OMSP Bid Contract - Statement of Work - blankmsu.pdf

Statement of Work

Mississippi State, MS

Occupational Medical Surveillance Program

List of Services Bid Contract

Vendor’s Name:

Contact Person:

Address:

Phone Number:

Email:

The purpose of the Occupational Medical Surveillance Program is to provide medical surveillance for all authorized USDA-ARS employees who are exposed to hazards, even just occasionally, that could potentially result in a work-related illness. The results of the medical testing and examination will determine if action is required on the part of USDA-

ARS to correct actual or potential health problems, and possibly eliminate exposures. The medical provider shall identify problems and determine what changes may be necessary.

Specific Services Mark Here If You

Can Meet

These Criteria

Price (Mark N/A if Service is

Not Available)

Occupational History and Baseline Physical Evaluation

(Height, weight, TPR, and blood pressure are considered normal components of the physical exam and there is not a separate charge for these items. The charge for this exam does not include Lab work and other components-these may be charged separately as noted below)

USDA shall provide the required forms. They are USDA forms 186-A, - B, -C, -D. Respirator Medical Clearance may be required as a part of the exam.

We expect that the client having the physical exam shall be scheduled for a minimum of 30 minutes with the examiner.

This time should include a full explanation of all lab test and exam results, a comprehensive physical examination, and an opportunity for the Federal Employee to get any questions answered. Employees are to receive copies of any tests or reports as requested. Any employee, who has a life-threatening condition, or serious finding requiring urgent evaluation or intervention, must be notified by the vendor within 24 hrs.

Yes, can meet criteria

No, can Not meet criteria

Examiners shall be licensed to practice in the state where services are provided. A Certified Occupational Health

Physician would be preferred.

Please check which personnel would be performing the exams:

Physician

Certified Occupational Health Physician

Certified Physician’s Assistant

Certified Nurse Practitioner

Check Correct Box on left.

Originals of All USDA/ARS forms and copies of ALL test results are to be sent within two weeks of the date of the exam to the Medical Review Officer.

Federal Occupational Health, Room 443

50 United Nations Plaza

San Francisco, CA 94102

The Medical Review Officer is Lee Wugofski, MD, PhD.

Certified Occupational Health Physician. Please feel free to call Lily Murphy, RN, Certified Occupational Health Nurse

Specialist, at (415) 437-8020 for any questions or concerns about the medical review process.

Yes, can meet criteria

No, can Not meet criteria

Specific Exam Components Mark Here If You

Can Meet

These Criteria

Price (Mark N/A if Service is

Not Available)

AUDIOMETRY Using AAOHN Standards.

Use certified, regularly calibrated microprocessor audiometer

(with a noise reduction booth. Consistent with 29 CFR

1910.95)

Usual Standard: an audiogram should be done as a baseline and at an exit exam. It should be done with each yearly exam if the client is exposed to noise at work or gets Respiratory Medical

Clearance. Periodic audiograms may be done every one to four years if the client has had an abnormal audiogram and may be done at the client’s request.

Audiogram retests will be done (within 30 days) for a standard threshold shift (STS) or if indicated by the physician. Required frequencies to be tested are 500, 1000, 2000, 3000, 4000, 6000, 8000 Hertz. Copy of results (audiometer printout) to be sent to

MEDICAL REVIEW OFFICER.

CHEST X-RAY (PA) (Including cost of interpretation)

Usual Standard: A chest x-ray should be done for any employee who will need medical clearance for respirator use (baseline x-ray only), or who may be occupationally exposed to lung toxins

(irritants) or dust that may cause pneumoconiosis, or who is an asbestos worker (follow OSHA standard for asbestos chest x-rays) or who has a histoplasmosis test that converts from negative to positive, or who has a TB test that converts from negative to positive, or who severely decreased Pulmonary Function Tests, is

Short of Breath, or symptomatic. AS A GENERAL RULE, ROUTINE PERIODIC X-RAYS ARE NOT INDICATED (unless medically indicated).

Copy of results to be sent to MEDICAL REVIEW OFFICER.

Yes, can meet criteria

No, can Not meet criteria

EKG-RESTING (12Lead EKG)

Usual Standard: An EKG should be done as a baseline at first exam, repeat at age 35, and then every 5 years until age 50. At age

50+, do an EKG every 2 years.

EXCEPTION: At 40+, do an EKG every two years if 2 or more risk factors for coronary artery disease such as diabetes, smoking, family history of premature coronary artery disease, high B/P, high cholesterol, or when symptomatic.

Copy of results to be sent to MEDICAL REVIEW OFFICER.

