36C10G23Q0105.docx

36C10G23Q0105 Combined synopsis/solicitation for commercial services.

PAGE 1 OF

1. REQUISITION NO.

2. CONTRACT NO.

3. AWARD/EFFECTIVE DATE

4. ORDER NO.

5. SOLICITATION NUMBER

6. SOLICITATION ISSUE DATE

a. NAME

b. TELEPHONE NO. (No Collect Calls)

8. OFFER DUE DATE/LOCAL

TIME

9. ISSUED BY

CODE

10. THIS ACQUISITION IS

UNRESTRICTED OR

SET ASIDE:

% FOR:

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

WOMEN-OWNED SMALL BUSINESS

(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

8(A)

NAICS:

SIZE STANDARD:

11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

SEE

SCHEDULE

12. DISCOUNT TERMS

13a. THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

13b. RATING

14. METHOD OF SOLICITATION

RFQ

IFB

RFP

15. DELIVER TO

CODE

16. ADMINISTERED BY

CODE

17a.

CONTRACTOR/OFFEROR

CODE

FACILITY CODE

18a. PAYMENT WILL BE MADE BY

CODE

TELEPHONE NO.

UEI:

EFT:

PHONE:

FAX:

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER 18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW IS CHECKED

SEE ADDENDUM

19.

20.

21.

22.

23.

24.

ITEM NO.

SCHEDULE OF SUPPLIES/SERVICES

QUANTITY

UNIT

UNIT PRICE

AMOUNT

(Use Reverse and/or Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA

26. TOTAL AWARD AMOUNT (For Govt. Use Only) 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA

ARE

ARE NOT ATTACHED.

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA

ARE

ARE NOT ATTACHED

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN _______________

29. AWARD OF CONTRACT: REF. _____________

______________________ OFFER

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND

DATED ________________________________. YOUR OFFER ON SOLICITATION

DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY

(BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE

ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED

SET FORTH HEREIN IS ACCEPTED AS TO ITEMS:

30a. SIGNAT

URE OF OFFEROR/CONTRACTOR

31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER) 30b. NAME AND TITLE OF SIGNER (TYPE OR PRINT) 30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (TYPE OR PRINT) 31c. DATE SIGNED

AUTHORIZED FOR LOCAL REPRODUCTION

(REV. NOV 2021)

PREVIOUS EDITION IS NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.212

7. FOR SOLICITATION

INFORMATION CALL:

STANDARD FORM 1449

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL

PRODUCTS AND COMMERCIAL SERVICES

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

36C10G23Q0105 Kristal Hall 240-917-9690 09-21-2023

2PM

EDT

36C10G U.S.

Department of Veterans Affairs OPAL | Strategic Acquisition Center 10300 Spotsylvania Ave | STE 400 Fredericksburg VA 22408-2697 X 541910 $22.5 Million N/A X

36C10G U.S. Department of Veterans Affairs OPAL | Strategic Acquisition Center 10300 Spotsylvania Ave | STE 400 Fredericksburg VA 22408-2697

VAFSC

U.S. Department of Veterans Affairs Financial Services Center

PO BOX 149971

(see Section B.3 invoicing/payment) Austin TX 78714-8917 1 (877) 489-6135 See CONTINUATION Page Dental Patient Satisfaction Survey(s) (DPSS) See Schedule and PWS which are included.

PO to be identified on order.

See CONTINUATION Page X Kevin Pendleton

VA-OPAL-SAC-2022-90354

Table of Contents

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

1. Contract Administration: All contract administration matters will be handled by the following individuals:

a. CONTRACTOR: TBD

b. GOVERNMENT: Contracting Officer 36C10G U.S. Department of Veterans Affairs OPAL | Strategic Acquisition Center

10300 Spotsylvania Ave | STE 400 Fredericksburg VA 22408-2697

2. CONTRACTOR REMITTANCE ADDRESS: All payments by the Government to the contractor will be made in accordance with:

3. INVOICES: Invoices shall be submitted in arrears:

4. GOVERNMENT INVOICE ADDRESS: All Invoices from the contractor shall be submitted electronically in accordance with VAAR Clause 852.232-72 Electronic Submission of Payment Requests.

ACKNOWLEDGMENT OF AMENDMENTS: The offeror acknowledges receipt of amendments to the Solicitation numbered and dated as follows:

36C10G23Q0105

Page 1 of Page 1 of

B.2 PERFORMANCE WORK STATEMENT

Performance Work Statement for:

Veterans Health Administration Dental Patient Satisfaction Surveys

I. Background Veterans Health Administration’s (VHA) mission is to provide high quality medical and dental care to eligible veterans. VA’s Office of Dentistry (OOD) is responsible for policy, oversight, and new program development for Veteran dental care. Executive Order 12862, dated September 11, 1993, calls for the establishment and implementation of customer service standards; for agencies to “survey customers to determine the kind and quality of services they want and their level of satisfaction with current services”. VA’s Blueprint for Excellence emphasizes customer feedback and encourages services to measure patient satisfaction.

