A2 PWS FY25.docx

PERFORMANCE WORK STATEMENT OCCUPATIONAL HEALTH PROCUREMENT OF MEDICAL SURVEILLANCE EXAMINATIONS:

1.0. General:

1.1. Scope: The medical examinations and procedures shall be the responsibility of the Medical Contractor. The administrative controls shall be the responsibility of the New York Army National Guard (NYARNG) Safety and Occupational Health Manager (SOHM). The Contractor’s medical provider (MD, PA, NP) and contractor will review the roster of employee exams and procedures, sign-off, date the exams and procedures, and return signed document within 2 business days of confirmation of contract, to establish written medical orders and contractors’ responsibility to fulfill the same. Any addition or removal of exams or procedures will be in consultation with the NYARNG Occupational Health Nurse (OHN) / Project Officer.

1.2. Background: The purpose of the NYARNG Mobile Occupational Medical Examination Program is to provide job-related medical surveillance examinations and occupational health services to NYARNG qualifying full-time support (FTS), part-time and temporary civilian technicians who are potentially exposed to health hazards in the work environment or who are assigned to positions requiring specific standards of physical fitness. The primary focus for FY25 will be: (1) evaluation of need for respirator in performance of duties, pulmonary function tests as needed, medical clearance, and respirator fit testing. Respirator fit testing and medical clearance will occur on approximately thirty (30) individuals. (2) Hearing testing, including otoscopic exams prior to testing, instruction to use of hearing PPE (plugs, muffs, caps, etc.) to include determining when to use protection, how to select the correct PPE, when double protection is to be used, donning / doffing, and maintenance of hearing protection. This may be provided in the form of a handout.

In addition to above, Medical Surveillance will include:

Vital Signs: Including height, weight, pulse, blood pressure.

Vision exams: Including distance, near, depth perception and field of vision. New employees will also receive color vision testing.

Laboratory tests: Including Urinalysis, Complete Blood Counts, Complete Blood Count w/ Differential, Comprehensive Metabolic Panels.

Updates to the medical surveillance roster will be provided to contractor at least 3 days before the start of the POP. The contractor shall conduct each for the quoted per test price provided in the quote and established in the contract. The government may evaluate the quality of professional and administrative services provided but retains no control over the medical professional aspects of services rendered. The contractor shall provide all labor, tools, supervision and supplies to conduct mobile medical surveillance / occupational health services for the NYARNG.

1.3. Period of Performance (PoP): The PoP shall be a total of thirty (30) days from 08 July 2025 – 07 August 2025. The specified exam days will be from 08 July – 25 July 2025 with standard hours of operation between 0700 and 1600. The contractor shall conduct medical surveillance examination / occupational health services at eight (8) work sites / locations as listed below:

0730-1530

1.5. New York Army National Guard Project Officer: The NYARNG Project Officer is Christopher M. Gardner, OHN, MNAV-OS, 330 Old Niskayuna Rd, Latham, NY 12110-2224. Commercial Phone (518) 786-6040, Fax (518) 786-6032, email: Christopher.m.gardner43.civ@army.mil

2.0. References:

2.1. Department of Defense Instructions 6055.05-M, Occupational Medical Examinations and Surveillance Manual.

2.2. Army Regulation 40-5, Preventive Medicine.

2.3. Army Regulation 385-10, Army Safety and Occupational Health Program.

2.4. U. S. Department of Labor (DOL) 29 CFR 1910, Occupational Safety and Health Standards for General Industry.

2.5. Headquarters Department of the Army Pamphlet (DA PAM) 40-501, Hearing Conservation.

2.6. Military References made in the Performance Work Statement (PWS) are available from the government POC.

3.0. Procedures and Standards:

3.1. The contractor shall ensure that all procedures are conducted in accordance with applicable American Board of Occupational and Environmental Medicine (ABOEM), American Association of Occupational Health Nurses, U. S. Department of Labor, OSHA, and NIOSH Standards.

3.2. The contractor shall ensure that all clinical laboratory / chemistry services are performed by a laboratory licensed by the U. S. Department of Health and Human Services Health Care Financing Administration pursuant to the terms of the Clinical Laboratories Improvement Act of 1967 (42 U.S.C 263a) and the College of American Pathologists.

