47QFWA22R0008 Appendix C - DD Form 2808.pdf

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Attached to
DoDMERB Medical Services Federal contract opportunity
Solicitation number
47QFWA22R0008
Issued by
General Services Administration Federal Acquisition Service Assisted Acquisition Services Region 7

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This solicitation requests proposals for Department of Defense Medical Examination Review Board medical services. The Defense Health Agency requires a subcontracted network of medical providers to conduct initial medical examinations and additional medical services for applicants to the five Service Academies, Reserve Officers' Training Corps programs, and Uniformed Services University of Health Sciences. The General Services Administration will award a one-year contract with four one-year option periods to begin on May 17, 2022. Evaluation will consider technical approach, previous experience, past performance, small business participation plan, and price. Proposals are due through GSA ASSIST by April 29, 2022. A pre-proposal conference will be held on April 5, 2022. Interested parties must register by April 1, 2022. Questions are due by April 1, 2022 and two days after the pre-proposal conference. The North American Industry Classification System code is 621999 and small business size standard is $16.5 million.

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47QFWA22R0008 Questions and Answers 4.18.2022.xlsx XLSX spreadsheet
47QFWA22R0008 Revised Appendix M - Pricing Spreadsheet 4.18.2022.xlsx XLSX spreadsheet
47QFWA22R0008 Revised Solicitation Sections K-M 4.18.2022.pdf PDF
47QFWA22R0008 Revised Solicitation Sections B-J 4.18.2022.pdf PDF
47QFWA22R0008 Revised Appendix M - Pricing Spreadsheet.xlsx XLSX spreadsheet
47QFWA22R0008 Appendix K - Historical Data - AMS by Month 2019 - 2022.xlsx XLSX spreadsheet
47QFWA22R0008 Revised Appendix D - DD Form 2807-2.pdf PDF
47QFWA22R0008 Questions and Answers 4.11.2022.xlsx XLSX spreadsheet
47QFWA22R0008 Appendix I - Historica Data - Exams by Month 2019 - 2022.xlsx XLSX spreadsheet
47QFWA22R0008 Revised Solicitation Sections K-M 4.4.2022.pdf PDF
47QFWA22R0008 Revised Solicitation Sections B-J 4.4.2022.pdf PDF
47QFWA22R0008 Appendix L - QASP.pdf PDF
47QFWA22R0008 Solicitation Sections K-M 2.24.2022.pdf PDF
47QFWA22R0008 Appendix M - Pricing Spreadsheet.xlsx XLSX spreadsheet
47QFWA22R0008 Solicitation Sections B-J 12.29.2021.pdf PDF
47QFWA22R0008 Appendix J - Subcontracting Plan.docx DOCX document
47QFWA22R0008 Appendix H - Historical Data - Exams by Zip Code.xlsx XLSX spreadsheet
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DRAFT

DD FORM 2808, July 2019 Page of Prescribed by: DoDI 1304.2 9.0.0.2.20120627.2.874785

REPORT OF MEDICAL EXAMINATION

REPORT OF MEDICAL EXAMINATION

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 504, Persons not qualified; 10 U.S.C. 505, Regular components: qualifications, term, grade; 10 U.S.C. 507, Extension of enlistment for members needing medical care or hospitalization; 10 U.S.C. 532, Qualifications for original appointment as a commissioned officer; 10 U.S.C. 978, Drug and alcohol abuse and dependency: testing of new entrants; 10 U.S.C. 1201, Regulars and members on active duty for more than 30 days: retirement; 10 U.S.C. 1202, Regulars and members on active duty for more than 30 days: temporary disability retired list; 10 U.S.C. 4346, Cadets: requirements for admission; DoD Directive 1145.2, United States Military Entrance Processing Command; E.O. 9397 (SSN) and 10 U.S.C. 1204, Members on Active Duty for 30 Days or Less or on Inactive Duty Training: Retirement, as amended.

PRINCIPAL PURPOSE(S): To obtain medical data for determination of medical fitness for enlistment, induction, appointment and retention for applicants and members of the Armed Forces. The information will also be used for medical boards and separation of Service members from the Armed Forces.

ROUTINE USE(S): The Routine Uses are listed in the applicable system of records notice found at: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570661/a0601-270-usmepcom-dod/ DISCLOSURE: Voluntary; however, failure by an applicant to provide the information may result in delay or possible rejection of the individual's application to enter the Armed Forces.

For an Armed Forces member, failure to provide the information may result in the individual being placed in a non-deployable status.

