Attachment 4 - Statement of Work V2.pdf

MEDICAL OPERATIONS AND READINESS UNIT

PHYSICAL EVALUATIONS AND MEDICAL SERVICES

SCOPE OF PRACTICE 2020

C.1. Purpose The purpose of this contract is to acquire professional occupational health services through a nationwide private provider network (PPN) comprised of many Providers, secured by the Contractor to support the Federal Bureau of Investigation’s (FBI) global mission – specifically to provide medical examinations for current FBI Employees and Applicants for employment.

C.2. Scope The Contractor shall furnish all necessary personnel, materials, services, facilities, (except as otherwise specified), and do all things necessary for the performance of the work as set forth in each service / work order. As applicable, services shall be provided by licensed healthcare practitioner’s (Medical Doctor (MD), Doctor of Osteopathic Medicine (DO), Nurse Practitioner (NP), Physician’s Assistant – Certified (PA-C), in good standing, working within their scope of practice. Physician assistants should be authorized to provide patient care services so long as the physician assistant is functioning under the direction and supervision of a physician or group of physicians.1

The Contractor’s primary role is the delivery of occupational health services in areas designated by FBI. Services include immunizations, lab work, Fitness for Duty (FFD) exams, OSHA mandated medical surveillance exams, official short-term travel reviews, provision of travel medications, and Department of State (DoS) medical clearances. NOTE: Immunizations are not authorized as part of an Applicant medical exam. Where licensed, the Contractor must be required to provide Commercial Driver’s License (CDL) medical clearance exams, and Federal Aviation Administration (FAA) medical clearance evaluations. Locations capable of performing CDL and FAA evaluations shall be specifically identified in writing and provided to the Contracting Officer’s Representative (COR).

The work performed under this contract requires the Contractor to receive / access service authorization from FBI via service / work orders, assign the provider(s) to be used, schedule patients, perform examinations, collect results, submit required medical records, perform quality assurance (QA) reviews of the performed services and results for completeness, and transmit completed medical record reports to the location(s) designated by FBI.

The Contractor can only perform work under this contract when authorized on the FBI General Authorization form or electronic list provided by a sanctioned COR designated FBI point of contact (POC). Exams completed without proper authorization shall not be payable by the government.

Service results, forms, and other information shall be transmitted to FBI via secure email (primary method) or with data transfer once capability approved by the FBI (secondary method).

The Contractor shall maintain a PPN of public Provider locations and staff capable of performing these services within the distance requirements and timeframes specific herein. The Contractor shall designate a qualified Contractor program manager (CPM) to be responsible for all Contractor operations. The Contractor shall review all service / work order results and

1 AMA Policy H-35, 989, Physicians Assistants associated documentation for QA prior to submission to FBI.

Service / work order requirements may be performed through a variety of PPN Provider facilities such as, hospitals, occupational health clinics, general medical clinics, specialty clinics, urgent care facilities, and more. Outreach services may be conducted using mobile van service and / or traveling medical staff.

The Contractor shall distribute all service / work order required forms, documents, and supplies to the PPN provider responsible for performing services. All required forms will be specified in the service / work orders and made available to the Contractor in advance of service requests.

The Contractor shall receive, and process completed documentation from the provider(s) and shall review all materials for completeness, adequacy of testing, and accuracy according to component and instructions of the service / work orders. All testing and services shall meet the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards for Ambulatory Care. The Contractor shall assist the FBI in assessing and improving the quality, timeliness, and accuracy of services in meeting JCAHO standards as well as recommending innovative continuous quality improvement techniques.

C.3. FBI Policy The quality of services provided by the Contractor shall be guided by national standards. These standards include, but are not limited to:

• JCAHO standards http://jointcommission.org; the

• American Medical Association (AMA) standards http://www.ama-assn.org; the

• American Association of Occupational Health Nurses (AAOHN) standards http://www.aaohn.org; the

• American College of Occupational and Environmental Medicine (ACOEM) standards http://www.acoem.org/,

• Other standards recognized by relevant national medical specialty boards, established principles and ethics of related professions; and the standards of care in the state or locality where the services are provided.

• OSHA 1910.141, Sanitation Standards.

• Blood Borne Pathogens and Bio-Hazardous waste disposal regulations in accordance with

OSHA 1910.1030.

C.4. Place of Performance Contract services shall be performed nationwide, as indicated in the individual service / work orders. It is preferred the Provider will be able to provide all required services at one (1) Provider location in two (2) appointments spaced forty eight (48) – seventy two (72) hours apart to allow for overview of lab results and to have purified protein derivative (PPD) read.