Yes, can meet criteria

No, can Not meet criteria

EXERCISE STRESS TEST (EST) using Bruce Protocol An EST is routinely needed when the employee needs medical clearance to wear a Self-Contained Breathing Apparatus (SCBA) and is age 50 or older. After age 50, periodic ESTs are needed every 2 years (or yearly if medically indicated). The EST is begun at age 45 when the employee needs medical clearance to wear a

Self-Contained Breathing Apparatus (SCBA) and has 2 or more major risk factors for heart disease such as Hypertension, Diabetes, a family history of heart disease, high cholesterol, or tobacco.

Copy of results to be sent to MEDICAL REVIEW OFFICER.

Yes, can meet criteria

No, can Not meet criteria

GLAUCOMA TEST

Puff Tonometer or other method. Use certified regularly calibrated equipment. Copy of results to be sent to MEDICAL REVIEW

OFFICER.

Yes, can meet criteria

No, can Not meet criteria

RESPIRATOR MEDICAL CLEARANCE (RMC)

The Local USDA point of contact must give vendor a list of employees that require Respirator Medical Clearance and the type of respirator they will be using. RMC is the responsibility of the local vendor. The Medical Review Officer does not make RMC decisions. RMC is not standardized throughout the country. The vendor should follow their own policies and OSHA’s standards as well.

Recommendation: all employees who are to have medical clearance to wear a respirator should have a complete baseline physical exam including spirometry and a baseline PA chest x-ray.

Vendor must send RMC information directly to USDA Local

Contact. Note that the USDA Local Contact is to receive notification of clearance or no clearance ONLY. No actual test results or confidential information is to be given to the USDA

Local Contact. Copy of results (complete print out of test curves and results) to be sent MEDICAL REVIEW OFFICER if employee also has a physical examination. No forms need to be sent to the Medical Review

Officer if employee has a Respirator Medical Clearance without an exam.

SPIROMETRY

NIOSH Standards. The best three curves should be printed out.

Use Clinical Standard including FVC, FEV-1 ratio. Use certified, regularly calibrated equipment, and personnel who have successfully completed a NIOSH approved course in Spirometry consistent with applicable sections of 29 CFR 1910.

Usual Standard: PFT done at the baseline exam, exit exam, and when the client needs a respirator Medical Clearance. In addition, PFT should be repeated at each exam if history of lung problems such as asthma, chronic bronchitis, COPD, TB, or is a smoker.

Copy of results with complete print out of test curves and results to be sent Medical Review Officer.

STOOL FOR OCCULT BLOOD TEST

Usually done as a patient self test at home. Results to be noted on physical exam form and sent to MEDICAL REVIEW OFFICER.

Yes, can meet criteria

No, can Not meet criteria

VISUAL ACUITY

Includes near and far vision, with glasses or contacts. Includes color vision and peripheral vision test.

Copy of results to be sent MEDICAL REVIEW OFFICER

Yes, can meet criteria

No, can Not meet criteria

IMMUNIZATIONS

Mark Here If You

Can Meet

These Criteria

Price (Mark N/A if Service is

Not Available)

HEPATITIS-A VACCINATION

A series of 2 shots to be charged per injection.

Verification of vaccination to USDA Local Contact and copy to be sent to

MEDICAL REVIEW OFFICER.

Yes, can meet criteria

No, can Not meet criteria

HEPATITIS-B VACCINATION

A series of 3shots to be charged per injection.

Verification of vaccination to USDA Local Contact and copy to be sent to

MEDICAL REVIEW OFFICER.

Yes, can meet criteria

No, can Not meet criteria

TETANUS DIPTHERIA VACCINATION

Due every ten years.

Note vaccination on chart and send to MEDICAL REVIEW

OFFICER.

Yes, can meet criteria

No, can Not meet criteria

TUBERCULOSIS SKIN TESTING (MANTOUX)

Includes reading test within 72 hours.

Note results on chart and send to MEDICAL REVIEW

OFFICER.

Yes, can meet criteria

PHOTOCOPYING

ORIGINALS of all USDA forms and copies of all test results must be provided to the MEDICAL REVIEW

OFFICER.

NOTE: NO FORMS OR TEST RESULTS ARE TO GO TO

USDA/ARS Local Management. This is Confidential

Medical Information!

NOTE: Two Exceptions

1. Hepatitis A and B Vaccination forms may go directly to the

USDA Local Contact with a copy to the Medical Review

Officer.

2. Information regarding Respirator Medical Clearance does go directly to the USDA Local Contact. However, the USDA is to receive notification of clearance or no clearance only. No test results or confidential information is to be given to the USDA Local

Contact.

(See section regarding Respirator Medical Clearance.)