3.3. The contractor must supply a copy of all service provider certifications / licenses to the government with the contractor’s quote.

3.4. A comprehensive review and evaluation will be performed within thirty (30) days following the conclusion of testing. The NYARNG will contact and schedule a follow-up review and evaluation meeting to discuss overall performance of the purchase order.

3.5. The contractor will arrange for initial coordination of services with the government POC within fifteen (15) working days after award of the contract.

3.6. The contractor will arrange to consult with a representative of the NYARNG SOH or Contracting Office by telephone to coordinate or resolve issues that might arise before, during, and after the testing period. Any issues with testing must be reported immediately and no later than 30 minutes of findings so as not to delay the completion of testing. Any work that is not completed or is not completed within the time frame of the contract will be credited from the contract in an amount equal to the cost to have the matter addressed locally, if not fully resolved within two weeks of Medical Surveillance exam period.

3.7. Only qualified medical technicians will perform medical surveillance screening / testing elements. Personnel performing audiograms will be certified by the Council for Accreditation in Occupational Hearing Conservation (CAOHC).

3.8. Personnel conducting spirometry and fit testing will be certified through a program approved by the National Institute of Occupational Safety and Health (NIOSH). Copies of license and certifications must be provided to the Project Officer as previously indicated.

3.9. Instrumentation must meet or exceed appropriate performance standards, and accuracy must be verified IAW current Occupational Medicine Certification standards.

3.10. The contractor shall safeguard all sensitive / Personally Identifiable Information and adhere to all HIPAA and NYARNG regulations regarding facility and personnel privacy and safety. The contractor shall provide documented confirmation that all contractor staff involved in administering any part of the contract have received annual HIPAA training.

3.11. While on NYARNG property, the contract employees shall display identification on their person indicating employing agency, name, and title. They shall make available, upon request, active government issued photo identification.

3.12 The contractor must provide all paperwork associated with medical surveillance at the testing site, including all DOD forms provided by the Project Officer for employee completion. The contractor will also be responsible for supplying the testing roster for each medical surveillance site as provided by the Project Officer.

4.0. Medical Surveillance:

4.1.1. Physical examination, vital signs (including, pulse, blood pressure, height and weight), audiology testing for significant threshold shifts, including re-testing, vision (Including distance, near, color, depth perception, field of vision), respiratory clearance (including review of documentation, physical exam for fitness to wear respirator), pulmonary function test, medical clearance by qualified Board Certified Occupational Health and Medicine Provider, fit testing, respirator use, care and maintenance training, hearing protection training, with written report of all findings, recommendations and medical clearance, signed by provider. In lieu of a Board-Certified Occupational Health and Medicine Provider, a medically qualified and licensed provider with a minimum of five years military or occupational health experience may be substituted.

4.1.2. Should the medical provider find any employee is not medically cleared to perform the functions of their position, the Project Officer will be notified immediately by phone and in writing within twenty-four hours of findings. Notification will be in the form of a written medical referral form indicating follow-up clearance requirement that may remove any restriction to work. (Ex. Written referral. Follow-up vision exam and prescription glasses to correct near vision to better than 20:40 OU, based on employees work requirements).

4.1.3. It is the responsibility of the contractor to notify the Project Officer, within 30 minutes of completing what they deem to be the last employees, of any employees who were scheduled to attend medical surveillance but did not. The contractor may also notify the Project Officer, between 1100-1200, of any employees who had not yet attended. This will ensure Project Officer has time to reach out to supervisors to determine the status of the employee and assure greatest compliance. This notification is to occur while the contractor’s employees are at the facility to be able to provide contract services to all scheduled NYARNG Federal Civilian employees. The contractor or authorized employee will notify Project Officer if any employee who was not scheduled arrives for testing. The contractor understands there has been an estimated increase in number of employees built into this agreement to support employees returning from deployment or other details. The contract physician will add these employees to the master spreadsheet / orders and re-sign or initial (as appropriate) orders for those additional employees.

4.2. Laboratory testing: Will include the drawing of blood, collection of urine and disposal of all waste products generated by the blood draw and urine collection in accordance with the Blood-Borne Pathogen Standard. The waste products will not be disposed of at the testing site. The laboratory tests will consist of urinalysis (~95), CMP (~80), CBC (~5), CBC w/ Diff (~90). Tests may also include lead, ZZP, Hexavalent chromium, blood and urine cadmium, urine beta 2 microglobulin, Urine phenol, BUN, creatinine, if determined necessary by contracting physician.

