Attachment A - Performance Work Statement.pdf

36C24825Q0168 Attachment A – Performance Work Statement

1. GENERAL SCOPE

The VA Caribbean Healthcare System (VACHS) is soliciting a service contract for Respirator Fit Testing and Training Services throughout their facilities.

This contract will provide necessary labor, materials, supplies, and related travel expenses for monthly fit testing and training for approximately 2,500 employees and a minimum of 500 employees across multiple locations in Puerto Rico, including San Juan, Utuado, Comerio, Arecibo, Guayama, Ceiba, and Vieques, as well as in the U.S. Virgin Islands, specifically Saint Croix and Saint Thomas. The period of performance will be for one (1) base year of twelve consecutive months of service, with four (4) option periods.

2. PERFORMANCE REQUIREMENTS:

2.1 Contractor shall provide services to conduct the quantitative and qualitative fit testing of any of the following types of respirators in compliance with all applicable regulations including but not limited to 29 CFR 1910.134, OSHA Respirator Standard: disposable particulate respirators

(i.e. N95 filtering face piece) and elastomeric half-face and full-face respirators. All respirators to conduct the fit testing and fit testing kits will be supplied by the VACHS.

2.2 Contractor shall provide annual respirator training prior to fit testing. Training must include as a minimum:

2.2.1 Why the respirator is necessary and how improper fit, usage, or maintenance can compromise the protective effect of the respirator.

2.2.2 Rationale for respirator use.

2.2.3 Limitations and capabilities of the different types of respirators.

2.2.4 Procedures to inspect, donning and doffing procedures.

2.2.5 Procedures for maintenance and storage of respirators.

2.2.6 User seal check procedures.

2.3 VACHS’s Respiratory Protection Program Manager (RPPM) will provide the Contractor inventory of respirators used at VACHS to perform fit testing.

2.4 VACHS’s RPPM will provide the Contractor with access to the Respiratory Protection Program database containing the information of all employees required to be trained and fit tested. In addition, the Supervisors point of contact information will be provided. The Contractor shall contact supervisors to schedule fit testing services for employees during different shifts at their work areas (i.e. wards, clinics, etc.). Contractor shall create fit testing schedule listings and provide them to the POC a month prior to the fit testing due dates. For example, if services are to be provided in February, the Contractor must submit the schedule by January 11th, which is

20 days prior to February 1st. It is essential that this process is followed consistently each month to maintain effective communication and planning.

2.5 The Contractor shall provide a monthly schedule for respirator fit testing services at VACHS, which must include at least two days of services every workweek from Monday to Friday.

These services will be conducted during the hours of 7:00 AM to 4:30 PM, with a minimum of

16 hours of fit testing services arranged for each work week. In addition to the regular weekly schedule, the Contractor is required to arrange 8 hours of fit testing services on a biannual basis for all Outpatient and Satellite clinics. It is important to note that these 8 hours of service for the Outpatient and Satellite clinics are in addition to the weekly 16 hours of fit testing services provided at VACHS.

2.6 The Contractor shall use the Respiratory Protection Training & Fit Testing Record form

(attached in section D) provided by VACHS to document the respirator training and fit testing in the field. In addition, the Contractor will provide the employee with a label to be affixed to the employees’ ID HOLDER with the following information:

2.6.1 The employees name.

2.6.2 The respirator's make, model, and size.

2.6.3 The date of the fit testing and training.

2.6.4 The date when the next fit testing and training is due.

2.7 The Contractor must enter the data collected in the Respiratory Protection Training & Fit

Testing Record form in the Respiratory Protection Program database within 24 hours of fit testing completion.

2.8 The RPPM will provide the Contractor access to the database. The Contractor shall submit all

Respiratory Protection Training & Fit Testing Record forms to the RPPM on a weekly basis.

The RPPM will validate the database entries using these forms.

2.9 The Contractor shall include the clerical services required to scan, digitalize, and complete digital and physical entry and filing of all the data and results of the Respiratory Protection

Training & Fit Testing Record forms that have been completed each month on a weekly basis as a minimum. The RPPM will validate the database entries using these forms.

2.10 The Contractor shall make efforts to contact employees prior to fit testing and complete all due fit testing and training. Efforts by the contractor will be considered contacting an employee or supervisor at least three times via e-mail or phone (not consecutive calls or on the same day).

