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DocuSign Envelope ID: A55F15CO-1 E47-4E4E-AD3E-815FB09D12138 <br />aCITY OF SANTA ANA <br />ATTACHMENT A <br />PROPOSER'S CERTIFICATION, PROPOSAL PRICING <br />Certification - I certify that I have read, understand and agree to the terms and conditions of this Request <br />for Proposals. I have examined the Scope of Services (Exhibit 1) and am qualified to provide services <br />being requested as specified herein. I understand and agree that I am responsible for reporting any <br />errors, omissions or discrepancies to the City for clarification prior to the submission of my proposal_ <br />Proposal Item Price - Pricing shall be based on the services performed, for services described in Exhibit <br />I. Fee must be inclusive of all costs, including but not limited to, direct and indirect costs for labor, <br />overhead, incidental supplies, travel, mileage, and fuel. Attach additional pages as needed. <br />PROPOSER'S STATEMENT: I have read, understood and agree to the terms and conditions on all <br />pages of the Request for Proposals. Upon request, I will transfer and deliver goods or services to the <br />City in accordance with said terms and conditions. <br />TYPE OF MEDICAL PROCEDURE <br />ESTIMATED <br /># OF TESTS <br />COST PER <br />TEST <br />ESTIMATED <br />TOTAL COST <br />Audiogram <br />77 <br />$40.00 <br />$3,080 <br />Back X-Ray <br />Unknown <br />$60.00 <br />Per Test <br />Blood Lead Level ZZP <br />Unknown <br />$64,00 <br />Per Test <br />Breath Alcohol Test <br />Unknown <br />$38.00 <br />Per Test <br />Blood Chemistry Profile (SMA 241Equivalent) <br />86 <br />$83,00 <br />$7,138 <br />Complete Blood Count (CBC wlDiff) <br />86 <br />$55.00 <br />$4,730 <br />Chest X-Ray 1 View <br />92 <br />$74.00 <br />$6,808 <br />Occupational Health Centers of California, a Medical Corporation dba Concentra Medical Centers 714,288.8303 714 744-1991 <br />LEGAL NAME OF COMPANY PHONE AND FAX NUMBERS <br />1045 North Tustin St., Orange, CA 92867 <br />BUSINESS ADDRESS <br />Kathy T. Le, MD, MPH President and Treasurer <br />OF AUTHORIZED AGENT TITLE <br />August 30, 2023 dhaubner@concentra.com (contact) <br />THORIZED AGENT DATE <br />E-MAIL ADDRESS <br />NA <br />FEDERAL ID NUMBER (IF APPLICABLE) CONTRACTOR LICENSE NUMBER <br />(IFAPPLICABLE) <br />THIS FORM MUST BE COMPLETED AND INCLUDED WITH THE PROPOSAL. <br />PROPOSALS THAT DO NOT CONTAIN THIS FORM WILL BE CONSIDERED NONRESPONSIVE. <br />23-115 Pre -Employment Medical Screening Services Page 28 of 34 <br />