Attachment 2 Performance Work Statement for OHC BPA 20 May 2022.pdf

PERFORMANCE WORK STATEMENT

Occupational Health Care and Consultation Services for USFORAZORES Civilian Employees

Blanket Purchase Agreement

Lajes Field

20 May 2022

Table of Contents

1 Introduction and Description of services

1.1 Objectives

1.2 Government personnel

1.2.1 The Government

1.2.2 Contracting Officer (CO)

1.2.3 Contract Administrator (CA)

1.2.4 Contracting Officer’s Representative (COR)

1.2.5 Medical Occupational Health Administrator (MOHA)

1.2.6 MOHA Alternate

1.3 OHCP Facilities and Personnel Licenses

1.3.1 OHCP certifications and Licenses

1.3.2 OHCP Contract Manager (CM)

1.3.3 Occupational Health Medicine certified physician

1.3.4 Occupational Health Care certified nurses

1.3.5 Other personnel

1.3.6 Sub-contractors

1.4 Occupational Health Care

1.4.1 Scope

1.4.2 Regulations and standards

1.4.3 List of required exams per LN and other documents

1.4.4 OHCP hours of operation

1.4.5 Timeframe for scheduling appointments upon Government request

1.4.6 OHCP provision of the completion certificates

1.4.7 LNs attending appointments/exams without the Government knowledge and authorization

1.4.8 Appointments outside the annual OHC requirements

1.4.9 Follow up exams and appointments

1.4.10 OHC physician final report regarding potential Occupational Health related disease. 11

1.4.11 LNs determined with NO occupational illness

1.4.12 LNs with an apparent occupational illness

1.4.13 Section title?

1.4.14 LNs unfit for duty

1.4.15 MOHA notification if an occupational illness is determined

1.5 Communication methods and communication language

1.6 Security Requirements

1.6.1 Electronic communication

1.6.2 Confidentiality

1.6.3 Automated Data Processing System and disposition of employee records

1.6.4 Assessment Data

1.6.5 Cooperation in Transition

1.7 Inclement Weather Conditions

1.8 General information

1.8.1 Government Quality Assurance

1.8.2 OHCP Quality Control Plan (QCP)

1.9 OHCP Furnished Items and Services

1.10 Government Furnished items and services

1.11 Invoicing

2 Services Summary (SS)

2.1 Service Summary Description

2.1.1 SS1 – OHCP’s punctuality

2.1.2 SS2 - LNs satisfaction with the OHCP’s services

2.1.3 SS3 - OHC monthly availability for exams and appointments to meet the Government needs

2.1.4 SS4 - OHCP provision of the completion certificates within the specified timeframe (5 work days)

3 Abbreviations and Translation Terms in PWS

5 List of Applicable Publications (current editions)

6 Attachment list

6.1 Attachment 1 – Exams and appointments list

6.2 Attachment 2 – Exams/appointments description and requirements

6.3 Attachment 3 – Employee’s Occupational Health List of Exam Requirements (Examples)

6.4 Attachment 4 – Applicable references

1 Introduction and Description of services

This is a non-personal services Performance Work Statement (PWS) for Occupational Health Care

(OHC) and consultation services , in accordance with (IAW) the United States of America

Occupational Health and Safety Standards and Work Regulation of 1995 , for local national civilians (herein LNs) employed by United States Air Force in the Azores (USFORAZORES, herein Government) at Lajes Field, Terceira, Portugal.

The Occupational Health Care Provider (herein OHCP) shall provide all personnel, equipment, tools, materials, supervision and other items and services necessary to perform OHC as defined in this PWS, except as specified in 1.10 as Government furnished items and services.

1.1 Objectives

The OHP shall:

a) Provide OHC to LN employees that may experience health concerns that may be related to their occupation.

b) Provide periodic assessments or measurements to detect abnormalities to LNs exposed to work-related health hazards.

c) Provide baseline examinations and consultation for new hires, upon Government request.

d) Provide LN examinations and consultation to LN’s requiring updated position requirements.

Recommendations to the US Government on the LNs ability to perform the essential job functions

(fit for duty).

The Government will provide guidance to LNs upon notification of medical decision.

1.2 Government personnel.

1.2.1 The Government.

Refers to the United States Government, as used herein, it refers specifically to the

USFORAZORES, the 86th Airlift Wing and the 65th Air Base Group.

1.2.2 Contracting Officer (CO).

The CO is the only person authorized to enter into, administer, or terminate the contract, and the only person authorized to obligate funds on behalf of the Government.

The CO will be responsible for ensuring all contract actions comply with the appropriate laws, executive orders, regulations, and other applicable procedures and approvals. The CO shall ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and shall safeguard the interests of the Government in the contractual relationship. The CO shall also ensure that the OHCP receives impartial, fair, and equitable treatment under this contract.

Any changes to this PWS and contract requirements must be coordinated and approved through the CO, prior to any changes in work being performed.

1.2.3 Contract Administrator (CA)

The CA is the person within the contracting office who performs day-to-day administration of the contract.

1.2.4 Contracting Officer’s Representative (COR).

The COR is a representative of the CO, and will participate in the administration of this contract.

The COR is responsible for:

Providing continuous technical oversight of the OHCP’s performance; to ensure that the OHCP meets the performance standards contained in the contract.

Reporting early identification of performance problems to the CO.