4.3. Respiratory clearance IAW OSHA Standard 29 CFR 1910.34 for identified employees. Contractor will utilize single-use, non-cross contaminating, disposable mouthpieces for pulmonary function tests (PFTs), to be able to perform PFTs regardless of environmental COVID or other environmental respiratory illnesses. Qualified contract staff shall fit test qualified employees who require or request voluntary use respirators in the workplace and provide education on the use, care, and maintenance of respirators, cartridges, and filters. This training may be in written format, and most be documented in the employees’ medical record. The employees will bring their respirators and filters / cartridges for fit testing.

4.5. Audiogram:

4.5.1. Examiner: The following are the requirements for certified hearing technician examiners performing hearing testing for Army Hearing Conservation and Readiness.

4.5.2. Hearing testing must be completed by a physician, audiologist, or certified hearing technician.

4.5.3. Hearing technicians must administer audiometric tests under the supervision of a physician or audiologist.

4.5.3. Hearing technicians must have Council for Accreditation in Occupational Hearing Conservation (CAOHC) or equivalent military certification.

4.5.4. Hearing technicians shall be trained for otoscopic examination and earplug fitting and will perform otoscopic exams prior to audiology testing to identify and document any physical findings which may interfere with hearing exam (ex. Outer ear infection, obstruction by cerumen). Any employee who has findings which may interfere with a hearing exam will be referred to contract physician for assessment and documentation, prior to proceeding with the audiometry exam.

4.5.5. Contractor staff shall provide education to all NYARNG employees completing audiometric testing on prevention of hearing loss, proper donning, doffing, selection of plugs, muffs, caps and when to use single or double protection. This training will be in the form of written material, signed by the employee upon receipt, and provided to the Project Officer with all other documents after the completion of medical surveillance. The education must be documented in the employee medical record.

4.5.6 The NYARNG Project Officer reserves the right to request the vendor perform a same-day follow-up audiogram on any participant that displays a positive or negative threshold shift during the initial medical surveillance audiogram performed by the certified hearing technician.

5.0 Equipment:

5.1.1. Hearing testing will be completed using the approved DoD audiometer. The current DoD approved audiometer is the Benson CCA 200 or CCA 200mini.

5.1.2. Audiometers must have an annual, comprehensive electro-acoustical calibration to ensure it is functioning properly and IAW the American National Standards Institute (ANSI) Standard S3.6. A copy of annual calibration will be provided to the Project Officer prior to the first day of Medical Surveillance.

5.1.3. Audiometers must pass a daily calibration and functional check. Daily calibration check results must be recorded on a DD Form 2217, Biological Audiometer Calibration Check.

5.1.4. Earphone cushions must be clean and in good condition, without dryness or cracks.

5.1.5. Headbands must be in good condition and provide proper tension.

5.1.6. Earphone cords must be in good condition with no cracks or breaks in the insulation or shorts in the wires.

5.1.7. Hearing booths must meet OSHA MPANL requirements with adequate insulation, adjustments in booths, and with booths in mobile units, with generators running. Additionally, other tasks must not be taking place within the same room/space as hearing booth tests are occurring.

5.2. Test Environment:

5.2.1. Audiometric tests must be completed in a sound booth. The noise levels within the hearing test environment must not exceed those shown in DA PAM 40-501, Table 7-1. Audiometric test booths must be evaluated on an annual basis and each time a mobile unit is moved, using sound level meter equipment conforming to:

5.2.2. At least the Type 1 requirements of the ANSI Standard S1.4-1983 (R 1997) and S1.4A- 1985 Amendment (or latest approved standard).

5.2.3. The band filter sets shall conform to requirements for Order 3, Type 3-D, extended range as specified by the latest ANSI Standard S1.11.