II. Deliverables

Performance Objective

Minimum Acceptance Standard

Performance Threshold

Frequency

Method of Observation

Conduct Post Award Conference

100% Compliance

At least 95% of the time, reports are submitted in accordance with the PWS.

Two weeks after award

Contracting Officer Representative(COR) Surveillance

Provide Post Award Conference Minutes

Compliance

COR/QA Feedback, 100% Inspection.

Within two weeks of the Post Award Conference

COR

Coordination of Services

Ensure coordination between the contractor, Office of Procurement, Acquisition and Logistics | Publication Services Division, and the Government Printing Office representative to deliver patient data delivery in a timely manner.

Contractor will create workflow and billing schedule of the for the Dental Patient Satisfaction Survey process and provide to the COR for approval. The approved workflow schedule will be provided to representative of the Publication Services Division, who will provide to the Government Printing Office.

Compliance

COR/QA Feedback, 100% Inspection.

Specified timeframe will be provided at Post Award Conference

Conducting Dental Patient Satisfaction Surveys By Mail

Surveys will be conducted to assess dental care down to the individual site level (approx. 240, plus). Surveys will be customized to include Number of completed surveys per site level will depend upon the number of staff dentist FTE at each site according to the following:

1 Dentist 45/yr.

2-3 Dentists 120/yr.

>3 Dentists 200/yr.

See notes under

**See Option1 and 2 for Sampling Methodology

COR/QA

Feedback, 100%, Inspection

Monthly

Conducting Dental Patient Satisfaction Surveys Online

The Dental Patient Satisfaction Surveys will be customized with relevant identifiable information and made available (online) via web address (URL) established by contractor. Invitations and instructions to participate in the surveys will be sent to those veterans who emails have been provided and identified in the monthly file list submitted to the contractor for processing. Mailings of all the surveys will also be provided, to accommodate all eligible veterans, who’s preference or need may necessitate to complete a paper survey. All Surveys will be conducted the same, to assess dental care down to the individual site level (approx. 240, plus) Number of completed surveys per site level will depend upon the number of staff dentist FTE at each site according to the following:

1 Dentist 45/yr.

2-3 Dentists 120/yr.

>3 Dentists 200/yr.

**See Option1 and 2 for Sampling Methodology

*Online survey must contain identical questions as survey mailed.

*The statistical data deriving from online surveying, via email or web address will be provided in the monthly reporting. Examples are as follows: Number of emails sent, completed online, uncompleted, returned with bad email addresses, etc. (To be determined and approved by the Office of Dentistry)

*Contractor must adhere to all VA security measures and policies that apply and are outlined in the contract.

100% Compliance

COR/QA Feedback, 100%, Inspection

Monthly

Surveying Methodology

Surveys shall utilize a modified Dillman Methodology, Total Design Methodology (TDM)

COR/QA

Feedback, 100% Inspection.

Entire Contract

Secure Data Transfer Compliance

Be able to receive coded/ secure files from the OOD will be supplied with the patient’s name, dental classification, and address files in American Standard Code for Information Interchange (ASCII) comma delimited format (compressed if necessary, using PKZIP) or in a Statistical Analysis System (SAS) dataset.

COR/QA

Feedback, 100% Inspection.

Monthly

Website Build, Design, Maintenance & Technical Support

Create and maintain web-based reporting site updated real time as new surveys come are received. Website will represent the Office of Dentistry and allows secure access for VHA Dental Reports. These secure, web-based reports shall, at a minimum, contain descriptive elements about the surveyed group and their responses displayed in both text and graphical format and are approved by the Office of Dentistry and updated monthly. As part of the web-based reporting tool. Data collection remains open for at a minimum of three weeks, unless otherwise coordinated approved by the COR. Technical support will be provided to Department of Veteran Affairs staff for accessing the DPSS Website, registration and accessing reports.

Website shall include open access to all Department of Veterans Affairs’ staff required to utilize the data and reporting, to complete the mission and goals of the VA. Office of Dentistry reserves the right to change and edit others accessibility to the website and reporting information as deemed not beneficial to the mission.

COR/QA

Feedback, 100% Inspection.

Monthly

Reporting

Establish a numerical tracking mechanism to report monitor response rates. As part of the web-based reporting tool.

100% Compliance

COR/QA

Feedback, 100% Inspection.

Monthly

Develop report that provides national, VISN, parent facility and site levels. As part of the web-based reporting tool. Provide proof of concept and demonstrate their ability to successfully analyze and these report results.

Office of Dentistry reserves the right to request other types of reports originating from the collection of information and data received as a result of the monthly surveying of dental patients, whether being inhouse or care in the community (IVC Integrated Veterans Care).

Office of Dentistry must be able to adapt to the growing (eligible) veteran population, dental service expansions and fluctuation in staff.