Maintains liaison with own staff, the contractor and customers related to the project.

Conducting a monthly periodic surveillance to monitor the OHCP’s performance that will be aggregated into an annual report. The annual report will be provided to the CO which will be used in documenting past performance.

Verifying that the invoices for services rendered to the Government are under the terms of the contract, before final acceptance of the services in the Procurement Integrated Enterprise

Environment (PIEE).

1.2.5 Medical Occupational Health Administrator (MOHA).

Civilian Occupational Health Technician assigned to the Occupational Health Section of the

Medical Aid Station (MAS).

The MOHA will be responsible for:

Scheduling appointments and exams on behalf of the Government. The OHCP will receive phone calls and emails from the MOHA, periodically throughout the contract, to schedule appointments.

Providing the OHCP with a list of the required exams for each LN.

Providing and retrieving any paper format documentation, such as LNs’ exam list requirements, fit for duty forms (generated by MAS), and any medical documentation to be added to the LNs files for reference as completion of the annual OHC requirements.

1.2.6 MOHA Alternate.

Civilian assigned to the Occupational Health Section of the Medical Aid Station (MAS) authorized to schedule appointments and exams, whenever the MOHA is not available. The alternate is also authorized to provide and retrieve any paper format documentation from the OHCP.

1.3 OHCP Facilities and Personnel Licenses

The management of the OHCP personnel shall be the sole responsibility of the OHCP.

1.3.1 OHCP certifications and Licenses.

The OHCP shall ensure that all employees and sub-contractor/s assigned to the awarded contract have current and valid professional certifications, licenses, and malpractice insurance when performing services for the Government.

The OHCP facility and sub-contractor/s (facility or individual provider) must be licensed to practice medicine in the Republic of Portugal and in the Autonomous Region of the Azores (ARA).

The OHCP facility must be credentialed by the Azorean Regional Health Authority to practice

OHC services on the island of Terceira.

The sub-contractor/s must be credentialed by the Azorean Regional Health Authority to practice medicine in Terceira.

Any changes to the contract must be IAW Portuguese regulations and law as well as be contractually admissible; the Government must be informed beforehand of any changes and the

OHCP must present the necessary documentation from the Azorean Regional Health Authority, authorizing the mentioned changes. Any modifications to OHCP personnel and facility’s status, name and location must be submitted to the CO, CA, COR and MOHA within three (3) work days, including changes to all licenses previously mentioned.

The OHCP shall ensure availability of personnel and facility’s certificates/licenses/mal-practice insurance for Government review upon request at any time. The MAS are the only authorized personnel to request review of the OHCP licenses, certifications and mal-practice insurance.

OHCP personnel involved in the OHC program rendered to the Government must comply with the

Portuguese privacy laws indicated for Health Care Providers.

1.3.2 OHCP Contract Manager (CM).

The OHCP shall identify a primary CM responsible for being the Point of Contact (POC) for every contact to and from the authorized personnel of the Government. The CM will have authority to act on behalf of the OHCP on all contract matters relating to the daily operation of this contract.

Also an alternate CM should be identified in the absence of the primary CM.

Names and telephone numbers shall be submitted in writing to the CO, CA, COR and MOHA within five (5) work days after the contract has been awarded.

1.3.3 Occupational Health Medicine certified physician.

The physician(s) providing services to the Government are appointed by the CM.

The appointed physician(s) must be certified by the Azorean Regional Health Authority for OHC and must be authorized to render services on Terceira Island and at the OHCP indicated in the contract.

1.3.4 Occupational Health Care certified nurses.

The nurse(s) providing services to the Government are appointed by the CM.

The appointed nurse(s) must be certified by the Azorean Regional Health Authority for OHC services provided on Terceira Island.

1.3.5 Other personnel.

OHCP personnel involved in the OHC program rendered to the Government must comply with the

Portuguese privacy laws indicated for Health Care Providers.

OHCP shall ensure the ready availability of all medical personnel. A backfill is required when medical personnel assigned to an area is unavailable. All OHCP employees who conduct ancillary services must possess a current certification/licenses from an appropriately recognized accreditation body in Portugal.

1.3.6 Sub-contractors

If the OHCP intends to contract a subcontractor/s as part of this contract, the OHCP shall submit their credentials to the Government for review prior to services being provided by the subcontractor.

1.4 Occupational Health Care.

1.4.1 Scope

The medical services will be provided by the OHCP in the area of Occupational Health Care and following the Government requirements. The Government will not be held accountable for any medical appointments and exams completed that are not listed and/or not authorized. The only exception is when the Government authorizes further testing to determine a possible illness/injury related to the employees’ occupation.

1.4.2 Regulations and standards

Comply with Portuguese Standards and Regulations. If applicable the OHCP shall provide OHC and exams to designated LNs IAW U.S. regulations and standards.

The OHCP shall perform the medical examinations requirements per U. S. Air Force (USAF) regulations (see attachment 1 and 2 for details), including but not limited to Air Force Instruction

(AFI) 48-145, Occupational and Environmental Health Program, Air Force Manual (AFMAN)

48-146, Occupational and Environmental Health Program Management, and Clinical

Occupational Health Examination Requirements (COHERS).

