75H71026Q00166 amd0001.pdf

(x)

75H71026Q00166 x x copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted ; or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGEMENT TO BE

RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR

OFFER. If by virtue of this amendment you desire to change an offer already submitted , such change may be made by letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

x

Gallup NM 87301 1808 W. Aztec Avenue Acquisition Department Gallup Indian Medical Center

06/18/20260001

13. THIS ITEM ONLY APPLIES TO MODIFICATION OF CONTRACTS/ORDERS. IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

12. ACCOUNTING AND APPROPRIATION DATA (If required) is not extended.is extended, Items 8 and 15, and returning

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended , by one of the following methods: (a) By completing

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

FACILITY CODE CODE

10B. DATED (SEE ITEM 13)

10A. MODIFICATION OF CONTRACT/ORDER NO.

9B. DATED (SEE ITEM 11)

9A. AMENDMENT OF SOLICITATION NO.

CODE

8. NAME AND ADDRESS OF CONTRACTOR (No., street, county, State and ZIP Code)

7. ADMINISTERED BY (If other than Item 6)CODE 6. ISSUED BY

PAGE OF PAGES

4. REQUISITION/PURCHASE REQ. NO.3. EFFECTIVE DATE2. AMENDMENT/MODIFICATION NO. 5. PROJECT NO. (If applicable)

1. CONTRACT ID CODE

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

05/20/2026

CHECK ONE A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER (Specify type of modification and authority) appropriation data, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

E. IMPORTANT: Contractor is not is required to sign this document and return __________________ copies to the issuing office.

ORDER NO. IN ITEM 10A.

14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

**This is a Small Business (SB) set-aside**

**The new deadline is June 29, 2026 at 10:00 a.m. MDT.**

This contract is subject to the electronic payment process by the Department of Treasury.

All invoices complying to the requirements at 52.212-4(g) must be submitted through www.ipp.gov For additional information, refer to the incorporated clause at 352.232-71

Electronic Submission of Payment Requests (APR 2026)(DEVIATION).

If the Government's and Contractor's terms and conditions are in conflict, the Government's terms and conditions will prevail.

Continued ...

16A. NAME AND TITLE OF CONTRACTING OFFICER (Type or print)15A. NAME AND TITLE OF SIGNER (Type or print)

15C. DATE SIGNED 16B. UNITED STATES OF AMERICA 15B. CONTRACTOR/OFFEROR 16C. DATE SIGNED

(Signature of person authorized to sign) (Signature of Contracting Officer)

JERLYN R. BEGAY

STANDARD FORM 30 (REV. 11/2016)

Prescribed by GSA FAR (48 CFR) 53.243

Previous edition unusable

Except as provided herein, all terms and conditions of the document referenced in Item 9 A or 10A, as heretofore changed, remains unchanged and in full force and effect .

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

NAME OF OFFEROR OR CONTRACTOR

2 40

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

(A) (B) (C) (D) (E) (F)

75H71026Q00166/0001

FOB: Destination

Period of Performance: 07/01/2026 to 09/30/2026

NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)

Sponsored by GSA

FAR (48 CFR) 53.110

Rev. 04/29/2026

SECTION B – CONTINUATION OF SF-1449

THIS PAGE IS INTENTIONALLY LEFT BLANK

SECTION C – CONTRACT CLAUSES

52.212-4 CONTRACT TERMS AND CONDITIONS –

COMMERCIAL PRODUCTS AND COMMERCIAL

SERVICES

NOV 2025

(DEVIATION)

The following Federal Acquisition Regulation clauses also apply:

52.203-3 GRATUITIES APR 1984

52.203-6 RESTRICTIONS ON SUBCONTRACTOR SALES TO THE GOVERNMENT Alt I

NOV 2021

52.203-12 LIMITATION OF PAYMENTS TO INFLUENCE CERTAIN FEDERAL

TRANSACTIONS

JUN 2020

52.203-13 CONTRACTOR CODE OF BUSINESS ETHICS AND CONDUCT NOV 2021

52.203-16 PREVENTING PERSONAL CONFLICTS OF INTEREST JUN 2020

52.203-17 CONTRACTOR EMPLOYEE WHISTLEBLOWER RIGHTS NOV 2023

52.203-19 PROHIBITION ON REQUIRING CERTAIN INTERNAL CONFIDENTIALITY

AGREEMENTS OR STATEMENTS

JAN 2017

52.204-9 PERSONAL IDENTITY VERIFICATION OF CONTRACTOR PERSONNEL JAN 2011

52.204-13 SYSTEM FOR AWARD MANAGEMENT MAINTENANCE NOV 2025

(DEVIATION)

52.204-14 SERVICE CONTRACT REPORTING REQUIREMENTS NOV 2025

(DEVIATION)

52.204-15 SERVICE CONTRACT REPORTING REQUIREMENTS FOR INDEFINITE-

DELIVERY CONTRACTS

NOV 2025

(DEVIATION)

52.204-91 CONTRACTOR IDENTIFICATION NOV 2025

(DEVIATION)

52.209-6 PROTECTING THE GOVERNMENT’S INTEREST WHEN

SUBCONTRACTING WITH CONTRACTORS DEBARRED, SUSPENDED, OR

PROPOSED FOR DEBARMENT

NOV 2025

(DEVIATION)

52.209-9 UPDATES OF PUBLICLY AVAILABLE INFORMATION REGARDING

RESPONSIBILITY MATTERS

NOV 2025

(DEVIATION)

52.209-10 PROHIBITION ON CONTRACTING WITH INVERTED DOMESTIC

CORPORATIONS

NOV 2025

(DEVIATION)

52.213-1 RESERVED

52.219-3 NOTICE OF HUBZONE SET-ASIDE OR SOLE-SOURCE AWARD NOV 2025

(DEVIATION)

52.219-6 NOTICE OF TOTAL SMALL BUSINESS SET-ASIDE NOV 2025

(DEVIATION)

52.219-6 Alt I

NOTICE OF TOTAL SMALL BUSINESS SET-ASIDE, WITH ALTERNATE I NOV 2025

52.219-7 NOTICE OF PARTIAL SMALL BUSINESS SET-ASIDE NOV 2020

52.219-7 Alt I

NOTICE OF PARTIAL SMALL BUSINESS SET-ASIDE, WITH ALTERNATE I MAR 2020

52.219-8 UTILIZATION OF SMALL BUSINESS CONCERNS NOV 2025

(DEVIATION)

52.219-9 SMALL BUSINESS SUBCONTRACTING PLAN NOV 2025

(DEVIATION)