COR/QA

Feedback, 100% Inspection.

Monthly, Quarterly, and Yearly

Aggregated Data Feed for Office of Dentistry Reporting

The Contractor shall provide the data in an unformatted comma-delimited file format, which shall include all the attributes collected in the dental patient satisfaction survey with columns of fiscal year and quarter, location at the station division level (As the VA defines as sta6a), survey question, category of measure as (score, peer index, difference) and the score.

Data Reporting Format

• There will be one file per quarter and the file will have five columns.

a. Quarter (no blank rows)

· - This column will

· have fiscal year

· and quarter of the

· data in it.

· - To be reported

· using the FYXX-QX

· format

· Ex) FY19-Q4

b. Location (no blank rows)

· This column will be used to indicate which location the results are for. There will be four levels for this data.

· Station/Facility: To be reported using the Sta6a

- VISN: To be reported using the VXX format

· Ex) V01 or V23

· - National: To be

· reported as

· National.

· Standards: To be reported as FYXX VA-SHEP or CYXX-QX National (non-VA)

c. Question (no blank rows)

100% Compliance

COR/QA Feedback, 100% Inspection.

Quarterly

Referent Data

Provide comparable results (Referent Data) on a non-VA patient population. As part of the web- based reporting tool.

100% Compliance

COR/QA Feedback, 100% Inspection.

Monthly

Reporting for Mail Returns and Decease Patients

Report number of Return to sender (RTS) and deceased patients. As part of the web-based reporting tool.

COR/QA

Feedback, 100% Inspection.

Monthly

Benchmarking Benchmark survey against 1,000 civilians to be used for future evaluations.

100% Compliance

COR/QA Feedback, 100% Inspection

Monthly

WEB-Based Training Tools

Provide four (4) hours of training annually, if requested by the Office of Dentistry’s COR. Training may be conducted via live teleconference or pre-recorded video training, which is to be scheduled by the Program Office (PO).

Education and Training tools such as video recorded training with transcripts, brochures, posters, and fact sheets will be made available for staff and veterans nationwide. Materials shall be accessible for review on the Office of Dentistry SharePoint and DPSS Website.

Provide access and website registration support to Dept. of Veterans Affairs staff.

COR/QA

Feedback 100% Inspection.

Annually

III. Description of Required Services

a. Production and Fielding of Surveys and Data Collection The OOD is seeking a contractor to provide the following products and/or services as soon as VA receives approval from OMB: VHA-wide use of the survey instrument, access to detailed data files for comparable analysis, statistical consulting on an as needed basis, and data collection services, survey data file transfer protocol (FTP), white mail handling, and translation into Spanish used in the territory of Puerto Rico for the each surveyed patient population, and selected data analysis and reporting. Please note that any survey questions used by VHA must be approved by OMB in accordance with the Paperwork Reduction Act of 1995. It is expected approximately 48,000 to 60,000 veterans will receive a survey each year based on the data sent from the OOD identifying veterans receiving care.

b. Data Analysis and Results Reporting The contractor shall provide all services and written materials required to support the analyses of data and report preparation needed to produce the quarterly reports from the Dental Patient Satisfaction Survey (DPSS). The contractor shall develop full national, VISN, parent facility and site level reporting on a monthly, quarterly, and yearly basis. The contractor will provide proof of concept and demonstrate their ability to successfully analyze and report results.

Technical training and documentation shall be provided to OOD and other VHA staff as needed to ensure maximum practical use at all organizational levels.

c. Data Requirements for Office of Dentistry Reporting

1. An unformatted comma-delimited file containing all the attributes collected in the dental patient satisfaction survey. This file should be compatible with Structured Query Language (SQL) database table or Microsoft Excel and structured to enable easy data analysis.

2. The data should be provided quarterly with data attributes (columns), fiscal year and quarter, location at the station division level (As the VA defines as sta6a), survey question, category of measure as (score, peer index, difference) and the score.

3. Submission of a sample data table for review.

d. Web-Based Reporting Site The contractor shall create and maintain a website that allows secure access for VHA reports. These secure, web-based reports shall, at a minimum, contain descriptive elements about the surveyed group and their responses displayed in both text and graphical format. Critical informational elements include mean ratings on the DPSS, sample sizes, response rates, trending, statistically significant results, external (non-VHA) comparisons, correlation analysis, and other demographic variables. Additionally, the contractor shall provide a secure web-based reporting site updated real time; the website shall experience no more than a 24hr down time at any period during the Period of Performance. The C&A requirements do not apply, and a Security Accreditation Package is not required.

e. Comparative questionnaire database VHA’s success in achieving a patient driven culture has been the result of using consistent survey methods and instruments/questionnaires since the inception of the satisfaction program as well as the ability to compare these results to an external referent (i.e., patients completing the same survey outside the VHA health care system). VHA is seeking a contractor that can field the survey for data collection purposes and conduct routine analysis and reporting of the results.

f. Referent Data A key to measuring the success of VHA in achieving a patient driven culture is the ability to compare VHA performance on the DPSS to a comparable non-VHA patient population. OOD is seeking a contractor that can provide comparable results on a non-VA patient population.