C.5. Contract Locations The Contractor will be responsible for all PPN referrals within the following locations:

Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Guam, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New York, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Puerto Rico, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, and Wyoming. (See Attachment 9 - Locations)

C.6. Provider Service Locations Service appointments shall be scheduled at a single Provider location for each examination to the greatest extent possible. Every effort shall be made to ensure all referred service / work orders are scheduled in order that medical laboratory results are available to the provider at the time of the second medical examination. Advance approval from the COR or other COR designated FBI personnel must be obtained if services will be performed at more than one (1) location, or if additional appointments are needed due to a failure to complete all requested services during the examination appointment. In areas where more than one (1) Provider location is available within the Contractor’s PPN, the FBI may dictate which provider location is used. The COR may choose to discontinue the use of Provider service locations, unable to meet the quality standards set forth in the contract, be discontinued at any time.

On rare occasions, the Contractor can request to provide services via mobile van when a fixed Provider location is unavailable. In such instances, FBI will not be responsible for any charges associated with the mobile van service, hourly outreach practitioner charges, or any charges other than the services provided. The Contractor shall obtain written approval from the COR to utilize mobile service Provider(s) prior to entering into any Provider agreement pertaining to this contract for service.

At a minimum. the following equipment shall be calibrated and have annual preventative maintenance (PM) in all service locations: Titmus machines, EKG, Audiometric Screening equipment, Hearing Booth, and Spirometer to adhere to American National Standards Institute (ANSI) and Occupational Safety and Health Administration (OSHA) standards. Documentation of PM in accordance with original equipment manufacturer (OEM) specifications shall be current and prominently displayed on the equipment and / or available for review during site visits.

Records of calibration will also be available for review during site visits and upon request.

C.7. Distance Requirements Provider locations in cities / towns with populations under one hundred thousand (100,000) shall be within a driving distance of twenty – five (25) miles of the Employee’s home office or the Applicant’s processing office. The distance requirement originating location shall be based on the most recent United States Census Bureau’s Population Estimate Tool at https://www.census.gov/quickfacts/fact/table/US#.

https://www.census.gov/quickfacts/fact/table/US

Provider locations in cities / towns with populations greater than one hundred thousand (100,000) people shall be within a driving distance of ten (10) miles of the Employee’s home office or the Applicant’s processing office. The distance requirement originating location shall be based on the most recent United States Census Bureau’s Population Estimate Tool at https://www.census.gov/quickfacts/fact/table/US#. The distance requirements may be waived on a case -by - case basis, with written COR approval. The Contractor shall submit in writing to the COR details on actions taken by the Contractor to locate a Provider location within the specified distance requirement, and detailed information on the closest available Provider location. The COR may assess a disincentive up to ten percent (10%) of the total cost of all service / work orders per Employee / Applicant referral for any service(s) performed outside the distance requirements without prior written COR approval.

C.8. New Provider Locations The Contractor shall verify if the service / work order can be satisfied by the Contractor’s existing PPN or if a new Provider location will be required.

When the FBI identifies a new location requirement, the FBI will notify the Contractor of the requested location. The Contractor shall add new Provider locations within the assigned region at no additional cost to the Government.

If a requested location is not covered by the Contractor’s existing PPN, the Contractor shall establish a new Provider location within sixty ninety(6090) calendar days of notification from the COR. Failure to establish a new Provider location within the required sixty ninety (6090) calendar days may result in a disincentive of $25.00 for each calendar day beyond the sixty ninety (6090) calendar days until a new Provider location is available for service scheduling. This disincentive shall not exceed $500.00 per new Provider location request. The Contractor shall not be penalized for timeline delays for which the FBI is responsible (e.g., site visit availability, startup call / telecon availability, etc.).

C.9. New Provider Start-up Call / Telecon The Contractor shall support a new Provider location “startup call / telecon” with FBI and any other key stakeholders determined by the COR. The purpose of the call / telecon is to identify and understand FBI forms, training, Provider - specific logistics, or criteria that will need to be addressed prior to scheduling any contract services at the new Provider location.

C.10. Agency Usage The Contractor shall perform these services for the Department of Justice (DOJ), Federal Bureau of Investigation (FBI) and may perform these services for other federal agencies upon mutual agreement with an agency requesting to issue a task order from this IDIQ.

C.11. Services at FBI Facilities The Contractor shall receive written approval from the COR prior to scheduling and completing outreach services if required by a specific location. Mobile services typically require the use of a mobile van. However, in some instances the FBI may consider a traveling practitioner(s) when space is available in a local FBI office and the service(s) requires minimal equipment (i.e. flu vaccinations).

https://www.census.gov/quickfacts/fact/table/US

C.12. Overview of Services Service / work orders shall be completed by licensed health care practitioner(s) whose knowledge, skills, and abilities are commensurate with the scope of practice per the state or territory requirements in which the service is performed.

All tests and services shall be performed utilizing accurate, properly calibrated and maintained testing equipment, and properly trained and credentialed personnel familiar with the required occupational health standards for testing and services. Tests and services enable providers to determine fitness for duty, ensuring the applicant or employee can perform the essential functions of a position and can safely deploy outside the continental united states (OCONUS).

This includes an evaluation for any condition that could cause sudden incapacitation, restrict, or prohibit participation in defensive tactics and dangerous assignments that might entail the use of firearms or potential exposure to hazardous substances.