52.219-9 Alt I

SMALL BUSINESS SUBCONTRACTING PLAN, WITH ALTERNATE I NOV 2025

(DEVIATION)

52.219-9 Alt II

SMALL BUSINESS SUBCONTRACTING PLAN, WITH ALTERNATE II NOV 2025

(DEVIATION)

52.219-9 Alt III

SMALL BUSINESS SUBCONTRACTING PLAN, WITH ALTERNATE III NOV 2025

(DEVIATION)

52.219-9 Alt IV

SMALL BUSINESS SUBCONTRACTING PLAN, WITH ALTERNATE IV NOV 2025

(DEVIATION)

52.219-13 NOTICE OF SET-ASIDE OF ORDERS MAR 2020

52.219-13 Alt I

RESERVED

52.219-16 LIQUIDATED DAMAGES—SUBCONTRACTING PLAN NOV 2025

(DEVIATION)

52.219-27 NOTICE OF SET-ASIDE FOR, OR SOLE-SOURCE AWARD TO, SERVICE-

DISABLED VETERAN-OWNED SMALL BUSINESS (SDVOSB) CONCERNS

ELIGIBLE UNDER THE SDVOSB PROGRAM

NOV 2025

(DEVIATION)

52.219-28 POSTAWARD SMALL BUSINESS PROGRAM REREPRESENTATION NOV 2025

(DEVIATION)

52.219-28 Alt I

POSTAWARD SMALL BUSINESS PROGRAM REREPRESENTATION, WITH

ALTERNATE I

NOV 2025

(DEVIATION)

52.219-29 NOTICE OF SET-ASIDE FOR, OR SOLE-SOURCE AWARD TO,

ECONOMICALLY DISADVANTAGED WOMEN-OWNED SMALL BUSINESS

CONCERNS

NOV 2025

(DEVIATION)

52.219-30 NOTICE OF SET-ASIDE FOR, OR SOLE-SOURCE AWARD TO, WOMEN-

OWNED SMALL BUSINESS CONCERNS ELIGIBLE UNDER THE WOMEN-

OWNED SMALL BUSINESS PROGRAM

NOV 2025

(DEVIATION)

52.219-33 NONMANUFACTURER RULE NOV 2025

(DEVIATION)

52.222-3 CONVICT LABOR NOV 2025

(DEVIATION)

52.222-19 CHILD LABOR—COOPERATION WITH AUTHORITIES AND REMEDIES NOV 2025

(DEVIATION)

52.222-35 EQUAL OPPORTUNITY FOR VETERANS NOV 2025

(DEVIATION)

52.222-36 EQUAL OPPORTUNITY FOR WORKERS WITH DISABILITIES NOV 2025

(DEVIATION)

52.222-36

ALT I

EQUAL OPPORTUNITY FOR WORKERS WITH DISABILITIES, WITH

ALTERNATE I

JUL 2014

52.222-37 EMPLOYMENT REPORTS ON VETERANS NOV 2025

52.222-40 NOTIFICATION OF EMPLOYEE RIGHTS UNDER THE NATIONAL LABOR

RELATIONS ACT

NOV 2025

(DEVIATION)

52.222-41 SERVICE CONTRACT LABOR STANDARDS NOV 2025

(DEVIATION)

52.222-43 FAIR LABOR STANDARDS ACT AND SERVICE CONTRACT LABOR

STANDARDS-PRICE ADJUSTMENT (MULTIPLE YEAR AND OPTION

CONTRACTS)

NOV 2025

(DEVIATION)

52.222-44 FAIR LABOR STANDARDS ACT AND SERVICE CONTRACT LABOR

STANDARDS-PRICE ADJUSTMENT

NOV 2025

(DEVIATION)

52.222-50 COMBATING TRAFFICKING IN PERSONS NOV 2025

(DEVIATION)

52.222-50 Alt I

COMBATING TRAFFICKING IN PERSONS NOV 2025

(DEVIATION)

52.222-51 EXEMPTION FROM APPLICATION OF THE SERVICE CONTRACT LABOR

STANDARDS TO CONTRACTS FOR MAINTENANCE, CALIBRATION, OR

REPAIR OF CERTAIN EQUIPMENT—REQUIREMENTS

NOV 2025

(DEVIATION)

52.222-53 EXEMPTION FROM APPLICATION OF THE SERVICE CONTRACT LABOR

STANDARDS TO CONTRACTS FOR CERTAIN SERVICES—

REQUIREMENTS

NOV 2025

(DEVIATION)

52.222-54 EMPLOYMENT ELIGIBILITY VERIFICATION NOV 2025

(DEVIATION)

52.222-55 MINIMUM WAGES FOR CONTRACTOR WORKERS UNDER EXECUTIVE

ORDER 14026

NOV 2025

(DEVIATION)

52.222-62 PAID SICK LEAVE UNDER EXECUTIVE ORDER 13706 NOV 2025

(DEVIATION)

52.222-90 ADDRESSING DEI DISCIMINATION BY FEDERAL CONTRACTORS APR 2026

(DEVIATION)

52.223-2 REPORTING OF BIOBASED PRODUCTS UNDER SERVICE AND

CONSTRUCTION CONTRACTS

NOV 2025

(DEVIATION)

52.223-5 POLLUTION PREVENTION AND RIGHT-TO-KNOW INFORMATION MAY 2024

52.223-11 OZONE-DEPLETING SUBSTANCES NOV 2025

(DEVIATION)

52.223-12 MAINTENANCE, SERVICE, REPAIR, OR DISPOSAL OF REFRIGERATION

EQUIPMENT AND AIR CONDITIONERS

NOV 2025

(DEVIATION)

52.223-23 SUSTAINABLE PRODUCTS NOV 2025

(DEVIATION)

52.224-1 PRIVACY ACT NOTIFICATION APR 1984

52.224-2 PRIVACY ACT APR 1984

52.224-3 PRIVACY TRAINING JAN 2017

52.224-3

ALT I

PRIVACY TRAINING, WITH ALTERNATE I JAN 2017

52.225-1 BUY AMERICAN-SUPPLIES NOV 2025

(DEVIATION)

52.225-1 Alt I

BUY AMERICAN-SUPPLIES, WITH ALTERNATE I OCT 2022

52.225-3 BUY AMERICAN-FREE TRADE AGREEMENTS-ISRAELI TRADE ACT NOV 2025

(DEVIATION)

52.225-3

ALT I

RESERVED

52.225-3 Alt II

BUY AMERICAN-FREE TRADE AGREEMENTS-ISRAELI TRADE ACT,

WITH ALTERNATE II

NOV 2025

(DEVIATION)