Critical to the comparison of performance on the DPSS is the ability for the contractor to subset the non-VA population on key demographic characteristics, such as the age and gender of respondents, and to report results on dimensions of care and key survey questions, like self-reported health status and overall quality.

g. Training The contractor will provide up to four (4) hours of training on accessing and reviewing the survey data via online video/teleconference to be scheduled by the Program Office (PO). All instructional material will be reviewed by the PO two weeks prior to the scheduled event and provide technical training and documentation to OOD and other VHA staff as needed to ensure maximum practical use at all organizational levels. Training tools will be available 90 days from date of the kickoff meeting. All recorded videos, transcripts, brochures, posters, and fact sheets will require final approval by Office of Dentistry Leadership and be delivered to the COR via email to be uploaded to the Office of Dentistry Sharepoint. All educational and training materials required for the DPSS Website are to be uploaded by the awarded contractor.

h. Monthly Meetings The contractor will provide the Office of Dentistry with updates to the Dental Patient Satisfaction survey through regular scheduled monthly meetings. The agenda will be distributed to COR two days prior the meeting for approval.

IV. General Description of Additional Services Required Services The OOD is seeking a contractor to provide the following products and services: VHA-wide use of the survey instruments, access to detailed non-VA data files for comparable analysis, statistical consulting on an as needed basis, address file cleaning, and data collection services, survey data FTP, white mail handling, and translation into Spanish used in the territory of Puerto Rico for each of the following patient-survey populations.

V. Data Collection Methodology The OOD requires that the surveys are completed utilizing a modified Dillman TDM. The mailing sequence is a multiple step process consisting of a pre- notification letter, a first survey and cover letter, and a thank you/reminder postcard The timing sequence of the mailings in each study is as follows:

Week 1 Pre-notification letter mails Week 2 First survey with cover letter mails Week 3 Thank you / reminder postcard mails Week 5 Close of data collection

The OOD will provide text for the survey pre-notification letter explaining the nature and goals of the upcoming survey and encouraging the veteran to participate, survey cover letter, postcard, and survey questionnaire to the contractor.

Electronic surveying will be conducted for those veterans who emails that have been provided. Invitations and instructions to participate in the surveys will be sent to those veterans who emails have been provided and identified in the monthly file list submitted to the contractor for processing. Mailings of all the surveys will also be provided, to accommodate all eligible veterans, who’s preference or need may necessitate to complete a paper survey.

VI. Details of Process and Deliverables The OOD expects the DPSS to be conducted monthly. The table below outlines some details regarding the frequency and sample size of each survey project. The estimated total number of completed surveys is approximately 48,000 to 60,000 annually. Active Data Collection, regular reports of progress, and delivery of accurate final data sets and related files will be the prime responsibility of the contractor. The approximate numbers of patients and the reporting frequency are described as follows:

Collection Frequency

Yearly roll- up approx.

Class I-VI, program recently cared for by VA dental Services. Class V excluded.

Quarterly written reports.

Web based reporting service updated weekly

VII. Sampling Methodology (Option 1) VA dental services annually provide care to approximately 460,000 veterans at 240+ parent facility sites. Each parent site may include one or more smaller ambulatory clinics with dentists per parent site ranging from one (1) to twenty-two (22) Full Time Equivalent(s) (FTE). Sampling of veterans will be performed based upon the number of dentists FTE per 240+ parent facility sites.

The total annual number of completed surveys per facility will be:

· 1 dentist FTE at facility: 45 completed patient surveys per year

· 2-3 dentist FTE at facility: 120 completed patient surveys per year

· 4 or greater dentist FTE at facility: 200 completed patient surveys per year

Veteran patients included in the sampling methodology will be all those receiving dental care under eligibility Classifications I-VI. Survey reports will further delineate survey results based upon whether veterans are receiving care as a Class I, II, IIc or IV, or receiving care as a Class III or VI. Class V excluded from surveying. Attachment A provides a breakdown of dentist FTE at each parent facility and will routinely be updated by the OOD as required. Based upon this methodology, it is anticipated approximately 48,000 – 60,000 completed surveys will be required each year.

Sampling Methodology – Option 1 is based on FTE levels at each site. However, if this sample plan is utilized, all of the sites with 1 Dentist FTE and some of the measures of 2-3 Dentist FTE would not have enough aggregate data to generate a score, so they would only be reporting data of the larger sites. The threshold for quarterly reports is an N size=20 for each question (some respondents skip questions).