All attempts to coordinate a fit testing/training, including successful calls shall be documented and provided to the RPPM POC monthly. The RPPM will proceed to make the appropriate notifications and/or program dis-enrollments of employees that were attempted to contact to no avail.- it is not clear what constitutes a "successful call" and how this should be documented.

2.11 The Contractor will notify the RPPM of any situations or problems that may arise during fit testing (i.e., unavailability of employee, refusal of fit test by employee.

2.12 Per 29 CFR 1910.134, fit testing and training must be completed on an annual basis. Therefore, the Contractor must complete all annual fit testing/training within a year of the last fit test/training as documented in the Respiratory Protection Program database.

2.13 VACHS will be responsible for the completion of all aspects of the Medical Surveillance for respirators as required in 29 CFR 1910.134.

2.14 The Contractor shall provide all services described in section 2.0 Performance requirements as a single unit cost per fit test service to the Government. Monthly invoicing is required for completed services. The contract stipulates a minimum of 500 and a maximum of 2,500 respirator fit testing services to be performed within the calendar year of the contract. The

Government may request additional fit testing services beyond the annual fit testing in writing, due to reasons such as respirator inventory changes or national/local emergencies. These additional services, if needed, will be evaluated, and potentially awarded through a supplemental agreement to the contract.

3. COMPETENCY AND GENERAL REQUIREMENTS:

3.1 The Contractor or the employee(s) that are to perform the services solicited shall meet the qualifications of an Occupational Safety and Health Administration (OSHA) Authorized Trainer for General Industry. The Contractor shall provide training documentation with the solicitation and upon request.

3.2 The Contractor or the employee(s) that are to perform the services solicited shall have taken the

OSHA Respiratory Protection Course #2225. The Contractor shall provide training documentation with the solicitation and upon request.

3.3 The Contractor or the employee(s) that are to perform the services solicited must demonstrate knowledge of the Respiratory Protection Program elements as outlined in 29 CFR 1910.134, ANSI Z88.10-2010, and completed a Train-the-Trainer fit testing course provided by a respirator manufacturer (i.e. 3M, North, Moldex, etc.). The Contractor shall provide training documentation with the solicitation and upon request.

3.4 The Contractor or the employee(s) that are to perform the services solicited must demonstrate of having at least of 5-years’ experience in managing and conducting Respiratory Protection

Program as outlined in 29 CFR 1910. The Contractor shall provide with the solicitation:

3.4.1 Name of the Setting,

3.4.2 Scope,

3.4.3 Service Technician

3.4.4 Point of Contact Name,

3.4.5 Email,

3.4.6 Phone, and

3.4.7 Period of Performance

3.5 The Contractor shall submit a written version of their respirator fit testing protocol along with the initial solicitation. This document should detail the specific procedures and methods that will be used for conducting respirator fit testing, ensuring that the Government understands the

Contractor's approach to respiratory safety.

3.6 The Respiratory Protection Access Database is formatted using the Microsoft Access program.

The Contractor, or any employees performing the services, must demonstrate basic knowledge of Microsoft Access. This includes understanding fundamental concepts such as managing databases, working with tables and fields, entering and retrieving data, designing forms for data entry, and generating reports. Basic knowledge also encompasses familiarity with the user interface, including how to navigate through various functions like creating queries to retrieve specific data. The ability to effectively utilize these features ensures that personnel can manage the Respiratory Protection Access Database efficiently and accurately.

3.7 The Contractor, or any employees designated to perform the solicited services, must have experience in carrying out administrative duties. This includes demonstrating strong communication skills, clerical abilities, proficiency with computer applications, and effective organizational skills.

3.8 The Contractor, or any employees designated to perform the solicited services, must be able to read, write, speak, and understand both English and Spanish. This bilingual proficiency is essential for effective communication with all stakeholders involved in the services provided under this contract.

3.9 The Contractor must include a detailed breakdown of the services to be provided throughout the calendar year with their initial solicitation. This breakdown should clearly outline how the services will meet the specified requirements of the contract. Also, the Contractors shall provide subject certifications with each option exercised (annually).

3.10 The Contractor shall maintain an updated record of all Contract Employee’s educational documents, evaluation methods and qualifications standards; and these records must be available to the Government upon request.

3.11 Age: All Contractor employees performing work under this contract shall be a minimum of eighteen (18) years of age or as required by local laws.