52.225-3 Alt III

BUY AMERICAN-FREE TRADE AGREEMENTS-ISRAELI TRADE ACT,

WITH ALTERNATE III

NOV 2025

(DEVIATION)

52.225-3 Alt IV

BUY AMERICAN-FREE TRADE AGREEMENTS-ISRAELI TRADE ACT,

WITH ALTERNATE IV

NOV 2025

(DEVIATION)

52.225-5 TRADE AGREEMENTS NOV 2023

52.225-14 INCONSISTENCY BETWEEN ENGLISH VERSION AND TRANSLATION OF

CONTRACT

FEB 2000

52.225-19 CONTRACTOR PERSONNEL IN A DESIGNATED OPERATIONAL AREA OR

SUPPORTING A DIPLOMATIC OR CONSULAR MISSION OUTSIDE THE

UNITED STATES

MAY 2020

52.225-26 CONTRACTORS PERFORMING PRIVATE SECURITY FUNCTIONS

OUTSIDE THE UNITED STATES

OCT 2016

52.226-1 UTILIZATION OF INDIAN ORGANIZATIONS AND INDIAN-OWNED

ECONOMIC ENTERPRISES

NOV 2025

(DEVIATION)

52.226-5 RESTRICTIONS ON SUBCONTRACTING OUTSIDE DISASTER OR

EMERGENCY AREA

NOV 2025

(DEVIATION)

52.226-6 PROMOTING EXCESS FOOD DONATION TO NONPROFIT

ORGANIZATIONS

NOV 2025

(DEVIATION)

52.226-8 ENCOURAGING CONTRACTOR POLICIES TO BAN TEXT MESSAGING

WHILE DRIVING

MAY 2024

52.229-12 TAX ON CERTAIN FOREIGN PROCUREMENTS AUG 2025

(DEVIATION)

52.232-18 AVAILABILITY OF FUNDS APR 1984

52.232-29 TERMS FOR FINANCING OF COMMERCIAL PRODUCTS AND

COMMERCIAL SERVICES

NOV 2021

52.232-30 INSTALLMENT PAYMENTS OF COMMERCIAL PRODUCTS AND

COMMERCIAL SERVICES

NOV 2021

52.232-33 PAYMENT BY ELECTRONIC FUNDS TRANSFER—SYSTEM FOR AWARD

MANAGEMENT

OCT 2018

52.232-34 PAYMENT BY ELECTRONIC FUNDS TRANSFER—OTHER THAN SYSTEM

FOR AWARD MANAGEMENT

JUL 2013

52.232-36 PAYMENT BY THIRD PARTY NOV 2025

(DEVIATION)

52.232-40 PROVIDING ACCELERATED PAYMENTS TO SMALL BUSINESS

SUBCONTRACTORS

MAR 2023

52.232-90 FAST PAYMENT PROCEDURE NOV 2025

(DEVIATION)

52.233-3 PROTEST AFTER AWARD NOV 2025

(DEVIATION)

52.233-4 APPLICABLE LAW FOR BREACH OF CONTRACT CLAIM NOV 2025

52.237-2 PROTECTION OF GOVERNMENT BUILDING, EQUIPMENT, AND

VEGETATION

APR 1984

52.237-3 CONTINUITY OF SERVICES JAN 1991

52.240-91 SECURITY PROHIBITIONS AND EXCLUSIONS NOV 2025

(DEVIATION)

52.240-91 Alt I

SECURITY PROHIBITIONS AND EXCLUSIONS, WITH ALTERNATE I NOV 2025

(DEVIATION)

52.240-92 SECURITY REQUIREMENTS NOV 2025

(DEVIATION)

52.240-92 Alt II

SECURITY REQUIREMENTS WITH ALTERNATE II NOV 2025

(DEVIATION)

52.240-93 BASIC SAFEGUARDING OF COVERED CONTRACTOR INFORMATION

SYSTEMS

NOV 2025

(DEVIATION)

52.242-5 PAYMENTS TO SMAL BUSINESS SUBCONTRACTORS JAN 2017

52.242-13 BANKRUPTCY JUL 1995

52.244-2 SUBCONTRACTS JUN 2020

52.244-6 SUBCONTRACTS FOR COMMERCIAL PRODUCTS AND COMMERCIAL

SERVICES

NOV 2025

(DEVIATION)

52.245-1 GOVERNMENT PROPERTY SEP 2021

52.245-2 GOVERNMENT PROPERTY INSTALLATION OPERATION SERVICES APR 2012

52.245-9 USE AND CHARGES APR 2012

52.247-64 PREFERENCE FOR PRIVATELY OWNED U.S.-FLAG COMMERCIAL

VESSELS

NOV 2025

(DEVIATION)

52.247-64 Alt I

PREFERENCE FOR PRIVATELY OWNED U.S.-FLAG COMMERCIAL

VESSELS, WITH ALTERNATE I

APR 2003

52.247-64 Alt II

PREFERENCE FOR PRIVATELY OWNED U.S.-FLAG COMMERCIAL

VESSELS, WITH ALTERNATE II

NOV 2021

52.252-2 CLAUSES INCORPORATED BY REFERENCE FEB 1998

This contract incorporates one or more clauses by reference, with the same force and effect as if they were given in full text. Upon request, the Contracting Officer will make their full text available. Also, the full text of a clause may be accessed electronically at this/these address(es):

Revolutionary FAR Overhaul - FAR Overhaul - FAR Part Deviation Guidance | Acquisition.GOV

Federal Acquisition Regulation - https://www.acquisition.gov/browse/index/far

Department of Health and Human Services Acquisition Regulation – https://www.acquisition.gov/hhsar

(End of clause)

52.252-6 AUTHORIZED DEVIATIONS IN CLAUSES NOV 2020

(a)The use in this solicitation or contract of any Federal Acquisition Regulation (48 CFR Chapter 1) clause with an authorized deviation is indicated by the addition of "(DEVIATION)" after the date of the clause.

(b)The use in this solicitation or contract of any Department of Health and Human Services (48 CFR Chapter 3) clause with an authorized deviation is indicated by the addition of "(DEVIATION)" after the name of the regulation.