Contract services will be quality checked by the FBI and documentation will be reviewed for accuracy, legibility, and completeness. The Contractor will provide a monthly, quality check report to the FBI COR with every invoice. The FBI reserves the right to request calibration and maintenance documentation from the Contractor for any service provider location or mobile provider – this documentation shall be provided to the COR within five (5) calendar days of the request.

The Contractor shall be responsible for ensuring that all necessary training and instructions are provided to all PPN personnel dealing directly with FBI, including but not limited to, penalties for late exams, missing items, and improper billing. The service / work order may request individual services or services included as part of a customized physical exam. All service / work orders will be initiated by FBI. All records and results will be maintained, stored, and submitted by the Contractor within ten (10) business days after the services are performed. All electronic and paper medical records associated with the Contractor’s PPN shall remain the property of FBI. No paper originals or copies are to be permanently stored with the Contractor or at any provider locations. The use of electronic medical records at a Contractor’s PPN location must be approved by FBI.

The Contractor shall report any critical service results directly to the Employee or Applicant within twenty – four (24) hours of receiving the results.

The volume estimates included in Pricing Model (Attachment 6 – Pricing Model), are designed to assist with initial line item pricing only. The service titles and descriptions provide a general summary of each line item. Additional requirements and / or instructions for each line item may be included in the individual referral service / work order requirements, and / or dictated by the

FBI.

C.13. Specialized Services Service / work order requirements may include specialized customer services and are not limited to tailored operational process flows, scheduling process, timing, specialized services or examinations, agency specific forms, Practitioner credentials and certifications, and / or other specialized requirements. Further clarification beyond the service / work order requirements may be obtained from the FBI upon request.

C.14. Management of the Private Provider Network The Contractor shall maintain a PPN and provide FBI with a comprehensive list of all active Provider locations with associated Practitioners and service capabilities identified. The initial report will be provided to the COR at the time of award and any time upon request. The Contractor shall schedule all services identified at a single Provider location, unless otherwise noted within the service / work order requirements. The Contractor CPM shall participate in a monthly telecon with COR and / or COR authorized designees regarding the PPN.

C.15. Provider Site Visits The Contractor’s PPN Providers and Practitioners shall conduct themselves in an appropriate and professional manner. This includes patient interaction, equipment quality, facility cleanliness, and more. The Contractor shall monitor and manage PPN performance. Providers that fail to complete the requirements of the referral adequately may be requested by FBI to complete a Complaint Resolution Plan. The Contractor shall also review all complaints regarding inappropriate or unprofessional performance at a provider location. The Contractor shall present all complaints to the COR with a plan for resolution within seven (7) calendar days of notification. Failure to present or resolve the complaints may necessitate discontinuation of Contractor's Provider location performing services on this contract.

FBI reserves the right to perform site visits to any provider location, as FBI or agency needs may require. The COR, or COR designated POC, will contact the CPM to schedule site visits and will determine FBI designee(s) for such visits. Site visits may include a detailed evaluation of the provider’s facility by FBI designated personnel. At any time during the life of the contract, the COR may direct discontinuation of Contractor’s Provider location(s) performing services on this contract.

C.16. Emergency / Surge Services The Contractor may be required to provide emergency / surge services beyond the estimated volume. Under emergency / surge circumstances, the COR will notify the Contractor of the specific service(s) required. The Contractor shall have emergency / surge capability in place to accommodate such requirements. When emergency / surge services are invoked, the Contractor shall meet service requirements in accordance with existing best practices.

NOTE: This section is only applicable when the CO issues a contract modification.

C.17. Scheduling and Completion of Services The Contractor shall ensure that the Provider works directly with Employees / Applicants to schedule appointments, as designated only by an FBI work order. Providers shall yield a list of scheduled exams to the designated FBI POC upon request.

The Provider shall make direct contact with Employees / Applicants, or FBI customer scheduling POCs, within forty – eight (48) hours of work order receipt. The Contractor shall make at least three (3) attempts via phone to contact the Employee / Applicant or defined FBI POCs to schedule the appointment, with at least four (4) hours between each attempt. The Provider shall document all communication attempts. If attempts to communicate with the requester are successful, the Contractor shall provide the Employee / Applicant with an appointment confirmation notice via email immediately after scheduling. The appointment confirmation shall include, but is not limited to information on the Provider, Provider’s physical address location, practitioner name, any special instructions, etc. Content and structure of the appointment confirmation notice email may be changed by the COR at any time. Centralized, online, scheduling is the preferred method for scheduling appointments.

The Contractor shall submit a listing of all service / work order requirements that could not be scheduled due to Employee / Applicant availability on their Monthly Self - Assessment Report (MSAR). If all three (3) attempts to communicate with the Employee / Applicant are unsuccessful, the referral shall be returned to FBI. Rescheduled appointments or additional appointments needed to complete all service / work order requirements shall be documented within the MSAR. This shall include all Employee / Applicant missed appointment(s) which are considered as ‘no-show’ appointment(s) to include cancellations within twenty-four (24) hours.