1.4.3 List of required exams per LN and other documents

The MOHA will provide the OHCP a package with the LN’s personal information to include the initial compliant/claim, a job description if requested, an updated copy of the Occupational and

Environmental Health Exposure Data (OEHED) form, where workplace conditions are described and a fit for duty form), if applicable and a fit for duty form generated by MAS (see attachment

3).

The documentation will be provided to the OHCP, at least 5 work days before the scheduled exams.

The documentation must be returned to the MOHA or alternate, signed, sealed and stamped by the

Occupational Health physician, stating if the LN is fit for duty, fit for duty with restrictions or unfit for duty.

1.4.4 OHCP hours of operation

The OHCP must be available from Monday through Saturday during work hours 09:00-20:00.

The OHCP is responsible for conducting all appointments and exams scheduled between the above specified hours except for Portuguese holidays, when the Government facility is closed due to local or national emergencies, administrative closings, or similar Government-directed facility closings.

The following Portuguese holidays are excluded from the regular hours of operation. The holidays listed as “varies yearly” will be excluded IAW each calendar year.

New Year’s Day 1 January Mardi Gras varies yearly Good Friday varies yearly Day of Liberty 25 April Day of the Worker 1 May Espirito Santo Monday varies yearly Day of Portugal 10 June Corpus Christi varies yearly Praia da Vitoria Day 11 August Assumption Day 15 August Founding of the Republic 5 October All Saints’ Day 1 November Restoration of Independence Day 1 December Immaculate Conception 8 December Christmas Day 25 December

1.4.5 Timeframe for scheduling appointments upon Government request.

The OHCP shall provide the Government with dates and times for the requested appointments/exams within a period of five (5) work days after being requested. MAS personnel are available from Monday through Friday during work hours 09:00 – 16:00.

The OHCP is responsible for scheduling/cancelling appointments as well as discussing issues that may arise within the Program between the above specified hours except for Portuguese holidays, when the Government facility is closed due to local or national emergencies, administrative closings, or similar Government-directed facility closings.

Portuguese holidays are mentioned in 1.4.4.

Cancellation of appointments made by the OHCP and or the LN outside of this timeframe MUST be coordinated between the OHCP and the LN. The OHCP will send a notification to MAS.

1.4.6 OHCP provision of the completion certificates

The OHCP shall provide the LNs completion certificate (exam list/fit for duty form provided by the Government) of all medical services provided within five (5) work days after examination or appointment, as appropriate.

1.4.7 LNs attending appointments/exams without the Government knowledge and authorization

No exams or appointments can be conducted without prescheduling/authorization by the

Government. The Government will not be held accountable for these appointments or any expense on that behalf.

It is the OHCP responsibility to turn away LNs should they show up without an appointment and/or exams scheduled by the Government.

1.4.8 Appointments outside the annual OHC requirements.

If at any time a LN experiences ill health, or struggles with difficulties they feel may to be related to their occupation on base, the MOHA will schedule a face to face appointment for evaluation.

1.4.9 Follow up exams and appointments.

If a LN, under paragraph 1.4.8 requires further testing and/or appointments regarding any medical specialty, in order to rule out an occupational health related disease, the OHCP will notify the

MOHA of the required exams and/or appointments. Any subsequent specialty appointments, necessary to review the medical exam(s), are also covered in this contract.

The MOHA will schedule the required follow up exams and/or appointments with the OHCP. If follow up care is not available within the OHCP’s facility it is the responsibly of the OHCP to sub contract these services.

Follow up exams and appointments will not be scheduled without the acknowledgement/authorization of the MOHA. If they are scheduled, the Government will not be held accountable for these expenses.

1.4.10 OHC physician final report regarding potential Occupational Health related disease.

After any appointments and/or exams under paragraph 1.4.8 and 1.4.9, a final evaluation and report, determining if the LN is fit or unfit for duty, having or not a work/occupational related condition, shall be completed by the OHCP‘s physician.

If the physician determines that the LN does not have an occupational illness, the medical recommendation must be reported in writing and the OHCP must provide the Government with a medical report and any other documentation used to substantiate the conclusion.

If the physician determines that the LN appears to have an occupational illness, the medical recommendation must be reported in writing and the OHCP must provide the Government with a medical report and any other documentation used to substantiate the conclusion.

1.4.11 LNs determined with NO occupational illness.

If the OHCP’s physician determines an illness or injury was not a work-related condition caused by factors of current employment, then no further care or medical work-up for the condition will be provided by the Government.

1.4.12 LNs with an apparent occupational illness

If the OHCP’s physician determines that a LN appears to have an occupational illness, the physician will complete the necessary documentation in order for the employee to submit their case to the Portuguese Social Security Institute for certification by the appropriate department

(DPRP – Departamento de Proteccao de Riscos Profissional), for final approval in accordance with the Work Regulation of 1995, article 90.

1.4.13 Section title?

After any evaluation under the paragraphs 1.4.8, 1.4.9 and 1.4.10, if the physician determines that the LN is fit for duty or fit for duty with restrictions, with or without an occupational illness being identified and to include non-related occupational illness, the OHCP shall provide the Government with a fit for duty form generated by MAS.

If the LN is medically capable of performing the required job tasks only with some restrictions (fit for duty with restrictions), without risk to his/her health or to that of others, the physician shall provide a list of restrictions, expected duration, and therapeutics or risk-avoiding benefits.

If the LN has a large number of restrictions but is otherwise qualified, the physician shall complete a case summary outlining findings and the medical logic that led to the conclusions, recommendations and restrictions.