(Option 2)

This sampling methodology has proven to be most effective. Approximately, a minimum of 4200 surveys a month across 140 parent sites, which require each site to sample around 30 patients. With a fluctuating response rate (RR) around 29-33%, this anticipated a yield at least 10 completes per Admin Parent roll-up per month, so that there would be at least 30 completes per quarter in the reports. The 30+ patients sampled per month further divided up into 3 Class categories, roughly using a 18/5/7 split (See Dental Class Group Categories below) to receive a combination of patients and their dental needs. Patients will be randomly selected from each Admin Parent until the maximum sample target is reached. This recommended methodology, utilizes an 80% rule that is placed on facilities where 100% of their sample for smaller dental class groups would be reached, in order not to use up all the available sample and spread it across the quarter for consistency. Any additional sample needed to meet the max monthly targets will be randomly pulled from the dominating Dental Class Group 1.

Process

a. The OOD obtains the sample of patients by accessing appropriate VA databases. The samples will be drawn monthly from Department of Veteran’s Affairs medical facilities throughout the United States and Puerto Rico. The program office selects targeted patient types that meet the inclusion criteria from each specified medical facility’s location. Inclusion data will be all veterans receiving facility dental treatment under eligibility rules as outlined under dental Classifications I-VI. Class V excluded. At the end of the first year, each facility will have the total targeted number of dental patient satisfaction surveys completed.

b. The contractor will be supplied with the patient’s name, dental classification, and address files in ASCII comma delimited format (compressed if necessary, using PKZIP) or in a SAS dataset, and must undergo Code 1 mail-streaming and National Change of Address (NCOA) cleaning. The contractor’s systems must be compatible with these methods. Before beginning the project, a test of contractor/OOD system compatibility must be conducted.

c. Once a mailing list is received by the contractor, an output able file must be created containing each clinic and medical facility’s number, corresponding facility name, and the number of patients sampled. The contents of the output file must be verified and approved by OOD before proceeding to Code 1 mail streaming and NCOA cleaning. To do this the output file must be transmitted electronically to the OOD so they can verify that the contractor has received the full contents of the address file. Examples of the layout and content of this file can be furnished.

d. The mailing list must undergo standard Code 1 mail streaming and NCOA cleaning to remove any undeliverable addresses before printing of the names and addresses on the surveys begins. An output file containing the rejected names and addresses must be provided to OOD along with the reject code or some explanation for reason of rejection. The output containing the names and addresses of those records retained after NCOA cleaning (i.e., cleared for mailing) must be provided to OOD in the layout described above. Information regarding the NCOA process can be obtained from the Post Office or other survey vendors that provide mailing services. NCOA software is available through a software retailer. NCOA software must be updated monthly to guarantee accuracy.

e. The contractor shall coordinate with the Government Printing Office (GPO) representative to ensure that patient files are sent over to the GPO representative as specified by OOD.

f.

f. The contractor must adhere to Secure Socket Layer (SSL) Protocols and Public Key Infrastructure (PKI), as appropriate, in the transference of any sensitive patient identifiable data. All data transfers must be completed via secure FTP sites between the contractor and OOD in accordance with the attached Business Associate Agreement and all parts.

g. All answered surveys shall be returned to the contractor for evaluation and reporting purposes.

VIII. Personalization of Survey Materials

a. The purpose of the patient unique identification number serves as a way of tracking respondents so that their names will not appear directly on the questionnaire. The OOD guarantees survey respondents’ anonymity. The identification numbering system used to track surveys specifies a unique number to each individual in the sample. This number will be used during data analysis to link survey respondents to their demographic data. The numbering system can be sequential or non-sequential and can be developed collaboratively between the contractor and the OOD.

b. The contractor shall develop a unique identification number for each survey that will monitor the delivery and receipt of patient correspondence in accordance the survey components. The tracking mechanism for the survey must include a unique identifier for each survey participant. The unique identifier must also serve as a link with the name and address file. The number also must include an identifier designating which survey cycle and mailing sequence the survey questionnaire belongs to.

IX. Data Collection Data collection for the surveys shall be done using optical scanning or digital image capture techniques backed up by direct double entry keypunching where necessary for damaged surveys. OOD requires that survey data collected be made available in ASCII or SAS file types, on request.

X. White-mail Processing Additional comments veterans enclose on attached sheets of paper, recorded audiocassettes, photographs, etc. are commonly called “white mail”.

a. The contractor shall be required to screen all white mail for veterans in distress or in need of critical assistance. Indications of these conditions include language consistent with threats of suicide, homicide or other threats self or others, threats of lawsuit, indications of depression and or desperation, or complaints being brought to the President, members of Congress or the local media,

b. Any instance of a critical alert in white mail must be brought to the attention of OOD immediately for review and response via telephone, email and/or fax, depending on the urgency, and a next day follow up mailing of any original correspondence to OOD.

c.

c. Non-critical white mail must be secured and electronically returned to OOD for processing at least once a week from receipt as some of the material may be time sensitive. All White mail to be electronically sent to the Assigned COR in zip files using an approved secure transfer system. White mail must have the patient’s ID code to allow rapid follow-up in critical situations. Special care must be taken to ensure the security of these identified white mail in transit. Details regarding this process and the contact information for the recipients of the white mail will be worked out with the contractor upon award of the contract.