This shall also include missed appointments due to Provider/Contractor failure to complete scheduled appointment.

C.18. Scheduling It is preferred that “block” scheduling be available in high volume locations; “block” scheduling requires the examining facility provide standardized days and times for FBI exams to meet the volume needs of the specific location. FBI will release unused appointments to the provider within ten (10) business days prior to the “blocked” date.

The PPN practitioner shall schedule and complete all service / work order requirements within the following schedule:

• Official Foreign Travel Reviews, including DoS examinations - ten (10) business days of work order receipt.

• Applicant Medical Assessments- fifteen (15) business days from work order receipt.

• Routine Periodic Fitness for Duty Assessments and Medical Surveillance Exams - thirty (30) business days from work order receipt.

Failure to schedule and complete all services within the required days from work order date received will result in a disincentive of $25.00 for each business day beyond the designated days up to 50% of the price of the service..

C.19. Expedited Referral Service Completion The PPN practitioner shall schedule and complete all orders within two (2) business days of work order receiptand complete all expedited work orders within five (5) business days of receipt.. FBI will clearly mark the work order as “Expedited”. Failure to schedule and complete all expedited work orders within twofive (52) business days from receipt will result in forfeiture of the Expedited Service Fee (C.15.4) and the Standard Referral Service Completion (C.10.220) requirements will apply.

C.20. Standard Referral Report Submission Once all requirements listed on the service / work order are completed, the PPN practitioner shall compile the information (e.g., test results, procedures, completed forms, exam summary, etc.) and pair it with the appropriate work order, perform quality assurance, and submit the completed order to FBI within ten (10) business days. Failure to submit the completed work order to the FBI queue within ten (10) business days from the final appointment date will result in a disincentive of $25.00 for each business day beyond the ten (10) business day requirement up to 50% of the price of the service.

FBI reviewing personnel may contact PPN practitioners directly for clarification regarding the services provided. The Contractor shall support and facilitate this direct communication within all PPN agreements. Charges for this service will not be applicable if consultation is due to incomplete / insufficient fulfillment of services.

C.21. Expedited Referral Report Submission Once all requirements listed on the expedited service / work order are completed, the PPN Practitioner shall compile the information (e.g., test results, procedures, completed forms, etc.)

and pair it with the work order, perform a quality check, and submit the completed referral back to FBI within five two (52) business days. Failure to submit the referral back to the FBI queue within twofive (52) business days from the final appointment date will result in forfeiture of the Expedited Service Fee (C.15.4). The Standard Referral Report Submission (C.10.520) requirements would then apply. This Expedited Service Fee will not be applicable if late submission is due to incomplete / insufficient work orders sent on behalf of the FBI.

FBI reviewing officials may contact PPN practitioners directly for clarification regarding the services provided. The Contractor shall support and facilitate this direct communication within all PPN agreements.

C.22. Missing Items A missing item may include, but is not limited to, a missing service, missing signature, incomplete documents, etc. An exam submitted to FBI as “final” discovered to contain one (1) or more missing items will be considered incomplete and returned to the Contractor with all missing items identified. Applicable timeframe(s) annotated in this SOW will resume, including any associated disincentives. Submission of an exam containing missing items will result in a disincentive of $10.00 per missing item not to exceed more than 50% of the price of the service and must be reported in the monthly quality assurance report.

C.23. Examination Services The Contractor shall perform occupational health exam services in accordance with Attachment 4 – Statement of Work, as requested. Practitioners shall conduct hands - on evaluations for all exam types.

The Contractor shall send all required forms listed in the service / work order directly to the COR designated POC. The FBI requires that all service results, lab results, forms, and any other required information be digitally submitted.

Certain examination components (e.g., lab work, immunizations, etc.) may require additional appointment(s). This should not delay the Contractor from submitting the completed primary examination results and / or the results of other completed testing in accordance with timeframes identified. Written notification regarding any pending results shall accompany the medical record that is submitted.

All exceptions to the stated timeframes shall be documented and provided to the COR for review. Justification shall include the reasons for the delay and the expected delivery date.

Failure to justify a valid reason for the delay shall result in a penalty for each business day a report / document / result is late beyond the stated timeframe requirements described in this section.

The examining Provider shall review and evaluate all medical examinations, tests, and findings for completeness, accuracy, and indicate the need for any additional follow - up to determine the Employee or Applicant’s ability to meet the essential duties of the position. The Contractor shall conduct a quality review of completed examinations prior to submitting to the FBI.

The Provider shall discuss the examination results with the Employee at the conclusion of the exam. The Provider shall not address abnormal values, with the Applicant, except for critical values or findings deemed by the examining Practitioner as life threatening or emergent.

C.24. Same Sex Observer The Contractor shall provide a same sex observer if requested by any FBI examinee.