1.4.14 LNs unfit for duty

After an evaluation under the paragraphs 1.4.8, 1.4.9 and 1.4.10, if the LN is unfit for duty

(permanent or temporary), with or without an occupational illness being identified, and to include non-related occupational illness, the physician shall provide the Government with an unfit for duty form.

A LN will be considered as unfit for duty if he/she does not meet the medical requirements for the job, is unable to perform essential tasks related to his/her job, or will become unsafe to keep performing the assigned duties related to the workplace.

If a LN is considered as temporarily unfit for duty, the OHCP should provide guidance to the

Government on the estimated duration of the unfit situation, and provide information on necessary exams, other medical specialties appointments and new OHC appointments for reevaluation of the unfit situation.

1.4.15 MOHA notification if an occupational illness is determined.

The OHCP will provide the Government and the LNs with copies of all documentation to be supplied to the Portuguese Social Security Institute.

1.5 Communication methods and communication language.

All communication between both parties must be in English, to include all types of communication methods assigned for this contract. Any reports and observations written by the OHCP physician must be in English.

1.6 Security Requirements.

1.6.1 Electronic communication.

All electronic communications in reference to scheduling between both parties must be through an official secure email address.

The OHCP shall assure that only authorized personnel assigned to this contract has access to any information sent by the Government.

1.6.2 Confidentiality.

The OHCP and any secondary staff shall maintain confidentiality concerning all Government internal matters revealed to them during their surveillance or appointment/s with the LNs. This also applies to all documentation in the possession of the OHCP.

1.6.3 Automated Data Processing System and disposition of employee records.

The OHCP shall store, process, protect, and maintain all necessary medical records for LNs employed by the US Government to fulfill the requirements of this PWS. The OHCP shall maintain all LNs medical records IAW Portuguese standards.

The OHCP shall establish and maintain an accurate file of medical records, including, but not limited to, data for all physical examinations, diagnostic data, Portuguese Social Security

Institute’s occupational illness and injury forms, medical documentation provided by the patients, and laboratory work.

The data processing and disposition of LNs medical records, under this contract, does not require the OHCP to create or maintain any records that the OHCP does not maintain in the ordinary course of business or pursuant to a provision of law.

All medical records are considered confidential medical information, and shall not be discussed or provided to any party other than the patient without a written release from the patient.

The OHCP shall make available the records, materials, and other evidence of examination, for audit by the Government upon previous request, and for reproduction for LNs upon the LNs own request, at its facilities during duty hours.

The OHCP shall maintain the LNs’ medical records for the time period IAW the Portuguese standards.

1.6.4 Assessment Data.

The OHCP has the sole responsibility for the accuracy of assessment data inputs and outputs as well as for a safe maintenance of this data in its record keeping system.

The OHCP shall also cooperate with 86th Medical Group (MDG) Occupational Health staff, responsible for implementing the accident prevention and occupational safety and health program, administered at Lajes Field by the 65th Air Base Group, Medical Aid Station.

1.6.5 Cooperation in Transition.

If a transition of performance will become necessary upon contract expiration or termination, the

OHCP shall cooperate with a subsequent OHCP to assure uninterrupted services and inform the subsequent OHCP of all pending requirements for examinations.

Medical records (or copies) shall be forwarded to the subsequent OHCP upon request by the COR.

Also the records (or copies) relating to the work expired or terminated shall be made available by the OHCP IAW the Portuguese law.

1.7 Inclement Weather Conditions.

On occasion, due to inclement weather conditions, the base may be closed. The Government will not be financially liable for any missed scheduled appointments by LNs. For this or any other reason payment will be made only for services rendered or examinations performed.

1.8 General information

1.8.1 Government Quality Assurance.

The Government will periodically evaluate the OHCP’s performance IAW a Quality Assurance

Surveillance Plan (QASP). The evaluation shall be completed by a Government appointed POC, which will monitor performance and ensure services are being received IAW the PWS. The

Government Quality Assurance should ensure early identification and resolution of performance issues to minimize impact on mission performance.

The Government will inform the OHCP when discrepancies occur and will request corrective action(s).

The CO will implement the Quality Assurance plan after contract is awarded. The point of contact

(POC) may inspect each task as they are completed or increase the number of quality control inspections, if deemed appropriate because of repeated failures discovered or because repeated

LNs complaints.

The OHCP shall be responsible for addressing the LN’s complaints.

1.8.2 OHCP Quality Control Plan (QCP).

The OHCP has the contractual responsibilities for quality control and inspect services rendered to the Government, and shall define actions to control the performance of services so that they meet the requirements of this PWS.

The QCP shall be documented and provided to the Government for acceptance upon issuance of the contract. The CO shall notify the OHCP of acceptance or required modifications to the plan 15 work days after receipt of the OHCP’s QCP. The OHCP shall make appropriate modifications (at no additional costs to the Government) and obtain acceptance of the plan by the CO within 30 days of contract award and before any appointments and exams are provided to LNs.

The OHCP is required to notify the COR immediately when there is a problem caused by the

Government.

The OHCP shall provide copies of all discrepancies to the COR.

The QCP shall be a comprehensive plan detailing how the OHCP intends to ensure the quality of services to the Government and how quality levels will be maintained. The QCP shall cover all services described in this PWS.

