emergencies. Lightning Oral presentation at: Society for Academic Emergency Medicine Annual Meeting, 2022; May 13, 2022; New Orleans, Louisiana. • Sandoval, S., Goyal, A., Gappy, R., Crowe, R., Frawley, J., Chen, NW., Swor, R. Prehospital Use of Ketamine vs Benzodiazepines for Sedation Among Pediatric Patients With Behavioral Emergencies. Poster presented at: Beaumont 50th Annual Resident and Fellow Research Forum; April 28, 2022; Royal Oak, Michigan. • Sandoval, S., Keene, S., Berger, D., Klausner, H., Otero, R. Clinician Accuracy in Predicting Sources of Infection for Septic Patients in the Emergency Department. Poster presented at: Beaumont 50th Annual Resident and Fellow Research Forum; April 28, 2022; Royal Oak, Michigan. • Hallucinogens. Presented to Toxicology Class, Detroit, MI on April 1, 2022 • EKG Review. Presented to Birmingham Fire Department, Birmingham, MI on February 9 and 11, 2022 • In Flight Emergencies. Presented at Grand Rounds, Royal Oak, MI on October 28, 2021 • Brain and Spinal Cord Trauma. Presented at Grand Rounds, Royal Oak, MI on April 15, 2021 • Cat Scratch Disease. Presented at Pediatric Grand Rounds, Royal Oak, MI on January 7, 2021 • Chalazion. Presented at Pediatric Grand Rounds, Royal Oak, MI on May 28, 2020 • Sandoval, S., Wiseman, M., Patel, P., Tenbarge, M. N-Acetyl-L-Cysteine (NAC) to the rescue! Poster presented at: American Medical Women’s Association 103rd Anniversary Meeting; March 24, 2018; Philadelphia, PA. • Hernandez, C., Sandoval, S., Metcalf, M., Rohr-Kirchgraber, T. Cough, Cough..Colon Cancer. Poster presented at: American Medical Women’s Association 102nd Anniversary Meeting; April 1, 2017; San Francisco, CA. Speaking Engagements: • SNMA/LMSA Physician Panel. Panelist at Oakland University William Beaumont School of Medicine Meeting SERVICE & LEADERSHIP Diversity, Equity, and Inclusion Committee 01/2022 – 06/2022 Share, discuss, and address concerns relating to diversity, equity, and inclusion within the emergency department and residency program Culture of Safety Committee 08/2021 – 06/2022 Discuss safety issues that impact patient care, work environment, and resident education Healthcare Disparities Committee 07/2021 – 06/2022 Plan and incorporate healthcare disparities activities and lectures into residency curriculum House Officer Council 07/2021 – 06/2022 Share, discuss, and address concerns/issues experienced by residents and fellows Trauma Quality Improvement Committee 07/2021 – 06/2022 Discuss concerns related to trauma patient transfer/care and solutions for these issues Emergency Medicine Mentor 07/2021 – 06/2022 Partnership with Student National Medical Association (SNMA), Latino Medical Student Association (LMSA), and Queers and Allies Student Group to guide and mentor underrepresented medical students Social Media Outreach for Recruitment 07/2021 – 06/2023 Manage and maintain all residency and fellowship social media platforms including Instagram, Facebook, Twitter Page 4961 of 6526 Sariely Sandoval – 7848 Martino Cir, Naples, FL 34112 – sarisand3@gmail.com – (805) 223-3205 4 Advanced Training in Medical Education 07/2019 – 06/2020 Completed Residents as Teachers course where I was exposed to and practiced medical teaching concepts to apply at the workplace Ultrasound SIM Day 10/2018 Taught emergency medicine-interested students the proper way of performing various ultrasounds including FAST, Renal/Pelvis, Cardiac, Aortic Indiana University Student Outreach Clinic (IUSOC) – IU School of Medicine 08/2015 – 05/2019 Student-run free clinic containing 11 interprofessional partners that operates 50 Saturdays out of the year providing healthcare services to the underserved east Indianapolis community • Director of Operations (01/2018 – 12/2018) o Hire, train, and manage 34 clinic managers, coordinate clinic flow, establish clinic protocols and procedures, and collaborate with 15 other board members on clinic-wide projects and events • Medical Student 3/4 Volunteer (08/2017 – 05/2019) o Perform H&Ps on patients and present assessment and plan to attending physician, teach first and second year medical students, and write SOA notes for patient