3.12 All employees shall be literate in English to the extent of reading and understanding printed regulations, detailed written orders, training instructions and material, and shall be able to compose reports which convey complete information.

3.13 The Contractor must provide backup employees to fill in during the absence (such as vacation or illness) of any employees assigned to work under this contract. These backup employees must comply with all contract regulations and specifications to ensure continuity of services, with no break in service. Backup contract employees must be approved by the Government before they can perform any services. Additionally, no changes to assigned employees shall be made without the prior authorization of the designated POC.

3.14 Upon contract award, Contractor shall provide the name of each Contract Employee assigned to this contract. The Contractor is responsible to maintain this list always updated.

3.15 Contractor-Furnished Training: The Contractor shall perform all recruiting, hiring, training, and supervising. The Government will provide the Contractor all mandatory trainings required for all Contract Employees. The Contractor shall submit to the Contracting Officer written certification annually that each contract employee has been trained in the subject areas. The

Contractor shall provide training to all Contract Employees prior to assignment under this contract.

3.16 Government-Furnished Trainings: The Government will provide facility orientation to all contracted employees assigned to this contract to include health, safety, and emergency procedures at the VACHS medical center. These trainings will be scheduled at a post award meeting at a mutually agreeable date.

3.17 Conduct of Contractor’s Employees: The Contractor shall maintain satisfactory standards of employee competency, conduct, appearance, and integrity, and for taking such disciplinary action against his/her contract’s employees as may be necessary. The Contractor shall require his employees to comply with the instructions, pertaining to conduct and building regulations, issues by duly appointed officials, such as the Point of Contact (POC), guards, inspectors, etc.

3.18 Appearance: The Government requires a favorable image and considers it to be a major asset of a customer service team; the employee's attitude, courtesy, and job knowledge are influential in creating a favorable image. Uniforms and protective clothing: all contractor personnel working in or around buildings designated under this contract shall wear distinctive uniform clothing.

3.19 Disorderly Conduct: The use of abusive or offensive language, quarreling, intimidation by words, actions, or fighting shall not be condoned; also included is participation in disruptive activities which interfere with normal and efficient Government operations.

3.20 Intoxicants: The Contractor shall not allow any employee to possess, sell, consume, or be under the influence of intoxicants, drugs, or substances that produce similar effects.

3.21 Criminal Actions: Contractor’s employees may be subject to criminal actions as allowed by law in certain circumstances and these include, but are not limited to, the following:

3.21.1 Falsification or unlawful concealment, removal, mutilation, or destruction of any official documents or records or concealment of material facts by willful omission from official documents or records.

3.21.2 Unauthorized use of Government property, theft, vandalism, or immoral conduct.

3.21.3 Unethical or improper use of official authority or credentials.

3.21.4 Security violations.

3.21.5 The Government reserves the right to direct the Contractor to remove any employee from the work site for failure to comply with the standards of conduct.

3.21.6 The Contractor shall initiate immediate action to replace such an employee to maintain continuity of services at no additional cost to the Government.

3.21.7 The Contractor shall provide protective equipment and attire to personnel and require employees to use it while performing their duties as necessary.

3.21.8 The Contractor shall comply with all regulations, agency, federal, local, and TJC

Standards as applicable.

3.22 Coverage: The Contractor shall comply with applicable Federal and Commonwealth of Puerto

Rico Worker’s Compensation and occupational disease statutes. The contractor shall provide Workers

Compensation, Professional liability insurance, Health examinations, Chicken Pox Vaccinations, provide means for employees’ income tax withholding, and Social Security payments.

3.23 Meetings: During the term of the contract, it may be necessary to schedule meetings between the Contractor and VA to address areas of concern and provide additional exchange information. Such meetings shall require attendance by the Contractor at no additional charge to the VA. A meeting would only be required if issues could not be resolved via telephone, conference calls or in writing. Location of meeting would be at the VACHS, San Juan, Puerto

Rico and/or at Network Contracting Office 8 located at the Administrative Building- 4M440.

Attendees should include, but may not be limited to, the Contractor, Contractor key personnel, Contracting Officer's Representative, and the Contracting Officer.

4. SAFETY REQUIREMENT

4.1 The contractor while performing the services described in the statement of work shall take all safety precautions and safety measures necessary to protect the lives and health of their own employees and VA employees, patients, and visitors.