C.25. Routine Periodic Fitness for Duty Examinations These examinations are conducted on a periodic basis, as determined by FBI, for employees in designated positions with medical requirements. The network Provider shall refer to the FD- 1126 and complete items authorized by the ordering FBI POC. The network Provider must ensure that forms FD-1065 and FD-1093 (or FD-1093A) are completed in their entirety.

Incomplete forms will be returned for correction.

Distant Vision - If corrective lenses are used, the evaluation shall be accomplished with and without correction. Results for both readings should be given in Snellen equivalents and should be recorded for both left and right eyes. The reading provided for each eye will indicate the acuity level at which the line is read without error by the examinee. Distant vision must be 20/20 in one eye and no worse than 20/40 in the other eye (Corrected or uncorrected). If these standards not met, retest using the Snellen wall chart.

Near Vision - If corrective lenses are used, the evaluation shall be accomplished with and without correction. Results for both readings must be given in Snellen equivalents and recorded for both left and right eyes. The reading provided for each eye will indicate the acuity level at which the line is read without error by the examinee.

Field of Vision – to include strabismus.

Resting Electrocardiogram (12-lead EKG) - The Contractor shall include the original test or submit an electronic copy of the EKG with interpretation by the evaluating Provider along with the Provider’s signature.

Screening audiometric test – Prior to the test, the examining Practitioner shall assess both ear canals and follow Occupational Safety and Health Administration (OSHA) 5CFR1910.95 guidelines for both left and right ears. Test will be performed in HZ levels: 500, 1000, 2000, 3000, 4000, 6000, and 8000. The graphical print out from the audiometer must accompany the results documented on the FD-1093.

Additional tests (The following tests are not part of the routine FFD exam but may be ordered on an as needed basis).

• Chest X-ray (PA and Lateral views for employees if needed for specialty exams or NEW TB test conversions.)

• Spirometry / Pulmonary Function Screening- Documentation of results will include graphs and written interpretation.

• Blood Group and Type

• G6PD

• Lead and Zinc Protoporphyrin (ZPP)

• Hepatitis B Antigen / Antibody

• Hepatitis C Antibody

• Glycosylated Hemoglobin (A1C)

• HIV I and HIV II

• RBC and Plasma Cholinesterase

Immunization History—The Contractor shall comply with FBI Immunization Policy and update vaccines if needed. The FBI requires the following vaccines:

• Hepatitis A Series

• Hepatitis B Series

• Combination Hepatitis A/B series in lieu of individual Hepatitis A and Hepatitis B series

• Measles / Mumps / Rubella (MMR) – (two doses)

• Meningitis

• Polio (four (4) childhood doses and one (1) booster after the age of 18 years)

• Tetanus / Diphtheria OR Tetanus / Diphtheria / Pertussis

• Varicella or proof of disease history

The Provider shall document administered vaccines in the INTERNATIONAL CERTIFICATE OF VACCINES (CDC 731, Yellow Card) and shall include documentation of all administered vaccines in the completed exam package.

The Provider shall mark box 26 of the FD-1093, under the EMPLOYEE IS “Qualified for strenuous exertion and worldwide duty” OR “IS NOT Qualified for strenuous exertion or worldwide duty.

PENDING FBIHQ REVIEW”.

If the Employee is not qualified, the Provider shall indicate finding(s) to support this disposition in box 26a of the FD-1093.

C.26. Pre - Employment / Applicant Physical Examinations Refer to FD-1126, FD-1065 (Report of Medical History Form), FD-1093A (Medical Evaluation Form – Applicants), FD-967 (New Agent Activity Form).

Spirometry / Pulmonary Function Screening – Documentation of results shall include graphs and written interpretation.

Color vision – Documentation of results shall be provided in the following format: type of test used; number of plates correct / number of plates used. Ishihara 14 plate is preferred. Include the Ishihara results document. Alternatives to Ishihara 14 must be approved by FBI COR.

Provider will also document the plate number(s) of any plate(s) that are missed by the examinee.

The Provider shall not address abnormal values, with the Applicant, except for critical values or findings deemed by the examining Provider as life threatening or emergent.

If the Applicant does not return to the facility for TB skin test reading within seventy – two (72) hours, the Provider shall mark the paperwork as “did not return” and submit the completed exam to the FBI.

Immunization History—Applicants must provide copies of all immunization records at the time of their exam. The Provider will receive and include immunization documents in their exam package to the FBI POC. Immunizations shall not be provided during an Applicant exam.

Applicant’s and existing Employees are not eligible for FBI-funded immunizations during the applicant process.

The FBI will provide the Contractor with the Special Agent Essential Task List. Please note that this information is proprietary and must not be shared outside of FBI business.

C.27. Department of State Embassy Personnel Medical Clearance Examinations

Refer to Fitness for Duty Periodic Exam Forms (FD-1065 and FD-1093), FD-1126 and DoS Form DS-6561. All DOS forms must be the most current version available from the DoS web site. If the employee fails to provide forms, Provider can obtain them from:

www.state.gov/m/med/c35188.htm

The Provider shall complete DS form 6561 pages 3 and 4. It must be completed legibly and in its entirety. It must be signed and dated by the examining Provider.