The following Department of Health and Human Services Acquisition Regulation clauses also apply:

352.203-70 ANTI-LOBBYING DEC 2015

352.208-70 PRINTING AND DUPLICATION DEC 2015

352.211-3 PAPERWORK REDUCTION ACT DEC 2015

352.219-71 MENTOR-PROTÉGÉ PROGRAM REPORTING REQUIREMENTS JAN 2010

352.223-70 SAFETY AND HEALTH DEC 2015

352.224-70 PRIVACY ACT DEC 2015

352.226-6 INDIAN ECONOMIC ENTERPRISE SUBCONTRACTING

LIMITATIONS

MAR 2022

352.227-70 PUBLICATIONS AND PUBLICITY DEC 2015

352.231-70 SALARY RATE LIMITATION DEC 2015

352.237-70 PRO-CHILDREN ACT DEC 2015

352.237-71 CRIME CONTROL ACT – REPORTING OF CHILD ABUSE DEC 2015

352.237-72 CRIME CONTROL ACT – REQUIREMENTS FOR BACKGROUND

CHECKS

DEC 2015

352.237-73 INDIAN CHILD PROTECTION AND FAMILY VIOLENCE ACT DEC 2015

352.232-71 ELECTRONIC SUBMISSION OF PAYMENT

REQUESTS

APR 2026

(a) Definitions. As used in this clause –

Payment request means a bill, voucher, invoice, or request for contract financing payment with associated supporting documentation. The payment request must comply with the requirements in FAR 32.905(b) and the applicable payment clause included in this contract.

(b) Submission instructions. Except as provided in paragraph (c) of this clause, the Contractor must submit payment requests electronically using the Department of Treasury Invoice Processing Platform (IPP) or successor system. Information regarding IPP, including IPP Customer Support contact information, is available at www.ipp.gov or any successor site.

(c) Alternate submission procedures. The Contractor may submit payment requests using other than IPP only when the Contracting Officer authorizes alternate procedures in writing.

(d) Submission of alternate payment procedures authorization. If alternate payment procedures are authorized, the Contractor shall include a copy of the Contracting Officer’s written authorization with each payment request.

The following local Indian Health Service, Navajo Area terms also apply:

NAIHS-ACQ-09 UNAUTHORIZED COMMITMENTS NOV 2025

(a) Definitions.

Contracting Officer means a person with the authority to enter into, administer, and/or terminate contracts and make related determination and findings.

Ratification means the act of approving an unauthorized commitment by an official who has the authority to do so.

Unauthorized Commitment (UAC) means an agreement that is not binding solely because the Government representative who made it lacked the authority to enter into that agreement on behalf of the Government.

(b) Policy.

The Government is not bound by agreements with, or contractual commitments made to, prospective contractors by individuals who do not have delegated contracting authority. Unauthorized commitments do not follow the appropriate process for the expenditure of Government funds. Consequently, the Government may not be able to ratify certain actions, putting a contractor at risk for taking direction from a Federal official other than the contracting officer (see FAR 1.403-2). Government employees responsible for unauthorized commitments are subject to disciplinary action. Contractors perform at their own risk when accepting direction from unauthorized officials. Failure to follow statutory and regulatory processes for the expenditure of Government funds is a very serious matter.

(c) Procedure.

Any agreement, modification, or change to a contractual agreement made by a government personnel who lack authority will be deemed an unauthorized commitment. The Government is not liable to the Contractor or under the terms of the contract, financially or otherwise – unless the unauthorized commitment successfully passes the ratification process.

The ratification process does not have any lead time, nor does the Government make any promise that an unauthorized commitment will be ratified and, therefore, the Contractor would be paid. The Contractor proceeds at its own risk if any of the terms of the contract are altered, changed, or modified without the written concurrence by a Contracting Officer.

(End of Clause)

NAIHS-ACQ-19 REAL ID ACT MAY 2025

In alignment with the Department of Homeland Security (DHS) and the Transportation Security Administration (TSA), the U.S. Department of Health and Human Services (HHS) will fully implement and enforce REAL ID Act requirements for all HHS facility access beginning May 7, 2025. All individuals entering HHS-owned, leased, or operated facilities must present a REAL ID-compliant credential or another federally approved form of identification. Below is the list of acceptable forms of ID.

• State-issued Enhanced Driver’s License

• U.S. passport

• U.S. passport card

• DHS trusted traveler cards (Global Entry, NEXUS, SENTRI, FAST)

• U.S. Department of Defense ID, including IDs issued to dependents

• Permanent resident card

• Border crossing card

• An acceptable photo ID issued by a federally recognized Tribal Nation/Indian Tribe, including Enhanced

Tribal Cards (ETCs)

• HSPD-12 PIV card

• Foreign government-issued passport

• Canadian provincial driver's license or Indian and Northern Affairs Canada card

• Transportation worker identification credential

• U.S. Citizenship and Immigration Services Employment Authorization Card (I-766)

• U.S. Merchant Mariner Credential

• Veteran Health Identification Card (VHIC)

NAIHS-ACQ-20 PROTECTING FEDERAL EMPLOYEES AND

THE PUBLIC FROM EXPOSURE TO TOBACCO

SMOKE IN THE FEDERAL WORKPLACE

APR 2026

In accordance with Executive Order 13058 “Protecting Federal Employees and the Public from Exposure to Tobacco Smoke in the Federal Workplace,” and the Assistant Secretary for Health memorandum “Prohibition of Tobacco Use in HHS Occupied Facilities,” the use of tobacco products, in any form, is strictly prohibited at IHS-operated properties including, but not limited to:

1. All interior and exterior spaces of IHS-operated properties.

2. All HIS-operated spaces in multi-tenant buildings.

3. All Government vehicles regardless of their location.

4. Private vehicles while on IHS property.

The IHS continues to recognize the value and efficacy of patients’ traditional beliefs and ceremonial practices. The use of tobacco products for ceremonial purposes is allowed in the designated traditional healing room, including any space designated for a ceremony, or in a patient’s hospital room.

To the maximum extent practicable, Contractor must notify the Contracting Officer’s Representative in advance of using tobacco products in a ceremony.

(End of Clause)

SECTION D – DOCUMENTS, EXHIBITS, ATTACHMENTS, ETC.

Attachment A – Statement of Work

Attachment B – Office Measurements

Attachment C – Pre-Construction Risk Assessment

Tohatchi Health Center

Scope of Work

Business Office Furniture

Scope of Work

The contractor shall provide all necessary labor, equipment and supplies to install workstations/furniture to rooms 156, 157 and 158.

Deliverables

1. New office furniture. All furniture to be wipeable and with micro-bacterial surfaces.

a. Two U Shaped Desks with Hutch.

i. Electric adjustable height desk.

ii. Combo file with 2 box drawers, 1 file drawer and 1 lateral file drawer.