The QCP shall include, but is not limited to the following general features:

Overall approach, internal management controls, processes, and procedures for reporting to the

Government on identified aspect of quality issues.

Methods of communication with the Government regarding quality control questions and remarks.

The QCP shall address specifically how all documentation regarding quality control will be created/maintained.

Description of what is measured, how often it is tracked and provided, and who reviews and assures that appropriate action is initiated when trends are unfavorable.

Specific surveillance techniques of all services required in this PWS shall be described. The surveillance methods shall be comprehensive and adaptable to the reporting system of the QCP.

The OHCP shall address what corrective actions (short-term and long-term) will be taken to ensure responses are prompt to correct deficiencies discovered in contract performance without

Government guidance. Internal records shall be kept of these situations as well as corrective action implemented.

1.9 OHCP Furnished Items and Services.

Except for those services to be Government furnished, in paragraph 1.10, the OHCP shall furnish all items and services required to perform the work described in this PWS and contract.

All OHC and examinations shall be at the OHCP facility address or at the sub-contractor facility address designated in the contract, and ensure that the facilities contain the appropriate equipment for the required examinations.

1.10 Government Furnished items and services.

Upon a detailed written request, the Government will be available for the OHCP to visit LNs worksites.

1.11 Invoicing.

The OHCP shall provide invoices on a monthly basis. The invoice must include LN name and the list of completed exams per LN. The OHCP shall ONLY submit the invoice when the requested package of appointment/s and/or exam/s are completed.

The invoice shall be sent to the MOHA, via email, up to the 15th calendar day of the following month, for preliminary validation. The MOHA has 5 work days to validate and inform the OHCP.

If no discrepancies are found the OHCP shall submit the invoice into Wide Area Workflow

(WAWF) under 252.232-7006 Wide Area Workflow Payment Instructions (May 2013) or its successor; if discrepancies are found the OHCP has 5 work days to correct it and submit into

WAWF and validated by COR.

2 Services Summary (SS)

Explanations and clarifications of the table items are given below the table.

Performance Objective

PWS

Paragraph reference

Performance Threshold

Method of assessment How long for the

OHCP to improve

SS1 - OHCP’s punctuality

1.4.8 1.4.9

Average of 4 or above

Punctuality survey completed by the LNs, tracked by MOHA.

Assessed on a monthly

1 month after the communication of non-compliance with the

SS2 – LNs satisfaction with the OHCP’s services

1.4.9 1.4.10

Average of 4 or above

Satisfaction survey completed by the LNs, tracked by MOHA.

A d hl

1 month after the communication of non-compliance i h hSS3 - OHCP monthly availability for exams and appointments to meet the Government d

1.4.5 Maintain 90%

of availability referring to the monthly

Inspection tracked by MOHA, monthly basis

2 months after the communication of non-compliance with the

SS4 - OHCP provision of the completion certificates within the specified timeframes (5 k d )

1.4.6 Maintain 90%

accuracy and timeliness

Inspection tracked by MOHA, monthly basis

1 month after the communication of non-compliance with the

Note:

Performance objectives define the desired outcomes and relate directly to mission-essential items.

Performance thresholds define the level of service required under the contract to successfully meet the performance objective. Defines the minimum acceptable levels of service necessary for each requirement. These thresholds are critical to the contract success.

Method of assessment defines how the service will be assessed in measuring performance. The methods and degree of performance assessment may change over the course of the contract in direct relation to the COR’s level of confidence in the OHCP’s performance.

2.1 Service Summary Description

2.1.1 SS1 – OHCP’s punctuality

The OHCP will be evaluated regarding punctuality according to an anonymous LNs survey, on base. This represents a firsthand information of the service being provided by the OHCP personnel.

The survey will evaluate the OHCP within a scale from 0 to 5. The average must to be of 4 or above to meet the performance threshold.

The MOHA will collect the surveys, process the data and inform the COR and CO on the results.

The survey evaluation will be monthly and will be communicated to the COR and CO until the

10th day of the following month. If any discrepancies are found the OHCP has up to one (1) month to resolve the situation and meet the performance threshold, after being informed.

2.1.2 SS2 - LNs satisfaction with the OHCP’s services

The OHCP will be evaluated regarding LNs satisfaction according to an anonymous LN survey, on base. This represents a firsthand information of the service being provided by the OHCP personnel. The survey will evaluate the OHCP within a scale from 0 to 5. The average must to be of 4 or above to meet the performance threshold.

The MOHA will collect the surveys, process the data and inform the COR and CO on the results.

The survey evaluation will be monthly and will be communicated to the COR and CO until the

10th day of the following month. If any discrepancies are found the OHCP has up to one (1) month to resolve the situation and meet the performance threshold, after being informed.

2.1.3 SS3 - OHC monthly availability for exams and appointments to meet the Government needs.

The OHCP’s monthly availability for exams and appointments is an important mission-essential item as it will guarantee that the LNs fall under the “current” status for the OHC program.

The OHCP shall fulfill the Government monthly requests for exams and appointments in at least

90% of the number of requests. This will be reviewed on a monthly basis as the MOHA has direct access to the numbers of requests and availability. If discrepancies are found then the OHCP has two (2) months to improve the situation.

2.1.4 SS4 - OHCP provision of the completion certificates within the specified timeframe (5 work days)

The MOHA will collect the completion certificates and keep a log with dates of delivery signed by the MOHA and the OHCP.