5. CONTRACTOR PERSONNEL SECURITY REQUIREMENT CONTRACT

5.1 The contractor’s employee assigned to perform the services described in this statement of work shall report, face to face, to the VACHS RPPM in the Safety Office daily and/or when reporting for duty.

5.2 All personnel performing work under this contract shall satisfy all requirements imposed on sensitive data and information by law, Federal regulations, VA statutes and policy, Veterans

Health Administration (VHA) policy, guidelines, and the associated requirements for appropriate security eligibility in dealing with access to sensitive information and information systems belonging to or being used on behalf of the Department of Veterans Affairs. This requirement is applicable to all subcontractor personnel requiring the same access. To satisfy the requirements a minimum Background Investigation shall be conducted prior to performing work under this contract. The level of access and the individual's capability to perform work under this contract will be the determining factor in deciding if a higher investigative requirement is needed to protect the security and safety of veterans and employees. The contractor shall ensure that those requirements are fully satisfied within 30 days of initiation of such investigations. No work can be performed by employees who have not undergone the

Background Investigation and/or clearances process.

6. CONTRACTOR AND GOVERNMENT RESPONSIBILITIES

6.1 The security risk level assigned for the services required herein is considered Low Risk (LR) equating to non-sensitive defined, as "These positions are positions with limited potential for adverse impact involving duties of limited relation to a program or VA’s mission". The

Contractor shall certify that all personnel performing under this contract have the necessary clearance to meet this level of security risk and provide required supporting documentation.

6.2 The contractor shall prescreen all personnel requiring access to the computer systems to ensure they maintain a U.S. citizenship and are able to read, write, speak, and understand the English language.

6.3 The delegated POC, VA Program Manager, or other designee shall serve as VA Sponsor for

Contractor or Contract Employee personnel.

6.4 Procedures

6.4.1 The VA sponsor is the requesting office and is responsible for preparing the VA

Form (VAF) 2280a, Contractor Position Sensitivity Level Designation, for each contractor position. The sponsor may submit one VAF 2280a for contractor employees who possess the same risk level designation. VA Sponsors shall coordinate with their Contracting Officers and

VA Sponsors to ensure that VA initiates and ultimately pays for only necessary investigations for key contractor personnel.

6.4.2 VA Sponsors will forward the VAF 2280a to the Information Security Officer

(ISO) for review and completion of Step 4 of the form. In those instances where the ISO has questions about the designated risk and sensitivity levels, the ISO will confer with the originating office and agree upon risk and sensitivity levels for the position.

6.4.3 Upon completion of the VAF 2280a, the VA Sponsor will submit a background investigation request to the Security and Investigation Center (SIC) and receive access to the

Contractor Request Database (CRD) located at http://vaww.letc.little-rock.med.va.gov. The SIC will provide guidance to VA Sponsors to complete this process.

6.4.4 Upon receipt, the Contractor Request Database (CRD) will automatically generate an e-mail notification identifying the web site link that includes detailed instructions regarding completion of the application process and what level of background was requested.

6.4.5 Applicants will be informed of due dates to complete all portions of the investigative package. Reminder notifications will be sent if the complete package is not submitted by the due date.

6.4.6 Contractors who have a current favorable background investigation conducted by another Federal agency may be accepted through reciprocation. Members of the SIC staff will coordinate verification of existing favorable background investigations.

6.4.7 Contract performance shall not commence prior to confirmation from the SIC that the investigative documents have been submitted. The SIC will notify the VA Contracting

Officer, VA Sponsor, and the contractor upon receipt of the appropriate investigative documents.

6.5 SIC Responsibilities

6.5.1 The SIC will provide a help desk and necessary forms via the VA forms web site, http://www.va.gov/vaforms/search_action.asp. The SIC help desk hours or operation are from

7:30 a.m. to 5:30 p.m. Eastern Time and may be reached on (501) 257-4160.

6.5.2 The SIC will notify the VA Contracting Officer, VA Sponsor, and the contractor after adjudicating the results of the background investigation.

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6.6 The Contractor shall be responsible for all costs associated with obtaining clearances for contract employees. Further, the contractor shall be responsible for the actions of all individuals provided to work for the VA under this contract. In the event that damages arise from work performed by contractor provided personnel, under the auspices of this contract, the contractor will be responsible for all resources necessary to remedy the incident.

6.7 The contractor shall be required to show that the employee(s) hold results of investigations and/or clearances before computer access can be given.