111. Hutch with 2 silver framed glass doors.

b. One Sit-to-Stand Full Casing Desk

i. Electric adjustable height desk.

c. One 4 Shelf Bookcase with Doors Covering Lower¾ of Unit.

d. One 29 1/2 inch Height Laminate Wood Door Storage Cabinet

e. One 2 Drawer Under Desk Mobile File Pedestal

f. Two 2 Drawer Lateral File with Hutch

g. One 42 inch Wide x 24 inch Depth Reversible Return

h. One PL142 Half Leg

i. One Under Desk Full Box/File Pedestal

j. Two Big & Tall Dual Layer Air Grid Mesh Manager Chairs

k. One High Back Multifunction Mesh Executive Office Chair

l. All hardware to connect furniture to complete installation.

m. Site visit to verify measurements, door locations, power and data outlets.

General Conditions

1. Codes and Standard. The Contractor shall adhere to all the following code and standards requirements for work performed.

a. 2018 Edition NFPA 99

b. Occupational Safety and Health Act (OSHA)- CFRA1926

2. Project Safety

Attachment A

a. Contractor shall provide all worksite safety equipment.

b. Housekeeping accomplished on a daily basis. Contractor will remove all debris and trash generated by this project to be disposed of properly at a state certified disposal site in accordance with national, state and local environmental regulations.

c. Contractor shall be responsible for complete and strict compliance with Gallup Service Unit Facility policies, including safety policy.

d. Pre-Construction Control Risk Assessment (PCRA) shall be approved and signed before any work starts.

e. Contractor(s) shall sign in and out with Security room 101.

3. Product Specifications

a. Office desks

4. Submittals

a. Submittals of all products and materials. Provide in scanned PDF format.

5. Inspection

a. The Government has the right to inspect all aspects of work performed.

b. Final acceptance will be based on an acceptable final inspection.

6. Quality Assurance

a. Only materials approved on product submittal are used. No substitution without prior approval by Contracting Officer.

b. All new materials shall be installed per manufacturer's instructions.

c. All work to be performed by a contractor specialized in the specific trade required on this project.

7. Execution

a. All activities shall be coordinated with Tohatchi Health Center Facility Management staff to ensure there are no detrimental impact on the day-to-day operations of the clinic. Advance notification of 72 hours is required to properly coordinate issues and delays.

b. Contractor is responsible for obtaining all appropriate signed forms and permits prior to starting any work.

c. Contractor shall verify all existing site conditions and measurements prior to removal and installation.

d. Facility staff will terminate electrical power to workstations and IT staff will provide data lines and jacks for the work stations.

8. Inspection

a. The government reserves the right to inspect all aspects of work performed, including hiring a third party inspector to verify proper installation and operation.

b. Contractor is required to demonstrate full and complete operation of all work performed.

c. Final acceptance will be based on an acceptable final inspection, including final verification testing of all materials and workmanship.

9. Project Schedule

a. The contractor shall provide a detailed schedule indicating starting and completion dates of the project.

b. Contractor shall work with local contact for job access and work time coordination.

c. Contractor shall provide a coordinated schedule to Contract Officer

Representative (COR) and Contract Specialist (CS).

d. Hours of operation for the facility are 8:00 am - 4:30 pm, Monday-Friday

(excluding federal holidays). Work outside these hours must be submitted three business days in advance in writing to the Contract Officer for approval.

1O. Performance Period

a. From date of award through three months to complete install of all furniture.

11. Final Payment

a. Final payment will not be authorized until all work is complete, including punch list items and final inspection has been made.

b. Close out documents shall include approved submittals and copies of warranty letters.

12. Warranty

a. Contractor shall warranty all work for one year from date of acceptance.

9’6

11’6” 108 Sq Ft

10’4” 98 Sq Ft

10’2” 97 Sq Ft Window

Attachment B

08/14/18 Update

Pre-Construction Risk Assessment – Cover Page Project Title: Project/Contract #:

GIMC Coordinator: PCRA Submit Date:

Project Conducted by:

Fac. Mgmt. I.T. Telecom Clin. Eng.

Contractor: __________________________

Proposed Start Date:

Staff/Cont. Name: Est. Duration:

Supervisor Name: Est. Complete Date:

Telephone: Date Project Completed: Email:

Project Description: (include specific sites and tasks)

ICRA Classification Class I Class II Class III* Class IV*

Section 1. Initial Project Impact Review

Topic Will project negatively impact or involve…? No Yes Responses (If YES to any)

Fire Safety Section 2A(1)

Ceiling tile removal (less than 4 hours total) Complete Above the Ceiling Access Permit (ACAP) Existing fire-stop; minor barrier penetrations

Fire Safety Section 2A(2)

Fire detection/alarm/suppression systems Complete Interim Life Safety Measure (ILSM) evaluation. Exit paths or fire/smoke barriers

Hot work practices

Extra fire load or flammable materials

Utilities Section 2B

Water, sewer, electricity, steam, or HVAC (including outside air intakes)

Complete the Utility System Risk Assessment (USRA)

Medical gases or vacuum

Call systems, telephones, or IT systems

Environmental/ Occupational Section 2C

Lead or asbestos containing materials Complete Env./Occ. Risk Assessment (EORA) Chemical hazards (i.e. mercury, volatile organics)

Exposure to infectious agents or mold

Security Section 2D

Security systems (badge readers, cameras) Complete Security Risk Assessment (SRA) Security processes (tours, foot/vehicle traffic)

Infection Control Section 2E

Patient care areas or critical utilities Complete an Infection Control Risk Assessment (ICRA) Moderate to high levels of dust, noise, vibration

More than one work shift

Project Approval Evaluator Signature & Title Date: Required for: All

Facility Manager Signature Date: Required for: All

Safety Officer Signature Date: Required for: All

Infection Preventionist Signature

Date: Required for: USRA and ICRA

Supervisor (affected area) Date: Required for: All

Project Close-out Facility Manager Signature Date: Required for: All

Safety Officer Signature Date: Required for: All

Infection Preventionist Signature

Date: Required for: ICRA-Class III & IV

Supervisor (affected area) Date: Required for: All

Attachment C

Section 2A(1). Above Ceiling Permit

Project Title: Project/Contract #:

Staff/Cont. Name: Start Date:

Supervisor Name: Estimated Duration:

Topic Issue for Evaluation No Yes Responses (If NO to any) Date Completed

GSU Training 1. Have all supervisors/workers been trained on fire safety requirements

Schedule training with Facility Mgr or Safety Ofcr

Review policy and sign acknowledgement below.

2. Has supervisor read above ceiling access policy?

Project Plans/ Drawings

1. Has a cable routing plan been provided to Facility Manager?

Provide Facility Mgr with written plan or drawing.