5.2.4. Sound booth noise measurements must be recorded on the U. S. Army Public Health Command Audiometric Test Booth Certification Form with a copy furnished to the Project Officer or their representative. Each new test, with move of mobile units, will be documented and emailed or faxed to Project Officer prior to hearing booth use. The USAPHC Audiometric Test Booth Certification Form is available at: http://phc.amedd.army.mil/PHC%20Resource%20Library/AudiometricTestBoothCertification.pdf

5.2.5. Ventilation systems in audiometric test booths must provide adequate air exchange for patient comfort and acceptable sound levels for valid audiometric testing.

5.2.6. The standard for testing maximum permissible ambient noise levels (MPANL) within DoD is the ANSI S3.1, 1999 (R 2008) standard which requires sound measurements with a Type 1 sound level meter. The OSHA standard which allows measurements with a Type 2 sound level meter and allows much higher MPANL is not applicable for testing within DoD.

5.2.7. Hearing technicians will ensure that tests are completed in a sound booth that meets the DoD and Army Maximum Permissible Ambient Noise Levels (MPANL) IAW ANSI standards for MPANL and will ensure that the USAPHC Audiometric Test Booth Certification Form is posted on their test booth(s).

5.3. Audiometric Evaluation Requirements:

5.3.1. Hearing technicians will complete the daily functional checks and daily calibration on their DoD approved audiometers at the beginning of each test day with results recorded on a DD Form 2217, Biological Audiometer Calibration Check. The hearing technician will, upon request, provide the Hearing Program Manager, Case Manager, or their representative a daily copy of the DD Form 2217.

5.3.2. Otoscopic examinations will be performed prior to all hearing test.

5.3.3. Hearing technicians will ensure hearing aids and any other objects that may interfere with testing (glasses, earrings, gum, etc.) are removed prior to administering any monitoring audiometry hearing tests.

5.3.4. DD Form 2215 and DD Form 2216 Audiograms will be completed by the hearing technician. Thresholds will be completed for 500 Hz, 1000 Hz, 2000 Hz, 3000 Hz, 4000 Hz and 6000 Hz using the Benson CCA 200 or CCA 200mini audiometer, Standard Test Configuration, Modified Hughson-Westlake threshold procedure, and DoD Significant Threshold Shift method.

5.3.5. The hearing technician shall use the appropriate form and ensure that all DD Form 2215 and DD Form 2216 audiograms are appropriately filled out immediately following the completion of the test.

5.3.6. Hearing test results will be explained to the individuals being tested, and have employee sign the form at the conclusion of each test.

5.3.7. The DD2215 or DD2216 will be given to the contract physician for review. The contract physician or representative shall inform both the individual and the Project Officer of the need for a referral at the time of the test. The employee shall sign the DD2215 or DD2216 at the time of notification of the need for follow-up. The referral will be given to employee, along with a written referral for re-test or audiology exam. A second copy will be sent to the Project Officer within 24 hours of identifying a referral is required. This will serve as proof of notification to Project Officer.

5.3.8. The hearing technician will, upon request, provide the Project Officer or their representative desired reports at the end of each test day. All daily audiometer calibration reports will be submitted to the Project Officer within thirty days of completion of Medical Surveillance exams.

6.0. Vital signs:

6.1. Vital signs will include height, weight, pulse, and blood pressure, if indicated on the spreadsheet, which will be provided to the contractor after all contract documents are secured, as well as periodically with updates.

7.0. Visual exams:

7.1. Visual exams will include, distance, near, color, depth perception, field of vision, if required. All abnormal findings will be discussed with employee at the time of finding and documented on a referral form which will be given to the employee at time of exam. Project Officer will be notified in writing on a referral form within twenty-four hours of any abnormal findings by having contractor or representative send copy of the written referral to Project Officer. An additional copy will be included in the employee’s medical record sent to the employees’ home of record.

7.2. All abnormal findings not likely related to the employee’s job and requiring follow-up with a private health care provider will be communicated to the employee by way of a written referral at the time of identification of the abnormal finding with a copy of the same provided to the Project Officer and a third copy included in the employee’s medical record which is sent to the employees’ home of record.

8.0. Physician Services:

8.1. Physician will provide an on-site evaluation of the mobile testing to the (FTS) employees at the time of other testing as indicated in the Medical Surveillance Roster and as determined by the contract medical provider, in consultation with the Project Officer, based on employee potential exposure risks.