To meet the performance threshold, the certificates need to be delivered within 5 work days after exam or appointments, as applicable, for at least 90% of the times. The MOHA will, on a monthly basis, evaluate this SS and the results will be provided to the COR and CO up to the 10th day to the following month. In case of non-compliance the OHCP has one (1) month to resolve the situation and meet the performance threshold.

3 Abbreviations and Translation Terms in PWS

AFI Air Force Regulations AFMAN Air Force Manual CA Contract Administrator

CM Contract Manager CO Contracting Officer COHERS Clinical Occupational Health Examinations Requirements COR Contracting Officer Representative CTIP Combating Trafficking in Persons IAW in accordance with LN Local National MAS Medical Aid Station MDG Medical Group MOHA Medical Occupational Health Administrator OEHED Occupational and environmental Health Exposure Data OHC Occupational Health Care OHCP Occupational Health Care Provider PIEE Procurement Integrated Enterprise Environment POC Point of Contact PWS Performance Work Statement QASP Quality Assurance surveillance Plan QCP Quality Control Plan RAA Autonomous Region of the Azores SS Services Summary USAF United States Air Force USFORAZORES United States Forces Azores WAWF Wide Area Workflow

5 List of Applicable Publications (current editions)

NFPA 1582 – Standard on comprehensive occupational medical program for fire Departments, NFPA 1582-18 Technical implementation Guide (TIG) 2018

29 Code of Federal Regulations (CFR) 1910 - Occupational Safety and Health Administration

(OSHA)

5 CFR 339 - OSHA Medical qualification determinations

AFI 48-123 - Medical Examinations and standards (5 November 2013)

AFI 48-127 - Occupational noise and Hearing conservation program. (26 Feb 2016)

AFI 8-137 – Respiratory Protection Program (12 Sep 2018)

AFI 48-145 - Occupational and Environmental Health Program (11 July 2018)

AFMAN 48-146 - Occupational and Environmental Health Program Management (15 October

2018)

DoDM 6055.5 M - Occupational Health Surveillance Manual (2 May 2007 incorporating change

3, august 31, 2018)

DoDI 6055.12 – Hearing Conservation Plan (14 August 2019)

Work Regulation of 1995

6 Attachment list

6.1 Attachment 1 – Exams and appointments list

6.2 Attachment 2 – Exams/appointments description and requirements

6.3 Attachment 3 – Employee’s Occupational Health List of Exam Requirements (Examples)

6.4 Attachment 4 – Applicable references

Attachment 1

Exams and appointments list

IDs CONSULTATON/EXAM TYPE Observations

Initial OHC medical appointment

Can include when applicable, but not limited to, medical history questionnaire, physical examination, confrontational fields, prostate exam.

0002 Follow up OHC appointment To also include a documented review of results from any applicable exams performed under CLINs 004-0181

Occupational disease report participation and other

Initial and follow up Allergist/Immunologist appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

0005 Skin tests

0006 Anesthetic appointment

Initial and follow up Cardiology appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

0008 Electrocardiogram 12 lead EKG

Initial and follow up Dermatology appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

Initial and follow up Endocrinology appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

Initial and follow up Gastroenterology appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

Initial and follow up General Clinic appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

Initial and follow up General Clinic appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

Initial and follow up General Surgery appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

Initial and follow up Gynecology appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

Obstetric/gynecological ultrasound

0017 Obstetric twin ultrasound

Obstetric ultrasound with CD burn

0019 4D ultrasound

Intrauterine device (IUD)/pessary

To place or to remove

0021 Vulvar condyloma treatment

Subcutaneous contraceptive implant

To place or to remove

0023 Colposcopy

0024 Colposcopy with biopsy

0025 Cervix morphological cystoscopy

0026 Cervix biopsy

0027 Hysterosalpingography

0028 Support 4 X-ray

0029 Hysteroscopy

0030 Suprapubic ultrasound

0031 Implant placement

0032 Implant removal

0033 Intrauterine device (IUD) To place or remove

0034 Endometrium biopsy

Initial and follow up internal medicine appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

Initial and follow up internal medicine appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

Initial and follow up Nephrology appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

Initial and follow up Neurology appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

Initial and follow up Neurology appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

Initial and follow up Neurosurgery appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

Initial and follow up nutritionist appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

Initial and follow up ophthalmology appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

Initial and follow up orthopedics appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

Initial and follow up osteopathy appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

Initial and follow up Otorhinolaryngology appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

Initial and follow up pediatrics appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

Initial and follow up Plastic Surgery appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

Initial and follow up Psychiatry appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

Initial and follow up Psychology appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

Initial and follow up podiatry appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

Initial and follow up Pulmonology appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

Initial and follow up Rheumatology appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

0053 Bone densitometry (DEXA) With extra body segment please add extra 30euro

Intra-articular injection of viscosuplementation

0055 Depo Medrol injection

0056 Aclasta administration

0057 Speech therapy appointment

0058 Speech therapy session

Initial and follow up Urology appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

0060 Neuromodelation PTSN Percutaneous Tibial Nerve Stimulation

0061 Trans rectal prostate ultrasound

0062 Trans rectal prostate biopsy Add the injectable value of 3.00euro

0063 Suprapubic puncture

0064 Bladder instillation

0065 Urethrocystoscopy

0066 Vasectomy

0067 Papaverine test

0068 Electrocoagulation

0069 Meatoplasty

0070 Circumcision

Initial and follow up Vascular Surgery appointment

To include any OHC physician medical referral to complete more extensive testing and evaluation.