encounters • Director of Promotions (01/2017 – 12/2017) o Organize and lead bimonthly, interprofessional promotions meetings, plan annual IUSOC Open House, and organize multiple other fundraising events in collaboration with the IU Office of Gift Development • Medical Clinic Manager (01/2016 – 05/2019) o Oversee logistics of a 5-hour clinic day, delegate tasks to 1 attending physician, 1-3 residents, and up to 12 medical student volunteers, and improvise to solve problems that occur • Medical Student 1/2 Volunteer (08/2015 – 07/2017) o Interview patients, present patients to senior medical students, participate in patient care and assist with clinic flow Medical Spanish Society of Latinos – IU School of Medicine 01/2016 – 05/2019 • President (01/2018 – 12/2018) o Plan meetings and organize speakers, collaborate with community organizations to plan involvement in local events, and organize annual summer Spanish course • Vice President (01/2017 – 12/2017) o Assist President in above tasks as necessary • Director of Community Service (01/2016 –12/2016) o Help organize events throughout the community and encourage participation of student body in MSSOL activities Page 4962 of 6526 Sariely Sandoval – 7848 Martino Cir, Naples, FL 34112 – sarisand3@gmail.com – (805) 223-3205 5 Pre-Medical Club – Pepperdine University 08/2011 – 05/2013 • Director of Communications o Plan annual trip to AMSA Pre-medical Conference for 20 students and organize multiple volunteer opportunities for members throughout the school year Colleges Against Cancer – Pepperdine University 08/2011 – 05/2013 • Director of Cancer Education o Plan and organize fundraising and cancer education activities throughout the school year for the student body and organize cancer education booth at annual Relay for Life event Mission at Natuvu Creek, Fiji 05/2010 – 05/2010 • Teach English, math, and dental hygiene at local primary school, interview patients at local clinic and present to physician, and interpret for Spanish-speaking only physician WORK EXPERIENCE Medical Scribe Systems – Ventura, CA • Medical Scribe 12/2013 – 05/2015 o Document patient histories and complete hospital course in patient charts and interpret for Spanish speaking patients California Lutheran University – Thousand Oaks, CA • Tutor 08/2013 – 06/2015 o Teach high school students key concepts and assist with homework and studying in biology and various levels of mathematics and mentor students in regards to college applications and volunteer opportunities Ventura Unified School District – Ventura, CA • Health Technician 08/2013 – 06/2015 o Administer daily medications, basic first aid, and screen ill or injured students Pepperdine Natural Science Division – Malibu, CA • Human Anatomy Teaching Assistant 01/2013 – 12/2013 o Teach students important anatomy concepts, provide support during laboratory classes, host review sessions for students, and administer laboratory exams Pepperdine Natural Science Division – Malibu, CA • Human Anatomy/Physiology Teaching Assistant 01/2013 – 12/2013 o Provide academic support for students and grade all homework assignments Pepperdine Natural Science Division – Malibu, CA • Human Prosection Teaching Assistant 01/2011 – 12/2012 o Teach students important anatomical concepts on human cadaver, host review sessions for students, and write and grade final exam Page 4963 of 6526 Sariely Sandoval – 7848 Martino Cir, Naples, FL 34112 – sarisand3@gmail.com – (805) 223-3205 6 HONORS & AWARDS William M. Plater Civic Engagement Medallion 05/2019 For exceptional commitment to the service of the community Gold Humanism Honor Society 08/2018 PROFESSIONAL DEVELOPMENT National Association of Emergency Medicine Physicians Conference Yearly, since 2023 Gathering of the Eagles 06/2024 First There, First Care Conference 06/2024 Society of Academic Emergency Medicine Conference 05/2019 American Medical Woman’s Association Annual Meeting 03/2017 and 05/2018 Society of Student Run Free Clinics Annual Conference 02/2017 and 02/2018 PROFESSIONAL ORGANIZATIONS Florida Association of EMS Medical Directors Florida College of Emergency Physicians National Association of EMS