6.8 The ability to obtain and maintain such clearance is a mandatory requirement for continued employment for this contract.

6.9 The Contractor and contract employees with access to sensitive areas or automated information systems are responsible to follow and comply with all AIS security awareness policy during the contract period and shall be responsible for reporting AIS security violations or incidents to their supervisor and/or ISO.

6.10 The Contractor shall provide to the POC evidence of all new hired personnel, including all necessary documentation required to initiate the investigation process through the SIC prior to commence work.- states that contractors must provide evidence of new hires and documentation to initiate the investigation process, but doesn't specify what exact documentation is required.

6.11 The Contractor shall be responsible to provide ongoing security awareness training for all contract employees performing under this contract.

7. SYSTEM SECURITY & RULES OF BEHAVIOR

7.1 The Contractor shall provide to the Contracting Officer within 10 days from contract award documentation that security measures have been implemented which are consistent with all

VHA, VA, HIPAA and other federal standards and guidelines.

8. SECURITY REQUIREMENTS FOR UNCLASSIFIED INFORMATION TECHNOLOGY

RESOURCES

8.1 The contractor, their personnel, and their subcontractors shall be subject to the Federal laws, regulations, standards, and VA Directives and Handbooks regarding information and information system security as delineated in this contract.

9. ACCESS TO VA INFORMATION AND VA INFORMATION SYSTEMS

9.1 The contractor will have access to VA information systems only to the extent necessary to perform the services specified in the contract.

9.2 All contractors 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.

9.3 The contractor must notify the Contracting Officer immediately when an employee working on a VA system is reassigned or leaves the contractor. The Contracting Officer must also be notified immediately by the contractor prior to an unfriendly termination.

9.4 Information made available to the contractor 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.

9.5 If VA determines that the contractor has violated any of the information security provisions of the contract, it shall be sufficient grounds for VA to withhold payment to the contractor or terminate the contract for default or terminate for cause under Federal Acquisition Regulation

(FAR) part 12.

9.6 Security Incident

9.6.1 The term “security incident” means an event that has, or could have, resulted in unauthorized access to, loss or damage to VA assets or an action that breaches VA security procedures. The contractor shall immediately notify the POC and simultaneously, the designated

ISO and Privacy Officer for the contract of any known or suspected security incidents, or any unauthorized disclosure of sensitive information, including that contained in system(s) to which the contractor/subcontractor has access.

9.6.2 To the extent known by the contractor, the contractor’s notice to VA shall identify the information involved, the circumstances surrounding the incident (including to whom, how, when, and where the VA information or assets were placed at risk or compromised), and any other information that the contractor/subcontractor considers relevant.

9.7 Training

9.7.1 All contractor employees and subcontractor employees requiring access to VA information and VA information systems shall complete the following before being granted access to VA information and its systems:

a. Sign and acknowledge (either manually or electronically) understanding of and responsibilities for compliance with the Contractor Rules of Behavior, Appendix E relating to access to VA information and information systems;

b. Successfully complete the VA Cyber Security Awareness and Rules of Behavior

c. training and annually complete required security training;

d. Successfully complete the appropriate VA privacy training and annually complete required privacy training; and

e. Successfully complete any additional cyber security or privacy training, as required for VA personnel with equivalent information system access.

9.7.2 The contractor shall provide to the contracting officer and/or the POC a copy of the training certificates and certification of signing the Contractor Rules of Behavior for each applicable employee within 1 week of the initiation of the contract and annually thereafter, as required.

9.7.3 Failure to complete the mandatory annual training and sign the Rules of Behavior annually, within the timeframe required, is grounds for suspension or termination of all physical or electronic access privileges and removal from work on the contract until such time as the training and documents are complete.

9.8 Background Investigations and Special Agreement Checks

All contractor employees are subject to the same level of investigation as VA employees who have access to VA Sensitive Information. This requirement is applicable to all subcontractor personnel requiring the same access. The contractor shall bear the expense of obtaining background investigations. If the investigation is conducted by the Office of Personnel Management (OPM) through the VA, the contractor shall reimburse the VA within thirty (30) days. The POC is responsible for coordinating finger printing requirements with the designated VHA Office. The POC shall inform the contractor of the scheduled Special Agreement Check (SAC) appointment, the location, and who their point of contact shall be.