0072 BUN and Creatinine

0073 CBC with Diff

0074 HIV screening

0075 HEP C screening

0076 HEP B screening

0077 HEP A screening

0078 Toxoplasmosis screening

0079 Leptospirosis screening

0080 Lipid panel To include total cholesterol, HDL, LDL, total cholesterol/HDL ration, clinically useful rations and triglycerides.

0081 Liver function panel To include ALT, AST, alkaline phosphatase and direct and indirect bilirubin.

0082 AST liver function panel To only include this parameter.

0083 Urinalysis

0084 Urine Glucose

0085 Urine microalbumin

0086 Fecal occult blood

0087 Fecal culture Coproculture

0088 Fecal culture Search for eggs, cysts and parasites in feces

Immunization titer test for HEP A (A Hepatitis)

To check if the individual is immune to the disease

Immunization titer test for HEP B (B Hepatitis)

To check if the individual is immune to the disease

0091 X-ray to the head

0092 X-ray to the cervical spine

0093 X-ray to the thoracic spine

0094 X-ray to the lumbar spine

0095 X-ray to the spine To include cervical, thoracic and lumbar spine.

2 planes

0096 X-Ray to the chest AP 1 plane

X-Ray to the chest AP and profile

2 plane

0098 X-Ray to the abdomen

0099 X-Ray to the pelvis

0100 X-Ray to the femur

0101 X-Ray to the knee

0102 X-Ray to the patella Multiple incidences

0103 X-Ray to the tibia/fibula

0104 X-Ray to the tibia/tarsal

0105 X-Ray to the foot

0106 X-Ray to the shoulder

0107 X-Ray to the humerus

0108 X-Ray to the elbow

0109 X-Ray to the radius/ulna

0110 X-Ray to the wrist

0111 X-ray to the hand

0112 X-Ray 3 planes

0113 X-Ray 4 planes

0114 Other X-ray 2 planes

0115 Abdominal = kidney (CT scan)

0116 Pelvic (CT scan)

0117 Thorax (CT scan)

0118 Knee (CT scan)

0119 Mediastinum (CT scan)

0120 Thyroid (CT scan) (soft tissues of the neck)

0121 Head (CT scan)

0122 Cervical spine (CT scan)

0123 Lumbar spine (CT scan)

0124 Thorax spine (CT scan)

0125 Pelvic/sacro-iliac (CT scan)

0126 Sella turcica/pituitary (CT scan)

0127 Orbital

ORL (Otorhinolaryngology) or TMJ (Temporomandibular joint) (CT scan)

Paranasal sinus – nasosinusal (CT scan)

0130 Macro facial (CT scan)

0131 Angiography CT scan

0132 Dental scan (CT scan)

0133 Virtual colonoscopy (CT scan)

0134 Abdominal ultrasound

Kidney and adrenal glands ultrasound

0136 Pelvic ultrasound

0137 Thyroid ultrasound

0138 Salivary glands ultrasound

0139 Breast ultrasound

0140 Prostate ultrasound

0141 Transrectal prostate ultrasound

0142 Bladder ultrasound

0143 Scrotum ultrasound

0144 Soft tissues ultrasound

Ultrasound for gastroesophageal reflux

Ultrasound for developmental dysplasia of the hip

Ultrasound guided biopsy thyroid/breast

Ultrasound + biopsy thyroid/breast

0149 MRI

0150 Liver MRI (Primovist)

0151 Entero MRI Pelvic + abdominal

0152 Cholangio MRI

0153 Anesthesia for MRI

0154 Dr. attendance to a MRI When the patient is under anesthetic

0155 Mammogram

0156 Breast Ultrasound

Breast ultrasound + mammogram

0158 Audiogram

Electromyography (includes EMG and/or neurography and/or repetitive stimulation)

0160 Visual acuity To include color vision, when applicable.

0161 Spirometry

0162 24h Blood pressure monitoring

Attachment 2

Exams/appointments description and requirements, when applicable

6.5 ID 001 - Face to face appointments

The LN will attend to an appointment with an occupational health physician.

The face to face appointments should include but not limited to:

- A documented review of the results from any applicable exams mentioned at the exam list provided to the OHCP for that service.

- Medical history questionnaire, when applicable (References: NFPA 1582; NFPA 1582-18;

DoDM 6055.5 M).

o An initial medical history questionnaire shall be completed to provide baseline information with which to compare future medical concerns. The annual medical history questionnaire shall also be completed, and shall include any changes to the health status of the LN and known occupational exposures since last annual evaluation. Each questionnaire must be signed by the LN, validating the information provided.