Physicians American College of Emergency Physicians Emergency Medicine Residents Association LICENSURES & CERTIFICATIONS ICS-100, Introduction to Incident Command ICS-200, Basic Incident Command System for Initial Response ICS-300, Intermediate ICS for Expanding Incidents ICS-400, Advanced Incident Command System for Complex Incidents IS-700, Introduction to the National Incident Management System IS-800, National Response Framework, An Introduction Basic Disaster Life Support Advanced Disaster Life Support Basic Life Support Advanced Cardiac Life Support Pediatric Advanced Life Support Advanced Trauma Life Support LANGUAGES Spanish – Native Page 4964 of 6526 •eamnont J,taltfJ ll\opal ®ak, ;!fBltcbigan ~rimarp 'Ol:eacbing 1!,ospital of ®aklanb fflnibersitp William TSeaumont ~cbool of fflebicine · certifies tbat ~arielp ~anbobal, ;fmlJlB. bas successfuUp completeb toe requirements for resibencp in ~mergencp ~ebicine fl~J~~ Prasram Director -~-:> 3/ulp 1, 2019 -3/une 30, 2022 ( . Ho5!/I P;eslden ·~~· --~ 1tlon Page 4965 of 6526 Sariely Sandoval, M.D. December 31, 2028Expires: Status:Active A s of July 5, 2023 Page 4966 of 6526 Page 4967 of 6526 Emergency Management Institute This Certificate of Achievement is to acknowledge that SARIELY SANDOVAL has reaffirmed a dedication to serve in times of crisis through continued professionaldevelopment and completion of the Independent Study course:IS-100.C:INTRODUCTION TO INCIDENT COMMAND SYSTEM, ICS-1000.20 IACET CEUIssued this 14th Day of September, 2022 Jeffrey D. Stern, Ph.D. Superintendent Emergency Management Institute Federal Emergency Management AgencyPage 4968 of 6526 Emergency Management Institute This Certificate of Achievement is to acknowledge that SARIELY SANDOVAL has reaffirmed a dedication to serve in times of crisis through continued professionaldevelopment and completion of the Independent Study course:IS-200.C:BASIC INCIDENT COMMAND SYSTEM FOR INITIAL RESPONSE ICS-2000.40 IACET CEUIssued this 21st Day of April, 2023 Jeffrey D. Stern, Ph.D. Superintendent Emergency Management Institute Federal Emergency Management AgencyPage 4969 of 6526 ICS 300 Intermediate ICS for Expanding Incidents Sariely Sandoval 15 May 2023 08:00, 16 May 2023 08:00, 17 May 2023 08:00 21 C ertifi cate of A tten dan ce Page 4970 of 6526 ! !! ! !! ! !! . VEMBE Sariely Sandoval Page 4971 of 6526 Emergency Management Institute This Certificate of Achievement is to acknowledge that SARIELY SANDOVAL has reaffirmed a dedication to serve in times of crisis through continued professionaldevelopment and completion of the Independent Study course:IS-700.B:AN INTRODUCTION TO THE NATIONAL INCIDENT MANAGEMENTSYSTEM0.40 IACET CEUIssued this 22nd Day of April, 2023 Jeffrey D. Stern, Ph.D. Superintendent Emergency Management Institute Federal Emergency Management AgencyPage 4972 of 6526 Emergency Management Institute This Certificate of Achievement is to acknowledge that SARIELY SANDOVAL has reaffirmed a dedication to serve in times of crisis through continued professionaldevelopment and completion of the Independent Study course:IS-800.D:NATIONAL RESPONSE FRAMEWORK, AN INTRODUCTION0.30 IACET CEUIssued this 24th Day of April, 2023 Jeffrey D. Stern, Ph.D. Superintendent Emergency Management Institute Federal Emergency Management AgencyPage 4973 of 6526 CERTIFICATE of ACHIEVEMENT This is to certify that Sariely Sandoval has completed the course Basic Disaster Life Support December 2, 2022 Credit Hours: 7.5 National Disaster Life Support Foundation This certificate expires three years from issue date. Powered by TCPDF (www.tcpdf.org) Page 4974 of 6526 CERTIFICATE of ACHIEVEMENT This is to certify that Sariely Sandoval has completed the course Advanced Disaster Life Support May 23, 2023 Credit Hours: 15 National Disaster Life Support Foundation This certificate expires three years from issue date. Powered by TCPDF (www.tcpdf.org) Page 4975 of 6526 Vendor Check List IMPORTANT: Please review carefully and submit with your Proposal/Bid. All applicable documents shall be submitted electronically through OpenGov. Vendor should checkoff each of the following items. Failure to provide the applicable