8.2. The Physician’s evaluations will be provided at the locations delineated in paragraph 1-4.

8.3. Physician will review all laboratory tests, x-rays and medical records and determine if the employee requires follow-up and / or is cleared for work duties. Any employee requiring follow-up will receive a written referral at time of evaluation or when laboratory results are received, indicating need for follow-up. A general statement can be made stating that the employee should bring their medical record to their private healthcare provider to assess identified abnormal findings that are not known to be work related but, may impact the employees’ health or ability to work in the future if not addressed. If the finding does not appear to be work related but does prevent the employ from preforming their duties, that must be stated and submitted to the Project Officer immediately, within 24 hours of identification. If the finding is work related, that also must be noted and the Project Officer must be notified immediately, within 24 hours as well.

9.0. Medical Records and Reports:

9.1. The contractor will ensure two (2) copies of the employee examination findings are furnished. One copy is to be sent to the NYARNG Project Officer, and one copy is to be mailed directly to the individual employee’s home of record. The medical examination records shall be sent to the employee’s home of record in a secured, confidential envelope. Medical examination results shall include all diagnostic tests, graphs, charts, reports, and examination results, written referral (This may be in the form of one document and include all required medical follow-up). The contractor will provide the NYARNG Project Officer with a hardcopy of these records within thirty (30) working days of the completion of testing. Results of Medical Surveillance testing which are questionable and / or of critical significance will be communicated directly, and immediately, to the NYARNG Project Officer by telephone and electronic or express mail. All abnormal findings which require follow-up are to be communicated to the Project Officer by sending a copy of the referral within 24 hours via secured email. If any employee is not medically cleared, the contractor must notify the Project Officer immediately by phone and forward the referral within 24 hours.

9.1.2. The Project Officer’s copy of employee medical records shall be placed in a manila folder with a straight cut tab on top. A 15/16 inch x 3 7/16 inch white folder label shall be affixed to the top, right, front side of the folder tab.

9.1.3. An identification label shall also be affixed to each page of the medical record which does not already include at minimum, employees full name (last, first, MI), as follows:

a. Affix to the bottom left margin of each page of the employee medical record, a 15/16 inch x 3 7/16 inch white label, in a manner that the label does not obscure and

b. Labels for the folder and the pages of the employee medical record shall include the following information in all caps, using Arial 10pt. font and printed as follows:

Line 1: Left margin, Employee’s full name (Last, First, Middle) as documented on the Medical Surveillance roster, then 5 spaces, then date of birth as follows: DOB: YY-MM-DD Line 2: Blank Line 3: Left margin. Social Security Number in format XXX-XX-XXXX

c. Should there not be adequate space on the first line to include the above information, place a dash (-) at the end of the first line and continue text on the second line. Then, leave the third line blank and place the SSN on the fourth line.

9.2. The Contractor will provide a comprehensive report that outlines the following in an Excel Spread Sheet Format:

a. Column # 1 – Personnel Name

b. Column # 2 – SSN

c. Column # 3 – D.O.B.

d. Column # 4 – Sex

e. Column # 5 – Facility of employment

f. Column # 6 – Position

g. Column # 7 – Wage Grade (WG or GS codes)

h. Column # 8 – Phys Exam (PE) and Medical Clearance (MC), (-/-): N = normal, A = abnormal, / C = cleared, O = not cleared,

i. Column # 9 – Vitals: Temp., Pulse, Blood Pressure (B/P), Resp. N = normal, A = abnormal,

j. Column # 10 – Audiology – N = anormal w/ no significant threshold shift, A = abnormal with significant threshold shift, O = Early Warning

k. Column # 11 – Vision with Corrective Lenses: N = normal, A = abnormal,

l. Column # 12 – Spirometry/PFT - N = normal, A = abnormal, X – Test Not Performed,

m. Column # 13 – Respirator use clearance P = Pass, F = Fail, X – Test Not Performed,

n. Column # 14 – Urinalysis – N = normal, A = abnormal, X – Test Not Performed,

o. Column # 15 – Comprehensive Metabolic Panel (CMP) - N = normal, A = abnormal, X – Test Not Performed,

p. Column # 16 – Complete Blood Count (CBC) - N = normal, A = abnormal, X – Test Not Performed,

q. Column # 17 – CBC w/ Differential (CBC w Diff) – N = normal, A = abnormal, X – Test Not Performed,