9a. BIRTH SEX 9a. BIRTH SEX 9b. PREFERRED GENDER 9b. PREFERRED GENDER 10a. ETHNIC CATEGORY 10a. ETHNIC CATEGORY 10b. RACIAL CATEGORY (Select one) 10b. RACIAL CATEGORY (Select one)

11. TOTAL YEARS GOVERNMENT SERVICE

11. TOTAL YEARS GOVERNMENT SERVICE

15a. SERVICE 15a. SERVICE 15b. COMPONENT 15b. COMPONENT 15c. PURPOSE OF EXAMINATION 15c. PURPOSE OF EXAMINATION MEDICAL EVALUATION (Check each item in appropriate column. Enter "NE" if not evaluated.)

MEDICAL EVALUATION (Check each item in appropriate column. Enter "NE" if not evaluated.)

Normal Abnormal

NE

17. Head, face, neck and scalp

18. Nose

19. Sinuses

20. Mouth and throat

21. Ears - General (Int. and ext. canals/Auditory acuity under item 71)

22. Tympanic Membranes (Perforation)

23. Eyes - General

24. Ophthalmoscopic

25. Pupils (Equality and reaction)

26. Ocular motility (Associated parallel movements, nystagmus)

27. Heart (Thrust, size, rhythm, sounds)

28. Lungs and chest (Include breasts)

29. Vascular system (Varicosities, etc.)

30. Anus and rectum (Hemorrhoids, Fistulae) (Prostate if indicated)

31. Abdomen and viscera (Include hernia)

32. External genitalia (Genitourinary)

33. Upper extremities Normal

34. Lower extremities (Except feet)

35. Feet (Check category) 35a.

35b.

35c.

36. Spine, other musculoskeletal

37. Body marks, scars, tattoos

38. Skin, lymphatics

39. Neurologic Normal

40. Psychiatric (Specify any personality disorder)

41. Pelvic (Females only)

42. Endocrine

43. DENTAL DEFECTS AND DISEASE

(Please explain. Use dental form if completed by dentist. If abnormality noted, explain in item 44.)

43. DENTAL DEFECTS AND DISEASE

(Please explain. Use dental form if completed by dentist. If abnormally noted, explain in Item 44.)

LABORATORY FINDINGS

TESTS

RESULTS

49. HIV

50. DRUGS

51. ALCOHOL

52. OTHER

a. PAP SMEAR

b. EKG

c. CXR

MEASUREMENTS AND OTHER FINDINGS

54. WEIGHT (lbs.)

58. BLOOD PRESSURE

58. BLOOD PRESSURE

a. 1ST

a. 1ST

b. 2ND

b. 2ND

c. 3RD

c. 3RD

61. DISTANCE VISION

61. DISTANCE VISION

62. REFRACTION

62. REFRACTION

63. NEAR VISION

63. NEAR VISION

64. HETEROPHORIA

64. HETEROPHORIA

65. ACCOMMODATION

65. ACCOMMODATION

66. COLOR VISION (Pass/Fail and Score)

66. COLOR VISION (pass/Fail and score)

67. DEPTH PERCEPTION (Pass/Fail and Score)

67. DEPTH PERCEPTION (Pas/Fail and Score)

67. DEPTH PERCEPTION (Pas/Fail and Score)

70. INTRAOCULAR PRESSURE

70. INTRAOCULAR PRESSURE

HZ

Left Right

HZ

Left Right 72a. READING ALOUD TEST:

72a. READING ALOUD TEST:

72b. VALSALVA:

72b. VALSALVA:

72c. OTHER TESTING

74. EXAMINEE

75. I have been advised of my disqualifying condition(s).

76. PHYSICAL PROFILE

P U L H E S X D

PROFILER INITIALS

DATE (YYYYMMDD)

77. SIGNIFICANT OR DISQUALIFYING MEDICAL DIAGNOSES

ITEM NO.