9.9 Risk Level Designation

A position description establishing the duties and name of position is required, as per new requirements, to obtain the risk level designation (This can be requested at the time of quote review).

All VHA office shall use Position Designation System and Automated Tool (PDAT) for designating position risk and sensitivity levels and the corresponding level of background investigation (or background screening) for all contractor positions.

10.0 Records Management Language for Contracts (NARA)

Contractor shall treat all deliverables under the contract as the property of the U.S.

The following standard items relate to records generated in executing the contract and should be included in a typical Electronic Information Systems (EIS) procurement contract:

10.1. Citations to pertinent laws, codes and regulations such as 44 U.S.C chapters 21, 29, 31 and 33;

Freedom of Information Act (5 U.S.C. 552); Privacy Act (5 U.S.C. 552a); 36 CFR Part 1222 and Part

1228.

10.2 Government for which the Government Agency shall have unlimited rights to use, dispose of, or disclose such data contained therein as it determines to be in the public interest.

10.3 Contractor shall not create or maintain any records that are not specifically tied to or authorized by the contract using Government IT equipment and/or Government records.

10.4 Contractor shall not retain, use, sell, or disseminate copies of any deliverable that contains information covered by the Privacy Act of 1974 or that which is generally protected by the

Freedom of Information Act.

10.5 Contractor shall not create or maintain any records containing any Government Agency records that are not specifically tied to or authorized by the contract.

10.6 The Government Agency owns the rights to all data/records produced as part of this contract. 7.

The Government Agency owns the rights to all electronic information (electronic data, electronic information systems, electronic databases, etc.) and all supporting documentation created as part of this contract. Contractor must deliver sufficient technical documentation with all data deliverables to permit the agency to use the data.

10.7 Contractor agrees to comply with Federal and Agency records management policies, including those policies associated with the safeguarding of records covered by the Privacy Act of 1974.

These policies include the preservation of all records created or received regardless of format

[paper, electronic, etc.] or mode of transmission [e-mail, fax, etc.] or state of completion [draft, final, etc.]. 9. No disposition of documents will be allowed without the prior written consent of the

Contracting Officer. The Agency and its contractors are responsible for preventing the alienation or unauthorized destruction of records, including all forms of mutilation. Willful and unlawful destruction, damage or alienation of Federal records is subject to the fines and penalties imposed by 18 U.S.C. 2701. Records may not be removed from the legal custody of the Agency or destroyed without regard to the provisions of the agency records schedules.

10.8 Contractor is required to obtain the Contracting Officer's approval prior to engaging in any contractual relationship (sub-contractor) in support of this contract requiring the disclosure of information, documentary material and/or records generated under, or relating to, this contract. The

Contractor (and any sub-contractor) is required to abide by Government and Agency guidance for protecting sensitive and proprietary information.

11 IT CONTRACT SECURITY

VA INFORMATION AND INFORMATION SYSTEM SECURITY/PRIVACY

1. 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.

2. ACCESS TO VA INFORMATION AND VA INFORMATION SYSTEMS

a. 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.

b. 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.

c. 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.

d. 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.

e. 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.

3. VA INFORMATION CUSTODIAL LANGUAGE

a. 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).

b. 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 onsite 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.

c. 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.

d. 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.

e. 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.

f. 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.

g. 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.

h. 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.

i. 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.

j. 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.

k. 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.

l. 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.

4. INFORMATION SYSTEM DESIGN AND DEVELOPMENT

a. Information systems that are designed or developed for or on behalf of VA at non-VA facilities shall comply with all VA directives developed in accordance with FISMA, HIPAA, NIST, and related VA security and privacy control requirements for Federal information systems. This includes standards for the protection of electronic PHI, outlined in 45 C.F.R. Part 164, Subpart C, information, and system security categorization level designations in accordance with FIPS 199 and FIPS 200 with implementation of all baseline security controls commensurate with the FIPS 199 system security categorization (reference Appendix D of VA Handbook 6500, VA Information Security Program).