XI. Return to sender (RTS) and deceased patients The file containing the sample of patients provided by OOD will only include veterans that were known to be alive at the time of the sample pull. OOD requires the contractor to run the mailing list through National Change of Address (NCOA) and Code 1 mail streaming to remove any incorrect addresses or ambiguities; some veterans pass away or move before the surveys reach them. Any survey returned to the contractor as undeliverable will be coded in the data set as “returned to sender” or “deceased” according to the reason noted on the envelope. The name of the veteran must be removed from the mailing list of non-responders to prevent future mailings. This information is vital for statistical purposes of computing the true and adjusted response rates. Any white mail forwarded to the OOD from returned surveys marked as deceased must have some indicator written on them by the contractor that the accompanying survey has been coded as deceased in the data file.

XII. Mailing

a. The contractor shall incur all cost related to mailing and shipping costs to the Office of Dentistry.

b. The business reply envelopes must have the name of the VHA Office of Dentistry (11DEN) as the recipient of the returned piece along with the address of the data processing facility of the contractor.

XIII. Term of Contract This contract will include a base period that will begin at the Date of Award, plus 4 option periods.

XIV. SECURITY REQUIREMENTS

The C&A requirements do not apply, and a Security Accreditation Package is not required.

The COR needs to:

· Ensure that a Contractor Security Control Assessment (CSCA) is completed within 30 days of contract approval and yearly on the renewal date of the contract.

· Ensure that the CSCA is sent to the ISO and the OCS Certification Program Office for review to ensure that appropriate security controls are being implemented in service contracts.

· Ensure a copy of the CSCA is maintained in the Security Management and Reporting Tool (SMART) database. COR will provide a copy of the completed CSCA to ISO for uploading into SMART database.

a. GENERAL Contractors, contractor personnel, subcontractors, and subcontractor personnel shall be subject to the same Federal laws, regulations, standards, and VA Directives and Handbooks as VA and VA personnel regarding information and information system security.

b. ACCESS TO VA INFORMATION AND VA INFORMATION SYSTEMS

1) A contractor/ subcontractor shall request logical (technical) or physical access to VA information and VA information systems for their employees, subcontractors, and affiliates only to the extent necessary to perform the services specified in the contract, agreement, or task order.

2) All contractors, subcontractors, and third-party servicers and associates working with VA information are subject to the same investigative requirements as those of VA appointees or employees who have access to the same types of information. The level and process of background security investigations for contractors must be in accordance with VA Directive and Handbook 0710, Personnel Suitability and Security Program. The Office for Operations, Security, and Preparedness is responsible for these policies and procedures.

3) Contract personnel who require access to national security programs must have a valid security clearance. National Industrial Security Program (NISP) was established by Executive Order 12829 to ensure that cleared U.S. defense industry contract personnel safeguard the classified information in their possession while performing work on contracts, programs, bids, or research and development efforts. The Department of Veterans Affairs does not have a Memorandum of Agreement with Defense Security Service (DSS). Verification of a Security Clearance must be processed through the Special Security Officer located in the Planning and National Security Service within the Office of Operations, Security, and Preparedness.

4) Custom software development and outsourced operations must be located in the U.S. to the maximum extent practical. If such services are proposed to be performed abroad and are not disallowed by other VA policy or mandates, the contractor/subcontractor must state where all non-U.S. services are provided and detail a security plan, deemed to be acceptable by VA, specifically to address mitigation of the resulting problems of communication, control, data protection, and so forth. Location within the U.S. may be an evaluation factor.

5) The contractor or subcontractor must notify the Contracting Officer immediately when an employee working on a VA system or with access to VA information is reassigned or leaves the contractor or subcontractor’s employ. The Contracting Officer must also be notified immediately by the contractor or subcontractor prior to an unfriendly termination.

c. VA INFORMATION CUSTODIAL LANGUAGE

1) Information made available to the contractor or subcontractor by VA for the performance or administration of this contract or information developed by the contractor/subcontractor in performance or administration of the contract shall be used only for those purposes and shall not be used in any other way without the prior written agreement of the VA. This clause expressly limits the contractor/subcontractor's rights to use data as described in Rights in Data - General, FAR 52.227-14(d) (1).

2) VA information should not be co-mingled, if possible, with any other data on the contractors/subcontractor’s information systems or media storage systems in order to ensure VA requirements related to data protection and media sanitization can be met. If co-mingling must be allowed to meet the requirements of the business need, the contractor must ensure that VA’s information is returned to the VA or destroyed in accordance with VA’s sanitization requirements. VA reserves the right to conduct on site inspections of contractor and subcontractor IT resources to ensure data security controls, separation of data and job duties, and destruction/media sanitization procedures are in compliance with VA directive requirements.