The Provider shall comment on all positive responses by examinee.

Employees Deploying to Department of State Identified War Zones:

Refer to Department of State Forms DS-6570 (ESCAPE Post Pre-Deployment Physical Exam Acknowledgement Form). Examiner must read, sign and date DS-6570 form.

For all DoS forms, please refer to eforms.state.gov for the most updated forms.

C.28. OSHA Medical Surveillance Examinations

These exams are for employees assigned to jobs or job tasks that require medical surveillance for compliance with OSHA CFR 1910. In addition to the Routine Examination, OSHA exams may include:

• Evaluation Questionnaire, OSHA 900

• FBI Respiratory Clearance and Hazardous Materials Response Medical Report, FD

899 Form

• RBC and Plasma Cholinesterase with each exam

• Blood Lead and ZPP with baseline exam only

C.29. Travel Reviews

The Provider shall provide FBI required immunizations even if CDC does not recommend, unless contraindicated.

C.30. Federal Aviation Administration (FAA) Examinations

A Provider certified as an Aviation Medical Examiner (AME) shall perform Class 1, Class 2 and Class 3 Federal Aviation Administration (FAA) examinations which typically consist of a physical evaluation and specific laboratory and testing requirements. The examination price shall include all required forms and any specimen collection / handling.

C.31. Commercial Driver’s License (CDL) Examinations CDL examinations are used to determine commercial driver physical fitness and must be performed by a CDL Certified Medical Examiner. CDL examinations typically consist of a physical evaluation and specific laboratory and testing requirements. All components of the examination and testing shall be as prescribed by 49 CFR parts 350, 383, 390, and 391 and meet certifications as required by the Federal Motor Carrier Safety Administration physical qualifications and standard and guidelines.

C.32 Diver Examinations

FBI Divers exams shall be guided by National Oceanic and Atmospheric Administration (NOAA) standards. All assessment exams must include in addition to the normal Fitness for Duty examination to include a completed FD-1065a, FD-899 and FD-900. Pulmonary Function Test (PFT) shall be done with the initial examination and every exam after if the individual is a smoker. A posterior and anterior (PA), and lateral (LAT) chest X-ray shall be completed with the initial examination only.

C.33 Hazardous Materials (HAZMAT) Response Examinations

All HAZMAT examinations in addition to all the components of a Periodic Fitness for Duty examination (see Section C.25) shall include a completed FD-899, FD-900, RBC and Plasma

Cholinesterase blood draw (one draw). These examinations shall also require a baseline Lead and Zinc Protoporphyrin (ZPP) upon initial exam only.

C.34 Respiratory Protection Examinations

The Respiratory Protection Exam shall consist of the following components: a completed FD- 900, FD-899, FD-1093. A pulmonary function test shall be completed only if clinically indicated per the Provider.

C.35 Language Specialist Examinations – Audiogram Only

Prior to the test, the examining Practitioner shall assess both ear canals and follow Occupational Safety and Health Administration (OSHA) 5CFR1910.95 guidelines for both left and right ears.

Test will be performed in HZ levels: 500, 1000, 2000, 3000, 4000, 6000, and 8000. The graphical print out from the audiometer must accompany the results documented on the FD-1093. The FD-1093 only needs to have the Audiometer section completed (box #20) for this examination.

C.36. Laboratory Testing and Analysis The Contractor shall be responsible for providing full - service diagnostic clinical laboratory services for PPN locations, to include oversight, management, and provision of general medical laboratory services.

The Contractor shall develop an alternate method of ordering lab tests and receiving test results. This alternate method may require the use of manual / paper requisitions and the receiving of test results via secure fax or overnight courier delivery service.

All test results shall be included in the final report submission to FBI for the referral to be considered final.

The Provider shall order, obtain and process the specimen for courier pick - up in accordance with clinical standards.

C.37. Travel Medications Service / work order requirements may include travel medications to be dispensed to FBI employees. The Contractor shall maintain stock on-hand to distribute travel medications through their PPN Providers, when needed. The Provider shall review travel destination(s), provide counseling related to travel risks, supply travel medications [prescriptions or dispense medications (antibiotics for traveler’s diarrhea, malaria prophylaxis medication, altitude sickness prophylaxis, etc.)] in accordance with the most up - to - date CDC recommendations. Contractor shall ensure network Providers have access to the most up to date TRAVAX and / or CDC guidelines. A written summary of the visit is required. Medications provided are not to exceed the length of official travel or a thirty (30) - day supply, whichever is less.

C.38. Vaccines FBI service / work order requirements may include immunization administration of vaccines— some of which may be difficult to obtain. The Contractor shall store and maintain a stock of all vaccines listed in in the FD -1126 to distribute to Providers for administration, when needed.

The Contractor shall follow vaccine storage and handling best practice guidelines provided by the CDC.