If req’d by Facility Mgr, request and redline Life Safety Plan drawings

2. Is a redlined drawing/CAD over the Life Safety Plan needed?

(GIMC use only)

Project Details 1. Have descriptions/fire ratings for any materials to be installed been provided?

Provide complete project details to Facility Manager; or utilize facility approved systems/materials.

2. Have additions of cables/wires to pre-existing pathways/sleeves been reviewed and found to comply with allowable loads?

3. Have descriptions of UL compliant firestop systems been provided; or will facility approved systems be used?

4. Have descriptions of approved hanger/ support systems been provided; or will facility approved systems be used?

5. Have product details for all firestop systems/materials been provided?

Pre-work inspection

1. Has a pre-work inspection been conducted?

Conduct pre-work inspection and notify Facility Manager of existing deficiencies.

2. Have any existing unprotected penetrations been identified?

3. Have existing items supported by sprinkler piping been identified?

ILSM 1. Will any ceiling/tile grid, fire/smoke barrier, or firestop system be compromised for more than 4 hours or beyond the end of the work day, without a temporary code compliant protection system/ methodology?

Conduct a full ILSM evaluation

ACA Permit Approval Facility Manager Signature Date:

ACA Permit Close-out

ABOVE CEILING ACCESS PERMIT

PERMIT MUST BE PROMINENTLY DISPLAYED AT THE JOB SITE

NOTICE TO PERMIT HOLDER

READ CAREFULLY

Certain spaces (such as above ceiling tile grids or utility closets) are restricted to authorized personnel, and are controlled in GSU facilities.

Access to these spaces is a privilege, which may be denied for those who do not comply with the Above Ceiling Access Permit Policy. This applies to all staff, as well as vendors and contractor personnel.

This form and the preceding pages are the permit and must be displayed at all times while creating new, or accessing existing penetrations in smoke or fire barriers. It must also be displayed when working above ceiling tile grids, in utility closets or in any other space identified as CONTROLLED SPACE.

Persons found working in these spaces without a valid permit visible are in violation of the ABOVE CEILING ACCESS PERMIT POLICY, and may lose their access privileges. Chronic non-compliers will be disciplined.

SOME EXAMPLES OF POLICY VIOLATIONS:

Accessing a controlled space without a permit

Failure to hold and display a valid permit

Failure to close out a permit

Performing work outside the scope of a permit

Providing false information to a permit issuer

Falsifying data on a permit

Allowing someone to work under the scope of a permit issued in another’s name

All individuals performing work in a CONTROLLED SPACE shall read and be familiar with the ABOVE CEILING ACCESS PERMIT POLICY, copies of which can be obtained in Facility Management.

I have read and understand the ABOVE CEILING ACCESS PERMIT POLICY, and agree to comply with it.

Staff/Contractor Signature Date:

Section 2A(2). Interim Life Safety Measure Risk Assessment

Project Title: Project/Contract #:

Topic Issue for Evaluation No Yes Responses (If YES to any) Date Initiated

Exits 1. Any exit access or travel distances altered/excessive? Post signage for an alternate means of egress Train staff on alternate means of egress* Inspect exit daily for blockage or debris Double fire drill frequency* Increase hazard surveys*

2. Any exits used by anyone other than contractors obstructed?

3. Absence of two remote exits?

Emergency Access

1. Access to emergency depts. or services obstructed? Designate an alternate means of access Notify GIMC Security Notify Gallup Fire Dept.

2. Access to construction area obstructed for emergency forces?

Fire Protection 1. Fire alarm/detection (>25% in one zone) impaired >4 hrs?

Submit fire watch request;

o Or, use/monthly test temp. alarm/detection/ suppression system

Notify Gallup Fire Dept.

Double fire drill frequency* Make affected staff aware

2. Fire suppression impaired >10 hrs?

Fire & Smoke Barriers

1. Major breaches of fire/smoke barriers (including vertical)?

Construct 1-hr smoke tight temp. barrier (as needed)

Inspect exits daily Double fire drill frequency Train staff to compensate*

2. Unprotected corridors or Haz. Areas?

3. Fire/smoke door maintenance/latching problem not immediately repairable?

Addl. Firefighting Equipment

1. Fire load significantly increased above normal for area/building?

Provide additional fire extinguishers in area

Addl. Firefighting Training

1. Additional firefighting equipment differs from normal equipment?

Train equipment staff/ contractors to use

Combustible Load Levels

1. New/increased storage of flammable/combustible materials? Minimize debris accumulation Increase hazard surveys

2. Flammable/combustible debris?

Hazard Surveillance

1. Addl. hazards such as excavations, etc.?

Initiate additional surveillance of area

Facility-wide Training

1. Life safety deficiencies or hazards impaired throughout entire building?

Train employees on ILSM Notify Gallup Fire Dept.

*-Need for response may be waived upon approval of Authority Having Jurisdiction based on scope and duration of project.

Describe any other life safety impacts, as well as specific actions to be implemented, for these and those above.

Evaluator signature & Title Date:

Safety Officer Signature Date:

Section 2A(3). Hot Work Permit

Project Title: Project/Contract #:

Section 2B. Utility System Risk Assessment

Project Title: Project/Contract #:

Will project affect? Yes No Minimum Recommended Precautions: (If Yes)

Noise

Review project and patient care schedules to identify least impactful times, or options to curtail or relocate patient care operations

Review how workers will access worksite and isolate from patient care as feasible Review tools and processes to be used for reasonable, quieter alternatives;

Install sound attenuating barriers where feasible. Monitor as needed.

Vibration Review work schedules for project and work area to identify least impactful times Review tools and processes to be used for reasonable alternatives Assess potential impacts on sensitive patient care equipment/processes; Monitor as needed.

Water

Submit ICRA and Utility Shutdown Request; Submit fire watch request per ILSM evaluation Pre-position materials needed to respond to a water leak Review need/options to isolate adjacent areas and equipment (i.e. lab analyzers, ice machines, HVAC appurtenances, etc.)

Flush and/or treat system if potential for residue or stagnation (See Legionella Plan)

Sewer

Submit ICRA and Utility Shutdown Request Pre-position materials needed to respond to leaks or spills, and to handle contaminated construction debris.

Review need/options to isolate adjacent areas and to curtail or alter patient care routines.