3) Prior to termination or completion of this contract, contractor/subcontractor must not destroy information received from VA, or gathered/created by the contractor in the course of performing this contract without prior written approval by the VA. Any data destruction done on behalf of VA by a contractor/subcontractor must be done in accordance with National Archives and Records Administration (NARA) requirements as outlined in VA Directive 6300, Records and Information Management and its Handbook 6300.1 Records Management Procedures, applicable VA Records Control Schedules, and VA Handbook 6500.1, Electronic Media Sanitization. Self-certification by the contractor that the data destruction requirements above have been met must be sent to the VA Contracting Officer within 30 days of termination of the contract.

4) The contractor/subcontractor must receive, gather, store, back up, maintain, use, disclose and dispose of VA information only in compliance with the terms of the contract and applicable Federal and VA information confidentiality and security laws, regulations and policies. If Federal or VA information confidentiality and security laws, regulations and policies become applicable to the VA information or information systems after execution of the contract, or if NIST issues or updates applicable FIPS or Special Publications (SP) after execution of this contract, the parties agree to negotiate in good faith to implement the information confidentiality and security laws, regulations and policies in this contract.

5) The contractor/subcontractor shall not make copies of VA information except as authorized and necessary to perform the terms of the agreement or to preserve electronic information stored on contractor/subcontractor electronic storage media for restoration in case any electronic equipment or data used by the contractor/subcontractor needs to be restored to an operating state. If copies are made for restoration purposes, after the restoration is complete, the copies must be appropriately destroyed.

6) If VA determines that the contractor has violated any of the information confidentiality, privacy, and security provisions of the contract, it shall be sufficient grounds for VA to withhold payment to the contractor or third party or terminate the contract for default or terminate for cause under Federal Acquisition Regulation (FAR) part 12.

7) If a VHA contract is terminated for cause, the associated BAA must also be terminated and appropriate actions taken in accordance with VHA Handbook 1600.01, Business Associate Agreements. Absent an agreement to use or disclose protected health information, there is no business associate relationship.

8) The contractor/subcontractor must store, transport, or transmit VA sensitive information in an encrypted form, using VA-approved encryption tools that are, at a minimum, FIPS 140-2 validated.

9) The contractor/subcontractor’s firewall and Web services security controls, if applicable, shall meet or exceed VA’s minimum requirements. VA Configuration Guidelines are available upon request.

10) Except for uses and disclosures of VA information authorized by this contract for performance of the contract, the contractor/subcontractor may use and disclose VA information only in two other situations: (i) in response to a qualifying order of a court of competent jurisdiction, or (ii) with VA’s prior written approval. The contractor/subcontractor must refer all requests for, demands for production of, or inquiries about, VA information and information systems to the VA contracting officer for response.

11) Notwithstanding the provision above, the contractor/subcontractor shall not release VA records protected by Title 38 U.S.C. 5705, confidentiality of medical quality assurance records and/or Title 38 U.S.C. 7332, confidentiality of certain health records pertaining to drug addiction, sickle cell anemia, alcoholism or alcohol abuse, or infection with human immunodeficiency virus. If the contractor/subcontractor is in receipt of a court order or other requests for the above-mentioned information, that contractor/subcontractor shall immediately refer such court orders or other requests to the VA contracting officer for response.

12) For service that involves the storage, generating, transmitting, or exchanging of VA sensitive information but does not require C&A or an MOU-ISA for system interconnection, the contractor/subcontractor must complete a Contractor Security Control Assessment (CSCA) on a yearly basis and provide it to the COR.

d. INFORMATION SYSTEM HOSTING, OPERATION, MAINTENANCE, OR USE

1) For information systems that are hosted, operated, maintained, or used on behalf of VA at non-VA facilities, contractors/subcontractors are fully responsible and accountable for ensuring compliance with all HIPAA, Privacy Act, FISMA, NIST, FIPS, and VA security and privacy directives and handbooks. This includes conducting compliant risk assessments, routine vulnerability scanning, system patching and change management procedures, and the completion of an acceptable contingency plan for each system. The contractor’s security control procedures must be equivalent to those procedures used to secure VA systems. A Privacy Impact Assessment (PIA) must also be provided to the COR and approved by VA Privacy Service prior to operational approval. All external Internet connections to VA’s network involving VA information must be reviewed and approved by VA prior to implementation.

2) Adequate security controls for collecting, processing, transmitting, and storing of Personally Identifiable Information (PII), as determined by the VA Privacy Service, must be in place, tested, and approved by VA prior to hosting, operation, maintenance, or use of the information system, or systems by or on behalf of VA. These security controls are to be assessed and stated within the PIA and if these controls are determined not to be in place, or inadequate, a Plan of Action and Milestones (POA&M) must be submitted and approved prior to the collection of PII.