MEDICAL DIAGNOSIS

ICD CODE

PROFILE SERIAL

RBJ DATE

(YYYYMMDD)

QUALIFIED

DISQUALIFIED

EXAMINER INITIALS

WAIVER RECEIVED

SERVICE

DATE (YYYYMMDD)

80. MEPS WORKLOAD (For MEPS use only)

WKID

ST

DATE (YYYYMMDD)

INITIALS

WKID

ST

DATE (YYYYMMDD)

INITIALS

81. MEDICAL INSPECTION DATE

HT

WT

%BF

MAX WT

HCG

QUAL

DISQ

EXAMINER'S NAME AND SIGNATURE

86. This examination has been administratively reviewed for completeness and accuracy.

Click this button to save this form.:
Click this button to print this form.:
Click this Reset button to erase data from all fields.:
CurrentPage:
PageCount:
DATE (YYYYMMDD):
2a. SOCIAL SECURITY

NUMBER:

2b. DoD ID NUMBER (If applicable):

3. LAST NAME - FIRST NAME - MIDDLE NAME

(Suffix):

4. HOME ADDRESS (Street, Apartment Number, City, State and Zip Code):

5.a. HOME TELEPHONE NUMBER (Include Area Code):
5.b. E-MAIL ADDRESS:
6. GRADE/

RANK:

7. DATE OF BIRTH

(YYYYMMDD):

8. AGE:
CYCLO:
a. MILITARY:
b. CIVILIAN:
12. AGENCY (Non-Service Members Only):
13. ORGANIZATION UNIT AND UIC/CODE:
14a. RATING OR SPECIALTY (Aviators Only):
14b. TOTAL FLYING TIME:
14c. LAST SIX MONTHS:
Active Duty:
Reserve:
National Guard:
Navy:
Coast Guard:
Other:
16. NAME OF EXAMINING LOCATION, AND ADDRESS

(Include Zip Code):

Asymptomatic: 0
Asymptomatic: 0
Asymptomatic: 0
Symptomatic: 0
Symptomatic: 0
Symptomatic: 0
c: 0
c: 0
c: 0
Class:
46. URINE HCG:
LAST NAME - FIRST NAME - MIDDLE NAME (Suffix):
SOCIAL SECURITY NUMBER:
DoD ID NUMBER:
45. URINALYSIS:
a. Albumin:
b. Sugar:
47. H/H:
48. BLOOD TYPE:
HZ:
50. DRUGS:
51. ALCOHOL:
52. OTHER:
a. PAP SMEAR:
b. EKG:
c. CXR:
HIV SPECIMEN ID LABEL:
DRUG TEST SPECIMEN ID LABEL:
53. HEIGHT (in.):
54. WEIGHT:
55.a. MIN WGT:
55.b. MAX WGT:
55.d. BMI:
56. TEMPERATURE:
HEART RATE:
Add::
SYS.:
SYS.:
DIAS.:
DIAS.:
DIAS.:
59. RED/GREEN:
60. OTHER VISION TEST:
ES:
EX:
R.H.:
L.H.:
Prism div.:
Prism Conv CT:
NPR:
PD:
Right:
Left:
PIP: Pass/ Fail and Score:
RED / GREEN: Pass/ Fail and Score:
Color Dx: Pass/ Fail and Score:
AFVT: Pass/ Fail and Score:
RANDOT / MCST : Pass/ Fail and Score:
68. FIELD OF VISION:
69. NIGHT VISION:
O.D.:
O.S.:
71a. AUDIOMETER Unit Serial Number:
Date Calibrated (YYYYMMDD):
71b. Unit Serial Number:
SAT:
UNSAT:
72c.OTHER TESTING:
73. NOTES AND/OR INTERVAL HISTORY :
LAST NAME - FIRST NAME - MIDDLE NAME (Suffix):
SOCIAL SECURITY NUMBER:
DoD ID NUMBER:
IS MEDICALLY QUALIFIED : 0
IS NOT MEDICALLY QUALIFIED: 0
75.a. SIGNATURE OF EXAMINEE:
75.b. DATE (YYYYMMDD):
DISQ:
D Entry:
D Entry:
D Entry:
D Entry:
EXAMINER’S NAME AND SIGNATURE:
PROFILER INITIALS:
PROFILER INITIALS:
PROFILER INITIALS:
PROFILER INITIALS:
DATE (YYYYMMDD):
DATE (YYYYMMDD):
DATE (YYYYMMDD):
DATE (YYYYMMDD):
78. SUMMARY OF MEDICAL DIAGNOSES (List diagnoses with item numbers) (Use additional sheets if necessary).:
89. ADDITIONAL REMARKS:
82.a. TYPED OR PRINTED NAME OF PHYSICIAL OR EXAMINER:
82b. Signature:
83.a. TYPED OR PRINTED NAME OF PHYSICIAL OR EXAMINER:
83b. Signature:
87. WAIVER GRANTED (If yes, date and by whom):
85b. Signature:
a. SIGNATURE:
c. DATE (YYYYMMDD):
No: 0
No: 0
88. NUMBER OF ATTACHED SHEETS:

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