Electricity Review work schedules for project and work area to identify least impactful times Review potential impacts to connected utility systems and electronic equipment Submit Utility Shutdown Request

Steam Submit Utility Shutdown Request Notify steam-based equipment users of potential impacts

Natural Gas Submit Utility Shutdown Request

HVAC

Submit ICRA and Utility Shutdown Request Review work schedules for project and work area to identify least impactful times Identify alternate environmental condition options

Medical Gas

& Vacuum

Submit Utility Shutdown Request Ensure work will be done in accordance with NFPA 99 or other relevant codes Notify patient care staff of potential impacts to prompt clinical intervention planning Ensure that post-completion testing is completed

IT Systems Collaboratively plan project between Facility Mgmt and IT Departments Notify patient care staff to plan for clinical process modification as needed

Telephones Collaboratively plan project between Facility Mgmt and IT Departments Notify patient care security staff to plan for emergency response modifications

Call systems Collaboratively plan project between Facility Mgmt and IT Departments Notify patient care staff to plan for clinical process modification as needed Plan for alternate notification means (standalone systems, bells, etc.)

Observation

Cameras

Collaboratively plan project between Facility Mgmt and IT Departments Notify patient care staff to plan for clinical process modifications as needed

Describe any specific actions to be implemented:

Evaluator Signature & Title Date:

Section 2C. Environmental and Occupational Risk Assessment

Project Title: Project/Contract #:

involve:

Yes No Minimum Recommended Precautions: (If Yes)

Lead-based paint

Review facility lead-based paint assessment and management plan

Ensure project staff are properly trained in precautions necessary to protect facility occupants and themselves

Establish plan to implement appropriate isolation, work practices, housekeeping, and waste handling

Establish plan for required air or surface sampling

Asbestos

Review facility asbestos assessment and management plan

Ensure project staff are properly trained in precautions necessary to protect facility occupants and themselves

Establish plan to implement appropriate isolation, work practices, housekeeping, and waste handling

Establish plan for required air or surface sampling

Chemical hazards

Review area or initial project plan to identify hazards inherent to work area

Compile and review listing of chemicals to be used; ensure Safety Data Sheets available

Review chemicals to be used for potential impacts on areas adjacent to project

Ensure project staff have receive Haz. Communications training including emergency response processes/responsibilities

Conduct Job Hazard Assessment and ensure appropriate personal protective equipment is available and used

Infectious

Agents

Review area or initial project plan to identify hazards inherent to work area

Ensure staff have received Bloodborne Pathogen Training including exposure response processes/responsibilities

Review need for medical screening/vaccination with employee health program

Conduct Job Hazard Assessment and ensure appropriate personal protective equipment is available and used

Mold

Review area or initial project plan to identify hazards inherent to work area

Consider potential risk of water damage due to compromising wall, ceiling, roof

Ensure project staff are properly trained in precautions necessary to protect facility occupants and themselves

Establish plan to implement appropriate isolation, work practices, housekeeping, and waste handling

Employee Health Signature

(as needed)

Date:

Section 2D. Security Risk Assessment

Project Title: Project/Contract #:

affect:

Yes No Minimum Recommended Precautions: (If Yes)

Badge

Readers

Collaborative plan project with IT Department

Notify Security staff of impaired system to plan for alternative access control methods

Notify affected work area staff of alternative access control methods

Security

Cameras

Collaboratively plan project between Facility Mgmt and IT Departments

Notify security to plan for surveillance process modifications

Physical

Barriers

Review need for temporary physical barriers

Processes

Review changes to area access with security to plan for alternate rounding paths

Review pedestrian/facility occupant foot traffic patterns to identify potential vulnerabilities

Review vehicle traffic patterns with security to ensure required access and to plan for traffic management as needed

Security sensitive areas

Review project staff listing with security

Notify project staff of access control requirements

Provide identification as needed.

Emergency

Response

Procedures

Notify external first responders/partners as appropriate

Provide training to staff regarding procedural changes

Relocate equipment and/or signage as needed

Review emergency response communications procedures/plan

Security Supv. Signature Date:

Section 2E. Infection Control Risk Assessment

Project Title: Project/Contract #:

Building: Floor(s): Department Name(s): Room Number(s) & Description(s)

Project Description: (include specific sites and tasks)

Infection Control Risk Assessment

Matrix of Precautions for Construction & Renovation

Step 1: Using the following table, identify the Type of Construction Project Activity (Type A-D)

TYPE A

Inspection and Non-Invasive Activities.

Includes, but is not limited to:

removal of ceiling tiles for visual inspection only, e.g., limited to 1 tile per 50 square feet painting (but not sanding) wallcovering, electrical trim work, minor plumbing, and activities which do not generate dust or require cutting of walls or access to ceilings other than for visual inspection.

TYPE B

Small scale, short duration activities which create minimal dust

Includes, but is not limited to:

installation of telephone and computer cabling access to chase spaces cutting of walls or ceiling where dust migration can be controlled.

TYPE C

Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies

Includes, but is not limited to:

sanding of walls for painting or wall covering removal of floorcoverings, ceiling tiles and casework new wall construction minor duct work or electrical work above ceilings major cabling activities any activity which cannot be completed within a single workshift.

TYPE D

Major demolition and construction projects

Includes, but is not limited to:

activities which require consecutive work shifts requires heavy demolition or removal of a complete cabling system new construction.

Step 1: _________________________________________________________

Step 2: Using the following table, identify the Patient Risk Groups that will be affected.

Low Risk Medium Risk Medium-High Risk Highest Risk

Office areas

Nonpatient-care areas not otherwise specified

(NOS)

Cardiology

Echocardiography

Endoscopy

Local Room

Physical Therapy

Radiology/MRI

Respiratory Therapy

Infusion Clinic

Orthopedic Clinic

Emergency Room

Labor & Delivery

Laboratories (specimen)

Medical Units

Newborn Nursery

Outpatient Surgery

Pediatrics

Pharmacy

Post Anesthesia Care Unit

Any area caring for immunocompromised patients

Central Sterile Supply

Intensive Care Units

Negative pressure isolation rooms

Operating rooms including C-section rooms

If more than one risk group will be affected, select the higher risk group:

Step 2: ______________________________________________________

Step 3: Match the following;

Patient Risk Group (Low, Medium, High, Highest) with the planned …

Construction Project Type (A, B, C, D) on the following matrix, to find the …

Class of Precautions (I, II, III or IV) or level of infection control activities required.

Type of Construction

Patient Risk Group Type A Type B Type C Type D

Low Risk Group I II II III/IV

Medium Risk Group I II III IV

Medium-High Risk

Group

I II III/IV IV

Highest Risk Group I –III

Consult ICP

III/IV III/IV IV

Class of IC Measures Class I Class II Class III* Class IV*

* Note Infection Preventionist approval will be required when the Construction Activity and Risk Level indicate that

Class III or Class IV control procedures are necessary.