During the development cycle a Privacy Impact Assessment (PIA) must be completed, provided to the

COR, and approved by the VA Privacy Service in accordance with Directive 6507, VA Privacy Impact

Assessment.

b. The contractor/subcontractor shall certify to the COR that applications are fully functional and operate correctly as intended on systems using the VA Federal Desktop Core Configuration (FDCC), and the common security configuration guidelines provided by NIST or the VA. This includes Internet

Explorer 7 configured to operate on Windows XP and Vista (in Protected Mode on Vista) and future versions, as required.

c. The standard installation, operation, maintenance, updating, and patching of software shall not alter the configuration settings from the VA approved and FDCC configuration. Information technology staff must also use the Windows Installer Service for installation to the default "program files" directory and silently install and uninstall.

d. Applications designed for normal end users shall run in the standard user context without elevated system administration privileges.

e. The security controls must be designed, developed, approved by VA, and implemented in accordance with the provisions of VA security system development life cycle as outlined in NIST Special

Publication 800-37, Guide for Applying the Risk Management Framework to Federal Information

Systems, VA Handbook 6500, Information Security Program and VA Handbook 6500.5, Incorporating

Security and Privacy in System Development Lifecycle.

f. The contractor/subcontractor is required to design, develop, or operate a System of Records Notice

(SOR) on individuals to accomplish an agency function subject to the Privacy Act of 1974, (as amended), Public Law 93-579, December 31, 1974 (5 U.S.C. 552a) and applicable agency regulations.

Violation of the Privacy Act may involve the imposition of criminal and civil penalties.

g. The contractor/subcontractor agrees to:

(1) Comply with the Privacy Act of 1974 (the Act) and the agency rules and regulations issued under the Act in the design, development, or operation of any system of records on individuals to accomplish an agency function when the contract specifically identifies:

(a) The Systems of Records (SOR); and

(b) The design, development, or operation work that the contractor/ subcontractor is to perform;

(1) Include the Privacy Act notification contained in this contract in every solicitation and resulting subcontract and in every subcontract awarded without a solicitation, when the work statement in the proposed subcontract requires the redesign, development, or operation of a SOR on individuals that is subject to the Privacy Act; and

(2) Include this Privacy Act clause, including this subparagraph (3), in all subcontracts awarded under this contract which requires the design, development, or operation of such a SOR.

h. In the event of violations of the Act, a civil action may be brought against the agency involved when the violation concerns the design, development, or operation of a SOR on individuals to accomplish an agency function, and criminal penalties may be imposed upon the officers or employees of the agency when the violation concerns the operation of a SOR on individuals to accomplish an agency function. For purposes of the Act, when the contract is for the operation of a SOR on individuals to accomplish an agency function, the contractor/subcontractor is considered to be an employee of the agency.

(1) "Operation of a System of Records" means performance of any of the activities associated with maintaining the SOR, including the collection, use, maintenance, and dissemination of records.

(2) "Record" means any item, collection, or grouping of information about an individual that is maintained by an agency, including, but not limited to, education, financial transactions, medical history, and criminal or employment history and contains the person's name, or identifying number, symbol, or any other identifying particular assigned to the individual, such as a fingerprint or voiceprint, or a photograph.

(3) "System of Records" means a group of any records under the control of any agency from which information is retrieved by the name of the individual or by some identifying number, symbol, or other identifying particular assigned to the individual.

i. The vendor shall ensure the security of all procured or developed systems and technologies, including their subcomponents (hereinafter referred to as "Systems"), throughout the life of this contract and any extension, warranty, or maintenance periods. This includes, but is not limited to workarounds, patches, hotfixes, upgrades, and any physical components (hereafter referred to as Security Fixes) which may be necessary to fix all security vulnerabilities published or known to the vendor anywhere in the

Systems, including Operating Systems and firmware. The vendor shall ensure that Security Fixes shall not negatively impact the Systems.

j. The vendor shall notify VA within 24 hours of the discovery or disclosure of successful exploits of the vulnerability which can compromise the security of the Systems (including the confidentiality or integrity of its data and operations, or the availability of the system). Such issues shall be remediated as quickly as is practical, but in no event longer than days.

k. When the Security Fixes involve installing third party patches (such as Microsoft OS patches or

Adobe Acrobat), the vendor will provide written notice to the VA that the patch has been validated as not affecting the Systems within 10 working days. When the vendor is responsible for operations or maintenance of the Systems, they shall apply the Security Fixes within days.

l. All other vulnerabilities shall be remediated as specified in this paragraph in a timely manner based on risk, but within 60 days of discovery or disclosure. Exceptions to this paragraph (e.g. for the convenience of VA) shall only be granted with approval of the contracting officer and the VA Assistant

Secretary for Office of Information and Technology.

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

a. 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.

b. 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.

c. 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.

d. 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…