r. Column # 18 – Lead (Pb) and Zinc Protoporphyrin (ZZP) – N = normal, A = abnormal, X – Test Not Performed,

s. Column # 19 – Hexavalent Chromium (CH6) - N = normal, A = abnormal, X – Test Not Performed,

t. Column # 20 – Blood Cadmium - N = normal, A = abnormal, X – Test Not Performed,

u. Column # 21 – Urine Cadmium - N = normal, A = abnormal, X – Test Not Performed,

v. Column # 22 – Urine Beta 2 Microglobulin (B2M) - N = normal, A = abnormal, X – Test not performed,

w. Column # 23 – Blood Ureic Nitrogen (BUN) - N = normal, A = abnormal, X – Test not performed

x. Column # 24 – Creatinine (Creat) - N = normal, A = abnormal, X – Test not performed

y. Column #26 – CXR 2 View PA & Lat - N = normal, A = abnormal, X – Test not performed

z. Column #27 – CXR w/ B Reader - N = normal, A = abnormal, X – Test not performed

aa. Employee Medically Cleared - Y = Yes, N = No

ab. Notes: Written referral copy included – Y -Yes, N – Not applicable

10.0. Logistics:

10.1. Examination scheduling: Coordination of scheduling shall be a joint effort between the Project Officer and the Contractor, a draft copy of the scheduled will be initiated by the Program Office and sent to the Contractor for review and any needed adjustments. One patient/employee per 12-minute intervals. All workdays include a one-hour lunch break. No testing shall be performed between 1130 – 1230 hours.

10.2. In the event of a Contractor equipment failure, specific testing and / or parts of examinations that are not completed during the testing period shall be completed at a scheduled time mutually convenient for the Contractor, Occupational Health Specialist, and the Facility(ies) but will be no later than two weeks from the last exam date listed in the Statement of Work. Unfinished testing / examinations will be completed at no additional cost to the Government. The option to schedule any component of Medical Surveillance exams not completed due to equipment failure or other contractor related events, through a local occupational medical facility, shall be done at no cost to the Government. The Contractor shall be directly responsible to cover costs for completing these make-up evaluations and the amount will be directly deducted from the final contract amount, without exception.

10.3. Medical surveillance testing shall be accomplished via a state-of-the-art mobile unit designed to be conducive to an efficient continuous flow of patients yet maintain the dignity of the patient and always achieve complete individual privacy. The unit should be designed to enhance maintenance of hygiene, e.g., running water sources should be distributed throughout the unit so that personnel movement is minimized, but that people undergoing examinations have access to hand washing and hygiene amenities. Features of the unit should include, but are not limited to, a climate -controlled atmosphere, patient waiting/holding area for registration, separate changing room, separate on board restroom, testing/phlebotomy station, individual audiometric testing booth, on-board x-ray processing, an on-board computer system to maintain the quality control during the data entry and physician examination area. The unit should be physically structured such that each examination component can be conducted independently, e.g., with respect to the EKG and the examination conducted by the physician, an EKG and a physician's exam should be able to be conducted concurrently.

10.4. The Contractor shall provide a schematic and sufficient interior and exterior photographs of the unit proposed for use under the contract with their quotes, such that the Government can determine the Contractor has met the requirements set forth in this paragraph. Mobile units are to be equipped with separate power source / generator to operate in conditions without access to shore power.

11.0. Personal Protective Equipment (PPE):

11.1. Contractor shall furnish and assure health workers are provided with appropriate PPE such as, but not limited to, gloves, protective eyewear etc., where there is a potential for exposure to blood or other potential infectious materials.

11.2. Contractor will ensure each health care worker complies with the requirements of 29 CFR 1910.1030 Blood-borne Pathogens Standard

12.0. Infectious Waste Disposal:

12.1. Disposal of all infectious waste must be in accordance with local, state, and federal regulation and disposal of by the contractor.

12.2. Puncture resistant sharps containers must be readily accessible to health care workers and located in all treatment areas where sharps could potentially be used.

13.0. The contractor will comply with all New York State COVID-19 guidelines. If Medical Surveillance is delayed due to COVID-19 or other Federal or State emergency, the contractor and Project Officer will determine alternate dates for completion of Medical Surveillance.