documents may deem you non-responsive/non-responsible. General Bid Instructions has been acknowledged and accepted. Collier County Purchase Order Terms and Conditions have been acknowledged and accepted. Form 1: Vendor Declaration Statement Form 2: Conflict of Interest Certification Proof of status from Division of Corporations - Florida Department of State (If work performed in the State) - http://dos.myflorida.com/sunbiz/ should be attached with your submittal. Vendor MUST be enrolled in the E-Verify - https://www.e-verify.gov/ at the time of submission of the proposal/bid. Form 3: Immigration Affidavit Certification MUST be signed and attached with your submittal. E-Verify Memorandum of Understanding or Company Profile page should be attached with your submittal. Form 4: Certification for Claiming Status as a Local Business, if applicable, has been executed and returned. Collier or Lee County Business Tax Receipt should be attached with your submittal to be considered. Form 5: Reference Questionnaire form must be utilized for each requested reference and included with your submittal, if applicable to the solicitation. Form 6: Grant Provisions and Assurances package in its entirety, if applicable, are executed and should be included with your submittal. Vendor W-9 Form. Vendor acknowledges Insurance Requirements and is prepared to produce the required insurance certificate(s) within five (5) days of the County’s issuance of a Notice of Recommend Award. The Bid Schedule has been completed and attached with your submittal, applicable to bids. Copies of all requested licenses and/or certifications to complete the requirements of the project. All addenda have been signed and attached. County’s IT Technical Architecture Requirements has been acknowledged and accepted, if applicable. Any and all supplemental requirements and terms has been acknowledged and accepted, if applicable. Page 4976 of 6526 6 64J-1 F.A.C. and any other applicable laws and regulations, all as may be amended from time to time. 15. Deputy Medical Director shall be available for consultation with the Director of Emergency Management during activations of the County's Emergency Operations Center or eminent emergency situation to assist in a public health emergency, disaster, pandemic, or mass medical event. Such efforts shall be in coordination with the Public Health Director and not in conflict with public health statutory authority. 16. Deputy Medical Director shall receive prior approval from the County Manager or designee preceding any COUNTY communication with the media. 17. Deputy Medical Director shall maintain current instructor level training in Advanced Cardiac Life Support (ACLS), or equivalent, or Advanced Trauma Life Support (ATLS), maintain provider or instructor level training in International Trauma Life Support (ITLS), Prehospital Trauma Life Support (PHTLS), or Advanced Trauma Life Support (ATLS); and Advanced Pediatric Life Support (APLS), Pediatric Advanced Life Support (PALS), Pediatric Education for Prehospital Professionals (PEPP), or Emergency Pediatric Care (EPC). Firms Proposal Intent The prospective firm shall select a category or categories with the submission of their proposal. The prospective firms may propose up to two (2) categories by checking the box of each category. The prospective firms will only be awarded one (1) category. Category A – Medical Director Category B – Deputy Medical Director The prospective firm will rank each category in order of preference, if proposing on multiple categories. The prospective firm will enter one (1) for the most preferred to two (2) being least preferred. The prospective firms proposing on a single category shall not rank in an order of preference. Category A – Medical Director Category B – Deputy Medical Director REQUEST FOR PROPOSAL (RFP) PROCESS 1.1 The Proposers will submit a qualifications proposal which will be scored based on the criteria in Evaluation Criteria for Development of Shortlist, which will be the basis for short-listing firms. The Proposers will need to meet the minimum requirements outlined herein in or der for their proposal to be evaluated and scored by the COUNTY. The COUNTY will then score and rank the firms and enter into negotiations with the top ranked firm to establish cost for the services needed. The COUNTY reserves the right to issue an invitation for oral presentations to obtain additional information after scoring and before the final ranking. With successful negotiations, a contract will be developed with the selected firm, based on the negotiated price and scope of services and submitted for approval by the Board of County Commissioners. 