All vaccine line items listed in FD - 1126 shall include both the price and the administration of the vaccine. The Contractor shall maintain a supply of the following vaccines for adult use:

Hepatitis A, Hepatitis B, Combined Hepatitis A / B, Influenza, Measles / Mumps / Rubella, Meningococcal, Polio, Rabies, Tetanus / Diphtheria, and Tetanus / Diphtheria / Pertussis. If available, Typhoid, Yellow Fever, Japanese Encephalitis, Varicella and Anthrax.

C.39. Vaccination Program Each local FBI Field Office (FO) may utilize Contractor services for the administration of FBI -supplied Flu vaccines and/or potential COVID-19 vaccines. Some lLocal FBI FOs will be directly responsible for the administration feemay work directly with Contractor to schedule any seasonal vaccine clinics onsite, which should be submitted on a separate invoice to the requesting FBI FO’s POC. Contractor is only responsible for the administration of FBI provided vaccine and submitting the administration fee. which shall not be billed under this contract.

C.40. Credentialing The Contractor shall manage all aspects of their PPN, including maintenance of credentialing files. The vetting process for individual PPN Provider credentialing shall cover the following, at a minimum:

• Medical license verification directly from an industry recognized primary source

• Verification that the Provider is not excluded from working on federal contracts

• HHS Office of the Inspector General Exclusions Database

• GSA System for Award Management Exclusion Database

• Verification of certification with DOT for any provider performing CDL and FAA exams

• Medical Doctors and Doctor of Osteopathic Medicine shall be board certified, or board-eligible, in any of the following specialties: cardiology, emergency medicine, internal medicine, physical medicine, family medicine, or preventive medicine (aerospace, occupational, or general preventive medicine or public health). Exceptions to this requirement may be approved by COR on a case - by - case basis.

• Nurse Practitioners shall be credentialed by American Nurses Credential Center (ANCC) or American Academy of Nurse Practitioners Certification Program (AANPCP).

• Physicians Assistants shall be certified by the National Commission on Certification of Physician Assistants (NCCPA).

• Audiologists shall be certified by the American Board of Audiology and are only authorized to complete Language Specialist examinations.

If there are any sanctions or censures discovered during this process that do not automatically exclude them from use, details of the sanction(s) must be submitted to the COR for a final written decision prior to contracting. All Providers shall be re - verified by the Contractor using the process above on an annual basis.

A list of all credentialed providers and / or any subcontractors must be approved by the COR before any work / service orders will be issued.

C.41. Contractor Self-Assessment The Contractor shall provide to the COR with each monthly invoice a MSAR of the Contractor’s performance in the billing period for which payment is requested, which shall include at a minimum:

• Section C.19 (Surveillance Matrix) and F.3 (Deliverables Chart) Line Number

• Services performed outside the mileage requirement

• New Provider status updates

• Listing of records that were unable to be scheduled due to availability

• Applicable disincentives – cumulative disincentives for a single referral shall not exceed the total cost of services for that referral

• Challenges encountered

• Contractor’s plan(s) to correct causes of disincentives

• PPN Provider Site Detail failing to meet all requirements in the Service/work Order (i.e., Missing Items)

Failure to include the MSAR with the monthly invoice will result in the rejection of the invoice.

C.42. Billing A separate, itemized invoice shall be submitted for each service location and will contain, at minimum, the following:

1. Invoice unique number

2. Name of Employee (applicant)

3. Date of Service

4. Date of Invoice

5. Service location

6. Itemized list of services

7. Unit cost of services

Contractor shall respond to accounting questions and concerns on an as needed basis.

The Contractor shall ensure that the FBI (including the individual Employee / Applicant) does not receive invoices / bills directly from the Contractor’s PPN Providers. In the event improper billing is discovered, FBI will inform the Contractor of the error immediately. The Contractor shall resolve the error and provide the COR with written proof that the situation has been resolved.

Written proof is specified as a zero - balance statement from the responsible PPN Provider’s billing department absolving FBI, FBI Employee, or Applicant of any responsibility to the COR, a notarized letter stating that the charges are the sole responsibility of the Contractor, or another form of written proof pre - approved by the COR. The Contractor shall resolve improper billing issues and provide written proof of resolution to the COR within five (5) business days of the bill resolution request notification to the Contractor from the COR. Failure to resolve improper billing issues within five (5) business days will result in a disincentive of $10.00 for each business day beyond the five (5) business days.

C.43. FBI Medical Documentation All medical records remain the property of the Government and shall be turned over or destroyed at the Government’s request. All medical record keeping shall be in accordance with the Privacy Act of 1974 and destroyed thirty sixty (360) calendar days after the appointment date

The service / work order will list the required medical documentation needed for each service request. The Contractor will have access to all required forms and documents. The Contractor shall be responsible for clerical costs necessary for printing, copying, and collating of all forms and documents used by its PPN Providers. Blank forms can be electronically sent directly to PPN Providers by the Contractor.

The COR will provide alternative access to forms and other documents in the event electronic communication is interrupted and / or unavailable. Hard copies will be delivered via overnight delivery, if necessary.