Yes, can meet criteria

No, can Not meet criteria

If your clinic sends a formal letter to the employee regarding their exam results, please send a copy to the MEDICAL

REVIEW OFFICER. The Medical Review Officer will then refer to the letter the employee has already received, instead of repeating the same information in another letter.

Yes, can meet criteria

No, can Not meet criteria

If the examiner uses a different form, the clinic’s form, and then transcribes information onto the ARS form D, please send a copy of the completed actual exam form used to the

MEDICAL REVIEW OFFICER.

Yes, can meet criteria

No, can Not meet criteria

POSTAGE / HANDLING

Mark Here If You

Can Meet

These Criteria

Price (Mark N/A if Service is

Not Available)

If not already, include in prices. Yes, can meet criteria

No, can Not meet criteria

RECORDS MANAGEMENT

Maintain medical records in a system that assures security and confidentiality. Vendor acts as “custodian” of the records and agrees to transfer employee records to another vendor as determined by ARS if termination of contract.

Yes, can meet criteria

No, can Not meet criteria

LAB TESTS

The lab must have current certification of program quality such as by accreditation by the College of American Pathologists, certification as a Medicare provider, or active participation in the

Clinical Laboratory Improvement Program of the Centers for

Disease Control and Prevention or the American Association for

Clinical Chemistry.

No, can Not meet criteria

LAB PROFILE FASTING

1. CBC

2. Routine Urinalysis

3. Chemistry to include: Fasting glucose, electrolytes, albumin, liver enzymes (ALT, AST, Alk. Phos., Total Bilirubin), and lipids

(Total cholesterol, Triglycerides, HdL, calculated LDL, ratio) Reports of all lab teats to be sent to MEDICAL REVIEW OFFICER.

Yes, can meet criteria

No, can Not meet criteria

Provide initial blood drawing for all participating employees Yes, can meet criteria

No, can Not meet criteria

Provide blood drawing for Summer Employee Cholinesterase

Screening

Yes, can meet criteria

No, can Not meet criteria

RBC and PLASMA CHOLINESTERASE Baseline testing should be RBC and Plasma Cholinesterase. This is provided upon entrance to the Medical Surveillance Program where there has been exposure on the job or has had a high-risk potential.

A NEW baseline is required if vendor changes the lab where testing is done. All baselines should be collected at least FOUR

WEEKS AFTER any pesticide spraying has been done and must consist of two samples taken on different days, but within two weeks of each other. If unable to collect two specimens within this time frame, draw second specimen as soon as possible, but later than four weeks from last exposure. LAB REPORT TO

INDICATE DATE OF LAST EXPOSURE.

Reports of all lab tests to be sent to MEDICAL REVIEW OFFICER.

Yes, can meet criteria

No, can Not meet criteria

RBC CHOLINESTERASE

Use RBC Cholinesterase testing for medical surveillance once the

RBC &

Plasma cholinesterase baselines have been established.

Cholinesterase levels should be collected as soon as pesticide spraying has been done, within one week of exposure.

Reports of all lab tests to be sent to MEDICAL REVIEW OFFICER.

Yes, can meet criteria

No, can Not meet criteria

RETICULOCYTE COUNT

This test is to be run ONLY if there is clear evidence of actual occupational exposure to Benzene.

Reports of all lab tests to be sent to MEDICAL REVIEW OFFICER.

URINE ARSENIC

This test is to be run ONLY if there is clear evidence of actual occupational exposure. If the vendor suspects the need for this test, please call the Medical Review Officer, Dr. Lee Wugofski at

(415) 437-8056 for consultation.

Reports of all lab tests to be sent to MEDICAL REVIEW OFFICER.

Yes, can meet criteria

No, can Not meet criteria

PHENOL URINE

This test is to be run ONLY if there is clear evidence of actual occupational exposure. If the vendor suspects the need for this test, please call the Medical Review Officer, Dr. Lee Wugofski at

(415) 437-8056 for consultation.

Reports of all lab tests to be sent to MEDICAL REVIEW OFFICER.

Yes, can meet criteria

No, can Not meet criteria

HEAVY METAL URINE (Arsenic, Lead, Mercury, and

Cadmium)

This test is to be run ONLY if there is clear evidence of actual occupational exposure. If the vendor suspects the need for this test, please call the Medical Review Officer, Dr. Lee Wugofski at

(415) 437-8056 for consultation.

Reports of all lab tests to be sent to MEDICAL REVIEW OFFICER.

HISTOPLASMOSIS ANTIBODY

This test is to be run ONLY if there is clear evidence of actual occupational exposure. If the vendor suspects the need for this test, please call the Medical Review Officer, Dr. Lee Wugofski at

(415) 437-8056 for consultation.

Reports of all lab tests to be sent to MEDICAL REVIEW OFFICER.