Step 3: ______________________________________________________

Description of Required Infection Control Precautions by Class Before Construction During Construction Project Upon Completion of Project

C L

A S

S I

1. Notify Department

Supervisor

1. Execute work by methods to minimize raising dust from construction operations.

2. Immediately replace a ceiling tile displaced for visual inspection

1. Clean work area upon completion of task.

C L

A S

S I

I

1. Notify Department

Supervisor

1. Provide active means to prevent airborne dust from dispersing into atmosphere.

2. Water mist work surfaces to control dust while cutting.

3. Seal unused doors with duct tape.

4. Block off and seal air vents.

5. Place dust mat at entrance and exit of work area

6. Remove or isolate HVAC system in areas where work is being performed.

1. Wipe work surfaces with cleaner/disinfectant.

2. Contain construction waste before transport in tightly covered containers.

3. Wet mop and/or vacuum with HEPA filtered vacuum before leaving work area.

4. Upon completion, restore HVAC system where work was performed.

C L

A S

S I

II

1. Contact

Housekeeping

Supervisor to schedule Post-work cleaning

2. Review ICRA with

Department

Supervisor(s)

1. Remove or Isolate HVAC system in area where work is being done to prevent contamination of duct system.

2. Complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from non-work area or implement control cube method (cart with plastic covering and sealed connection to work site with HEPA vacuum for vacuuming prior to exit) before construction begins.

3. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.

4. Contain construction waste before transport in tightly covered containers.

5. Cover transport receptacles or carts. Tape covering unless solid lid.

1. Do not remove barriers from work area until completed project is inspected by the owner’s Safety Department and Infection

Prevention & Control Department and thoroughly cleaned by the owner’s

Environmental Services Department.

2. Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction.

3. Vacuum work area with HEPA filtered vacuums.

4. Wet mop area with cleaner/disinfectant.

5. Upon completion, restore HVAC system where work was performed.

C L

A S

S I

V

1. Contact

Housekeeping

Supervisor to schedule Post-work cleaning

2. Notify Tour

Supervisor

3. Review ICRA with

Department

Supervisor(s)

1. Isolate HVAC system in area where work is being done to prevent contamination of duct system.

2. Complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from non-work area or implement control cube method (cart with plastic covering and sealed connection to work site with HEPA vacuum for vacuuming prior to exit) before construction begins.

3. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.

4. Seal holes, pipes, conduits, and punctures.

5. Construct anteroom and require all personnel to pass through this room so they can be vacuumed using a HEPA vacuum cleaner before leaving work site or they can wear cloth or paper coveralls that are removed each time they leave work site.

6. All personnel entering work site are required to wear shoe covers. Shoe covers must be changed each time the worker exits the work area.

1. Do not remove barriers from work area until completed project is inspected by the owner’s Safety Department and Infection

Prevention & Control Department and thoroughly cleaned by the owner’s

Environmental Services Dept.

2. Remove barrier material carefully to minimize spreading of dirt and debris associated with construction.

3. Contain construction waste before transport in tightly covered containers.

4. Cover transport receptacles or carts. Tape covering unless solid lid.

5. Vacuum work area with HEPA filtered vacuums.

6. Wet mop area with cleaner/disinfectant.

7. Upon completion, restore HVAC system where work was performed.

Step 4. Identify the areas surrounding the project area, assessing potential impact

Adjacent Area Impacts: Identify the areas surrounding the project area, to assess potential impact

Below Above Lateral Lateral Behind in Front

Adjacent Unit Name

Patient Risk Group

(per Table 1)

Step 5. Identify specific site of activity e.g., patient rooms, medication room, etc.

Step 6. Identify containment measures, using prior assessment. What type of barriers? (E.g., solid wall barriers);

Will HEPA filtration be required. Do plans allow for adequate number of isolation/negative airflow rooms?

(Note: Renovation/construction area shall be isolated from the occupied areas during construction and shall be negative with respect to surrounding areas)

Step 7. Consider potential risk of water damage. Is there a risk due to compromising structural integrity? (e.g., wall, ceiling, roof)

Step 8. Work hours: Can or will the work be done during non-patient care hours?

Step 9. Do plans allow for adequate number of isolation/negative airflow rooms?

Step 10. Do the plans allow for the required number & type of handwashing sinks?

Step 11. Does the infection prevention & control staff agree with the minimum number of sinks for this project?

Step 12. Does the infection prevention & control staff agree with the plans relative to clean and soiled utility rooms?

Step 13. Plan to discuss the following containment issues with the project team. (E.g., traffic flow, housekeeping, debris removal [how and when])

Appendix: Identify and communicate the responsibility for project monitoring that includes infection prevention & control concerns and risks. The ICRA will be modified throughout the project.

Revisions must be communicated to the Project Manager.

Infection Control Construction Permit

Permit No:

Location of Construction: Project Start Date:

Project Coordinator: Estimated Duration:

Contractor Performing Work Permit Expiration Date:

Supervisor: Telephone:

YES NO CONSTRUCTION ACTIVITY YES NO INFECTION CONTROL RISK GROUP

TYPE A: Inspection, non-invasive activity GROUP 1: Low Risk

TYPE B: Small scale, short duration, moderate to high levels

GROUP 2: Medium Risk

TYPE C: Activity generates moderate to high levels of dust, requires greater 1 work shift for completion

GROUP 3: Medium/High Risk

TYPE D: Major duration and construction activities

Requiring consecutive work shifts

GROUP 4: Highest Risk

CLASS I 1. Execute work by methods to minimize raising dust from construction operations.

2. Immediately replace any ceiling tile displaced for visual inspection.

3. Minor Demolition for Remodeling

CLASS II 1. Provides active means to prevent air-borne dust from dispersing into atmosphere

2. Water mist work surfaces to control dust while cutting.

3. Seal unused doors with duct tape.

4. Block off and seal air vents.

5. Wipe surfaces with cleaner/disinfectant.

6. Contain construction waste before transport in tightly covered containers.

7. Wet mop and/or vacuum with HEPA filtered vacuum before leaving work area.

8. Place dust mat at entrance and exit of work area.

9. Isolate HVAC system in areas where work is being performed; restore when work completed.

CLASS III

1. Obtain infection control permit before construction begins.

2. Isolate HVAC system in area where work is being done to prevent contamination of the duct system.

3. Complete all critical barriers or implement control cube method before construction begins.

4. Maintain negative air pressure within work site utilizing

HEPA equipped air filtration units.

5. Do not remove barriers from work area until complete project is checked by Infection…