1.2 The COUNTY will use a Selection Committee in the Request for Proposal selection process. 1.3 The intent of the scoring of the proposal is for respondents to indicate their interest, relevant experience, financial capability, staffing and organizational structure. 1.4 The intent of the oral presentations, if deemed necessary, is to provide the vendors with a venue where they can conduct discussions with the Selection Committee to clarify questions and concerns before providing a final rank. 1.5 Based upon a review of these proposals, the COUNTY will rank the Proposers based on the discussion and clarifying questions on their approach and related criteria, and then negotiate in good faith an Agreement with the top ranked Proposer. Page 4977 of 6526 Addendum # 1 Date: March 5, 2025 From: Barbara Lance, Procurement Strategist To: Interested Bidders Subject: Addendum # 1 Solicitation # 25-8350 – Medical Director and Deputy Medical Director The following clarifications are being made in response to questions posted on the County’s bidding platform, and are hereby incorporated into the bid: ADDITION: Uploaded 25-8350 Everify Registration Waiver Affidavit Form 12.12.23 In response to Question 4: Hello, I look forward to submitting my application this week. I currently work not as an independent contractor but as a w2 employee. The majority of these forms in the vendor questionnaire appear to more related to a business submitting a work proposal to the county rather than a physician applying for a directorship role. In particular submitting verification on e-verify, submitting a w9 form, or submitting proof of status to the Fl dept of state. The general proposal requirements will all be submitted that are required for the county commissioners grading system, but is it okay to leave these above questions blank? Thanks! Answer: Please list your name on the required forms in place of the Firm/Company Name. A copy of a W-9 and proof of status to the Florida Department of State (SunBiz) is required. Regarding the E-Verify requirement, per Addendum 1, please see the attachments section in OpenGov, for the following document has been uploaded. If waiver applies, please complete and upload in place of an E-Verify MOU/Company Profile: 25-8350 Attachment - Everify Registration Waiver Affidavit Form 12.12.23 If you require additional information, please post a question on our OpenGov (https://procurement.opengov.com) bidding platform under the solicitation for this project. Please sign below and return a copy of this Addendum with your submittal for the above referenced solicitation. (Signature) Date (Name of Firm) Email: Barbara.Lance@colliercountyfl.gov Telephone: (239) 252-8998 S Sandoval, MD LLC 4/6/2025 Page 4978 of 6526 Addendum # 2 Date: March 7, 2025 From: Barbara Lance, Procurement Strategist To: Interested Bidders Subject: Addendum # 2 Solicitation # 25-8350 – Medical Director and Deputy Medical Director The following clarifications are being made in response to a question posted on the County’s bidding platform, and are hereby incorporated into the bid: CHANGE: A clarification regarding the answer for Question 4 is listed below. In response to Question 4: Hello, I look forward to submitting my application this week. I currently work not as an independent contractor but as a w2 employee. The majority of these forms in the vendor questionnaire appear to more related to a business submitting a work proposal to the county rather than a physician applying for a directorship role. In particular submitting verification on e-verify, submitting a w9 form, or submitting proof of status to the Fl dept of state. The