3) Outsourcing (contractor facility, contractor equipment or contractor staff) of systems or network operations, telecommunications services, or other managed services requires certification and accreditation (authorization) (C&A) of the contractor’s systems in accordance with VA Handbook 6500.3, Certification and Accreditation and/or the VA OCS Certification Program Office. Government-owned (government facility or government equipment) contractor-operated systems, third party or business partner networks require memorandums of understanding and interconnection agreements (MOU-ISA) which detail what data types are shared, who has access, and the appropriate level of security controls for all systems connected to VA networks.

4) The contractor/subcontractor’s system must adhere to all FISMA, FIPS, and NIST standards related to the annual FISMA security controls assessment and review and update the PIA. Any deficiencies noted during this assessment must be provided to the VA contracting officer and the ISO for entry into VA’s POA&M management process. The contractor/subcontractor must use VA’s POA&M process to document planned remedial actions to address any deficiencies in information security policies, procedures, and practices, and the completion of those activities. Security deficiencies must be corrected within the timeframes approved by the government. Contractor/subcontractor procedures are subject to periodic, unannounced assessments by VA officials, including the VA Office of Inspector General. The physical security aspects associated with contractor/ subcontractor activities must also be subject to such assessments. If major changes to the system occur that may affect the privacy or security of the data or the system, the C&A of the system may need to be reviewed, retested and re-authorized per VA Handbook 6500.3. This may require reviewing and updating all of the documentation (PIA, System Security Plan, Contingency Plan). The Certification Program Office can provide guidance on whether a new C&A would be necessary.

5) The contractor/subcontractor must conduct an annual self-assessment on all systems and outsourced services as required. Both hard copy and electronic copies of the assessment must be provided to the COR. The government reserves the right to conduct such an assessment using government personnel or another contractor/subcontractor. The contractor/subcontractor must take appropriate and timely action (this can be specified in the contract) to correct or mitigate any weaknesses discovered during such testing, generally at no additional cost.

6) VA prohibits the installation and use of personally owned or contractor/subcontractor owned equipment or software on VA’s network. If non-VA owned equipment must be used to fulfill the requirements of a contract, it must be stated in the service agreement, SOW or contract. All of the security controls required for government furnished equipment (GFE) must be utilized in approved other equipment (OE) and must be funded by the owner of the equipment. All remote systems must be equipped with, and use, a VA-approved antivirus (AV) software and a personal (host-based or enclave based) firewall that is configured with a VA approved configuration. Software must be kept current, including all critical updates and patches. Owners of approved OE are responsible for providing and maintaining the anti-viral software and the firewall on the non-VA owned OE.

7) All electronic storage media used on non-VA leased or non-VA owned IT equipment that is used to store, process, or access VA information must be handled in adherence with VA Handbook 6500.1, Electronic Media Sanitization upon: (i) completion or termination of the contract or (ii) disposal or return of the IT equipment by the contractor/subcontractor or any person acting on behalf of the contractor/subcontractor, whichever is earlier. Media (hard drives, optical disks, CDs, back-up tapes, etc.) used by the contractors/subcontractors that contain VA information must be returned to the VA for sanitization or destruction or the contractor/subcontractor must self-certify that the media has been disposed of per 6500.1 requirements. This must be completed within 30 days of termination of the contract.

8) Bio-Medical devices and other equipment or systems containing media (hard drives, optical disks, etc.) with VA sensitive information must not be returned to the vendor at the end of lease, for trade-in, or other purposes. The options are:

· Vendor must accept the system without the drive;

· VA’s initial medical device purchase includes a spare drive which must be installed in place of the original drive at time of turn-in; or

· VA must reimburse the company for media at a reasonable open market replacement cost at time of purchase.

· Due to the highly specialized and sometimes proprietary hardware and software associated with medical equipment/systems, if it is not possible for the VA to retain the hard drive, then;

(a) The equipment vendor must have an existing BAA if the device being traded in has sensitive information stored on it and hard drive(s) from the system are being returned physically intact; and

(b) Any fixed hard drive on the device must be non-destructively sanitized to the greatest extent possible without negatively impacting system operation. Selective clearing down to patient data folder level is recommended using VA approved and validated overwriting technologies/methods/tools. Applicable media sanitization specifications need to be preapproved and described in the purchase order or contract.

(c) A statement needs to be signed by the Director (System Owner) that states that the drive could not be removed and that (a) and (b) controls above are in place and completed. The ISO needs to maintain the documentation.

e. SECURITY INCIDENT INVESTIGATION

1) The term “security incident” means an event that has, or could have, resulted in unauthorized access to, loss or damage to VA assets, or sensitive information, or an action that breaches VA security procedures. The contractor/subcontractor shall immediately notify the COR and simultaneously, the designated ISO and Privacy Officer for the contract of any known or suspected security/privacy incidents, or any unauthorized disclosure of sensitive information, including that contained in…