C.44. Quality Assurance Surveillance Plan (QASP) The Government intends to utilize a Quality Assurance Surveillance Plan (QASP) to monitor the quality of the Contractor’s performance. The oversight provided for in the contract and in the QASP will help to ensure that service levels reach and maintain the required levels throughout the contract term. Further, the QASP provides the COR with a proactive way to avoid unacceptable or deficient performance and provides verifiable input for the Contractor Performance Assessment Reporting System (CPARS). The QASP may be updated by modification to the contract.

The Contractor’s performance will be subject to both scheduled and unscheduled reviews by the Government, including staff, and customer satisfaction. FBI may at any time monitor and review the Contractor’s performance for compliance to FBI policies, standard operating procedures (SOPs), TJC’s AC standards and other elements within this performance contract. The Government may unilaterally increase quality review in the event of deficient Contractor performance. In addition, the COR will monitor and evaluate the Contractor’s progress through monthly invoices, program reviews, and regular meetings with the Contractor. No penalties will be assessed during the sixty (60) - day transition period; post-transition period penalties will be assessed at the COR’s discretion.

The Surveillance Plan (Attachment 5 - QASP) is a list of performance objectives and standards that must be performed by the contractor. The Surveillance Plan details the methods of surveillance the COR will use to validate and inspect these performance elements. Performance objectives define the desired outcomes. Performance standards define the level of service required under the contract to successfully meet the performance objective. The inspection methodology defines how, when, and what will be assessed in measuring performance. The Government performs surveillance to determine the quality of the Contractor’s performance as it relates to the performance element standards.

C.45. Safeguarding Information and Information Systems In accordance with the Federal Information Processing Standards Publication (FIPS) 199, Standards for Security Categorization of federal Information and Information Systems, the Contractor (and / or any subcontractor) shall protect Government information in order to ensure:

• Confidentiality, which means preserving authorized restrictions on access and disclosure, based on the security terms found in this contract, including means for protecting personal privacy and proprietary information; and

• Integrity, which means guarding against improper information modification or destruction, and ensuring information non-repudiation and authenticity; and

• Availability, which means ensuring timely and reliable access to and use of information

• Security for any Contractor systems, and information contained therein, operated by the Contractor on behalf of the FBI regardless of location. In addition, if new or unanticipated threats or hazards are discovered by either the agency or the Contractor, and existing safeguards have ceased to function, the discovery shall be immediately reported within one (1) hour or less, bringing the situation to the attention of the other party.

C.46. Protection of Sensitive Information Information is or may be sensitive because it requires security to protect its confidentiality, integrity, and / or availability. The Contractor (and / or any subcontractor) shall protect all government information that is or may be sensitive in accordance with OMB Memorandum M- 06-16, Protection of Sensitive Agency Information by security with a FIPS 140-2 validated solution.

C.47. Confidentiality and Nondisclosure of Information Any information provided to the Contractor (and / or any subcontract) by FBI or collected by the Contractor on behalf of FBI shall be used only for the purpose of carrying out the provisions of this contract and shall not be disclosed or made known in any manner to any persons except as necessary in the performance of the contract. The Contractor assumes responsibility for protection of the confidentiality of Government records and shall ensure that all work performed by its employees and subcontractors shall be under the supervision of the Contractor. Each Contractor employee or any of its subcontractors to whom FBI records may be made available or disclosed shall be notified in writing by the Contractor that information disclosed to such employee or subcontract can be used only for that purpose and to the extent authorized herein.

The confidentiality, integrity, and availability of such information shall be protected in accordance with FBI and other applicable policies. Unauthorized disclosure of information will be subject to the following laws and regulations:

• 18 USC 641 (Criminal Code: Public Money, Property or Record);

• 18 USC 1905 (Criminal Code: Disclosure of Confidential Information); and

• 44 USC, Chapter 35, Subchapter I (Paperwork Reduction Act).

C.48. Internet Protocol Version 6 (IPV6) All procurements using Internet Protocol shall comply with OMB Memorandum M-05-22, Transition Planning for Internet Protocol Version 6 (IPV6).

C.49. Government Websites All new and existing public-facing government websites must be securely configured with Hypertext Transfer Protocol Secure (HTTPS) using the most recent version of Transport Layer Security (TLS). In addition, HTTPS shall enable HTTP Strict Transport Security (HSTS) to instruct compliant browsers to assume HTTPS at all times to reduce the number of insecurity redirects and protect against attacks that attempt to downgrade connections to plain HTTP. For internal-facing websites, the HTTPS is not required, but it is highly recommended.

C.50. Contract Documentation The Contractor shall use provided templates, policies, forms and other agency documents provided by FBI to comply with contract deliverables as appropriate.

C.51. Standard for Encryption The Contractor (and / or any subcontractor) shall:

• Comply with the FBI Standard for Encryption of Computing Devices and Information to prevent unauthorized access to government information.

• Encrypt all sensitive federal data and information (i.e.,…