general proposal requirements will all be submitted that are required for the county commissioners grading system, but is it okay to leave these above questions blank? Thanks! Answer: Clarification Re: Florida Department of State Divisions of Corporations The requirement to upload Proof of Status from Division of Corporations - Florida Department of State (SunBiz) has been removed in OpenGov. If an individual is selected and wishes to create a legal entity for purposes of providing the services, registration must be completed through Florida Department of State Divisions of Corporations. If you require additional information, please post a question on our OpenGov (https://procurement.opengov.com) bidding platform under the solicitation for this project. Please sign below and return a copy of this Addendum with your submittal for the above referenced solicitation. (Signature) Date (Name of Firm) Email: Barbara.Lance@colliercountyfl.gov Telephone: (239) 252-8998 S Sandoval, MD LLC 4/6/2025 Page 4979 of 6526 Addendum # 3 Date: March 10, 2025 From: Barbara Lance, Procurement Strategist To: Interested Bidders Subject: Addendum # 3 Solicitation # 25-8350 – Medical Director and Deputy Medical Director The following clarifications are issued as an addendum: CHANGE: Question/Answer and Proposal Submission Deadlines have been extended. The “Question and Answer Deadline” has been extended from March 4, 2025, at 5:00 pm EST to March 19, 2025, at 5:00 pm EST. The “Proposal Submission Deadline” has been changed from March 11, 2025, at 3:00 pm EST to March 26, 2025, at 3:00 pm EST. If you require additional information, please post a question on our OpenGov (https://procurement.opengov.com) bidding platform under the solicitation for this project. Please sign below and return a copy of this Addendum with your submittal for the above referenced solicitation. (Signature) Date (Name of Firm) Email: Barbara.Lance@colliercountyfl.gov Telephone: (239) 252-8998 S Sandoval, MD LLC 4/6/2025 Page 4980 of 6526 From:Sariely Sandoval To:Barbara Lance Subject:Re: Missing Documents for 25-8350 Medical Director and Deputy Medical Director Date:Sunday, April 6, 2025 4:12:04 PM Attachments:CountyLogo-FullColor_948165c4-9665-41b4-9162-fbb16abff557.png Facebook_0522f546-5e75-4698-95f9-f15590a3defe.png Instagram_a8da4774-4b5b-4ad1-8d23-20e69b3b605d.png X-Twitter_8d678efc-bd14-44ce-97cf-7fbab1003b00.png Youtube_0078f7f1-7789-4afd-a015-50689fe1f99b.png 311IconforSignature_87c558eb-83f5-449b-87c1-3cc5ac8b0859.png Addendum 3.pdf Addendum 1.pdf Addendum 2.pdf EXTERNAL EMAIL: This email is from an external source. Confirm this is a trusted sender and use extreme caution when opening attachments or clicking links. Ms. Lance, Thank you so much for your email. Attached are all 3 signed addendums and answer to the missing criteria below: Evaluation Criteria No. 5: Cost of Services : $125,000 Hope to hear from you soon, On Fri, Apr 4, 2025 at 1:50 PM Barbara Lance <Barbara.Lance@colliercountyfl.gov> wrote: Good afternoon, Per Section Twelve: Reserved Rights of the Collier County Procurement Ordinance, Collier County reserves the right to request resubmission of proposal. The County is requesting the below listed documents be returned via email no later than 5:00 pm, Friday, April 11th: 1. Per Evaluation Criteria No. 5: Cost of Services – please provide a Cost of Services as outlined in the solicitation 2. Please sign Addendums 1 - 3 Failure to provide the requested documents, may be grounds to be deemed non-responsive. We look forward to receiving the requested information. Thank you. Barbara Lance Procurement Strategist II Procurement Services Office:239-252-8998 Barbara.Lance@colliercountyfl.gov Under Florida Law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records Page 4981 of 6526 request, do not send electronic mail to this entity. Instead, contact this office by telephone or in writing. -- Sariely Sandoval, MD Emergency Medicine; Physicians Regional Medical Center Medical Director; Immokalee Fire Control District Associate Medical Director; North Collier Fire Control and Rescue District Naples, Florida 805.223.3205 Page 4982 of 6526