- Physical examination, when applicable (References: NFPA 1582; NFPA 1582-18; DoDM

6055.5 M), that shall include:

o Vital signs, height, weight, body mass index and overall physical fitness.

o Head, neck, abdomen, extremities and back

The head and general body appearance and form should be checked (especially for deformities that might affect respirator or eyewear or other PPE use). Neck, extremities and back range of motion (ROM) should be checked. Check for abdomen hernia and liver status.

o Eyes, ears, nose, throat and oral cavity o Neurological exam that must include:

A general mental status evaluation and general assessment of the major crania/peripheral nerves

(motor, sensory, reflexes). Evaluation of balance, deep tendon reflexes, gait, coordination, and tremors. Any symptomatic balance disturbance, vertigo, change of gait and coordination, or history of these that has not resolved completely should be fully investigated. Current use of medication needs careful evaluation to be certain that the condition is completely controlled and that the side effects of the medication do not impose additional unacceptable risks for the successful and safe performance of critical job tasks. Evaluation of the ability to communicate

(hearing and speaking), including ability to articulate understandably. Evaluation of the general behavior, including evidence of inappropriate behavior, abnormal speech, hyperactivity, or lethargy.

o Lymph nodes and skin o Heart, lungs and thorax o Should include pulses at both wrists and feet.

- LNs immunization record review according to the COHER requirements, when applicable.

o Tuberculosis (PPD) (References: NFPA 1582)

Verification of PPD immunity through documentation of vaccination.

o Hepatitis B virus (References: NFPA 1582)

Verification of Hepatitis B immunity through antibody testing or documentation of vaccination.

o Hepatitis A (References: NFPA 1582)

Verification of Hepatitis A immunity through antibody testing or documentation of vaccination.

o Tetanus/diphtheria (Td) (References: NFPA 1582; DoDM 6055.5 M)

Verification of Tetanus (Td) immunity through documentation of vaccination.

6.6 ID 0158 - Audiogram

(References: NFPA 1582; NFPA 1582-18; 29 Code of Federal Regulations (CFR) 1910; AFI 48-

127; DoDM 6055.5 M; DoDI 6055.12)

The OHCP shall compare audiogram results obtained during annual evaluations with baseline test results to determine if there is a threshold shift.

The OHCP shall ensure that any medical recommendations to LNs, restricting hazardous noise exposure are based on:

- Inability of the worker to perform the essential functions of the job.

- Probability of the worker endangering himself/herself or other if allowed to work in a noise hazard environment.

The OHCP may assume a LN meets the minimum medical qualifications to perform a job in hazardous noise environment if one of the following conditions is true:

- The LN can wear standard HPDs, and does not report difficulty in hearing and understanding routine spoken communications, auditory cues, or signals.

- The LN has undergone a previous fitness and risk evaluation, hearing thresholds have not changed significantly (no significant threshold shift (STS) compared to most current reference), and medical condition that may affect job performance in a hazardous noise job has remained stable.

Also the OHC physician should send the LN for follow ups and referral procedures if a STS is detected during the annual examination.

6.6.1 Audiograms, audiometer and sound room standards and guidelines

6.6.1.1 Audiograms

Pure-tone, unaided, air-conducted hearing threshold examination shall be assessed annually in each ear at each of the following frequencies: 500 Hz, 1000 Hz, 2000 Hz, 3000 Hz, 4000 Hz and

6000 Hz. The threshold is 80 dBA.

6.6.1.2 Audiometers

Earphones must ONLY be used with the audiometer they were calibrated.

6.6.1.3 Audiometric sound rooms

Rooms used for audiometric testing shall not have background sound pressure levels exceeding those in table below.

For 500 Hertz (Hz), 27 dB.

For 1,000 Hz, 29 dB.

For 2,000 Hz, 34 dB.

For 4,000 Hz, 39 dB.

For 8,000 Hz, 41 dB.

6.6.2 STS

A STS (significant threshold shift) includes a change in hearing threshold relative to the current reference audiogram of an average of 10 db or more at 2.000, 3.000, and 4.000 Hz, in either ear.

That is, if the sum of the shifts at 2.000, 3.000, and 4.000 Hz equals or exceeds 30 dB in either ear, an STS has occurred. Age corrections will not be applied.

A single frequency 15 dB shift at 1.000, 2.000, 3.000, or 4.000 Hz is considered an early warning flag with no requirements for follow up testing or referrals, but with a requirement to advice the patient and check hearing protections.

6.6.2.1 Negative STS

If a negative STS (improved hearing threshold from reference audiogram) is noted, a follow up test will be administrated, which may be on the same day as the periodic test. Noise free hours are not required in the presence of a negative STS. The results may be used to re-establish a reference audiogram to reflect the improvement in pure tone acuity.

6.6.2.2 Positive STS

If a positive STS (decrease in hearing threshold from reference audiogram) is noted, one or two noise-free (i.e. no hazardous noise exposure at least 14-hours prior the test, less than 80dBA) follow up tests are administered to confirm, according to:

- The noise-free follow up tests may be administered on the same day, but not on the same day as the periodic audiogram.

- The OHCP should performsa lighted ear inspection prior to the noise-free audiogram.

- Follow up testing must be done within 30 days of the annual audiogram. If no follow up tests are performed within 30 days after the annual audiogram, then the annual audiogram is considered a PTS until further evaluation is completed.

- If the result of the first noise-free follow up test does not indicate an STS, a second follow up test is not required, and the shift is a temporary threshold shift (TTS). If the results of the first follow up does indicate an STS, a second noise-free follow up is, but if the second follow up test does not indicate an STS, then the shift is also a TTS.

- If an STS is noted on the two required follow up tests, then the STS should be considered a PTS and patient referred back to the OHCP or ENT for further testing, and if needed, confirmation and determination if it is work-related or not, or if it has…